[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



 
        NECESSARY REFORM TO PEDIATRIC DENTAL CARE UNDER MEDICAID

=======================================================================



                                HEARING

                               before the

                    SUBCOMMITTEE ON DOMESTIC POLICY

                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 23, 2008

                               __________

                           Serial No. 110-190

                               __________

Printed for the use of the Committee on Oversight and Government Reform


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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                 HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York             TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania      DAN BURTON, Indiana
CAROLYN B. MALONEY, New York         CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland         JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio             JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois             MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts       TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri              CHRIS CANNON, Utah
DIANE E. WATSON, California          JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts      MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York              DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky            KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa                LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of   PATRICK T. McHENRY, North Carolina
    Columbia                         VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota            BRIAN P. BILBRAY, California
JIM COOPER, Tennessee                BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland           JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
JACKIE SPEIER, California

                      Phil Barnett, Staff Director
                       Earley Green, Chief Clerk
               Lawrence Halloran, Minority Staff Director

                    Subcommittee on Domestic Policy

                   DENNIS J. KUCINICH, Ohio, Chairman
ELIJAH E. CUMMINGS, Maryland         DARRELL E. ISSA, California
DIANE E. WATSON, California          DAN BURTON, Indiana
CHRISTOPHER S. MURPHY, Connecticut   CHRISTOPHER SHAYS, Connecticut
DANNY K. DAVIS, Illinois             JOHN L. MICA, Florida
JOHN F. TIERNEY, Massachusetts       MARK E. SOUDER, Indiana
BRIAN HIGGINS, New York              CHRIS CANNON, Utah
BRUCE L. BRALEY, Iowa                BRIAN P. BILBRAY, California
JACKIE SPEIER, California
                    Jaron R. Bourke, Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on September 23, 2008...............................     1
Statement of:
    Kuhn, Herb, Acting Director, Center for Medicaid and State 
      Operations; and Alicia Cackley, Acting Director, Health 
      Care Team, Government Accountability Office................    36
        Cackley, Alicia..........................................    50
        Kuhn, Herb...............................................    36
    Tucker, Susan, MBA, executive director, Office of Health 
      Services, Maryland Department of Health and Mental Hygiene; 
      Patrick Finnerty, director, Virginia Department of Medical 
      Assistance Services; Mark Casey, DDS, MPH, medical 
      director, North Carolina Division of Medical Assistance; 
      Linda Smith Lowe, esq., public policy advocate, Georgia 
      Legal Services Program; Jane Grover, American Dental 
      Association; and Jim Crall, director, Oral Health Policy 
      Center, professor and Chair, Section of Pediatric 
      Dentistry, UCLA School of Dentistry........................    86
        Casey, Mark..............................................   112
        Crall, Jim...............................................   174
        Finnerty, Patrick........................................    95
        Grover, Jane.............................................   143
        Lowe, Linda Smith........................................   124
        Tucker, Susan............................................    86
Letters, statements, etc., submitted for the record by:
    Cackley, Alicia, Acting Director, Health Care Team, 
      Government Accountability Office, prepared statement of....    52
    Casey, Mark, DDS, MPH, medical director, North Carolina 
      Division of Medical Assistance, prepared statement of......   115
    Crall, Jim, director, Oral Health Policy Center, professor 
      and Chair, Section of Pediatric Dentistry, UCLA School of 
      Dentistry, prepared statement of...........................   178
    Finnerty, Patrick, director, Virginia Department of Medical 
      Assistance Services, prepared statement of.................    98
    Grover, Jane, American Dental Association, prepared statement 
      of.........................................................   145
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio:
        Prepared statement of....................................     5
        Prepared statement of Burton Edelstein...................   197
    Kuhn, Herb, Acting Director, Center for Medicaid and State 
      Operations, prepared statement of..........................    38
    Lowe, Linda Smith, esq., public policy advocate, Georgia 
      Legal Services Program, prepared statement of..............   126
    Tucker, Susan, MBA, executive director, Office of Health 
      Services, Maryland Department of Health and Mental Hygiene, 
      prepared statement of......................................    89


        NECESSARY REFORM TO PEDIATRIC DENTAL CARE UNDER MEDICAID

                              ----------                              


                      TUESDAY, SEPTEMBER 23, 2008

                  House of Representatives,
                   Subcommittee on Domestic Policy,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m. in 
room 2154, Rayburn House Office Building, Hon. Dennis J. 
Kucinich (chairman of the subcommittee) presiding.
    Present: Representatives Kucinich, Cummings, Higgins, and 
Issa.
    Also present: Representative Higgins.
    Staff present: Jaron R. Bourke, staff director; Noura 
Erakat, counsel; Jean Gosa, clerk; Charisma Williams, staff 
assistant; Leneal Scott, information systems manager; Jill 
Schmalz, minority counsel; Molly Boyl, minority professional 
staff member; and Larry Brady, minority senior investigator and 
policy advisor.
    Mr. Kucinich. We have just been informed that the ranking 
member is en route and he urges us to start, so we will.
    The subcommittee will come to order.
    This is the Domestic Policy Subcommittee of the Oversight 
and Government Reform Committee. Today is Tuesday, September 
23, 2008. The hearing today is entitled, ``Necessary Reform to 
Pediatric Dental Care under Medicaid.''
    Today's hearing is going to examine the progress of reform 
in Medicaid's pediatric dental entitlement.
    Without objection, the Chair and the ranking minority 
member will have 5 minutes to make opening statements, followed 
by opening statements not to exceed 3 minutes by any other 
Member who seeks recognition.
    Without objection, Members and witnesses may have five 
legislative days to submit an opening statement or extraneous 
materials for the record.
    Nearly a year and a half ago a 12-year-old boy named 
Deamonte Driver died of a brain infection caused by untreated 
tooth decay. Deamonte lived in Prince George's County, MD, and 
was a Medicaid beneficiary, and as such was en titled to dental 
care paid by the American taxpayers. But he hadn't seen a 
dentist for more than 4 years.
    Since then my subcommittee began an investigation into the 
adequacy of pediatric dental care under Medicaid. In May 2007 
my subcommittee held a hearing to determine the circumstances 
that led to Deamonte's preventable death. Nine months later we 
examined what corrective actions the Center for Medicaid and 
State Operations, CMS, had taken since Deamonte's death to 
reform the dental program for Medicaid-eligible children.
    Today we seek to move beyond identifying problems with our 
pediatric dental program under Medicaid and start identifying 
the reforms necessary to fix a broken system. Moreover, we will 
have the opportunity to recognize Federal and State officials 
who have taken the lead in fixing this system by implementing 
some of those reforms.
    After our May hearing, I instructed our subcommittee staff 
to investigate the adequacy of the dental provider network 
available to Medicaid-eligible children enrolled in the same 
managed care company that was responsible for Deamonte. My 
subcommittee investigated United Healthcare's dental network 
and records of claims submitted for services rendered to United 
beneficiary children in 2006.
    What my staff found was appalling. Deamonte was far from 
the only child in Maryland who hadn't seen a dentist in 4 or 
more consecutive years. In fact, nearly 11,000 Maryland 
children enrolled in United had not seen a dentist in 4 or more 
consecutive years, putting them in the same precarious position 
that Deamonte was in at the time of his death.
    The investigation also revealed that United Health Care's 
dental provider network was not nearly as robust as they 
claimed. We discovered that only seven dentists provided 55 
percent of all dental services rendered in 2000 in the county 
where Deamonte resided.
    Shortly after the release of our investigatory findings in 
October 2007 I instructed my subcommittee staff to expand its 
investigation into three managed care organizations in addition 
to United in three other States and counties. The survey, the 
results of which are made available to the Center on Medicaid 
and State Operations by letter last week, assessed United and 
Health Care Choice in Apache County, AZ; United and Amerigroup 
in Essex County, NJ; United and Keystone Mercy in Philadelphia 
County, PA; and Amerigroup in Prince George's County, MD.
    I ask unanimous consent to enter my letter into the record.
    The finding of this expanded investigation reveals that 
inadequate dental provider networks and poor utilization rates 
are not limited to any single MCO or to any single 
jurisdiction. The problems are system-wide.
    Our survey revealed that many, many thousands of children 
enrolled in Medicaid are not receiving dental care for up to 6 
consecutive years. We have a chart up that is supposed to 
represent that. I don't know if anybody is going to be able to 
read it. I certainly can't from here. But this slide indicates 
how many children did not see a dentist in 4 or more 
consecutive years.
    The percentage of children enrolled in Medicaid without 
dental services for 4 consecutive years between 2003 and 2006 
ranged between 25 and 31 percent across all States and MCOs. 
But percentages are one thing and numbers are another. This 
means that in Philadelphia County, for example, 34,947 children 
enrolled in Keystone Mercy did not see a dentist between 2003 
and 2006. These are children who are entitled to this care.
    Are any of those children suffering from untreated tooth 
decay? If so, will it be caught before it leads to another 
tragic story?
    Our survey also revealed that dental provider networks are 
as woefully inadequate in these other jurisdictions and MCOs 
are as they were in Prince George's County in 2006.
    In all jurisdictions among all MCOs examined, only between 
two and nine dentists performed half of all services rendered 
to children enrolled in Medicaid in fiscal year 2006. This is 
in Prince George's County.
    United's provider network in Essex County, NJ, boasts of 
203 dentists. At first glance, it appears that parents in Essex 
County can easily access a dentist to treat their child. But 
look a little closer and you will find that only 9 dentists of 
the 203 enrolled in United's provider network provided 50 
percent of all services to children enrolled in the MCO.
    Why are large numbers of dentists enrolled in a managed 
care organization's network but not providing care? What will 
it take to change their status from inactive to active 
providers of dental care for Medicaid-eligible children?
    We began to explore answers to this question earlier this 
year. In February this subcommittee held a hearing to evaluate 
CMS's reforms in pediatric dental care under Medicaid since the 
death of Deamonte. The hearing revealed the inadequacy of the 
agency's reforms, prompting this subcommittee to press CMS to 
do more to achieve greater access to and utilization of 
pediatric dental care. My subcommittee made six policy 
recommendations to CMS in this vein.
    I ask for unanimous consent to enter my letter into the 
record.
    Since that time, CMS has come under new leadership. Today 
we will hear from CMS and learn that the agency has taken great 
strides in responding to these recommendations. CMS's 
accomplishments since our last hearing mark a significant and 
positive shift in its approach to providing dental care for our 
country's poorest children.
    We will also hear from representatives of several State 
Medicaid agencies whose programs provide instructive lessons 
for other States struggling to improve their pediatric dental 
program under Medicaid. We will hear about the positive impact 
of increasing reimbursement rates in Maryland, about the 
positive impact of a disease management model in North 
Carolina, and about the positive impact of creating a single 
vendor administrator for dental care in Virginia.
    The history of pediatric dentistry under Medicaid is deeply 
disturbing. The system of Government and private managed care 
companies that was entrusted by the American people to take 
care of children like Deamonte Driver has been in a shambles. 
According to the Government Accountability Office's most recent 
report on oral health, not much has changed over the past two 
and a half decades. GAO's report is the first of its kind since 
2000, when the Surgeon General released a report on oral health 
in the United States and found that low-income children 
suffered twice as much from tooth decay than more affluent 
children.
    But our hearing today is going to show that over the past 
year and a half, through congressional oversight, the tireless 
work of advocates, and the dedication of State and Federal 
officials, lessons have been learned since Deamonte's death. 
Initiatives have been undertaken, and a Federal agency, long 
accustomed to a laissez-faire attitude toward Medicaid has 
finally awakened.
    I look forward to hearing the testimony from our witnesses 
and believe it will demonstrate to the American people that 
reform has come to Medicaid and society can be guardedly 
optimistic.
    Thank you.
    [The prepared statement of Hon. Dennis J. Kucinich and the 
information referred to follow:]


