[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
MEDICAID'S EFFORTS TO REFORM SINCE THE PREVENTABLE DEATH OF DEAMONTE
DRIVER: A PROGRESS REPORT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DOMESTIC POLICY
of the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
OCTOBER 7, 2009
__________
Serial No. 111-129
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.fdsys.gov
http://www.oversight.house.gov
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania DARRELL E. ISSA, California
CAROLYN B. MALONEY, New York DAN BURTON, Indiana
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts JOHN J. DUNCAN, Jr., Tennessee
WM. LACY CLAY, Missouri MICHAEL R. TURNER, Ohio
DIANE E. WATSON, California LYNN A. WESTMORELAND, Georgia
STEPHEN F. LYNCH, Massachusetts PATRICK T. McHENRY, North Carolina
JIM COOPER, Tennessee BRIAN P. BILBRAY, California
GERALD E. CONNOLLY, Virginia JIM JORDAN, Ohio
MIKE QUIGLEY, Illinois JEFF FLAKE, Arizona
MARCY KAPTUR, Ohio JEFF FORTENBERRY, Nebraska
ELEANOR HOLMES NORTON, District of JASON CHAFFETZ, Utah
Columbia AARON SCHOCK, Illinois
PATRICK J. KENNEDY, Rhode Island BLAINE LUETKEMEYER, Missouri
DANNY K. DAVIS, Illinois ANH ``JOSEPH'' CAO, Louisiana
CHRIS VAN HOLLEN, Maryland
HENRY CUELLAR, Texas
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
PETER WELCH, Vermont
BILL FOSTER, Illinois
JACKIE SPEIER, California
STEVE DRIEHAUS, Ohio
JUDY CHU, California
Ron Stroman, Staff Director
Michael McCarthy, Deputy Staff Director
Carla Hultberg, Chief Clerk
Larry Brady, Minority Staff Director
Subcommittee on Domestic Policy
DENNIS J. KUCINICH, Ohio, Chairman
ELIJAH E. CUMMINGS, Maryland JIM JORDAN, Ohio
JOHN F. TIERNEY, Massachusetts MARK E. SOUDER, Indiana
DIANE E. WATSON, California DAN BURTON, Indiana
JIM COOPER, Tennessee MICHAEL R. TURNER, Ohio
PATRICK J. KENNEDY, Rhode Island JEFF FORTENBERRY, Nebraska
PETER WELCH, Vermont AARON SCHOCK, Illinois
BILL FOSTER, Illinois
MARCY KAPTUR, Ohio
Jaron R. Bourke, Staff Director
C O N T E N T S
----------
Page
Hearing held on October 7, 2009.................................. 1
Statement of:
Edelstein, Burton, D.D.S., M.P.H., Chair, Children's Dental
Health Project; Mary McIntyre, M.D., M.P.H., medical
director, Office of Clinical Standards and Quality, Alabama
Medicaid Agency; Joel Berg, D.D.S., M.S., Chair, Department
of Pediatric Dentistry, University of Washington; and Frank
Catalanotto, D.M.D., professor and Chair, Department of
Community Dentistry and Behavioral Sciences, University of
Florida, College of Dentistry, representing American Dental
Education Association...................................... 58
Berg, Joel............................................... 83
Catalanotto, Frank....................................... 88
Edelstein, Burton........................................ 58
McIntyre, Mary........................................... 68
Iritani, Katherine, Assistant Director, Health Issues, U.S.
Government Accountability Office; and Cindy Mann, Director,
Center for Medicaid and State Operations................... 10
Iritani, Katherine....................................... 10
Mann, Cindy.............................................. 23
Letters, statements, etc., submitted for the record by:
Berg, Joel, D.D.S., M.S., Chair, Department of Pediatric
Dentistry, University of Washington, prepared statement of. 85
Catalanotto, Frank, D.M.D., professor and Chair, Department
of Community Dentistry and Behavioral Sciences, University
of Florida, College of Dentistry, representing American
Dental Education Association, prepared statement of........ 90
Edelstein, Burton, D.D.S., M.P.H., Chair, Children's Dental
Health Project, prepared statement of...................... 61
Iritani, Katherine, Assistant Director, Health Issues, U.S.
Government Accountability Office, prepared statement of.... 12
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio:
Letter dated December 15, 2008........................... 52
Letter dated October 7, 2009............................. 50
Prepared statement of.................................... 5
Mann, Cindy, Director, Center for Medicaid and State
Operations, prepared statement of.......................... 26
McIntyre, Mary, M.D., M.P.H., medical director, Office of
Clinical Standards and Quality, Alabama Medicaid Agency,
prepared statement of...................................... 70
MEDICAID'S EFFORTS TO REFORM SINCE THE PREVENTABLE DEATH OF DEAMONTE
DRIVER: A PROGRESS REPORT
----------
WEDNESDAY, OCTOBER 7, 2009
House of Representatives,
Subcommittee on Domestic Policy,
Committee on Oversight and Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:40 p.m., in
room 2154, Rayburn House Office Building, Hon. Dennis J.
Kucinich (chairman of the subcommittee) presiding.
Present: Representatives Kucinich, Cummings, Watson, and
Jordan.
Staff present: Jaron R. Bourke, staff director; Tom Mulloy,
Office of Representative Kucinich; Jean Gosa, clerk; Charisma
Williams, staff assistant; Carla Hultberg, chief clerk, full
committee; Leneal Scott, IT specialist, full committee; Adam
Hodge, deputy press secretary, full committee; Ashley Callen,
minority counsel; Molly Boyl, minority professional staff
member; and Adam Fromm, minority parliamentarian/Member
services coordinator.
Mr. Kucinich. The Domestic Policy Subcommittee of Oversight
and Government Reform will now come to order.
I want to thank the witnesses and those in the audience and
my colleague, Ranking Member Jordan, for your patience. The
House had in consideration a bill that I was the author of, and
so I had to be there to present it. It's good to be here with
you as we start this hearing.
This hearing is going to be the fourth in a series on
access to pediatric dental services in Medicaid. The
subcommittee has focused on this issue since the death of
Deamonte Driver in February 2007; and that's Deamonte Driver's
picture. His death highlighted the inadequacy of dental
services for Medicaid and rural children in Maryland.
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 5
legislative days to submit a written statement or extraneous
materials for the record.
On February 25, 2007, Deamonte Driver, a 12-year-old boy
from Prince George's County, Maryland, died from a brain
infection caused by untreated tooth decay. Deamonte's tragic
death could have been easily prevented by access to dental
care, dental care he was entitled to and should have received
through United HealthCare, Maryland's Medicaid dental provider.
Unfortunately, that company failed to meet its obligation
to provide beneficiaries with access to dental providers. So
onerous were the administrative barriers that United HealthCare
had created, ``it took one mother, one lawyer, one online help
supervisor, and three case management professionals to make a
dental appointment for one Medicaid child,'' according to
testimony we received from Laurie Norris, a legal advocate who
worked with the Driver family.
In the 2\1/2\ years since Deamonte's preventable death,
this subcommittee has been conducting an inquiry into the
adequacy of efforts on a State level to ensure access to
pediatric dental services under Medicaid, as well as the
actions that the Center for Medicaid and State Operations, CMS,
to conduct oversight of State systems.
At our first hearing in May 2007, we learned that Deamonte
Driver was not the only Maryland youth who wasn't receiving
dental care to which he was entitled by Medicaid. In fact, our
investigation of United HealthCare found that approximately
11,000 Maryland children in United HealthCare's Medicaid
operation had not seen a dentist in at least 4 years. We found
that United HealthCare provided information to Medicaid
beneficiaries that was so inaccurate and outdated it would have
been virtually impossible to find a dental care provider.
We also learned that CMS did virtually nothing to address
the problems in poorly performing State systems. Dennis Smith,
director of CMS at the time, argued that financial sanctions
are the only tool CMS has to enforce compliance; and he was
unwilling to hand down financial sanctions because he said the
cost was ultimately borne by the patient.
Simply put, this is not the case; and in a letter to Mr.
Smith the subcommittee outlined nine actions that CMS could
take that would serve to enforce the statutory responsibilities
that States have to ensure that Medicaid-eligible children have
access to dental services.
Our second hearing focused on CMS's response to this letter
and actions taken by them in the years since Deamonte Driver's
death to address the deficiencies in its oversight
responsibilities. While they did take some action, their
efforts, unfortunately, fell short of effecting any real
change. In fact, the hearing revealed that most of the progress
of the State of Maryland was made despite CMS, that the agency
was not actively involved in the State's efforts and provided
almost no guidance.
Additionally, CMS continued to neglect the issue of
provider reimbursement rates, despite hearing testimony about
the importance of them to effecting system-wide reform.
Astoundingly, Mr. Smith even acknowledged as such during our
first hearing, but stubbornly, stubbornly continued to avoid
the issue. Mr. Smith resigned from his post not long after our
second hearing.
After that, things began to change. A GAO report, the first
of its kind since 2000, revealed that millions of Medicaid-
enrolled children suffer from tooth decay, almost one-third of
the total Medicaid population. Medicaid children are roughly
twice as likely as privately insured children to suffer from
tooth decay.
Moreover, this pattern has persisted for years. Very little
has been done to improve access to and utilization of dental
services. In a sense, the problem of tooth decay is getting
worse, because the rate of decay in the teeth of children aged
2 to 5 has increased in recent years.
Now our third hearing on the issue demonstrated that
improvement is possible. Under new leadership and continued
congressional scrutiny, CMS began to turn a corner. The interim
director of the Center for Medicaid and State Operations
outlined a number of actions that they had taken to engages
States actively in reform as well as to improve their own
oversight functions. They conducted 17 reviews of State systems
with utilization rates below 30 percent and provided each State
with its own report and recommendations, worked with States to
develop oral health schedules that met Federal guidelines, and
formed an Oral Health Technical Advisory Group with State
Medicaid directors.
We also learned that the State of Maryland, where this
whole journey began, continued making considerable progress.
The dental action committee that they formed developed seven
recommendations to improve access to dental care for Maryland's
children. Two ended up in a budget submitted by Martin
O'Malley, the Governor of Maryland, and another was passed by
the State legislature.
Today, the GAO will share the findings of their most recent
report, commissioned at the request of myself and Mr. Cummings,
on the adequacy of pediatric dental oversight at the State and
Federal level. I am thankful to GAO for their hard work and
dedication in studying this problem.
We will also hear, for the first time, from the new
director of the Center of Medicaid and State Operations. I am
looking forward to their report on the progress they have made
and how they plan to use that momentum to address the gaps that
remain as identified in the GAO report.
Additionally, we are going to hear from State Medicaid
officials and researchers who have studied and implemented
successful initiatives to increase access to and utilization of
dental services, as well as to improve provider participation.
I believe and hope that CMS has turned a corner in their
oversight of pediatric dental services since the death of
Deamonte Driver. But the magnitude of the underlying problem is
great, and even today there are millions of children just like
Deamonte entitled to dental care but not receiving it. The
urgent job of everyone here today is to move quickly to prevent
another one of them from dying from preventable dental disease.
Finally, I just want to share with my colleagues, you know,
people ask me when Deamonte's death was first announced, why
are you so interested? It's just 1 person out of 300 million.
You know, these things happen.
I remember growing up in the inner city. I was the oldest
of seven. My parents never owned a home and lived in 21
different places by the time I was 17, including a couple of
cars. And one of the things we didn't have was dental care. I
mean, I can remember chewing on gum balls and having them just
breaking off--my teeth breaking off into the gum balls. And I
can remember having dental problems that didn't get treated for
a long, long time.
And I don't want to get too graphic about it, but for those
who have experienced being a child without access to dental
care, you know what a nightmare it can be.
Deamonte Driver, that's me. That's me as a young boy. His
life was sacrificed to an uncaring system. We can't have any
more Deamonte Drivers out there.
Look at his face. I mean, he is just--he is really asking
us, what we are going to do about this? Are we going to take a
stand to make sure that the children of America get the dental
services that they are entitled to?
That's the challenge we have, and I will not rest. I know
there are colleagues like Mr. Cummings and Mr. Jordan, we have
very powerful feelings about this as well.
But I will not rest until we have caused the death of
Deamonte Driver to be a driver of a new day in delivering
dental services to the children of this country and
particularly those who are served by Medicaid.
I want to thank you for your indulgence, Mr. Jordan.
With that, I yield to the ranking member of this committee,
Mr. Jordan, for his opening statement.
[The prepared statement of Hon. Dennis J. Kucinich
follows:]
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[GRAPHIC] [TIFF OMITTED] T4919.002
Mr. Jordan. I thank the chairman for his work and for
calling this hearing as well and for continuing to highlight
the importance of access to dental care for children. I look
forward to hearing from our witnesses about what has been done
to enhance pediatric dental services and improve access, since
these issues were first looked at by the subcommittee following
the tragic death of Deamonte Driver in 2007.
Barriers to care, including low reimbursement rates for
dentists, lack of understanding of the importance of our oral
health, and excessive administrative burdens for patients and
providers all contribute to the problem. According to the
report the GAO released today, State Medicaid programs have
taken steps toward improving access, but gaps remain that must
be addressed.
Likewise, CMS has worked to improve its oversight of
pediatric dental issues in Medicaid. More progress certainly is
necessary. In 2008, GAO estimated that one in three children on
Medicaid had untreated tooth decay. I hope our witnesses today
will tell us what is being done to fill these gaps and treat
these children.