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    Mr. Kucinich. At this time I recognize the ranking member, 
who has worked with us throughout this entire matter, Mr. Issa 
of California. Thank you, sir, for being here.
    Mr. Issa. Thank you, Mr. Chairman.
    Mr. Chairman, this is the fourth in a series of hearings. 
Unlike some of the hearings that often occur, not just in this 
committee but in other committees, where you have a hearing, 
you play ``gotcha,'' and then you move on, you have steadfastly 
stood to try to not only bring awareness to this problem, but, 
in fact, to go beyond that to bring and oversee changes.
    These hearings were, of course, first prompted by the 
tragic death and avoidable death of Deamonte Driver, who died 
of a brain infection as a result of tooth decay.
    Mr. Chairman, I appreciate your efforts to prevent any 
event like this from happening in the future. It is very clear 
that, of all the areas of medical coverage that America does 
the least well, it is dentistry, not because we don't have the 
finest dentists or the finest dentistry in the world--we do, we 
lead the world--but programs such as Medicaid, which often talk 
in terms of preventative activities, certainly do a fine job on 
vaccines, but they fail to hit the most important part of the 
responsibility. Poor oral health is a leading cause of so many 
other diseases and, of course, leads to a lifelong inability to 
be healthy and to regain that health.
    Mr. Chairman, the fact that you have made it your mission 
to go after failures of Medicaid and CMS, failures to oversee 
the States who have the primary responsibility--as we both 
know, dentistry is not an entitlement, but where, in fact, 
States have agreed to do it, the Federal Government is a full 
partner in that. We need to make sure that is being delivered 
properly.
    As you said in your opening statement, it is very, very 
clear that just having a program is not of any value if you 
have no access because of an insufficient number of dentists 
available. Dentists react to the market faster than any other 
part of medicine. Dentists will immediately recognize if we are 
not paying a sufficient amount or not authorizing services for 
those they need. Dentists are, in fact, small businessmen, for 
the most part, and, unlike physicians, they can't rely on a 
hospital or other offsets.
    A dentist who is particularly pediatric and operates in a 
poor area or under-served area is going to find himself with 
patients who can't pay that he is trying to finance, patients 
who seek Medicaid, and a relatively small amount of patients 
who have full dental coverage.
    Mr. Chairman, your work has prompted the GAO report being 
released today, which will be discussed in the first panel, but 
which, in fact, is an opportunity for you and I together and 
others in Congress to take this challenge, which has not yet 
been met, into the next Congress.
    I look forward to the briefing here today.
    I also would like to thank you for the invitation you 
placed to the American Dental Association. You and I both know 
that Government has often failed to go to those who have the 
expertise and say, why is it we are failing? Why is it that 
dentists often choose not to take Medicaid patients? Today we 
are going to have an opportunity to see and hear what is still 
wrong, what has been improved, and, equally importantly, to 
talk to the professionals who we have to make future programs, 
both at the Federal and State level and particularly Medicaid, 
fit their needs or we will not have full access to coverage.
    Mr. Chairman, often one person gives their life and becomes 
a poster child for people to complain about the system. In this 
case you have done a great job, and I would like to commend you 
as we near the end of Congress, for using that tragic loss to 
bringing about permanent and profound change.
    I look forward to, for the rest of this Congress and into 
the next Congress, working with you on a bipartisan basis to 
find solutions that work for the children who today are not 
getting the dental care that will lead to a healthy adult life.
    I yield back and thank the chairman for his leadership.
    Mr. Kucinich. I want to thank the ranking member. For those 
of you who may not be aware of it, Mr. Issa and I both hail 
from Cleveland, although I am privileged to represent it in the 
Congress. Mr. Issa and I both understand from our childhood 
experiences the relevance of this pediatric dental issue. When 
you know that personally, you understand and become very 
involved in a way that can be constructive.
    So I want to say that the progress that we have been able 
to have here could not have happened without your participation 
and your support, because when you have a committee work and 
something gets done, it is not just one person that brings it 
about; you have to have a partner on it. Mr. Issa has been a 
terrific partner on these things, so I want to thank you as we 
move forward.
    I also want to recognize our staff of the subcommittee, 
because without it we wouldn't be able to get into the depth 
that we have been able to get into. There is still a long way 
to go, but we have had some progress.
    Let's start by introducing the first panel.
    Mr. Herb Kuhn is the acting director of the Center for 
Medicaid and State Operations. He is a nationally recognized 
expert on value-based purchasing and payment policy. Mr. Kuhn 
most recently served as director for the Center of Medicaid 
Management. As CMM director, Mr. Kuhn oversaw the development 
of regulations and reimbursement policies for the fee-for-
service portion of Medicare, covering the universe of providers 
that care for 43 million elderly and disabled Americans under 
Medicare.
    Ms. Alicia Puente Cackley is an Acting Director at the U.S. 
Government Accountability Office. She currently directs several 
teams of analysts doing health policy research, including 
studies of Medicaid services for children and adults, and 
immigrant detainee health. Prior to joining the health care 
team, Ms. Cackley worked in GAO's education work force and 
income security team, where she managed teams analyzing Social 
Security reform, retirement and aging issues, as well as work 
force immigration issues.
    I want to thank you both for appearing before our 
subcommittee today.
    It is the policy of the Committee on Oversight and 
Government Reform to swear in all witnesses before they 
testify. I would ask that you rise and raise your right hands.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record show that the witnesses have 
answered in the affirmative.
    I would ask each of the witnesses to now give a brief 
summary of their testimony, and to keep the summary under 5 
minutes in duration. Bear in mind your complete written 
statement will be included in the hearing record.
    I want to thank Mr. Higgins from New York for joining us.
    Mr. Kuhn, let's begin with you.

 STATEMENTS OF HERB KUHN, ACTING DIRECTOR, CENTER FOR MEDICAID 
  AND STATE OPERATIONS; AND ALICIA CACKLEY, ACTING DIRECTOR, 
       HEALTH CARE TEAM, GOVERNMENT ACCOUNTABILITY OFFICE

                     STATEMENT OF HERB KUHN

    Mr. Kuhn. Good morning, Chairman Kucinich and members of 
the subcommittee. Thank you for inviting me to discuss 
pediatric dental care under Medicaid.
    CMS shares this subcommittee's conviction that we must 
improve dental care services for children with Medicaid. As I 
have personally shared with Chairman Kucinich, our agency is 
grateful for this subcommittee's leadership in this area. You 
have provided us with helpful information as we move forward on 
our efforts to improve care. In this regard, I wanted to take 
my time today to give you an update on where we are with our 
investigations and improvement efforts.
    First, CMS has completed its onsite reviews of 17 State 
dental programs. The States targeted for review were those 
States where less than 30 percent of the children on Medicaid 
were seen by a dentist in the previous year. CMS used 2006 as 
the benchmark year. When these reviews are completed, we plan 
to host a national town hall meeting to discuss our findings 
and ask for suggestions on policy options to improve the 
utilization of dental care for these vulnerable children.
    Once we complete the national town hall meeting, we plan to 
share our report through a State Medicaid director's letter to 
all States and the District of Columbia. We intend to complete 
this entire process by the end of this year.
    I want to assure the committee that we are not waiting to 
take actions with States on issues that are identified, 
however, during these reviews. Once each State review is 
completed, we are making a set of recommendations for each 
State and are initiating compliance actions on those 
recommendations.
    Second, CMS has asked all States to update and submit to us 
their dental periodicity schedules for review. As part of our 
review, we have found that some States were out of compliance 
with CMS requirements. Even more unfortunate, some States have 
still not responded to our request for these oral health 
schedules. Some of those States are represented by members on 
this subcommittee.
    We have shared with you the list of States that still have 
not provided us with these oral health schedules. As part of 
our ongoing partnership with this subcommittee on the Medicaid 
dental program, I would appreciate your assistance in 
contacting your own State to help us obtain those schedules.
    Third, in collaboration with the National Association of 
State Medicaid Directors, we have developed an oral health 
technical advisory group. They helped us update the policy 
questions and answers that you had inquired about, as well as 
helping us with improvements in the annual EPSDT reporting 
form. We all know we need to capture better data on dental 
services, and we are hopeful that by improving this reporting 
form it will help us identify areas of weaknesses on which we 
can focus our attention.
    We also are including dental activities in our State 
quality assessment reports, and we are working with the 
American Dental Association to create a dental quality alliance 
to help us develop evidence-based performance measures.
    Fourth, we have moved forward with the States on sharing 
best practices, convening a national call to discuss innovative 
State programs. I am excited about the growing collaborations 
that we are seeing in various events, including the National 
Oral Health Conference.
    Finally, I would like to share with the subcommittee that, 
since assuming the role as Acting Director of the Center for 
Medicaid and State Operations, I have met with State Medicaid 
Directors and discussed this issue at length. Furthermore, CMS 
staff have been in contact with every State, from State 
Medicaid directors to State dental officers to discuss these 
issues. I can assure you that every State understands the 
additional scrutiny we are putting them under.
    While our work is far from done, I am confident that we are 
moving in the right direction and look forward to continuing to 
work with this subcommittee and others on improved pediatric 
dental care.
    I would be happy to answer your questions.
    [The prepared statement of Mr. Kuhn follows:]
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    Mr. Kucinich. I thank the gentleman.
    The gentlelady may proceed.