Unfortunately, the issue of access to care is not unique to
pediatric dentistry for Medicaid enrollees but a problem across
the health care spectrum. The problems of access to care are
prevalent in our existing government-run programs, including
Medicaid, Medicare, and SCHIP. Low reimbursement rates set at
the State level for Medicaid and the national level for
Medicare lead to a low participation of providers in these
programs. In this respect, the terrible story of Mr. Driver can
prove to be a lesson as we move through health care reform and
evaluate the different options for ensuring a healthy America.
With that, Mr. Chairman, I yield back the balance of my
time.
Mr. Kucinich. I thank my colleague from Ohio; and the Chair
recognizes Mr. Cummings from Maryland, who has been working on
this issue from the time that it was first known. I want to
thank him for his dedication.
Mr. Cummings. Thank you very much, Mr. Chairman.
I really do thank you for your interest in this issue, and
I thank you--as I listened to you just a moment ago, I am
reminded that what you have done is you have taken some of your
experiences in life as a child and turned them around and used
them as a passport to help others, and that says a lot. So
often people want to bury what happened in their past. However,
you take it and you raise it up to remind us that this could
happen to anybody. So I do--but not only do you do that, you
then lay out a mission to correct it. So I really do appreciate
you doing this.
You know, Deamonte died on February 25, 2007, and I know
that the chairman has already talked about it, but I think
about it every day, just about. And when I think about an
untreated tooth and an infection spreading to a child's brain,
$80 worth of dental care might have saved his life, but
Deamonte was born, he never made it to the dental chair.
Mr. Chairman, you recall we first held a hearing on this
topic at my request back on May 2, 2007, in an effort to
identify the critical breakdowns in our Medicaid system's
provision of dental care to children. As our dental health
professionals here today know, oral health is an often
overlooked but vital component of health care. Preventive
dental care, especially for our children, is a fundamental need
for their healthy development into adulthood.
In fact, tooth decay is the most common childhood disease.
It is five times as common as asthma and seven times as common
as hay fever. This has the most detrimental impact on low-
income communities. Eighty percent of cavities occur in only 25
percent of children, predominantly low-income children. Low-
income children suffer twice as much from tooth decay as do
more affluent children. Millions of school hours are lost each
year to dental-related illness. Poor children suffer nearly 12
times more restricted activity days than children from more
affluent families due to dental-related illness.
Our previous hearings on this matter revealed woeful
failures of the Centers for Medicaid & Medicare Services and
its State partners to comply with section 1905(r)(3) of the
Social Security Act, which ensures that every child--every
Medicaid-eligible child will have access to medically necessary
dental care under the Early Periodical Screening, Diagnostic,
and Treatment [EPSDT], provision. We found that Medicaid fell
glaringly short of meeting this mandate and was given
directives to address these disparities. I am eager to hear
today about efforts that they have partaken in to address the
disparities.
Since Deamonte's death, my home State of Maryland has
resolved to do everything possible to prevent such an avoidable
tragic loss; and we have made significant gains to improve
children's access to dental care. In just 2 years, Mr.
Chairman, 41,000 more children in Maryland received Medicaid-
funded dental service than those who received such service in
2007. In 2009 alone, Maryland is making an overall $81\1/2\
million investment in Medicaid dental care services Statewide.
Governor Martin O'Malley, to his credit, also convened a
dental action committee which developed seven recommendations
to better serve our children, including raising reimbursement
rates for dental services, initiating a single State-wide
vendor for dental services, spending $2 million per year to
enhance the dental health infrastructure, providing dental
screenings for children, creating a new dental hygienist
position, improving education for dental students, and crafting
a public education campaign on oral health. The Governor
included the first three items in his 2000 budget, and he is
currently working with a dental action committee to implement
the others.
Similarly, the UnitedHealth Group has stepped up to the
plate to do its part. It invested $170,000 for a program at the
University of Maryland Dental School to improve children's
access to dental care in Baltimore City, including more than
$30,000 to hire a pediatric dentistry case manager, more than
$60,000 to hire a pediatric dentistry fellow, $30,000 to
establish a mini pediatric dentistry clinic, and $15,000 to
provide continuing access to education to pediatric and family
practice residents.
As I close, the company is now working to develop a similar
partnership with Howard University that will reach across the
Maryland border to Deamonte's home county, Prince George's.
All of these actions are commendable. However, they are
being implemented solely on a State level. In order for us to
see monumental gains, changes must be made Nationwide. We have
been anticipating a review of CMS's since our last hearing to
learn what has been accomplished at the Federal level. We were
sorely disappointed regarding the lack of demonstrable effort
between our first and second hearings, so GAO's report has been
eagerly awaited. I am hopeful that we are turning the page to a
new day.
With the leadership of Ms. Cindy Mann, CMS will work to
create innovative reforms to address the concerns raised in
GAO's report, and these reforms will incorporate the effective
and efficient programs that are already working on a State
level.
Mr. Chairman, a child died because of our failure as
adults, of our failure as adults to discharge this mandate. For
Deamonte Driver and for every child and adult like him, we must
proceed with a sense of great urgency and with an unfailing
determination to see our efforts to completion. It is their
turn. It is their turn to grow up. It is their turn to be
healthy children. It is their turn to deliver and develop the
gifts that they have been given to deliver to us. But if they
are not healthy and if their teeth are rotting and if we are
not doing anything about it, shame on us.
Thank you very much, Mr. Chairman. With that, I yield back.
Mr. Kucinich. Thank you, Mr. Cummings, for your commitment,
your statement, your heart, your passion, and your willingness
to take a stand.
We are now going to go to the witnesses. There are no
additional opening statements. The subcommittee will receive
testimony from the witnesses before us today.
I would like to start by introducing our first panel:
Ms. Katherine Iritani is Acting Director for Health Issues
at the U.S. Government Accountability Office. In her 27-year
career with GAO, she has helped plan and execute a wide variety
of program and evaluation assignments. In recent years, she has
overseen multiple evaluative studies on Medicare financing and
access issues, including children's access to preventive and
dental services. Ms. Iritani currently works in GAO's Seattle
field office and has a business administration degree from the
University of Washington.
Next, Ms. Cynthia Mann. Ms. Mann was appointed director of
the Center for Medicaid and State Operations [CMSO], in June
2009, where she is responsible for the development and
implementation of national policies governing Medicaid, the
State Children's Health Insurance Program, survey and
certification, Medicaid Integrity Program, and the Clinical
Laboratories Improvement Amendments. CMSO, the Center for
Medicaid and State Operations, also serves as the focal point
for all CMS interactions with States and local governments.
Prior to her return to CMS in 2009, Ms. Mann served as a
research professor at Georgetown University Health Policy
Institute and executive director of the Center for Children and
Families at the Institute. Her work at Georgetown focused on
health coverage, financing, and access issues affecting low-
income populations. Previously, she served as director of the
Family and Children's Health Programs at CMSO from 1999 to
2001, where she played a key role in implementing Medicaid and
the SCHIP program.
Before joining the government in 1999, Ms. Mann led the
Center on Budget and Policy Priorities, Federal and State
health policy work. She also has extensive State-level
experience, having worked on health care welfare and public
finance issues in Massachusetts, Rhode Island, and New York.
Thank you both for appearing before this subcommittee
today.
It's the policy of the Committee on Oversight and
Government Reform to swear in our witnesses before they
testify. I would ask that you rise.
[Witnesses sworn.]
Mr. Kucinich. Let the record reflect that each witness
answered in the affirmative.
I would ask that each of the witnesses now give a brief
summary of your testimony. I ask that you keep this summary
under 5 minutes in duration. Your complete written statements
are going to be in the record; and that's what we are here to
do, to have you amplify on that in your time that you will be
presenting.
So I would like you, Ms. Iritani, to be our first witness.
You may begin.
STATEMENTS OF KATHERINE IRITANI, ASSISTANT DIRECTOR, HEALTH
ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; AND CINDY MANN,
DIRECTOR, CENTER FOR MEDICAID AND STATE OPERATIONS
STATEMENT OF KATHERINE IRITANI
Ms. Iritani. Mr. Chairman, Ranking Member Jordan, and
members of the subcommittee, I am pleased to be here to discuss
children's access to Medicaid dental services, a longstanding
concern.
As you noted in your opening remarks, an estimated one of
every three children in Medicaid has untreated tooth decay. One
in nine have it in three or more teeth. This is about twice the
rate experienced by privately insured children and translates
to millions of Medicaid children in need of dental care. In too
many cases, this need is urgent.
My statement is based on GAO's report that you are
releasing today. This report summarizes at a national level
efforts of States and CMS to improve Medicaid dental services
for children. In summary, we found that State Medicaid programs
and CMS have taken a number of actions to monitor and improve
children's access to dental services, but problems with access
persist and gaps in CMS oversight remain.
First, let me share highlights of States' actions from our
Web-based survey of State Medicaid programs. All States
reported monitoring children's access to dental services, and
nearly all States had implemented one or more initiatives to
improve access through actions to reach out to families such as
establishing hotlines to help them find a dentist and
initiatives such as raising reimbursement rates to encourage
more dentists to serve Medicaid children.
Nonetheless, States reported multiple barriers to improving
access. These barriers are well-known and longstanding, for
example, for families finding a dentist to treat their
children; for providers, concerns remain about families missing
their appointments, low reimbursement rates and administrative
burdens. These barriers persist, despite States actions to
address them.
Of significance, most States indicated their initiatives to
improve access had not met their expectations; and two-thirds
of the 21 States that reported contracting with managed care
organizations to provide dental services said those
organizations were not meeting the States' access standards.
The bottom line, children's access to Medicaid dental
services has been improving but remains low. States report that
only about 35 percent of Medicaid children nationally received
any dental service in 2007, as compared to HHS's goal of 66
percent of low-income children receiving a preventive dental
service by 2010.
Now let's turn to actions of CMS. CMS has improved its
oversight of State programs in several ways, but more can be
done.
Two observations: First, CMS has focused dental reviews of
17 States with low dental access rates, identified significant
problems, including concerns in eight States that managed care
organizations had inadequate numbers of dentists in their
networks. CMS did not, though, require corrective action plans
of States or have plans to review other States with low dental
access rates.
Second, CMS has improved its guidance to and communications
with States. For example, CMS posted descriptions of four
States promising practices for improving access on its Web
site, but nearly every State, 49 in all, reported to us that
they need more from CMS. States reported, for example, that
they need specific guidance in areas such as establishing
appropriate dental payment rates and improving billing
policies.
Notably, when we ask States how CMS could help them, most
States answered that CMS should provide more information on
what was working in other States. Twenty-six States reported to
us that they believe their State had one or more best practices
for delivering dental services that could be shared with
others.
In conclusion, CMS and States have taken noteworthy steps
to improve children's access to Medicaid dental services.
Concerted and continued efforts and, in these challenging
fiscal times, innovative solutions will be needed to address
the multiple and longstanding barriers to improving children's
oral health. For its part, CMS can help through ongoing
assessment, guidance, and support of States' efforts, building
upon the steps the agency has recently undertaken. We have made
several recommendations to CMS toward this end and have ongoing
work for the Congress further examining these issues.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions.
Mr. Kucinich. I thank the gentlewoman.
[The prepared statement of Ms. Iritani follows:]
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Mr. Kucinich. The Chair recognizes Ms. Mann. You may
proceed.
STATEMENT OF CYNTHIA MANN
Ms. Mann. Good afternoon, Chairman Kucinich, Ranking Member
Jordan, and members of the subcommittee. I, too, appreciate the
opportunity to be with you today to talk about how children are
faring receiving needed dental services under the Medicaid
program; and I want to begin by commending you, Mr. Chairman,
for your sustained interest in this area.
I have been the director for the Center for Medicaid and
State Operations for a little less than 4 months, and I have
not been a witness to the prior hearings. However, in my
position at Georgetown University, I closely followed the
proceedings. And now that I am director of CMSO and have taken
stock of what we have done in the past period of time, it is
clear to me that the activity that has happened was triggered
in large part by the activity of this committee and by your
interest in this area and that you have been able to plant the
seeds for a renewed commitment on this very important matter.
While I am new to CMS, I am not new to this issue. As you
noted in your introduction of me, I have worked on children's
access issues for many years; and I would note that in my 18
months at CMS in 1999 and 2001 I helped author the letter that
was issued in January 2007, which you referred to in your first
hearing, which called for every State to conduct a dental
access review.
Since that time, many States have made progress narrowing
dental access gap for children. But, as the GAO correctly
points out, significant gaps remain. We know from the research
that there's an inextricable link between oral health and
overall health and that every child needs dental care,
preventive care, and treatment when appropriate.
Sadly, our country's record in assuring our kids have the
dental care they need, both in private coverage as well as in
public coverage, is not good; and the record is particularly
poor for low-income children. I can assure you, Mr. Chairman
and members of the committee, that Secretary Sebelius and I
share a firm belief that we have a responsibility to do much
more to assure that every child enrolled in Medicaid receives
the dental care they need.
The data show that about 36 percent of all Medicaid-
eligible children used dental services over a year's period of
time. With that data, there can be little doubt that
improvements are necessary.
States administer the program, they enroll the providers,
they set the provider rates, but CMS plays a critical role, and
we are intent on using all of the tools available to us to
assure that every child covered by Medicaid is as healthy as he
or she can be.
My written testimony lists a number of actions that CMS has
taken over the past period of time since the last hearing. I am
just going to review a few of those activities.