                  STATEMENT OF ALICIA CACKLEY

    Ms. Cackley. Mr. Chairman, Ranking Member Issa, members of 
the subcommittee, I am pleased to be with you today as you 
examine reform to pediatric care and Medicaid. This is an issue 
this committee has been focused on for some time, since the 
tragic death of Deamonte Driver.
    My comments this morning are based on a report we prepared 
for the subcommittee, which you are releasing today, entitled, 
``Medicaid: Extensive Dental Disease in Children Has Not 
Decreased, and Millions Are Estimated to Have Untreated Tooth 
Decay.''
    My remarks will cover three key questions that you asked us 
to investigate: the extent to which children in Medicaid 
experience dental disease, the extent of dental care they 
receive, and how these conditions have changed over time.
    In summary, dental disease and inadequate receipt of dental 
care remains a significant problem for children in Medicaid 
across the country. Our analysis of national data indicates 
that approximately one in three children on Medicaid age 2 
through 18 had untreated tooth decay, and 1 in 9 had untreated 
decay in more than three teeth.
    Projecting these percentages on 2005 Medicaid enrollment 
levels, we estimate that 6.5 million children in Medicaid have 
had untreated tooth decay. This rate of dental disease for 
children in Medicaid was nearly double the rate for children 
who had private insurance, and very similar to the rate of 
children who are uninsured.
    Turning to national data on receipt of dental care, we 
found that nearly two in three children in Medicaid had not 
received any dental care. Again, projecting these percentages 
on 2005 enrollment levels, we estimate that 12.6 million 
children in Medicaid didn't see a dentist in the previous year.
    In addition, the data show that only about one in eight 
children ever see a dentist.
    As you may know, HHS has national health goals known as 
Healthy People 2010, which include the target of having two-
thirds of low-income children receive a preventive dental 
service in a given year. Our analysis shows that as a nation we 
are way behind, since we found that only one-third of children 
in Medicaid received any dental care in the previous year.
    Looking over time, there is some good news to share with 
you. Comparisons of past and more recent survey data suggest 
that indicators of receipt of dental care, including the 
proportion of children who had received dental care in the past 
year and the proportion who had received dental sealants have 
shown some improvements over time. The percentage of children 
in Medicaid who received dental care in the previous year 
increased from 31 to 37 percent over approximately 10 years.
    In addition, the percentage of slightly older children, 
whose aged 6 through 18 with at least one dental sealant 
increased nearly three-fold.
    Despite these improvements, however, we found that rates of 
untreated tooth decay for children and Medicaid were largely 
unchanged. We look at data around two time periods around the 
early 1990's and compared it to the early 2000's. The 
proportion of children in Medicaid who experienced tooth decay, 
both treated and untreated, actually increased from 56 percent 
to 62 percent over this time period.
    In conclusion, the information provided by these national 
surveys regarding the oral health of our Nation's children on 
Medicaid raises serious concerns. Measures of access for dental 
care for this population remained far below our national health 
goals.
    Of even greater concern are data showing that dental 
disease is prevalent among children on Medicaid and is not 
decreasing over time. Millions of children on Medicaid are 
estimated to have dental disease and be treated. In many cases, 
this need is urgent.
    Given these conditions, it is important for all those 
involved in providing dental care to children in Medicaid, the 
Federal Government, States, providers, and others, to continue 
working to improve the oral health condition of these children 
and achieve stated national oral health goals.
    I am not making specific recommendations today, but expect 
to have more information for you once we have completed our 
ongoing work for this subcommittee. This work includes 
reviewing both State Medicaid programs ad CMS's efforts to 
monitor and ensure the children in Medicaid receive recommended 
dental services.
    Mr. Chairman, this concludes my prepared statement. I would 
be happy to respond to questions.
    [The prepared statement of Ms. Cackley follows:]
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    Mr. Kucinich. Thank you very much, Ms. Cackley. I would 
like to start with you.
    Why is the oral health condition in children with Medicaid 
not improving if receipt of dental care has improved?
    Ms. Cackley. That is a very good question. It seems 
counter-intuitive. I think part of the explanation in part can 
come from looking at the age differences in the children. When 
we look at tooth decay in younger children, we see a much 
larger increase, and that seems to be driving the overall trend 
that we see, whereas older children, who are the ones most 
likely to receive dental sealants, have no change, no increase 
in tooth decay over time.
    Mr. Kucinich. Well, in your testimony you say that children 
from birth to three are not among the population of children 
who are receiving greater treatment in the past 26 years. 
Please elaborate on this finding. Also, what policies would you 
recommend to Federal and State agencies to address lack of care 
for the youngest sector of children in our Nation.
    Ms. Cackley. The youngest children, in part, what we found 
was that younger children did not receive dental sealants, and 
partly that is it is not recommended for very young children. 
Dental sealants are for permanent teeth and not for the 
children who still have their primary teeth.
    We don't have recommendations of specific policies at this 
point, partly because we are still doing the work on looking at 
what State Medicaid programs and their dental programs do have 
in place, and I think our ongoing work will be able to give you 
more recommendations at a later time.
    Mr. Kucinich. Can you elaborate on how the condition of 
dental disease in Medicaid children compared to children with 
private health insurance and children without any insurance?
    Ms. Cackley. Absolutely. The children in Medicaid had much 
higher rates of tooth decay than children with private 
insurance, and over time we actually saw children with private 
insurance having lower rates of tooth decay, whereas children 
on Medicaid had higher rates, and uninsured children, basically 
their rates remained unchanged.
    Mr. Kucinich. So why do you think that is? Why do you think 
that children who have Medicaid have a higher rate of tooth 
decay? They have the coverage, right, but they are not getting 
the service? Is that it?
    Ms. Cackley. That is correct. They definitely have 
coverage. There are a number of reasons why they are not 
getting services. In previous work that we have done, we looked 
at the participants in our surveys who responded also to why 
they did not have access to dental care, and in many cases they 
responded that there were either cost issues or access issues 
in terms of ability to find a dentist or ability to travel to 
the dentist, so there are a number of different responses that 
were given as to what the problem could be.
    Mr. Kucinich. So in your model for further research, you 
are going to take into account the distance between providers 
and people who are clients?
    Ms. Cackley. Our ongoing work is looking more particularly 
at the State Medicaid programs and what they are doing, the 
initiatives that they are putting in place to improve access to 
care, which could include improving transportation or just 
increasing the provider network so that people don't have to go 
so far in order to find a dentist who will treat them.
    Mr. Kucinich. If you see in some provider networks that a 
few dentists are seeing half the patients, how do you explain 
that?
    Ms. Cackley. There are a number of reasons. In our previous 
work we learned that dentists gave for why they were not 
serving Medicaid children, and some of those included problems 
with payments, but also problems with missed appointments and 
administrative burden. Those are some of the reasons that we 
had learned about.
    Mr. Kucinich. Is there a point where GAO recommends that a 
health care provider should not list someone in their list of 
service providers if they are not willing to take Medicaid 
patients? But why should someone be listed as a service 
provider if they are not providing a service?
    Ms. Cackley. I think that we will be looking very 
specifically at the Medicaid State programs and how they go 
about creating their network of providers and how they monitor, 
how CMS monitors the provision of services so that we will be 
able to tell you more about what the State regulations are on 
that. We don't have information at this time.
    Mr. Kucinich. Mr. Kuhn, the very nature of people who find 
themselves on Medicaid, many of them are on the lower end of 
the economic scale. Many of them have found themselves in 
situations that have led to a certain amount of social 
disorganization. Would you agree with that?
    Mr. Kuhn. I would agree with that statement. Yes.
    Mr. Kucinich. So if that is the case, what is the thinking 
then of CMS, in looking at factors of social disorganization 
with respect to the delivery of service? For example, if, as 
Deamonte Driver's mother was faced with, you try and basically 
this service isn't available, even though you are told, how are 
people supposed to know how you keep proceeding? There is a 
certain amount of skill in maneuvering the system, which is 
required to be able to get this service.
    We want to provide dental services for children, and we are 
asking their parents to be able to be experts at maneuvering a 
system that most people who aren't burdened with the kind of 
problems that some of the poor may be burdened would have 
trouble negotiating.
    Transportation. You have a provider who might be on the 
other side of a county. People may not have even traveled over 
there before. There may not be adequate public transportation. 
I mean, when you look at the lower rates of utilization, as 
evidenced by the higher rates of tooth decay, it seems to me 
that the old models of service providing that are based on a 
society that has been a little bit less mobile than this one, 
that has been perhaps a little bit more stable in terms of 
economics than this one, that those old models are not as 
reliable for the provision of service. And that, 
notwithstanding the progress that you have made and are ready 
to make, that it may be that, in order to continue to provide 
services to a growing population of Medicaid clients, that you 
may have to look at changing the way that you serve this 
program population.
    Mr. Kuhn.
    Mr. Kuhn. Mr. Chairman, I would not only agree that we need 
to look at those; I think we need to challenge some of those 
old models. I think we are planning to challenge those in a 
number of different ways. I think the issues that you and the 
CBO have raised here in terms of the multi-factorial issues are 
all relevant that we have to look at when serving this 
population, and some of the challenges that we need to think 
about is, how good are these provider networks, whether they 
are MCOs or others, are reaching back out to the folks that are 
enrolled in the program and making sure that they are doing the 
appropriate followup, the proper education, the information 
that they need.
    I think you will hear about it from some of the innovations 
that we are hearing from some of the States that are here today 
in terms of really trying to capture the service of non-
dentists and others that are delivering care that can provide 
care, because if you look at the data that certainly I have 
seen and others, children on Medicaid and children overall tend 
to see a primary care physician or someone else much more 
frequently than they see a dentist. And in some cases and in 
some States because of licensure they are able to deliver at 
least some kind of services in those areas. Likewise with 
hygienists and others.
    So I think we need to challenge some of the models that are 
out there and try to find better ways to do this.
    I couldn't agree more.
    Mr. Kucinich. I want to recognize that CMS, since our last 
meeting in February and since your becoming Acting Director, 
and indicated by your testimony, under leadership CMS has done 
a much better job in addressing our policy recommendations. 
Significantly, it has resuscitated the oral health tag and 
enabled State dental agency leaders to collaborate with CMS and 
one another to tackle oral health disease. I want to thank you 
for that, and I hope that you will continue with your efforts 
in new and innovative ways.
    I have a few questions that I wanted to ask of you in light 
of recent developments.
    Before I do that, I want to recognize Mr. Higgins for the 
purposes of asking some questions.
    Mr. Higgins, you may proceed.
    Mr. Higgins. Thank you very much, Mr. Chairman.
    Just for context, Ms. Cackley, do all States provide 
children's dental services under the Medicaid program?
    Ms. Cackley. Yes, they do.
    Mr. Higgins. All do? Obviously, some do it better than 
others.
    Ms. Cackley. Yes.
    Mr. Higgins. What are the models that are particularly 
effective that meet or exceed the benchmarks that were outlined 
in your study?
    Ms. Cackley. The study that I just testified on was looking 
at the national data on receipt of dental services and 
prevalence of dental disease. It is the ongoing work where we 
will be able to talk about, across the State programs, what are 
some of the exemplary programs and where there are some places 
where we can make recommendations.
    I don't have that information yet.
    Mr. Higgins. Well, in assessing the problem, the period of 
study was between 2004 and 2005?
    Ms. Cackley. Yes.
    Mr. Higgins. Obviously, there are some that are more 
interesting and likely targets for further review based on the 
quality of these programs. I presume that these statistics are 
available on a State-by-State basis, as the Medicaid program is 
both funded by the Federal and the State governments.
    Ms. Cackley. The data that our study is based on are data 
sets that are provided by HHS, the National Health and 
Nutrition Examination and the Medical Expenditure Panel, so 
they are aggregate data nationally representative.
    Mr. Higgins. You are being too cautious with me.
    Ms. Cackley. I am sorry?
    Mr. Higgins. I am trying to understand this a little bit 
better.
    I mean, it would seem to me, at the request of Congress, if 
you have identified in your report a public health issue that 
addresses children in this Nation, and that the Medicaid 
program, again, is funded by both the Federal and the State 
governments, and in some States like New York by local 
governments--25 percent, which comes from the property tax--it 
would seem to me that a good place to start is within those 
States that are doing well, and why is it that they are doing 
better than everybody else, and then looking at that State or 
those States collectively as a basis from which to perhaps 
recommend to Congress specific recommendations as you 
acknowledge that you are not doing here today.
    Ms. Cackley. Right. You are absolutely right. What I am 
trying to say is that what we have done so far is to look at 
data that is not broken out State-by-State where the children 
live, so we can't give you that kind of information yet. The 
State-by-State kinds of information will come in the second 
phase.
    Mr. Higgins. I would think that information would be very 
valuable.
    Ms. Cackley. I am sure it will.
    Mr. Higgins. Yes.
    I have no further questions, Mr. Chairman. Thank you.
    Mr. Kucinich. Thank you, Mr. Higgins.
    Mr. Kuhn, you mentioned that you have finalized 4 of the 17 
early periodic screening and diagnostic treatment reviews, and 
that you have completed a draft of an additional seven of them. 
Can you tell us what challenges that all these States have in 
common?
    Mr. Kuhn. That is a good question. You know, in our written 
testimony on page 4 we list some of the initial observations 
that we are making as a result of all of our reviews of the 
States, and so when you look at it across the board what we are 
seeing here is that one of the fundamental things is clear 
information for beneficiaries, particularly those with 
different languages, particularly some that are of different 
cultures. Seems to be a barrier that we are seeing in all 
States in all the 17 areas.
    Also, we see deficiencies in many of the States in terms of 
processes that would remind beneficiaries that recommended 
visits were due that are out there.
    Updated provider listings, everybody seems to be falling 
down in terms of making sure those are current and adequate and 
they are appropriate that are in place there.
    A process to track when recommended visits ought to be 
occurring seems to be a common theme we are seeing across the 
States.
    These are some of the commonalities that we are seeing 
across the board.
    Likewise, for providers we are seeing the same thing that I 
think this subcommittee has heard in the past--low provider 
payment rates, the issue of missed appointments that were 
mentioned earlier, and also sometimes with prior 
authorizations. Sometimes the dentists find those are 
burdensome.
    So we are seeing those kind of common themes across the 
board.
    Mr. Kucinich. Why have people missed appointments? Do you 
ever go into deep detail about missed appointments? Are there 
any patterns?
    Mr. Kuhn. In one of the reviews I read in one of the States 
it was interesting, I think it was North Dakota, where the 
issue of missed appointments, the dental providers in that 
State, when they book an appointment with a Medicaid 
beneficiary, they double booked all those appointments because 
they said there was a high likelihood that the patient might 
not show up that day, and they didn't want an empty chair that 
is there. So we see some work-arounds the providers are doing. 
So as part of our reviews with these 17 States we have done 
detailed discussions with the providers to try to understand 
those kind of issues, what they are doing in order to 
ameliorate that.
    I think the issue of double booking is an interesting one. 
It seems to me that if we were more effective at reminding 
people of visits and appointments and doing some other things 
we might be able to help work in that area, but these are some 
of the things that we are seeing.
    Mr. Kucinich. I want to go a little bit deeper into this 
discussion about CMS and, for that matter, any Federal service 
that is being provided, how service is being provided, other 
than dental.
    If you are dealing with a population that is suffering from 
poverty and social disorganization, time, there is a different 
awareness of time. Now, I am speaking about this because this 
is basically how I grew up. Appointments don't mean the same 
thing to some people as they mean to others. Once you are 
working you are on a clock, there is a regimentation to life, 
you are out with the rest of society, you are moving with the 
crowd. Time, you are looking at a watch, means one thing. Some 
people, life doesn't work that way.
    It is the awareness of that which I think is important to 
be able to deliver service, because in a way, when appointments 
are made, I think the followup, calling people, asking the 
providers to call people a day before an appointment, for 
example, reminding them there is an appointment, the day of an 
appointment reminding them there is an appointment, I mean, 
there is something about that I would like you to think about 
to take into account.
    You know, this might sound a little bit like sociology, but 
let me tell you there is a practical application to doing this. 
There is also a practical application to outreach, to continual 
outreach to make people aware of the provision of services to 
maximize the use of the Medicaid dollar, itself.
    I just would like your response to that, and then I want to 
move on.
    Mr. Kuhn. I think those are good questions to ask, and in 
one regard I am very grateful that this particular hearing you 
have asked experts from the individual States who are actually 
on the ground grappling with those very issues as they 
implement these programs, so I will be interested to hear what 
they say.
    But what we hear on our interviews is, in addition to the 
issue of missed appointments, one of the things that they said 
is absolutely right. People have work, and how does that 
integrate with their work schedule. They have babysitter issues 
that they have to deal with. They have transportation problems 
and issues that come up. So all of those are kind of multi-
factorial things that I think we have to think about.
    Are there different things that we could do at CMS to help 
support the States in that regard or are there additional 
innovations that States can bring forward to help these 
Medicaid beneficiaries navigate the system with those kind of 
issues and challenges that they face.
    Mr. Kucinich. I appreciate that response. You indicated 
that CMS targeted States reporting dental screening rates below 
30 percent for focused dental reviews. However, a large number 
of States reported screening rates in the 30 to 40 percent 
range. What is CMS doing to improve access to Medicaid dental 
services in States beyond the initial targeted 15 States?
    Mr. Kuhn. Yes. What we have done in that regard, while we 
did focus on those 17 States, we have been in contact with each 
and every State to talk with them about the issues that are out 
there. We talked to them about trying to understand better what 
are the actions they are taking to followup with children, or 
at least the provider networks are following up with children 
to make sure that they are getting the services that they need 
and, as you so rightly said, that they are entitled to and that 
they deserve, to make sure that we are following up with each 
and every State to get the periodicity schedules. We have 
almost got those all done. We are still missing a few States. 
As we have shared with the subcommittee, we have shared with 
you the ones that are still missing and we hope to get those 
soon.
    We want to hear more from the States what they are doing to 
recruit more dental providers, to make sure that they are there 
to service this population that is out there.
    Also, we are exploring with them a lot these other States, 
as well, that are in that other range, what are the barriers 
that they are seeing, and are they doing anything recently in 
terms of dealing with provider rates, and are they taking 
action, are they considering action, and what more can we 
provide them to help them think those issues through.
    Mr. Kucinich. Thank you. As we will hear from the second 
panel, there is an inherent problem associated with risk-based 
contracts. Risk-based contracts are those written between the 
State and the managed care organization that allots a certain 
amount of funding for the managed care organization and tells 
it if it doesn't use all of the funding for servicing children, 
it can keep the excess as profit.
    On the other hand, if the managed care organization spends 
more than it has been allotted, it has to shoulder those costs.
    This clearly creates an incentive for those MCOs to provide 
less service for children, and therefore make a profit. In 
fact, this was the case in Georgia, where MCOs faced, with loss 
of profits, shut down their provider networks, terminating 
existing contracts and limiting reimbursement for some of the 
most common dental procedures.
    So tell me, No. 1, does CMS plan on drafting policy 
guidelines for States on how to draft contracts with MCOs in 
order to ensure the maximum access and utilization. And, 
second, what did you learn specifically about Georgia during 
the course of your early periodic screening and diagnostic 
treatment review, and could CMS have done differently to 
prevent the managed care organizations from limiting 
reimbursement and shutting down a dental provider network for 
the sake of their profits? Mr. Kuhn.
    Mr. Kuhn. On the issue of managed care organizations and 
risk contracts, 19 States currently use risk contracting for 
coverage for dental services; 15 of the States do it Statewide, 
4 or more are kind of geographically limited in terms of the 
State. Quite frankly, I think risk contracting has a role in 
health care and in this area. It is a chance for us to try to 
find incentives to drive greater efficiency in the systems and 
try to find ways for better coordination of care, so I think 
there is a role for risk contracting that is out there.
    Having said that, I think there are opportunities where we 
have seen where risk contracting has worked very good. I know I 
recently looked at a study out of Minnesota, as well as one out 
of New York, where they looked at their Medicaid programs under 
risk contracting and showed real good performance, particularly 
in the State of New York, for dental care. However, I recently 
looked at a study from the State of Kansas, where they showed 
better performance on fee-for-service side. So it is a mixed 
bag out there. I will be real candid with the subcommittee in 
that regard. It is a mixed bag.
    So what we are trying to do in terms of our review is look 
at those States where they are getting terrific performance 
through their managed care contracts and what kind of policy 
options can we put forward in that regard.
    I am not ready yet to commit to the subcommittee of what 
new guidance we might put out there for the States in terms of 
drafting contracts, because I don't think we are that far along 
in our evaluation. But one of the things I would like to do is 
that I am a big believer in greater transparency in health 
care, and I have been a very big advocate of what we have done 
at CMS in terms of our compare Web sites of getting data out on 
nursing homes and hospitals and others. I don't think there is 
enough information that is available to the public in terms of 
what is going on in dental care that is out there, and so I 
want us to be more transparent, and I think MCOs will be one 
area that I want to be transparent on as I go forward, so that 
I would say is one thing we are going to do in this area. The 
other is I think we need to finish our policy work.
    In terms of what is going on in Georgia, we haven't 
finished that report yet, but I will tell you what we have seen 
thus far is that we are concerned with the overall adequacy of 
providers in their network in terms of their managed care 
organizations. We have already begun talking to the State about 
potential improvements that they can make, and we want to have 
those further conversations with the State as we go forward.
    So basically that is where we are with that State. It looks 
like it is a pretty reasonable program they have put together, 
but they have hit some issues that we don't fully understand 
yet, and, as we finish our investigation, hopefully we will 
have more information we can share with you at that time.
    Mr. Kucinich. Well, as chairman of this subcommittee I just 
want to indicate to you that, with billions of Federal tax 
dollars involved in health care in this country, that I am very 
concerned about this issue of taxpayers' money going to provide 
services and then people not providing the services, having a 
structure where you actually incentivize not providing services 
so people can make a profit. Because it seems to me that, while 
you certainly want to promote the top utilization of services, 
you want to promote provider participation, people should be 
reimbursed at a rate that is sufficient enough to encourage the 
utilization instead of permitting a provider to capitalize on 
non-utilization.
    This is something I would like you to just give some 
thought to, because whenever there is money that hasn't been 
used that can be converted into profit, it really opens a door 
for service providers to just find a way to game the system, so 
I would like you to think about that in your deliberations 
about the regulations that you are doing now.
    Mr. Kuhn. Those are helpful comments for us, and we will. I 
think in that regard what we want to make sure is that, as we 
continue to move forward on our efforts here, that we don't be 
so prescriptive that we say one size fits all, that this is the 
only way that dental services will be delivered in a State; 
that we want to make sure States have a menu of options that 
are workable, but at the same time we need real accountability 
in all these programs, and so I heard you loud and clear, Mr. 
Chairman.
    Mr. Kucinich. In our May 2007 investigation the 
subcommittee uncovered significant deficiencies in availability 
of dentists to treat Medicaid patients. Our most recent survey 
revealed that such deficiencies are not unique to Prince 
George's County, MD. What has CMS done to monitor and insure 
that all CMS Medicaid programs have adequate dental networks, 
especially those using a managed care model? And, similarly, 
what have you done to ensure that State Medicaid payment rates 
for dental services are adequate to enroll sufficient numbers 
of dentists to provide services comparable to the general 
population?
    Mr. Kuhn. As part of our 17-State review, we have made a 
number of recommendations to States already in terms of what we 
think they ought to be doing to improve the adequacy of their 
networks.
    The other thing that we are looking at pretty hard is to 
make sure that we have some better reporting in terms of 
quality assessment reports that we get from States on an annual 
basis, those States that have managed care organization 
contracts for dental providers, and are there ways that we can 
improve that reporting, make that information publicly 
available so we can create greater accountability out there as 
we go forward.
    But one of the interesting things I noticed in the report 
that you all released on Friday, and, by the way, thank you for 
that report. That is going to be very helpful to us and I 
appreciate your leadership in doing that.
    Mr. Kucinich. Are you surprised by those findings, by the 
way?
    Mr. Kuhn. No, actually not. They are pretty consistent with 
what we are seeing. The one thing, though that was interesting 
in terms of that report was that, when you look at a maybe 1-
year or 2-year spread of an individual Medicaid beneficiary in 
a program, the dental service access wasn't very great, but as 
you got over a longer length of time, 3, 4, 5 years, their 
access tends to improve. And so we would like to explore that 
more and would like to find some time when we can sit down 
perhaps with your staff and others who prepared and worked on 
the report to understand some of the dynamics and see if there 
is any hypothesis they can share with us in what we saw.
    When you look at the data, it looks like you are seeing 
better coordination of care over the length of time, and so 
those will be helpful things for us to explore with you on a 
go-forward basis.
    Mr. Kucinich. Thank you. So when you look at the findings, 
will you study the pediatric dental programs in Arizona, New 
Jersey, and Pennsylvania, to help them improve their programs, 
as you are doing in at least 17 other States?
    Mr. Kuhn. We would be happy to go and look at those 
programs specifically. Certainly.
    Mr. Kucinich. Thank you. Now, what is your estimated 
budgetary request for next year?
    Mr. Kuhn. We haven't begun putting together the fiscal year 
2010 budget yet, so I am not sure where we are on that at this 
time, but I can get back to you on that one, Mr. Chairman.
    Mr. Kucinich. Is it anywhere near $700 billion?
    Mr. Kuhn. I don't think so.
    Mr. Kucinich. Now, of the estimated budgetary requests that 
you will have, we would like to know how much you plan on 
allocating to oral health, if you can do that?
    Mr. Kuhn. I think we can break that down. I can tell you 
right now though that within the Medicaid program roughly 5 
percent of Medicaid spending goes for oral health. That has 
been fairly consistent over the last several years, so as a 
rough gauge that is kind of where we are at this time.
    Mr. Kucinich. Well, as you are doing your planning and 
reviewing, we would like you to work with us with 
recommendations for a legislative agenda, and let us know how 
we can help CMS achieve the goals to reform the pediatric 
dental program. If we are looking at expanding the scope of 
providers, the dental work force has been in decline since the 
mid-1990's. Current projections estimate an absolute decline in 
the overall number of dentists beginning in 2014. Consider also 
that only 2 percent of dentists are trained as pediatric 
specialists. This projection will be especially detrimental to 
communities who bear the greatest dental disease burden, that 
is primarily low-income, inner-city, and rural communities.
    I would like to know how does CMS propose creating a more 
adequate distribution of professionals to meet the oral health 
needs of children.
    Mr. Kuhn. That is a good question to pose, and that really 
is something that we are looking at and how we can partner with 
other agencies like HRSA, the Health Resources and Services 
Administration, and others that actually provide training 
dollars to schools of medicine to help in the training factor 
who run the work force shortage area payment programs, and so 
it is our hope that they will be part of our effort as we do 
our evaluation, and that there are ways to partner with them to 
work with the States and others so we can deal with some of 
these distribution issues.
    Mr. Kucinich. So are you exploring the potential of 
expanding the scope of dental providers?
    Mr. Kuhn. Basically, what we are right now is we are really 
focused on the issue at hand, the challenge that this 
subcommittee laid before us and the challenge we have before us 
as an agency, to make sure that we have sufficiency, good 
coverage, and great access for children with Medicaid. The 
issue that you are raising is one that we have talked about 
that I think some time in the future we would like to explore 
with sister agencies, but it is not in the work plan now for 
what we want to do in the immediate future, but it is something 
that we will certainly think about in the future.
    Mr. Kucinich. On our second panel we are going to be 
talking about focusing on prevention and disease management and 
how that helps to create a positive result in a short amount of 
time. Will you consider adopting such a model and approach to 
addressing oral health?
    Mr. Kuhn. Tell me one more time the model, Mr. Chairman?
    Mr. Kucinich. The model is approaching oral health by 
focusing on prevention and disease management.
    Mr. Kuhn. That is certainly models we want to explore, and 
one of the witnesses----
    Mr. Kucinich. How might you be able to do that?
    Mr. Kuhn. Well, one of the things that would be interesting 
to explore with the committee, like I said, we are not prepared 
yet, because we haven't finished our report, to give you any 
legislative recommendations.
    Mr. Kucinich. Right.
    Mr. Kuhn. But what I can share with you is that some of the 
innovations that are going on in the State are terrific, and 
you will hear about them on the second panel. I think the work 
for the folks in North Carolina, Into the Mouths of Babes, is 
just a terrific program. The seed money for that program was 
based on some grant funds that came from the Centers for 
Medicare and Medicaid Services.
    Unfortunately, we don't have that authority right now, so I 
think working with you all in the future to look at some 
demonstrations designed to look at prevention programs for 
high-risk populations would be something that we could begin 
talking about now. I would assure you that my staff would 
provide any technical assistance your staff would need to help 
explore those options.
    Mr. Kucinich. I also, before I conclude with this round of 
questioning, Mr. Kuhn, I would also like you to think about 
another aspect of prevention and disease management, and that 
is with respect to parents, especially pregnant mothers. It is 
critical to provide dental care and education to child-bearing 
women and women of child-bearing age. In 2004, due to a lack of 
clinical guidelines, only one out of every five women who gave 
birth saw a dentist during pregnancy.
    What are your thoughts on this, and will you consider 
addressing outreach and care for pregnant mothers in a 
prevention and disease management model?
    Mr. Kuhn. I would hope that the actions that we are taking 
now on the pediatric side would have a great deal of 
portability throughout the entire Medicaid program for the 
entire dental benefit for everyone, so that what we are doing 
here would not be just focused in one aspect but it would cast 
the net far and wide and look at the entire enterprise of what 
the State does in terms of delivery of dental services.
    Mr. Kucinich. But you do get the connection between dental 
caries from mother to child?
    Mr. Kuhn. Absolutely. And we are focused on the pediatric 
side now, but I would hope that, again, what we do here as part 
of this effort is across the board with the States as they go 
forward.
    Mr. Kucinich. And just one final question. Are you going to 
be studying risk-versus non-risk-based contracts nationally to 
offer policy guidelines to States?
    Mr. Kuhn. We are going to be looking at the various payment 
models. Yes, sir.
    Mr. Kucinich. OK. Final question to Ms. Cackley. I had 
asked Mr. Kuhn about this situation where MCOs are getting 
funding for servicing children. They are not servicing children 
and they walk away with a profit. Have you been able to survey 
that in any quantifiable way to be able to address that?
    Ms. Cackley. That will part of our ongoing work. In our 
surveys to the States, we are looking at and asking them 
questions about their MCO contracts and how they are set up and 
how they are monitored.
    Mr. Kucinich. Let me tell you why that is important, 
because as CMS wants to be able to design a more effective 
model, it is important to be able to assess the degree to which 
the present model has not worked, and it is going to really be 
up to you to be able to delve deeply into this question of the 
providers who are gaming the system, who have found a way to be 
able to keep the so-called excess as profit.
    I would like you to look at the MCOs' internal 
documentation to see if there is any way in which they 
encourage that. I want to find that out, so if you would do 
that we would appreciate it.
    Ms. Cackley. We would be happy. That is part of our review, 
and we will be giving you more information soon.
    Mr. Kucinich. Because, Mr. Kuhn, if it is a policy to do 
that, that is something you ought to know about.
    Mr. Kuhn. You are absolutely right.
    You know, we want to make sure that we are looking at all 
aspects and that we give a State the options that they need to 
do their jobs, but also to make sure that we get accountability 
and we get the results that we all want.
    Mr. Kucinich. And when all is said and done, to both of 
you, this really is about children and making sure they get the 
dental health they need so that they have long and productive 
and healthy lives. I mean, that is what this is all about.
    Ms. Cackley. Absolutely.
    Mr. Kucinich. I want to thank both of you for the work that 
you are doing. Please continue. We look forward to following up 
on this. Thank you so much.
    Ms. Cackley. Thank you.
    Mr. Kucinich. The first panel is dismissed.
    We are going to call the second panel forward.
    Thank you very much for being here.
    We are fortunate to have an outstanding group of witnesses 
on our second panel, and I want to welcome all of you here.
    Ms. Susan Tucker is the executive director for the Office 
of Health Services for the Maryland Medicaid program. In this 
capacity she reports to the Deputy Secretary for the Health 
Care Financing Administration, which administers the Maryland 
Medicaid program within Maryland Department of Health and 
Mental Hygiene.
    Over the last 18 months, Ms. Tucker has been involved in 
developing and implementing initiatives aimed at improving 
access to dental services for low-income children in Maryland.
    Mr. Patrick Finnerty is Virginia's Medicaid director and 
has served in this position since 2002. He directs all aspects 
of Virginia's Medicaid and State Children's Health Insurance 
Programs and finance health coverage for more than 715,000 low-
income persons.
    Mr. Finnerty has worked in State government for 30 years. 
Prior to his current appointment he worked for the Virginia 
General Assembly's Joint Commission on Health Care for 8 years, 
including 4 years as the executive director.
    Dr. Mark Casey is the dental director for the North 
Carolina Department of Health and Human Services Division of 
Medical Assistance. He is the current secretary treasurer of 
the Medicaid S-CHIP Dental Association, also a member of the 
National Association of State Medicaid Directors Oral Health 
Technical Advisory Group, which has been formed to assist the 
Centers for Medicare and Medicaid Services in oral health 
policy matters.
    Ms. Linda Smith Lowe has been the health policy specialist 
with Georgia Legal Services for the past 29 years. Georgia 
Legal Services serves 154 of Georgia's 159 counties, including 
small cities in rural areas of the State.
    Ms. Lowe's involvement with the organization is focused on 
Medicaid and PEACH care for kids, Georgia's State children 
health insurance program. She also serves on several boards and 
works with other nonprofits on these health-related issues.
    Dr. Jane Grover has been dental director and clinician for 
the Center for Family Health in Jackson, MI, since 2001. She is 
the first vice president of the American Dental Association. 
Between 1983 and 2001 Dr. Grover was in private practice as a 
general dentist. Prior to that she served as dental director of 
the Jackson County Health Department in Michigan. She is an 
adjunct faculty member of the University of Michigan School of 
Dentistry and of the Lutheran Medical Center in New York, and 
has taught at Indiana University at South Bend.
    Dr. Jim Crall is professor and Chair of Pediatric Dentistry 
and director of the National Oral Health Policy Center at the 
University of California Los Angeles [UCLA]. Dr. Crall has been 
actively involved in national, State, and professional policy 
development concerning oral health over the past 15 years. He 
was the principal author of Guide to Children's Dental Care in 
Medicaid, which was completed under contract awarded by CMS, 
then known as HCFA, to the American Academy of Pediatric 
Dentistry.
    I want to thank each and every one of you for being here 
today. I am glad that you had the opportunity to listen to the 
two previous witnesses. I am sure that was instructive to you, 
as it was to me.
    It is the policy of the Committee on Oversight and 
Government Reform to swear in all the witnesses before they 
testify, so I would ask that you would rise and please raise 
your right hands.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record show that the witnesses have 
answered in the affirmative.
    As I indicated to those who testified in panel one, each 
witness is asked to give a summary of his or her testimony. I 
would ask that you try to keep the summary under 5 minutes in 
duration. Your written statement will be included in the 
hearing record.
    Ms. Tucker, let's begin with you. I would ask that you 
please proceed.