In policymaking activity, we are now actively involved in
providing guidance in the area of children's health insurance
coverage and the new CHIPRA provisions that expanded dental
benefits for children in a number of different ways. In fact,
today we released our guidance to States on the new CHIP dental
health benefit and the supplemental insurance option that's now
available to States to provide dental coverage to children who
have other sources of care.
CHIPRA also included several other provisions that we are
working on. One was a provision that required the Secretary to
publish the names of the dentists serving children in the
Medicaid program in every State around the country, Medicaid
and the CHIP program. We launched that Web site on August 4th
and have those dental providers listed at this point. That Web
site, I will say, is a work in progress.
We think that there's a number of improvements that we want
to continue to make. We have had a number of--a lot of activity
on that Web site, about 43,000 hits to the page, but there are
improvements that can be done; and we think we can use that Web
site not only to ultimately share information with families
like Deamonte Driver's family about where to get dental care
but also for us to use as a monitoring tool to be able to see
what the numbers of dentists are in each Medicaid program, how
many are taking new patients, and what that access looks like
over time.
We also are intent on changing our data reporting system.
We want to change the so-called CMS-416, which is our EPSDT
reporting form, to include information about other providers
that are providing oral health care, as well as to improve, to
make other improvements to the 416; and we are planning to do
that by the spring of this year. There were a number of
requirements to changes in the 416 that were part of CHIPRA, so
we want to consolidate those changes and put those out in the
spring.
We are also partnering right now with the Agency for Health
Quality and Research to come up with dental health quality
standards as part of the overall initiative to come up with
children's health standards. We believe that those health
standards, those dental quality standards themselves, which
will be reported by States, hopefully--it's a voluntary
reporting by States--will again give us another window to
assure that children are getting the care that they need and
get States to pay continued attention to the need for oral
health services.
We are also helped, as you noted, in your introductory
remarks, Chairman Kucinich, by a new oral health and technical
advisory group that's going to help us move forward in our
policymaking. But a second area of----
Mr. Kucinich. The gentlewoman's time has expired, but I
will let you make a concluding statement.
Ms. Mann. Let me conclude by saying our two other areas
that we are focusing on, besides policymaking, is identifying
best practices, sharing those widely with States, meeting with
States on best practices and then the issue of oversight.
On those 16 State reviews, on August 27th, I issued a
letter to all of those States, saying that we wanted to know
the results of those recommendations and those reviews. Our
regional offices are now working with each of those States, and
we will look at those reviews and also assess whether
additional reviews are needed.
Thank you. I wanted to just close by saying that we are
committed to continuing to make this a focus of our work as we
go forward and always welcome your insights and your
suggestions in terms of moving forward.
Mr. Kucinich. I thank the gentlewoman.
[The prepared statement of Ms. Mann follows:]
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Mr. Kucinich. We are going to go to questions of the
witnesses. The Chair and the ranking member will have 10
minutes for questions and followed by 5 minutes from other
Members' questions. We will see how we go in the rounds,
whether we go one rounds or two rounds.
I will begin by asking Ms. Iritani, does GAO have an
estimate of the number of Medicaid-eligible children who did
not receive a single dental service?
Ms. Iritani. Yes, we do.
Mr. Kucinich. How many?
Ms. Iritani. That would be 12.6 million on the basis of
nationally representative surveys.
Mr. Kucinich. Thank you.
What percent of children does that work out to be?
Ms. Iritani. That's 66 percent of Medicaid children.
Mr. Kucinich. So the reality is that--you say 66 percent of
the eligible children do not receive dental services.
Meanwhile, the Department of Health and Human Services has
established a national goal of achieving 66 percent of eligible
children who do receive dental services by next year. So we've
got 66 percent not receiving, and the goal is 66 percent who
will receive the preventative dental services. That is, to
achieve the national goal, we're essentially going to have to
turn the current statistics on their head.
Now, Ms. Mann, you've inherited an agency that, for the
better part of a decade, has been held back from making
progress toward this goal.
For instance, when we asked the official who preceded you
what it was going to take to increase access to dental
services, he indicated there wasn't much he could do. He didn't
believe that he could require corrective actions of the States.
What do you believe?
Ms. Mann. I think there's a great deal that we can do,
Chairman. I believe it's a multi-pronged problem, and we have
an obligation to have a multi-pronged solution. I think it's
both----
Mr. Kucinich. Excuse me. Those are words.
Ms. Mann. I think we have to give some guidance to States.
If they're looking for guidance on how to set dental rates, we
will provide that guidance on how to set dental rates. I
believe we need to do oversight. As I mentioned, we are
following up with each of the 16 States that we did the initial
reviews. There had not been followup till I got back--until I
came on at CMSO, and we will assess whether additional State
reviews are necessary. What I want to do is focus on these 16
States, see where we are, see what progress has been made.
I do think that CMS can do corrective action plans. We plan
on doing it in a number of different areas where it's
necessary. I'd like to work with States and share best
practices. These are complicated areas. These are troubling.
Mr. Kucinich. OK. We're going to get into the corrective
action in a little bit. I want to go back to Ms. Iritani--
excuse me--and thank you. We're, you know, trying to create a
dialog here.
Ms. Iritani, in your testimony, you mentioned that more
than half of the 21 States that provide dental services through
managed care organizations have reported that MCOs in their
State do not meet any--or only meet some of the State's dental
access standards.
Approximately how many children are going without dental
services in those States?
Ms. Iritani. That's a difficult question to answer,
because, unfortunately, the data by delivery system is not
reliable. So the 416 that captures the data on access by
delivery system, we have found, does not break out managed care
versus fee for service for access, and those States do not have
managed care throughout the State.
Mr. Kucinich. OK. If we're looking at achieving a goal
then, we need to really have some quantitative assessment of
where we start. Do you have any guess at all? Do you have a
best guess of what that number would be as to how many children
are going without dental services in the States?
Ms. Iritani. In the States that have managed care?
There are 21 States that reported that they have managed
care----
Mr. Kucinich. We know that.
Ms. Iritani [continuing]. But in some of those States, the
managed care penetration rate--that is the number of children
that were receiving dental services through managed care--was
very low.
Mr. Kucinich. OK.
Ms. Iritani. So we can't answer that question,
unfortunately.
Mr. Kucinich. We're going to work with you to help get the
breakdown so we know where the targets are in terms of the
goals that we have to reach. We have to know where we're
starting and since it is on a State-by-State basis, so we're
going to need your help on that.
Now, Ms. Mann, this subcommittee found that
UnitedHealthcare, as an inadequate dental provider network, was
a contributing factor to the preventable death of Deamonte
Driver. As you know, CMS recently conducted a significant
review of dental services in 17 States, and you identified
eight States where Medicare managed care organization provider
networks were not assured of being adequate to provide access
to dental services.