STATEMENTS OF SUSAN TUCKER, MBA, EXECUTIVE DIRECTOR, OFFICE OF 
   HEALTH SERVICES, MARYLAND DEPARTMENT OF HEALTH AND MENTAL 
  HYGIENE; PATRICK FINNERTY, DIRECTOR, VIRGINIA DEPARTMENT OF 
  MEDICAL ASSISTANCE SERVICES; MARK CASEY, DDS, MPH, MEDICAL 
DIRECTOR, NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE; LINDA 
    SMITH LOWE, ESQ., PUBLIC POLICY ADVOCATE, GEORGIA LEGAL 
SERVICES PROGRAM; JANE GROVER, AMERICAN DENTAL ASSOCIATION; AND 
 JIM CRALL, DIRECTOR, ORAL HEALTH POLICY CENTER, PROFESSOR AND 
CHAIR, SECTION OF PEDIATRIC DENTISTRY, UCLA SCHOOL OF DENTISTRY

                   STATEMENT OF SUSAN TUCKER

    Ms. Tucker. Chairman Kucinich and members of the 
subcommittee, my name is Susan Tucker. I am Executive Director 
of the Office of Health Services for the Maryland Medicaid 
program. Thank you for the opportunity to testify today about 
Maryland's efforts to improve access to dental care for low-
income children.
    In February 2007 this situation was brought into acute 
focus in Maryland with the tragic death of Deamonte Driver. 
Since that time Maryland Medicaid has re-energized efforts to 
improve dental care for children in Maryland. In the short 
term, we have conducted outreach to dental and primary care 
providers to remind them of the dental benefits package and 
encourage them to refer children to appropriate dental care.
    We instructed each managed care organization to verify and 
correct their dental provider directories, to directly assist 
enrollees in scheduling dental appointments, to submit weekly 
reports on enrollee requests for dental care, and we required 
MCOs to begin a series of outreach efforts to bring children in 
to dental care, including telephone calls, mailings, incentive 
plans, and dental education programs. Utilization of dental 
services increased from 46 percent in calendar year 2006 to 51 
percent in calendar year 2007.
    These approaches were an immediate way to address this very 
complex problem; however, in order to develop long-term 
strategies to improve oral health for children, we needed 
significant efforts on the part of dental providers, public 
health programs, parents, Medicaid staff, and Federal and State 
policymakers.
    Governor O'Malley made this one of the first priorities of 
his administration by forming a Dental Action Committee, which 
included all of these key stakeholders. The committee met 
throughout the summer of 2007 to discuss public health 
strategies, Medicaid payment rates, alternative delivery models 
for the Medicaid program, education and outreach for parents 
and caregivers, provider participation, capacity, and scope of 
practice.
    The committee made 60 recommendations. They highlighted 
seven over-arching recommendations for immediate action, with 
the goal of establishing Maryland as a national model for 
children's oral health care.
    Major recommendations that have been or are in the process 
of being implemented include increased payment rates. The 
Governor's fiscal year 2009 budget included $14 million as a 
first installment of a 3-year effort to bring Maryland Medicaid 
dental rates up to the 50th percentile of the American Dental 
Association's South Atlantic Region.
    This multi-year effort is critical to attracting additional 
providers. The first year of the fee increase was approved by 
the Maryland General Assembly and was implemented on July 1, 
2008. The first codes that we targeted were diagnostic and 
preventative codes. We paid very poorly in the past on these 
codes, but now compare very favorably with other State rates.
    Streamlined administration. In order to ease the 
administrative burdens for dental providers, the committee 
recommended that the Department carve dental services out of 
the seven managed care organization service packages and 
administer them through a single fee-for-service administrative 
services organization. Our long-term goal is to link every 
child with Medicaid coverage in Maryland to a dental home where 
comprehensive dental services are available on a regular basis. 
We do this for pediatricians for children, and we want to do 
this for dentists. We believe we will be the first State in the 
country to implement such a project.
    In the beginning of July 2008 the Department issued a 
request for proposals for a single State-wide vendor to 
coordinate and administer these benefits for Maryland Medicaid 
beneficiaries.
    Five entities recently submitted proposals, and we are now 
in the process of selecting a vendor. We will be implementing 
this by July 2009.
    Enhanced public health infrastructure. The Governor's 
budget included additional money for dental health public 
health clinics in under-served areas. We have opened two new 
clinics in areas that didn't have clinics in the past, and more 
are planned for the upcoming year.
    Increased scope of practice for dental hygienists. The 
legislature passed legislation during the last session to allow 
for increased scope of practice for dental hygienists working 
for public health agencies in Maryland and allowed them to 
provide those services offsites.
    The Dental Action Committee continues to meet regularly. 
This is a working, action-oriented committee. They have been 
asked by the Secretary not to write reports that will sit on a 
shelf, but instead to design practical, workable initiatives 
and to bring all parties in the State together to solve this 
difficult problem. They have the support of staff throughout 
the Department of Health and Mental Hygiene.
    One key subcommittee is developing a unified oral health 
message to encourage oral health literacy for all Marylanders. 
No child should wait until they are in pain to seek and receive 
dental care.
    Another committee is developing a pilot program for dental 
screenings in schools. Still another is training general 
dentists on how to provide high-quality dental services to 
young children.
    We are also fortunate that Congressman Elijah Cummings has 
provided a constant Federal presence by working to ensure that 
children have access to dental care in Maryland. He included 
language in the State Children's Health Insurance Program to 
guarantee dental benefits and introduced Deamonte's Law, which 
would enhance the dental safety net and work force by 
increasing dental services in community health centers and 
training more individuals in pediatric dentistry. We value his 
leadership in this important public health arena.
    Maryland is committed to implementing the Dental Action 
Committee's recommendations to ensure access to oral health 
services for all children on Medicaid. We need to increase the 
number of dentists willing to see children with Medicaid and to 
increase the awareness of the benefits of basic oral health 
care among our enrollees.
    Although it is too early to report on the impact of these 
long-term initiatives, we will regularly evaluate their 
success, as indicated by utilization of services, provider 
network adequacy, and health outcomes. We will remain flexible 
and will seek innovative ideas for adjusting our strategies as 
we move forward.
    Thank you.
    [The prepared statement of Ms. Tucker follows:]
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    Mr. Kucinich. Thank you very much.
    Mr. Finnerty.

                 STATEMENT OF PATRICK FINNERTY

    Mr. Finnerty. Good morning, Mr. Chairman and members of the 
subcommittee. My name is Patrick Finnerty, and I serve as the 
Medicaid Director for the Commonwealth of Virginia. I am 
pleased to appear before you this morning to review the 
significant changes and resulting improvements in our Medicaid 
and SCHIP dental programs.
    In Virginia we serve about 450,000 children through our 
Medicaid and SCHIP programs. Soon after becoming the Medicaid 
Director it was clear to me that our dental program for 
children was not functioning very well.
    As seen on slide two, fewer than 24 percent of our children 
received any dental service in 2003. One of the key reasons for 
this was that our dental provider network was inadequate. Only 
about 13 percent of licensed dentists in Virginia were 
participating in our program. Of that number, only about one-
half of them were actively seeing Medicaid and SCHIP children.
    While we had a pretty good idea what the problems were, we 
sat down with the leadership of the Virginia Dental Association 
and heard loud and clear that we needed to make some changes.
    First, our reimbursement was very low and far below what 
dentists were being paid by commercial carriers. Second, they 
identified a number of administrative hassles that needed to be 
removed, such as outdated billing procedures, overly burdensome 
prior authorization requirements, and poor responsiveness to 
provider concerns.
    They also felt our managed care program was not working for 
them. Overall, managed care has been a very successful program 
in Virginia; however, our dental providers had several 
concerns, including having to deal with multiple plan 
requirements, credentialing, and patients transferring between 
plans in the middle of treatment. Last, a significant concern 
was patient no-shows when patients fail to keep their scheduled 
appointments.
    After getting a clear understanding of the changes that 
were needed, we created an entirely new program and declared 
that it was a new day for dental in Virginia. We adopted a new 
program name, Smiles for Children, re-branded it with a new 
logo, and essentially started over.
    The new program was developed through ongoing and close 
collaboration with the Virginia Dental Association and the Old 
Dominion Dental Society. We were very fortunate to also have 
tremendous support from the Governor and the Legislature, who 
authorized us to implement a completely restructured program 
and approved an unprecedented 30 percent increase in fees.
    These actions did two things. First, it gave us the 
necessary authority and funding to implement our new program, 
but, equally important, it communicated to the dental community 
a commitment to work with them to improve access to dental care 
in Virginia.
    Smiles for Children was launched on July 1, 2005. Leading 
up to that date and ever since then, the support for the 
program from the dental community has been outstanding. Dr. 
Terry Dickenson, the Executive Director of the Virginia Dental 
Association, has been and continues to be a great champion and 
advocate of the program.
    Let me quickly review the major elements of our reform. 
First, we carved out dental services from the five managed care 
companies, and now all children have their dental services 
administered by one vendor, Doral Dental. Through our 
contractual relationship, we pay Doral an administrative fee to 
manage the program for us. It is a fee-for-service program 
wherein providers bill Doral and Doral pays the provider with 
funds that we make available. Neither Doral nor providers are 
paid on a capitated basis.
    In the old program, providers had to deal with multiple 
credentialing requirements in order to participate. With Smiles 
for Children there is one streamlined process.
    I mentioned earlier our providers had identified several 
administrative hassles in the old program. We now have industry 
standard administration.
    Prior to Smiles for Children, Virginia dentists had little 
involvement in program decisions. Now we have a Virginia Peer 
Review Committee and a Dental Advisory Committee.
    Last, by having all of the children in one dental services 
program, the potential for disruption of care that can result 
from children moving among different plans has been eliminated.
    We also established a dedicated dental unit within our 
agency to work with providers and monitor the program.
    Slide five summarizes the administrative improvements and 
other benefits that Smiles for Children provides for our 
participating dentists. I am not going to review each of them, 
but they represent important industry standard components of 
benefits administration that our dental partners were looking 
for.
    I would like to now focus on the results of our efforts.
    Following the start of our new program in July 2005, the 
number of participating dentists has increased 80 percent, and 
our network continues to expand each month. There are a handful 
of localities in Virginia which, prior to Smiles for Children, 
had no participating dentists, and now there is access to a 
dentist in their community.
    A key indicator of our success is that a higher percentage 
of providers are actively billing for treatment, and our 
provider and patient surveys show a high level of satisfaction 
with the program.
    More importantly, our program reforms have resulted in 
greater access to care for Medicaid and SCHIP children. As 
illustrated in slide seven, for children ages zero to 20 the 
percentage of eligible children receiving necessary dental 
services has increased 50 percent from 2005 to 2007. For 
children ages 3 to 20, we have seen a 55 percent increase.
    We believe that these increases are the result of the two 
major elements of our reform--the complete redesign of the 
program and the 30 percent increase in fees.
    Last, I just want to note that Virginia's reforms have 
received a good deal of national attention. Over the past few 
years, we have been asked to present at national meetings of 
the American Dental Association, the National Association of 
Dental Plans, the National Association of State Medicaid 
Directors, the Medicaid Managed Care Congress, the National 
Academy for State Health Policy, and the National Oral Health 
Conference.
    The successes we have achieved have come as a result of 
everyone working together for the same cause, that being 
increased access to dental care for low-income children. 
Organized dentistry has been very supportive and helpful, and 
they are a true partner in this. The Governor and General 
Assembly have given us the tools, resources, and support to 
make these improvements.
    We recognize that, while there have been marked 
improvements, far more children need to be receiving dental 
services, and we are working toward that goal. We continue to 
look for further enhancements to the program and will keep this 
issue as a high priority in Virginia.
    Mr. Chairman, that concludes my prepared testimony. I 
appreciate the invitation to be here today, and I am happy to 
answer any questions you may have.
    [The prepared statement of Mr. Finnerty follows:]
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    Mr. Kucinich. I thank the gentleman.
    We are going to declare a half hour recess. There are votes 
on right now. I ask the witnesses to please return in a half 
hour. If there are any difficulties with that, check with my 
staff. This committee stands in recess for a half hour.
    Thank you.
    [Recess.]
    Mr. Kucinich. Thank you very much. We are going to continue 
the hearing. The only need for a break will be if there are 
more votes. I want to thank you for your patience.
    I would ask, with the committee now having come to order 
again, if Dr. Casey would proceed with your testimony.

                    STATEMENT OF MARK CASEY

    Dr. Casey. Good afternoon, Mr. Chairman. I would like to 
thank you for the opportunity to testify about reforms to 
pediatric oral health care in Medicaid.
    My name is Dr. Mark Casey, and I am the Dental Director for 
the North Carolina Department of Health and Human Services 
Division of Medical Assistance. I am proud to highlight the 
Into the Mouths of Babes or IMB program, one successful 
strategy to improve oral health for low-income children in the 
State of North Carolina.
    About 40 percent of all children enrolled in kindergarten 
in North Carolina have experienced tooth decay, and this figure 
can reach as high as 70 percent in some counties. As we know 
from the tragic death of Deamonte Driver, untreated dental 
disease in children can have devastating systemic consequences.
    In addition, there are tremendous societal costs to 
families and others involved in the care of children that 
cannot be easily estimated--missed time at work, missed school 
time, time and money spent trying to find care for a child with 
dental problems. The lists of these costs is potentially 
endless.
    In North Carolina we found that there were not nearly 
enough dental resources available to address the problem of 
Medicaid preschool children through traditional delivery 
methods, so we turned to non-dental health care professionals 
for a preventive strategy to manage the chronic and widespread 
problem of early childhood caries or cavities.
    Preventive oral health care services are easily integrated 
into practices of primary care medical practitioners during 
well child visits, which occur at frequent intervals in the 
very first few years of life. The network of Medicaid enrolled 
primary care physicians in North Carolina was robust and 
distributed throughout all the counties of the State. All the 
elements of sustainability were present to translate this 
approach into success for a preventive program in primary care 
medical settings.
    After demonstration and pilot projects in limited areas 
which were supported by Federal funds, IMB was launched State-
wide in 2001. To date we have trained more than 3,000 
pediatricians, family physicians, nurses, and other types of 
health care professionals to conduct oral evaluations and 
detect oral pathology, assess risk for oral disease, counsel 
parents and/or caregivers about oral hygiene and nutrition, and 
apply fluoride varnish, the safest and most effective form of 
topical fluoride for the target population of children.
    More than 400 primary medical practice sites are currently 
participating providers in the IMB. From the inception of the 
program, the goals of the IMB have been to increase access to 
preventive dental care for low-income children zero to 3 years 
of age, reduce the incidence of early childhood caries in low-
income children, reduce the burden of treatment needs on a 
dental care system stretched beyond its capacity to serve young 
children.
    As it has matured, IMB has increasingly emphasized 
effective dental referrals for recipients, particularly those 
children at elevated risk for disease.
    The IMB program has resulted in a substantial increase, 
about 30-fold, in access to preventive oral health care 
services. Even in the early implementation phase of IMB, 
children from every County in North Carolina were receiving 
these services. In as many as one-third of the State's 
counties, no child received any preventive care in dental 
offices before implementation of the program. The IMB has had a 
positive effect on overall access for Medicaid children of all 
ages in North Carolina during any 1 year.
    The IMB research team has conducted systematic analyses to 
assess the effectiveness of the program. This research has 
demonstrated a statistically significant reduction in 
restorative treatments for anterior teeth that increased with 
age. By 4 years of age, the estimated cumulative reduction in 
the number of restorative treatments was 39 percent for 
anterior teeth.
    IMB has led to an increase of access to treatment services 
to the effect of referral of children with pre-existing disease 
at the time of the initial physician visit to a dentist. 
Children who are identified by their physician as having dental 
caries, when provided with a referral to the dentist, saw the 
dentist sooner than children with no dental caries who were not 
referred.
    We have gathered evidence that physician services are not a 
substitute for care in the dental office but supplement 
preventive care being rendered by dentists for Medicaid infants 
and toddlers.
    Taken together, these findings suggest that the IMB program 
both prevents early occurrence of dental disease and promotes 
earlier entry into the dental care system for those children in 
greatest need.
    It is important to note that Federal funding played a very 
vital role in the success of the IMB program. Funding from the 
Appalachian Regional Commission, CMS, the Health Resources and 
Services Administration, and the Centers for Disease Control 
and Prevention allowed Medicaid and partners in North Carolina 
to further develop our innovative approach to the prevention of 
early childhood caries. In particular, the funding provided for 
staff to develop the curriculum for training, conduct the 
training, and generally oversee the substantive aspects of the 
program and generate the science supporting the innovative 
program.
    In our opinion, the one-time funding initiative from CMS 
and other Federal agencies provides an excellent model for one 
strategy that could stimulate innovative thinking about new 
approaches to increasing children's access to dental care.
    Renewal of this funding program would result in new 
approaches beyond the medical model developed in North Carolina 
and would yield oral health benefits to children enrolled in 
public insurance nationwide. Federal sources of funding 
continue to make a difference in the sustainability of IMB. 
Treatment services provided in the program are supported 
through the Federal Medical Assistance Percentage FMAP funds, 
matching State appropriations. Current evaluation and research 
efforts are supported by HRSA and the National Institutes of 
Health. Initial achievements and the continued success of the 
IMB would not be possible without the active financial support 
the Federal agencies have provided over the life span of the 
program.
    The IMB partnership has moved beyond the original blueprint 
for the program to consider methods to improve the quality of 
program treatment services and extend the preventive model. 
Current expansion strategies focus on refining caries risk 
assessment tools used by both dentists and physicians and 
training them in their use, training general dentists to 
provide care for infants and toddlers, improving communication 
between primary care medical providers and dentists to 
facilitate referral when necessary due to elevated risk for 
dental disease, coordinating patient care to ensure parents 
and/or caregiver compliance with treatment regiments, and 
formulating oral health education initiatives targeted to 
parents and/or caregivers.
    The IMB team believes that the future looks bright for the 
program as we develop new ways to extend its success. IMB 
advocates are also encouraged by reports of the adoption of a 
similar model to provide preventive services for Medicaid 
children in many States throughout the country. We are proud to 
be at the forefront of this movement and stand ready to assist 
other States as they plan, develop, and implement similar 
programs.
    On behalf of the many partners in the IMB collaborative, I 
thank you for allowing me to bring well-deserved national 
attention to this important North Carolina dental public health 
initiative.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Casey follows:]
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    Mr. Kucinich. Thank you very much, Dr. Casey.
    Ms. Lowe, please proceed.

                 STATEMENT OF LINDA SMITH LOWE

    Ms. Lowe. Good morning, Mr. Kucinich. Thank you, Mr. 
Chairman. My name is Linda Lowe. I really appreciate the fact 
that you are having these hearings on this critical topic of 
our children.
    Like children in most States, Georgia's low-income children 
have poor dental health. In 2005, 56 percent of our third 
graders had tooth decay, and 27 percent of the children had 
untreated decay. School officials continue to say that a major 
reason for students' absences from school and their poor 
academic performance has to do with their lack of dental care.
    Getting oral health care right under Medicaid could make an 
enormous difference for this generation of children. In 2005, 
63 percent of Georgia's children had either Medicaid or PEACH 
Care, which is our State child health insurance program. Many 
other children were eligible but not enrolled.
    Your staff asked me to highlight Georgia's experience with 
dental care for children over the last decade. Georgia's story 
is one of somewhat successful multi-year efforts that saw some 
dentists accept Medicaid patients and produced noteworthy 
increases in utilization rates for children. Unfortunately, it 
also shows that budget cutbacks can too easily reverse such 
advances, and that moving to capitated managed care is no 
panacea.
    Just a little history: in 1999 advocates and dentists 
raised an alarm about Georgia's poor and diminishing access to 
oral health care for children. Medicaid dental reimbursement 
was about 30 to 40 percent of average customary fees. A 
Statewide referral hotline had located only 257 dentists 
willing to take new Medicaid patients, far too few to meet the 
need in our State, which is the largest geographically east of 
the Mississippi.
    In response, the State very wisely enacted a rate increase, 
raising reimbursement to about $0.50 on the dollar. It also 
took concrete steps to simplify billing.
    Two years later, the State raised rates to the 75th 
percentile, and afterward provided an inflationary increase. 
Also at that time Georgia moved to more electronic claims 
processing with instant online information about patient 
eligibility and claim status.
    During this period, more dentists began to accept Medicaid 
patients. Between 2000 and 2005, the number filing at least one 
claim per week increased by 57 percent to over 1,000. Also, a 
mobile dental service, which was the innovation of a Georgia 
practitioner, started operations and now serves children at 
school in 76 counties.
    Over 5 years, our children's utilization rates, as shown on 
the CMS 416, made steady progress. The proportion of children 
receiving any dental service, preventive dental services, and 
treatment services rose from below 20 percent to about one-
third of all children, and it really seemed that children's 
oral health care was on the right track.
    Then in fiscal year 2004 a State budget crisis led 
officials to eliminate reimbursement for a number of 
restorative dental services, cutting a total of 7.5 percent 
from the dental budget. In 2005, although the proportion of 
children receiving preventive dental services continued 
improving slightly, the proportion receiving treatment plunged 
from 34 percent to 19 percent and went down again the next year 
to 17 percent.
    In mid-2006, announcing its intention to save money and to 
improve access, Georgia required most Medicaid and all PEACH 
Care children to enroll in one of three capitated managed care 
organizations that we call CMOs. The CMOs would be responsible 
for almost all of their services, including dental care.
    At first the CMOs kept fees where they were, but that soon 
changed when they saw higher than expected utilization eating 
into their profits. They required more prior approvals, 
adjusted fees, and began closing networks. Two of them 
terminated their contracts with the dental organization that 
had served over 40,000 children.
    Dentists complained that the CMOs and their subcontractors 
have added new levels of administrative difficulty, not to 
mention cost. In addition, some dentists say it is harder to 
find specialists who will accept referrals. Although the CMOs 
list large networks of dentists, data from the State show that 
large number of the CMOs' dentists have not filed a single 
claim.
    It is too soon to know whether CMOs are making a difference 
in children's health care one way or the other. The first year 
of implementation is the latest for which we have data. The 
utilization rates remain close to the same as the year before 
CMOs began operation when treatment rates had dived. It will 
take systematic data collection and analysis to see how well 
children are actually doing.
    It would be worth evaluating the mobile school-based 
approach which claims 65 to 70 percent of their Medicaid 
children complete treatment, which they say is far more than 
the children in their office practice, which includes children 
with other kinds of insurance. While it is not the traditional 
model of a dental home, it helps solve the problems of 
inadequate transportation, a parent having to forego a day of 
earnings to take children to the dentist, and the no-shows that 
hinder efficient operations in a dentist's office.
    My testimony that is written lists a number of 
recommendations, some of which address issues I haven't had 
time to talk about here, but, once again, I want to thank you 
for your attention and for your concern about the problem with 
children's oral health.
    [The prepared statement of Ms. Lowe follows:]
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    Mr. Kucinich. Thank you for your testimony and your 
complete testimony, as well.
    Dr. Grover.

                    STATEMENT OF JANE GROVER

    Dr. Grover. Good afternoon, Chairman Kucinich and members 
of the subcommittee. My name is Dr. Jane Grover. I am very 
pleased to be here today representing the American Dental 
Association. In addition to being an ADA officer, I serve as 
the Dental Director for the Center for Family Health in 
Jackson, MI, a federally qualified health center. I also serve 
as a Medicaid reviewer for the Michigan Department of Community 
Health.
    As the Dental Director in an FQHC and as an experienced 
private practitioner before that, I understand the problems 
with the dental component of the Medicaid program. In my 
opinion, we need to take three actions to properly care for the 
Medicaid population.
    First, get many more dentists into the system, which is the 
primary focus of this hearing. Second, influence the geographic 
distribution of those dentists to make sure they can serve the 
Medicaid population in a timely fashion. Third, support other 
oral health initiatives that strengthen the oral health 
delivery system.
    I address all of these points in my written testimony; 
however, in the interest of time I am going to focus primarily 
on the first point, attracting dentists to the Medicaid 
program.
    A March 2008 study funded by the California Health Care 
Foundation confirmed what the ADA has been saying for some 
time: to improve dentists' participation in Medicaid, the 
States must improve fees, ease administrative burdens, and 
involve dentistry as an active partner. The Foundation's report 
examined six States where the number of participating dentists 
and patients seen in the Medicaid program rose significantly.
    For purposes of my testimony, I will focus on the Michigan 
Healthy Kids Dental Program, which is essentially the same as 
the private sector Delta Dental Plan used by many people with 
coverage provided by their employers. Dentists are paid at a 
PPO rate, which might be less than the usual rate charged, but 
is still widely accepted.
    The claims processing is identical to the private sector 
plan, except that beneficiaries have no co-pays and there is no 
annual maximum.
    From the dentists' perspective, there is no difference 
between the Healthy Kids Dental Program and the widely accepted 
Delta Dental private plan. For patients, the stigma associated 
with being on Medicaid has been removed. Families cannot be 
differentiated into Medicaid and non-Medicaid groups. And the 
Healthy Kids Dental Plan has been a resounding success.
    Dentists' participation shot from 25 percent to 80 percent 
1 year after the program was introduced and now stands at 90 
percent. The travel time to a dental office was cut in half, 
equaling that of the private sector Delta Dental Plans. The 
number of children with a dental home under the program far 
exceeds those with a dental home under the traditional Medicaid 
program in Michigan.
    Unfortunately, about two-thirds of the Medicaid eligible 
children remain in the traditional Medicaid program in 
Michigan. More needs to be done to bring all of the eligible 
children into the Healthy Kids Program.
    We believe CMS can help by issuing guidance outlining how 
such collaborative activities have effectively worked in 
Michigan, Alabama, Tennessee, and other States. In addition, a 
letter from CMS to State Medicaid directors requiring them to 
report on steps they are taking to improve their dental 
Medicaid programs would also help.
    The ADA also believes passing H.R. 2472, the Essential Oral 
Health Care Act, is important because the bill provides 
enhanced Federal matching funds if a State is willing to 
increase Medicaid fees, address administrative barriers, and 
reach out to the dental community.
    Finally, regarding initiatives that strengthen the oral 
health delivery system, Mr. Chairman, we agree with the 
Congressional Research Service where, in its September 18, 
2008, letter to this subcommittee, the agency identified 
barriers affecting the use of dental service among children. 
Those barriers include navigating government assistance 
programs, finding a dentist willing to accept Medicaid, 
locating a dentist close to home, transportation to a dental 
office, cultural and language barriers, lack of knowledge about 
the need for pediatric oral health care.
    The ADA is seeking funding to conduct demonstration 
projects for a potential new dental team member, the community 
dental health coordinator, designed to address those barriers. 
We describe the CDHC fully in our written testimony.
    Thank you, Mr. Chairman, for this opportunity to testify. I 
would be pleased to answer any questions.
    [The prepared statement of Dr. Grover follows:]
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    Mr. Kucinich. Thank you very much.
    Dr. Crall, you may proceed. Thank you.