Ms. Mann, do you believe that inadequate dental provider
networks in Medicaid managed care organizations are a
significant barrier for children to receive dental care?
Ms. Mann. Chairman, I think there's an access problem
inside managed care and outside managed care, and actually----
Mr. Kucinich. Well, let's talk about inside managed care.
What do you believe?
Ms. Mann. I think it depends on each State, and in some
States, their managed care organizations are not providing a
sufficient network.
Mr. Kucinich. OK. So what are you saying? It depends on
each State. That's not--I need something more specific here.
You're giving me answers that are interesting, but they're very
general, and the way that this committee works is we learn by
getting specific answers.
Can you be specific?
Ms. Mann. Each State is different, Chairman, so I can't
tell you that there is--it's not that inherently managed care
is a problem. It is that every State has an obligation to make
sure that network is sufficient. In those eight States, we're
following up specifically to look at what steps those States
have taken to ensure----
Mr. Kucinich. OK. Now, each State is different. Thank you.
Now I'm focusing on Medicaid managed care organizations because
they behave like a traditional HMO in the Medicaid context,
retaining the risk in exchange for capitation fees. Under
Medicaid, they make money when their enrollees don't get
medical and dental care.
This subcommittee held a hearing last month on the health
insurance industry and the industry spending--on numbers,
health care is known as medical losses, and insurance company
executives try hard to keep those losses to a minimum.
Obviously, one of the ways a for-profit Medicaid managed care
organization can please Wall Street and can keep their medical
losses to a minimum is by making it difficult for people who
are covered to find a dentist who will accept Medicaid.
In your opinion, have you seen any evidence that dental
utilization rates differ according to whether a State relies
upon for-profit Medicaid managed care organizations to provide
coverage?
Ms. Mann. The study that I have seen is the study that
actually you asked for, Chairman, in the CRS report, and it
certainly showed dental access problems. I have not seen a more
broad across-the-board study of it. I think that the evidence
is that, in risk-based contracts, there can be a greater
propensity for denial of care, and therefore there is a greater
obligation, if the State chooses to set up its system that way,
to oversee and make sure that care is sufficient. Medicaid
obligations----
Mr. Kucinich. OK. Now we're making some progress here. I
would like to ask that you and your staff consider
correspondence received by my staff from Dr. Burton Edelstein
in which he finds evidence for a correlation between Medicare
managed care organizations and lower dental utilization rates.
Did you collect data from the States which would allow you to
determine if this is a factor, if there is a correlation
between Medicaid----
Ms. Mann. You asked about for-profit managed care
organizations. I have not looked at data looking at for-profit
managed care organizations. We can look at that more closely,
Chairman, and I'd be glad to look at that more closely.
Mr. Kucinich. Good. Thank you.
Ms. Mann. I will say that we have a real problem in the
fee-for-service area as well, and so I think that----
Mr. Kucinich. Well, that's not what this hearing is about,
though, is it?
Ms. Mann. I thought the hearing is about Medicaid access
for children.
Mr. Kucinich. OK. Ms. Mann, do you believe that inadequate
dental provider networks, where they're connected to this for-
profit motive, are one of the reasons why so many of these
children are not getting health care? Is it because of the way
the system is structured?
Ms. Mann. I think that Medicaid managed care organizations
can make it worse or can make it better depending upon what the
financing looks like, what the incentives are and what the
oversight is.
Mr. Kucinich. I want to ask you about one of GAO's findings
that troubles me.
In testimony before this subcommittee in September 2008,
interim director Herb Kuhn testified: CMS will require
corrective actions for those States not in compliance with
Federal regulations.
However, you told GAO that you will only followup with
States but had no plans to require action from them. As you
wrote in a cover letter, ``These were programmatic reviews, and
as such, formal, corrective action plans,'' were not required.
I'm wondering if CMS has backed down from its earlier
commitment to this subcommittee to require corrective actions
from the States?
Ms. Mann. As I stated a moment ago, we believe the
corrective action plans are part of our toolkit in terms of
moving forward on the Medicaid program. These reviews were
done, as you noted, before I came, and they were set up as
technical assistance reviews.
Mr. Kucinich. So you plan to require corrective action
plans?
Ms. Mann. Can--if I could finish?
Mr. Kucinich. Well, just can you answer that question,
though?
Ms. Mann. If there--when we complete these reviews back
from the regional offices, if we still see problems, then we
will move forward in a separate action for corrective action
plans, yes.
Mr. Kucinich. So you're not adverse to corrective action
plans?
Ms. Mann. Absolutely not.
Mr. Kucinich. And you'll be letting this committee know
about timeframes for the component of that requirement?
Ms. Mann. Sure.
Mr. Kucinich. OK. Thank you very much.
The Chair recognizes Mr. Jordan.
Mr. Jordan. Thank you, Mr. Chairman.
Let me pick up where the chairman was.
The first question or the first point he made was only a
third of children--this, I guess--I think--I assume he got his
information from the same place I did--from a GAO study last
year. Only one in three children are getting treatment for
tooth decay and other dental problems. So I just want to, I
guess, cut to the chase.
Have you seen an improvement in the past year? Is it better
now? What is the status? And I understand that this is last
year's study, but here we are late in 2009. What kind of
improvement have we seen in helping these kids?
I'll go to Ms. Mann first.
Ms. Mann. The data from the last 2 years shows a slight
improvement from 33 percent to 36 percent of kids having a
dental visit in the past year. So we're--nationwide, we're
moving, albeit very slowly, in the right direction.
Mr. Jordan. I would say most people would say that's really
slowly in the right direction. OK.
Ms. Iritani, do you want to comment?
Ms. Iritani. Yes, and we've seen the same data.
Mr. Jordan. OK. Let me just bring up something to Ms.
Iritani.
You talked about one of the things that States have
reported is this rather heavy administrative burden. In fact, I
remember my days working at the Statehouse, and you talk to
local officials. It's always, you know, dealing with the
Federal Government--dealing with county government, dealing
with the State government and the Federal Government.
So, A, is it true? Do you feel like there's a big burden
you've placed--that has been placed by the Federal Government
on States, and you know, what ways can States better navigate
this and better deal with this situation?
We'll let both of you go at it.
Ms. Iritani. We asked States about the barriers in their
States to providers serving more children. Most States actually
reported broken appointments--patients missing appointments as
a major barrier. Administrative requirements was reported as a
major barrier to providers serving more children by about 28
States, so not as much of an issue.
Mr. Jordan. Would you be supportive of--and it's one of the
things I worked on in my days at the Statehouse because of the
whole welfare reform thing. Would you be supportive of some
kind of penalty for--I'm just curious--for parents who--the
appointment has been made. You know, it's in place. Would you
be in favor of some kind of penalty for families who don't
bring their child for that appointment?