                     STATEMENT OF JIM CRALL

    Dr. Crall. Thank you, Mr. Chairman. And I thank members of 
the subcommittee for the opportunity to participate in this 
hearing.
    My comments today largely focus on the impact of Medicaid 
reimbursement rate increases on dentist participation and 
children's utilization of dental services in Medicaid, and the 
benefits of no-risk contractual arrangements that separate or 
carve out Medicaid dental benefits from global Medicaid managed 
care arrangements.
    Access to an ongoing source of comprehensive dental care is 
a critical component for maintaining good oral health in 
children. Access to a dental home or regular source of dental 
care is especially important for children who are at elevated 
risk for tooth decay, predominantly children in low-income 
families and children with special health care needs, children 
typically covered by Medicaid.
    National surveys showing an increase in tooth decay in 
young children, what we now call early childhood caries, 
combined with the already large and growing numbers of children 
on Medicaid underscore the need for engaging substantial 
numbers of dentists as Medicaid providers across the United 
States. However, chronically low reimbursement to dentists for 
services rendered has been acknowledged by several private and 
governmental reports to be a major, if not the greatest, 
barrier to dentist participation in Medicaid.
    Access to dental services for children covered by Medicaid 
is a significant and chronic problem. Studies conducted by the 
U.S. Department of Health and Human Services in 1996 reported 
that, A, relatively few children covered by Medicaid received 
recommended dental services; and, B, inadequate reimbursement 
is the most significant reason why dentists do not participate 
in Medicaid.
    The GAO's April 2000 Report to Congress indicated that the 
level of Medicaid dental reimbursement in 1999 nationally and 
in most States was about equal to or less than the 10th 
percentile of respective fees; that is, at least 90 percent of 
dentists charged more, and usually substantially more, than the 
Medicaid fee.
    A subsequent assessment conducted in 2004 by myself and Dr. 
Don Schneider, former Chief Dental Officer at CMS, found that 
in 41 States the majority of dental Medicaid reimbursement 
rates for common children's dental procedures remained below 
the 10th percentile, and frequently were below even the first 
percentile of dentists' fees, meaning that the Medicaid rates 
were lower, and often substantially lower, than the fees 
charged by any dentist in the respective States.
    Beginning in the 1990's, following a series of Oral Health 
Policy Academies organized by the National Governors 
Association, several States moved to increase Medicaid 
reimbursement levels to considerably higher levels consistent 
with the market-base approached advanced in the NGO Oral Health 
Policy Academy. As shown on the table on this slide, subsequent 
evaluations suggest that, similar to the findings by the GAO, 
Medicaid payments that approximate prevailing private sector 
market fees do contribute to increased participation by 
dentists in Medicaid.
    Other States, including Virginia, Texas, and Connecticut, 
also have taken steps to raise their Medicaid dental 
reimbursement rates to what are considered reasonable, market-
based rates. Unfortunately, as in the case of Connecticut and 
Texas, these changes often follow years of protracted 
litigation in Federal courts.
    The table on the next slide provides a comparison of Texas 
Medicaid payment rates for selected procedures and fees charged 
by dentists within the State of Texas. This chart basically 
illustrates comparisons that are typical of many other States. 
You can see that in 2004, for example, for a periodic oral 
examination, or Code D-0120, that the Texas payment rate of 
$14.72 was roughly half of what the 50th percentile or average 
rate fee that dentists charge.
    More strikingly, if you look at the far right column on 
this table you will see that for 11 of the procedures that we 
normally monitor to try to assess adequacy of payment levels in 
Medicaid, that the Texas rates, as is true in many, many other 
States, was below the first percentile, or below what any 
dentist considers a reasonable charge for those services.
    In September 2007, however, following a settlement in the 
Federal court case of Frew v. Hawkins, Texas EPSTD dental 
Medicaid reimbursement rates for 35 common procedures were 
raised by 100 percent, effectively to the 50th percentile of 
Texas dentists' fees. This action followed more than a decade 
of essentially stagnant dental Medicaid rates in the face of 
steady modest increases in the cost of dental care, typically 
between 4 and 5 percent per year.
    Significant increases also were provided for approximately 
20 additional relatively common dental procedures.
    Information obtained from individuals involved in the Frew 
case indicates that following Medicaid reimbursement rate 
increases in Texas the State has issued approximately 500 new 
Texas Medicaid dental provider numbers. The actual number of 
new dentists in the program is not clear at this time because 
in Texas a dentist may have more than one provider number if 
they operate in multiple locations.
    The entire section of the document that the AAPD submitted 
to the Health Care Financing Administration, now CMS, on 
program financing and payments, Section C in the submitted 
table of contents, was deleted from the published version of 
the Guide to Children's Dental Care in Medicaid. Topics 
addressed within that section are delineated within my written 
testimony.
    Additional information provided in the Guide showed that 
roughly $14 to $17 per enrolled beneficiary, often referred to 
as PMPM, or per member per month, would be necessary to pay for 
dental services for children enrolled in Medicaid at market 
rates comparable to those used by commercial dental benefit 
plans for employer-sponsored groups. Typical benefits 
administration rates would raise those levels to $17 to $20 
PMPM.
    A subsequent actuarial analysis commissioned by the 
American Academy of Pediatric Dentistry in 2004 generally 
affirmed those findings; however, available information 
suggests that many States allocate only a small fraction of the 
financial resources suggested by these actuarial studies, 
oftentimes on the order of $5 to $7 per beneficiary per month.
    Now, shifting to the impact of Medicaid rates on increases 
in children's use of dental services, perhaps more directly to 
the point, the table on the next slide shows data from CMS 416 
annual reports illustrating significant increases in 
utilization of dental services by children covered by Medicaid 
in five States following significant reimbursement rate 
increases.
    The increased use of dental services demonstrated in this 
slide also constitutes a significant positive impact of 
Medicaid dental reimbursement rate increases.
    The rate increases, which have been implemented in these 
and a handful of other States, were not done in isolation; they 
are generally part of a broader combination of actions designed 
to address issues which have been identified as chronic 
barriers to dentist participation and access to dental care in 
Medicaid.
    Although addressing these other issues is viewed as an 
important element of comprehensive dental Medicaid program 
reform, increasing Medicaid rates to reasonable, market-based 
levels is critical to obtaining adequate levels of dentist 
participation in Medicaid.
    Finally, commenting on the topic of the advantages of no-
risk contractual arrangements or carve-outs for dental Medicaid 
benefits, in addition to the essential step of raising Medicaid 
dental reimbursement rates to reasonable, market-based levels, 
many States also have taken steps to implement no-risk or 
administrative services only, ASO, contracts that separate or 
carve out dental Medicaid benefits from global Medicaid managed 
care arrangements. Examples include Michigan's Healthy Kids 
Dental Program and Medicaid dental programs in Connecticut, 
Maryland, Tennessee, and Virginia.
    Such arrangements eliminate the need for subcontracting 
between global Medicaid managed care organizations, which often 
are not in the business of providing dental benefits, and 
dental benefits managers. This change not only helps to 
simplify program administration and reduce confusion among 
dentals and Medicaid beneficiaries, alike; the no-risk aspect 
also helps to eliminate the inherent incentive in risk-based 
contractual arrangements for managed care organizations and/or 
dental benefit managers to reduce payments to dentists in order 
to enhance the intermediary's profits.
    In addition to simplifying the administration of Medicaid 
dental benefits, these arrangements allow States to retain 
greater control in establishing reimbursement rates while 
affording reasonable profits for dental benefits managers.
    Additional advantages of the single vendor approach, as was 
mentioned for Virginia, from the dentists' perspective include 
more streamlined enrollment procedures, because dentists do not 
need to fill out multiple enrollment forms and undergo 
credentialing by multiple dental benefits management 
organizations, and less confusion about program policies 
governing allowable services and billing processes, which often 
results from having multiple intermediaries.
    Moreover, contracting with a single dental Medicaid 
intermediary or a single vendor simplifies the contracting 
process, improves the ease of program monitoring, and has the 
potential for better contract enforcement on the part of State 
Medicaid programs.
    So, in summary, several States have taken significant steps 
to increase dentist participation and access to dental services 
in their Medicaid ETSDP programs over the past decade. 
Successful efforts generally have involved the necessary step 
of raising Medicaid dental reimbursement rates to reasonable, 
market-based levels, combined with additional steps to make 
Medicaid dental program administration more dentist friendly. 
Streamlining provider enrollment and implementation of no-risk, 
contractual arrangements that separate or carve-out Medicaid 
dental benefits contracting from global Medicaid managed care 
arrangements have been prominent parts of these strategies. In 
my opinion, promoting the adoption of these strategies by other 
States would help to substantially improve children's access to 
dental care and Medicaid.
    Overall, basically we need to give credit for the States 
that have demonstrated leadership in reforming their dental 
Medicaid programs for children; however, clearly more 
systematic efforts are necessary, and additional congressional 
and regulatory assistance, whether it be in the form of an 
increase in the FMAP rates, loan repayment or loan forgiveness 
for dental school faculty and new dentists entering practice, 
or demonstration programs are needed and would be welcome.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Crall follows:]
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    Mr. Kucinich. Thank you very much, Dr. Crall.
    I would like to go to questions of members of the panel. We 
will begin with Ms. Tucker.
    In conversation with my staff, you mentioned that the 
number of dentists in Maryland is so limited that, even if they 
all enrolled in the Medicaid provider network, you still would 
not have enough dentists to service the State's Medicaid 
population. What are you doing to increase the number of 
dentists in Maryland, or what are you thinking of doing?
    Ms. Tucker. What have we been doing and what are we going 
to be doing?
    Mr. Kucinich. Yes.
    Ms. Tucker. We have entered into dialog with our Maryland 
chapter of the Dental Association and other dental associations 
in Maryland, and we have asked them to come to the table and 
participate in the Medicaid program. We have told them that we 
will increase payment rates, and we did in July.
    They just had their annual meeting. At their annual 
meeting, we had all our dental vendors there and helped them 
enroll in the program, so we actually had people there and 
assisted with that.
    In the long run, we are moving toward a single vendor, 
which is one administrative service organization that is fee-
for-service. The dentists have said that they will be more 
likely to participate, and many have said they won't 
participate until that move is made.
    So we have kind of been working on short-run efforts. We 
did enroll people during the last week at the convention, but 
we are also looking at the long-term changes.
    Mr. Kucinich. Well, you have obviously made some great 
strides in your pediatric dental program.
    Ms. Tucker. Right.
    Mr. Kucinich. What has provided the political will for such 
a change?
    Ms. Tucker. Which provided what?
    Mr. Kucinich. What has provided the political will for the 
strides that you have made in improving pediatric dental care?
    Ms. Tucker. I think the fact that it is a new Governor. 
This terrible tragedy occurred in our State. He made it a major 
priority of his administration. He pulled together all of the 
important stakeholders throughout the State, and our Secretary 
chaired the Dental Action Committee. We had everybody at the 
table making recommendations. Everybody was committed. They 
made very concrete recommendations that we could actually carry 
out.
    Mr. Kucinich. And could you tell me what have you learned 
about having multiple MCOs providing pediatric dental care to 
Medicaid enrollees?
    Ms. Tucker. Well, one thing that we learned, during the 
time when we had implemented the health choice program we 
actually had seen increases in utilization of services for 
children, but it wasn't enough. What we did learn was that this 
provider community is not willing to accept any administrative 
burdens. It is a provider community that actually doesn't like 
insurance as a whole, and is very able to survive with patients 
that are private fee-for-service patients. So one thing that we 
learned was that any administrative burdens caused by having 
multiple organizations was a real problem for this provider 
community. That was one thing that we definitely learned, and 
we are moving forward with this single vendor because of that.
    Mr. Kucinich. Thank you very much.
    Dr. Grover, the New York Times reported that the number of 
dentists in the United States has been roughly flat since 1990 
and is forecast to decline over the next decade. Can you tell 
us how many dentists graduate each year and how many retire? 
Also, what is the total number of dentists? Is there a dentist 
shortage? How do we meet the growing public need for oral 
health services with the population of dentists remaining 
static?
    Dr. Grover. Well, the particulars of the number that 
graduate from the 57 dental schools that we have now I don't 
have with me right now, but I would be happy to provide that. I 
can say that there are seven new dental schools that are 
opening, and the number of dentists in this country, some may 
say that there is a maldistribution of dentists. Clearly, there 
are dentists needed in areas where there are currently no 
access to oral health services. And there are States that are 
experimenting with loan forgiveness and other incentives to 
attract providers to those areas.
    The exact number of dentists that are retiring is a fuzzy 
number. There are some that retire and then come back into 
practice. We have had a private practitioner retire and came 
and joined our staff at our health center. It is a fluid 
number.
    Mr. Kucinich. Thank you. In your testimony you discuss a 
community dental health coordinator who would be responsible 
for such dental procedures as fluoride and sealant 
applications, as well as performing temporization on dental 
cavities with materials designed to stop the cavity from 
getting larger. What is the difference between a community 
dental health coordinator and a dental hygienist, and if a 
difference exists, why can't a dental hygienist perform these 
procedures?
    Dr. Grover. Well, a dental hygienist can do the duties that 
we have outlined with the community dental health coordinator. 
The difference is that a hygienist is most effective and most 
productive in performing clinical services with a dentist. The 
community dental health coordinator is meant to be a community 
worker with oral health skills. That is a person who helps 
these wonderful people navigate a very complicated system, 
helps get families enrolled, helps patients keep their 
appointments, and helps with transportation issues, which in my 
personal experience is one of the biggest barriers that this 
population faces.
    So the community dental health coordinator is certified, 
not licensed, and can perform procedures, but primarily 
functions as a navigator and oral health educator.
    Mr. Kucinich. You mention that one of the reasons dentists 
are not interested in participating in Medicaid is because of 
the administrative burdens. Do you believe that carving out 
dental from managed care structure would work to ease those 
burdens and therefore attract more dentists?
    Dr. Grover. Well, I can only speak from the Healthy Kids 
perspective. I know what a success it has been in Michigan. I 
know that in my health center we have had great success with 
helping our community become more involved. Healthy Kids dental 
has been a success story in Michigan because of the 
streamlining that they have done. Other MCO organizations I 
can't really speak for.
    Mr. Kucinich. Thank you very much.
    Dr. Crall, in your testimony you suggest that risk-based 
contracts have a built-in incentive to reduce payments to 
dentists who provide dental services to Medicaid beneficiaries. 
Why is that?
    Dr. Crall. Well, basically if the organizations are paid on 
a capitated basis it creates an incentive to reduce their 
payout. That contributes to their bottom line. There are 
multiple ways in which that can be done. If reimbursement rates 
or payments to dentists are kept low, that will suppress the 
supply of services. If administrative burdens are put in place 
that require preauthorization that isn't consistent with what 
dentists experience in other commercial plans nor plans that 
are not risk-based, then those are ways in which the supply of 
dental services will be constrained, which contributes directly 
to the bottom line of the organization.
    Mr. Kucinich. So why do States continue to enter into risk-
based contracts in MCOs?
    Dr. Crall. States, certainly over the period of the last 
decade or so and in the current clime, are faced with some 
fiscal pressures, budgetary pressures.
    Mr. Kucinich. That is why you would maintain----
    Dr. Crall. And the global managed care arrangement is a way 
to sort of try to cap the increases in the health care costs.
    Mr. Kucinich. Do you have any opinion on whether States 
should enter into non-risk-based contracts?
    Dr. Crall. I will reiterate the opinion in my testimony, 
which is, in fact, I think, that non-risk-based approaches such 
as was used in Tennessee in a global managed care arrangement 
that was very much risk-based, when the dental piece was carved 
out in Tennessee there were substantial and very rapid sort of 
increases in dentists' willingness to participate, and in the 
State's ability to manage that program more effectively.
    Mr. Kucinich. Well, you kind of answered part of this 
previously, but States have a limited amount of funding, have 
to make difficult decisions on how to allocate. If States were 
considering increasing reimbursement rates for a limited number 
of procedures, which ones would you recommend be prioritized?
    Dr. Crall. Without getting into too much detail, I was 
involved both with some of the workings in the State of Texas 
as well as the State of Connecticut recently, and there are a 
relatively small number, 50 to 60 perhaps, set of procedures 
when you are talking about pediatric dental care that cover the 
vast gamut of common procedures that children need. If States 
concentrate on making those rates attractive to dentists, they 
can both be fiscally responsible and improve access to care.
    Mr. Kucinich. I would really appreciate it if, for this 
committee, if you would, as a followup, give us a letter that 
would recommend, based on your experience, kind of a 
prioritization.
    Dr. Crall. I would be happy to do that, Mr. Chairman.
    Mr. Kucinich. That would be helpful.
    I would like to go to Dr. Casey.
    How has adopting a preventive disease model both improved 
the oral health of children and helped North Carolina reduce 
Medicaid costs?
    Dr. Casey. As of this time, Mr. Chairman, we have not been 
able to demonstrate cost savings, but additional research is 
ongoing. We are looking at pay claims over a long period of 
time, up to 7 years of age. So you have to understand that it 
is a complex research issue, and we hope in the future to 
demonstrate cost savings to our program.
    Mr. Kucinich. Did you have any plans to enhance that 
program model?
    Dr. Casey. I am sorry?
    Mr. Kucinich. Do you have any plans to enhance the 
preventive model?
    Dr. Casey. Yes, we do. We are actually working on a pilot 
model--and I address this a little bit in my written 
testimony--a pilot model to facilitate referrals from 
participating physicians to general dentists who have been 
trained to see kids in this age group, zero to 3\1/2\ years of 
age.
    Mr. Kucinich. So if States were interested in creating a 
prevention and disease control model, how would they go about 
doing that? What would you recommend?
    Dr. Casey. Well, I would recommend modeling their program 
after something similar to ours. Other States have addressed 
the issue, as well.
    Mr. Kucinich. Now, did you get support from CMS when you 
did that?
    Dr. Casey. We did.
    Mr. Kucinich. And so, from your experience, if the States 
contact CMS at this point they would be ready to assist them, 
based on your experience?
    Dr. Casey. I think that CMS in disseminating information of 
best practices, we plan to apply for a promising practices 
designation for CMS to help them spread the word about our 
program.
    Mr. Kucinich. Thank you.
    Mr. Finnerty, you mentioned that one of the reforms adopted 
by Virginia was strengthening its relationship with the State's 
dental community. Can you describe what that entailed and how 
it worked to improve access and utilization of pediatric dental 
care?
    Mr. Finnerty. Mr. Chairman, I think that is probably the 
most important thing that we did. Before we put into place any 
of the reforms that we were able to achieve, the first thing 
that I did as a Medicaid Director was to sit down with the 
Executive Director of the Virginia Dental Association and say, 
``what do we do to fix this program?''
    We started a dialog actually 2 years before our reform 
program actually went into effect, and the relationship that we 
have developed not only helped to develop the program, but once 
we had the program in place they were one of our biggest 
advocates in trying to go out to their membership to say, Look, 
the State has done what we have asked for. Now you all need to 
step up and join this program and treat these kids.
    It has been absolutely essential to it.
    Mr. Kucinich. Why did you decide to increase reimbursement 
rates? Did you think increasing reimbursement rates would have 
been enough to improve access and utilization?
    Mr. Finnerty. We increased the rates because they were 
very, very low, particularly on some codes. They were less bad, 
if that is the proper English, in some areas, but very, very 
bad in others.
    In terms of whether or not that would have been enough to 
get increased participation, I think it would have helped, but 
I really don't think that it was sufficient. I think that it 
was a necessary part of the reforms, but without making the 
administrative changes to the program I really don't think it 
would have had the impact that the combined effect has had or 
the combined effect of both administrative reforms and fee 
increases.
    Mr. Kucinich. So how did carving out dental out of the MCO 
model impact access and utilization?
    Mr. Finnerty. That, along with the fee increases, as I 
mention in my testimony, has increased our utilization quite 
significantly for children 3 to 20. We have seen a 55 percent 
increase in utilizations from just prior to the start of our 
new program, 2 years hence from that point in 2007. So it has 
had a major effect. We would not have seen those increases 
without the changes, I am very confident.
    Mr. Kucinich. Now, in your testimony you mention that the 
disruption of enrollment can disrupt care. Why is that the 
case?
    Mr. Finnerty. Well, when a child is receiving ongoing 
dental care in Virginia, children can move between managed care 
organizations. We have five of them that we contract with. If a 
child is receiving ongoing care, if the child moved from one 
plan to another and the dentist that was treating the child 
initially is not a participating dentist in the other plan, 
then that child is going to have to find another provider, and 
so that is transitioning the care to another provider and that 
type of thing.
    Under our streamlined program, all of the dentists 
participate and contract with one vendor, so, regardless of 
what health plan they are in, they get their dental care 
through one plan, and that has virtually been eliminated, the 
problem of transitioning.
    Mr. Kucinich. Thank you, Mr. Finnerty.
    Ms. Lowe, according to your testimony, utilization of 
dental care in Georgia did a turn-around between 2001 and 2007. 
What do you think CMS could have done to stop this deleterious 
trend?
    Ms. Lowe. What could CMS have done, sir? I am sorry, I 
didn't hear the last part.
    Mr. Kucinich. What could CMS have done during that period?
    Ms. Lowe. I think that the State was actually making 
progress during that period because of the changes in the fees, 
which went up, and also the changes in the administrative 
approach to things, which greatly simplified how things were 
going. That was over the period of 1999 to 2004.
    Then, when the State eliminated those 11 dental codes from 
payment, things crashed, and it crashed in the treatment area.
    So possibly if CMS had said, sorry, you can't eliminate 
payments or reduce payments for those codes, that would have 
made a difference.
    Mr. Kucinich. Well, did increasing reimbursement rates by 
33 percent have any impact on access and utilization?
    Ms. Lowe. Yes, it did. I think that was a major contributor 
to the improvements that we saw over a period of years, but it 
was pretty shocking how fast it could crash just because of the 
budget cuts that subsequently took place.
    Mr. Kucinich. So tell us what Georgia did to reform its 
pediatric dental program under Medicaid, in a nutshell.
    Ms. Lowe. In a nutshell, what they did over several years 
was to raise the fees quite substantially until they were at 
the 75th percentile. They also initially, when we were still 
operating our payment system under the old EDS, which was 
actually a DOS-based system and quite antique, at least 
standardized the forms and used standard dental codes, which 
had not been done before. Those two things together made a big 
difference.
    And then the State also changed to ACS from EDS and brought 
the State into a Windows-based system for processing claims, 
and that made a big difference eventually. It was a rocky 
start, but eventually it made a big difference in the way 
providers were able to file claims. They were able to check out 
claims online. They were able to check eligibility online.
    After that, after those improvements actually led to 
increases in utilization and in the number of dentists 
participating, the State did the budget cut, which eliminated 
payment for some of the codes, and then decided that they would 
require the children to enroll in capitated managed care. So we 
have had those two disruptions.
    Mr. Kucinich. Thank you very much.
    I don't have any further questions of the panel. Does Mr. 
Cummings have any questions?
    Mr. Cummings. I just have a few questions, Mr. Chairman. I 
apologize. It has been a very hectic day. I apologize to our 
witnesses, but I am glad you are here.
    Ms. Tucker, I have said many times that, in light of 
Deamonte Driver's death, I was glad to see that Governor 
O'Malley convened the Dental Action Committee to try to improve 
children's access to dental care. Out of Deamonte's death--I am 
sure it has been mentioned already--a lot of what we are doing 
now came out of that. His death has had a profound impact.
    I was further pleased to learn that the Dental Action 
Committee adopted all of the recommendations that I provided to 
the Governor, which is very unusual. I think the Governor took 
this situation very seriously. And, of course, we will be 
closely watching to see what goes on from here.
    One of the changes that is currently in progress is the 
move to a single vendor for providing Medicaid dental services 
in the State of Maryland. Where are we in that process?
    Ms. Tucker. We issued the RFPs in the early part of the 
summer, and all of the proposals were due at the beginning of 
September. We received five huge responses. Currently there is 
a RFP Procurement Committee process going through to analyzes 
all of the different vendors. It was a very, very complex RFP. 
The requirements were quite extensive. So that committee is 
going through and is in the process of picking the best of the 
five people or groups that applied.
    The goal will be to have that whole process done by the 
beginning of December so it can go to our Board of Public Works 
in January and be awarded so that we can begin the transition 
to the new vendor starting March 1st.
    Mr. Cummings. What kind of oversight do you anticipate 
there being with regard to the vendor once they are chosen?
    Ms. Tucker. The deliverables are quite extensive and 
incredible, so there will be a lot, and there will be a lot of 
oversight for this particular project. The Dental Action 
Committee didn't go away after they put forth their proposals. 
They are still an action committee. They are still going to be 
involved. But the State, the Health Department will be 
extremely involved in the day-to-day monitoring of that 
contract.
    Mr. Cummings. Now, Dr. Grover, again, I want to thank you 
for your testimony also and thank you for all that you are 
doing for children in Michigan, but I think your work is truly 
an example of what dentistry has the power to achieve. I am 
pleased also with many of the things that the American Dental 
Association has done to improve children's access to dental 
care across the country.
    I am concerned, however, that some actions by the ADA may 
have the opposite effect. You mention in your testimony the 
ADA's recognition that a work force shortage exists in the 
dental field and that alternate models need to be explored, and 
I appreciate that recognition. But you also describe the ADA's 
recognition for such a position as the community dental health 
coordinator. I think this model is a solid concept and it ought 
to be tested, but I do think other models ought to also be 
tested.
    Do you agree with this concept that other models of an 
alternate dental provider should be tested?
    Dr. Grover. I think that alternate models of providing 
dental services, if they involve irreversible procedures, could 
be potentially dangerous. In my experience as a dental 
director, where I see the need to be the greatest is in helping 
families work through the system and helping families keep 
appointments, have transportation, and handle some of the 
cultural and language barriers. Those models--and we have three 
sites which are going to be piloted--will help the dental team 
be more productive.
    I think the challenge is in working with the families not 
only to prevent disease but to navigate the system, which can 
be quite burdensome for families to understand.
    Mr. Cummings. Well, we saw that in the case of Deamonte 
Driver. The mother of Deamonte, as you are, I am sure, well 
aware, when trying to get services for his brother contacted 
over 40 doctors who said that they would take patients on 
Medicaid, and they weren't able to accomplish that. They even 
went to a lawyer type person to try to help them, like a legal 
type clinic, and still had problems. It is interesting. I 
notice that what you just said, you brought up something that I 
have heard dentists bring up over and over again, and I never 
thought of it until we got involved in this issue, and that is 
the issue of people keeping appointments. The dentists tell us 
that one of the reasons why they are not that interested 
sometimes in doing this kind of work is because the population 
that they deal with, of course, don't show up for appointments. 
Time is money, and they have but so many appointments they can 
set in a day, and of course when people don't show up they 
don't make money.
    So the pilots that you are talking about, how do they 
address that issue?
    Dr. Grover. Well, the pilot program, for example, in 
Jackson County, would help families that have appointments at 
my dental clinic in my health center and would help us track 
people who miss appointments. There is a variety of reasons why 
people miss appointments. But confirming those appointments and 
calling and, in fact, visiting the home of the family where 
there is a missed appointment can help us track those children 
more effectively and get them the care that they need. I think 
that would complete the puzzle, because, quite honestly, I see 
that as a huge barrier to folks. And it is not enough just for 
my health center, which has a van, and my health center, which 
confirms appointments, but to have somebody go to the home, to 
have somebody work with the mom.
    There are some community health workers in California that 
do that, to help track these kids and make sure nobody falls in 
between the cracks. There are too many that is happening to.
    Mr. Cummings. Well, you know, it is interesting that when 
you look at the way mothers take care of newborns, there are 
certain things that seem to be clear that they must do, and 
they do them. I think when you look at things like crib death, 
things of that nature, the word has gotten out that you do 
certain things to make sure that your babies survive. I am just 
wondering, could we do a better job with regard to dental 
education? I am sure you may all have gone over this. It seems 
to me that a lot of people don't have a clue about how 
significant the relationship is between the teeth and the rest 
of the body. Not a clue.
    So I would think that a mother and father, if they really 
had a clear understanding of this relationship, that might be 
helpful in, one, them staying on top of their dental 
appointments and making sure that they made them, because I 
don't think that when you get that well baby appointment--is 
that what it is called?
    Dr. Grover. Yes.
    Mr. Cummings. I don't think a lot of people go about 
missing those appointments. They know that they have to do 
these things. But it seems to me that if people really know 
that the health and perhaps the life of their child is 
dependent upon them taking certain actions, it seems to me that 
you might get some results there.
    One of the things that we try to do in the SCHIP bill, 
which the President vetoed twice, was a provision in it whereby 
mothers would be exposed and fathers exposed to information 
about dental care from the very beginning, from before the 
child is born. They would be educated on that and provided 
pamphlets, things of that nature.
    I am just wondering what do you all do in that regard, and 
what is ADA's position in that regard?
    Dr. Grover. Well, the ADA position, you are absolutely 
correct on many points. The ADA's position is to encourage a 
dental home, and the first dental exam by 12 months of age.
    What we are doing in Michigan, in particular, is we are 
having a pediatric oral health summit where physicians and 
dentists are coming together so that the physicians know what 
they can talk and discuss with the mom. We at our health center 
do have OB visits, particularly scheduled in special slots, 
because we know that a significant factor in children receiving 
oral health care is if the mom receives oral health care. That 
is a big component.
    I have also recently worked on a DVD for Delta Dental on 
infant oral health care, and we would look forward to Delta 
distributing that nationwide.
    Education is key, as you have pointed out correctly.
    Mr. Cummings. And what does the ADA want the Congress to 
do? I am sure you have testified. What would you like to see us 
do?
    Dr. Grover. Well, we have an Essential Oral Health Care 
Act, H.R. 2472, which we feel is key, but also to encourage CMS 
to adopt some guidance for States that are making some headway, 
that are making some successes, and encourage States to develop 
similar models.
    I think the rising tide lifts all the boats, and I think 
what goes on in one State could go on in another.
    I think we need to work at making oral health part of our 
cultural conversation, and I don't know that is totally up to 
Congress, but I am sure that would be a big help.
    Mr. Cummings. All right. I don't have anything else.
    Mr. Kucinich. I thank Mr. Cummings for the excellent work 
that he has done on this matter from its inception, so thank 
you very much for your presence here.
    I want to thank the witnesses.
    This has been a meeting of the Domestic Policy Subcommittee 
of the Oversight and Government Reform Committee. The title of 
today's hearing has been: Necessary Reforms to Pediatric Dental 
Care under Medicaid. We have had two panels, and I want to 
thank the members of the second panel for your contributions. 
Each of you has helped to sharpen this committee's awareness of 
where we have been, where we are headed, and what can be done 
to improve pediatric dental care for the Nation's children. 
Thank you for your own individual commitments in that regard 
and the work that you have done in your respective capacities 
on not only practice but in the States, as well.
    I want to thank the Members and the staff who have 
participated, and the staff, in particular, for the excellent 
work they have done in researching this from the beginning.
    Without any further comments, and finally with the 
unanimous consent request to insert the testimony of Burton 
Edelstein into the record, this committee stands adjourned.
    [The prepared statement of Mr. Edelstein follows:]
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    [Whereupon, at 1:25 p.m., the subcommittee was adjourned.]
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