Ms. Iritani. We asked States about model practices, and I
think there are States that are actually dealing with the
broken appointment issue without a penalty situation. Virginia,
for example, reported on a broken appointment initiative
whereby they tracked broken appointments and tried to help
patients get to their appointments.
Mr. Jordan. OK. Go ahead. I interrupted you. Go ahead. What
other actions are being taken to help States deal with the
administrative burden?
Ms. Iritani. Our report didn't look at those issues.
Mr. Jordan. Ms. Mann.
Ms. Mann. Representative, just to be clear, the Federal
Government does not in this instance require any paperwork that
the States use to enroll their providers. So there--I have
been--as GAO has reported, 28 States identify and providers
often have identified that paperwork is a problem. If so, it's
a State-initiated problem, and it's one of the things that, I
think, is routinely on States' lists to try and address, and I
think some of the States here to testify today will talk about
what they've done to----
Mr. Jordan. It's an internal issue?
Ms. Mann. It's a State--it's a State issue.
Mr. Jordan. OK. OK.
Ms. Mann. It's--to the extent that it's causing barriers,
we regard it as a CMS issue--an oversight issue, but it's not
requirements that we put on States.
Mr. Jordan. OK. OK.
Let me ask you--one of the things I remember--and this is,
oh, probably 15, 20 years ago--I guess 15, 18 years ago--and
maybe it would be better for the second panel, but in Ohio--
this was way back when I was just--when I was assistant
wrestling coach at Ohio State University. One of the programs
they had in place was the dental school would--we knew about it
because I was, you know, employed at Ohio State, but you know,
we had four children, so we were looking to get the cheapest
care possible for our kids.
We took them to the dental college--the dental school, and
we were very pleased, and it was very--you know, very
inexpensive. I don't know what it cost, but I just know, when
you're, you know, a young couple and you've got four kids--or
maybe at the time we only had three--you're looking to save
dollars wherever you can. It seemed to work. It seems to me
that's a concept where, you know, here is a State institution
receiving all kinds of taxpayer support already, many times in
large metropolitan areas. That's something that we should be
encouraging, and again, I was looking ahead in my briefing book
here. I think we're going to hear from one of our witnesses
about this issue, but--about this type of program. That makes
all the sense in the world to me. It may be a little more
difficult in rural areas where there may not be a dental school
as close, but you've got to believe that's a way to help meet
this need and not cost the taxpayers more money, which is
obviously something that I know I'm concerned about, and I
assume--and I think the rest of the committee is as well.
So, if you could, talk about that concept and what's going
on already and how we can encourage more----
Ms. Mann. I think there are a number of dental schools that
are providing direct services. Also, there are some new
programs being involved, and we are trying to think of
partnering with them in order to provide some payment for
training, so--and also some loan repayment programs so that the
dental students that get trained go out into low-income
communities. There's also county health departments that are
providing dental health services and a lot of federally
qualified health centers.
So, I think, looking at all of those avenues to build our
work force in terms of oral health providers is right.
I was just talking to a State legislator yesterday from
Kansas. They don't have a dental school in Kansas, so that's
why each--you know, each State you need to think about the
different--the landscape and what can work, but I think the
dental schools have been--can be very critical.
Mr. Jordan. Do either of you know how many States are
implementing such an approach right now with one of their
dental schools or, maybe, with their single dental school?
Ms. Mann. I don't know, but we can find that out and get
that information to you.
Mr. Jordan. It seems to me if it's like--look, if that's
working and, you know, many States have dental schools----
Ms. Mann. Sure.
Mr. Jordan [continuing]. It's certainly something we should
be doing; and again, not reinventing the wheel, we're always
talking about the reimbursement rates and what providers--these
are dental students. They need patients to learn their craft
on, so it makes sense to me.
Ms. Iritani, did you want to comment? Do you have any
idea----
Ms. Iritani. I think that there are many States that have
innovative practices such as that, and we recommended to CMS
that they develop more ways for sure.
Mr. Jordan. You don't know the number, though? OK. OK.
Mr. Chairman, I'll yield back the balance of my time.
Mr. Kucinich. I thank the gentleman.
The Chair recognizes Mr. Cummings. He may proceed.
Mr. Cummings. Thank you very much, Mr. Chairman.
I want to thank you both for your testimony.
I must admit that, Ms. Mann, I'm feeling a feeling of deja
vu in that, under the previous administration with CMS, so
often this committee felt like we were getting the rope-a-dope,
and I want to be specific because I'm talking about the lives
of children. You said that there were things that you were
willing to do.
Mr. Chairman, I hope you will understand what I'm about to
say. I want to make sure that Ms. Mann is held accountable, and
I want specific commitments for these children. We've been
through a process, Mr. Chairman, as you will recall, where we
were told things, and nothing happened. Now, either we're going
to get some specifics as to what is going to happen and address
these children's needs as the urgency of now, to borrow
President Obama's words--because it is the urgency of now when
only one-third of our children are getting what they need so
that they can grow up and be able to sit at a table like that,
to be able to go to school without pain, to be able to live a
healthy life or we need to do something different. We need to
be specific.
Ms. Iritani, you said here that CMS agreed to three of the
four recommendations--is that right?--and partly the fourth; is
that correct?
Ms. Iritani. That's correct.
Mr. Cummings. And which ones did they partly agree to?
Ms. Iritani. They agreed, in part, with our recommendation
to conduct reviews in all States with low dental access rates.
They indicated that they would consider conducting additional
reviews in the context of other programmatic reviews.
Mr. Cummings. All right.
Ms. Mann, you said that there were things that you all were
going to do. Can you go down each one of the things that you
said you're going to do or are doing and give us timetables
now? Because the way we like to operate is we like to bring you
back on the date within a week or two after you say it's going
to be done so that we can make sure it's done. See, we have a
limited amount of time to be in these jobs. We may not win the
next election, and so we have to be--we want to make sure that
we are effective and efficient while we are here. Other than
that, we might as well go and play golf. So the question
becomes:
What are you willing to do? When are you going to do it?
Mr. Chairman, you set the schedule, but I would like for
that--so that we can come back and check with Ms. Mann as to
what--if she makes a commitment that we be able to have her
come before us and let us know that the commitment has been
completed.
Mr. Kucinich. Will the gentleman yield?
Mr. Cummings. Yes, of course.
Mr. Kucinich. This is our fourth hearing, and you've been
instrumental in creating every one of these hearings; and as I
indicated in my opening remarks, we are going to stay on this.
So we're going to get to know each other real well, and we're
going to have a chance to be able to compare notes and
establish metrics, timetables, completion of items because look
where we are--66 percent are not getting the dental services to
which they are entitled; and the goal is for 66 percent of
children to get it.
So, with your persistence and in working with Mr. Jordan
and our subcommittee, I think we've got a long way to go, but
Ms. Mann is now on that road with us, so we'll look forward to
working with you.
Now I yield back to Mr. Cummings.
Mr. Cummings. I just want to go through the things that
you--the action that you are going to take and when you expect
to have it done. That's all. I mean, you can be brief. You
talked about it a little bit already, but I just want to know
exactly what you're going to do to correct this situation to
get to that goal.
Do you agree with the goal, first of all?
Ms. Mann. Absolutely.
Mr. Cummings. OK. Just tell us what you plan to do.
Ms. Mann, don't take this personally.
Ms. Mann. I'm not.
Mr. Cummings. I'm serious. I'm speaking about the kids. You
know, the chairman talked about himself. I was the same little
kid who got all kinds of dental treatment later in my life.
I've got kids right now in Baltimore who are going to the
University of Maryland Dental School because of Deamonte
Driver, in part, and they're discovering that the infection has
gone to their eyes. See, apparently--I don't know that much
about dentistry. Apparently, it goes to your eye before it goes
to your brain, and I'm talking out for those little kids
because I want them to grow up.
So that's why I'm kind of pushing hard on this because I
don't want us to be making these same arguments a year from now
or 2 years from now, and then some kid who only has, by the
way, a limited amount of time to be a child--I don't want to be
in the situation where that child is either harmed because we
did not do what we could have done. I want every child--I think
it was Masloff that says we must be what we can be, and I want
every child to be what he or she can be.
So you can go ahead and tell us when you're going to do
what you're going to do, what you're going to do, and then I'm
sure the chairman will deal with scheduling hearings
appropriately so that we can measure our progress.
Ms. Mann. There are a number of actions already underway.
As I noted on August 27th, I wrote to each of the States
that had 16--the 16 States that had reviews. The regional
offices are currently engaged with those States. I can commit
to you that, in 30 days, we can tell you a response from those
followup reviews from the regional offices and let you know
where we stand on each of those reviews.
We have a listening session on EPSDT and where we should go
on EPSDT, which is, as you know, the children's benefit package
in Medicaid, scheduled for October 16th. That's the first. We
plan to have a few in that series to help guide us on one of
the most important actions we can take going forward. I'm happy
to commit to you the week after that October 16th listening
session to let you know exactly what the recommendations were
going forward.
We plan to do dental reviews in each of the States that are
at the top of the list to identify, as the GAO has recommended,
what those best practices are, and I can commit to you to
provide you that information in the next--I have to figure out
exactly when we can do those reviews, but I can followup and
give you an exact date as to when we can do those and when we
can provide that information.
Mr. Cummings. Can you give me an outside date?
Ms. Mann. Sure. I would say by December.
Mr. Cummings. OK.
Ms. Mann. We have committed to do the change in the 416
report by the spring of this year. We have a number of changes
that we've already developed; and then there's new legislation
in CHIPRA that we want to incorporate in those changes, and we
want to do some consultation with experts. So we are having
that consultation. That's part of the listening session that's
scheduled for October 16th. We are doing that consultation this
fall. We are going to be doing those changes this spring in the
416, which is to improve some of the data collection issues so
that we can give you the numbers that you're looking for so
that we can have a better idea and a more accurate idea,
whether it's in managed care or fee for service, how many kids
are or aren't getting the services that they need.
Mr. Cummings. I see my time has expired.
Thank you, Mr. Chairman.
Mr. Kucinich. I think, Ms. Mann, you can tell by Mr.
Cummings' remarks that this committee needs your cooperation
and that we are not going to stand by and watch any more little
kids dying. Don't take this personally, but it's your job now;
it's your responsibility, and so whoever was sitting in that
chair is going to hear the same thing from members of this
committee about your obligation to these children.
These aren't statistics. This was a child who was full of
promise like every child, and the system let this happen to
this child; and I see from your background that you have
concerns about people in these lower economic situations.
That's where I come from, and I identify with Deamonte, so
that's why I will not give you or any witness who comes from
the administration any wiggle room on this question. You will
not have it. Just know that.
You know, with all due respect--because you know what? A
child died. Now, I want--one of the significant reforms that
could, in theory, increase the number of children who receive
some preventative dental services is allowing pediatricians to
apply fluoride varnishes. However, this subcommittee has heard
that the administrative barriers to reimbursement for providing
those services are discouraging doctors from doing it. My staff
has received this correspondence from the Maryland Chapter of
the American Academy of Pediatrics on this topic, and I ask
unanimous consent to put this in the record.
[The information referred to follows:]
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Mr. Kucinich. Can you do anything about streamlining
reimbursement for this procedure?
Ms. Mann. We do--thank you.
The Medicaid program does--will--does already in many
States reimburse many pediatricians for providing sealants, and
if there's any question that States have about their ability to
claim Medicaid reimbursement for that procedure, we can
certainly clarify that immediately.
Mr. Kucinich. Great. If you'd study that letter, it would
be very helpful, and maybe you could respond to it and send us
a copy.
Ms. Mann. I would be glad to do that.
Mr. Kucinich. In a letter to the subcommittee, Dr. James
Crall, who has testified before us on two occasions,
recommends, ``A uniform program oversight and performance
assessment regardless of State of residence.''
I ask unanimous consent to insert the entire text of Dr.
Crall's correspondence into the record.
[The information referred to follows:]
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Mr. Kucinich. Ms. Mann, what can CMS do to fix the
patchwork of oversight at the State level and to create a
uniform system of oversight and assessment.
Ms. Mann. I think we can do a uniform system of assessment,
Chairman. I think that the responses aren't uniform because the
problems aren't uniform, and that's--if I could wave the wand
and get that 66 percent and make it all happen by doing reviews
tomorrow, I would do that. We don't have providers in many
States and in many parts of the country that are willing to
take Medicaid beneficiaries. We have a participation rate--a
utilization rate in private health insurance of about 59
percent right now. We've got a multitude of problems in terms
of getting oral health care to children both in and outside of
the public systems. It is not an overnight problem.
We will commit, and we are committed to doing everything we
can to make the Medicaid program work for every child and to
make sure that dental care is there; but it is a multi-pronged
problem, and I don't say that to try and get around our
responsibilities. I say that to say that we're rolling up our
sleeves, and it is not a simple solution. If I could do the
oversight of 50 States tomorrow and say that would solve it, I
would do the oversight of 50 States tomorrow. It won't solve
it, but it will get us farther along, and we're willing to do
that, of course, and to be as aggressive as we can.
Mr. Kucinich. I think the watch words would be ``corrective
action'' here, wherever there is action to be taken, that you
don't stand by and figure they'll solve their own problems.
Ms. Mann. I agree. I agree. But when we have States come to
us and say they don't have a dental provider within, you know,
five counties of their State, corrective action plans won't get
the child the dental care.
Mr. Kucinich. But Deamonte Driver died. He had a provider,
all right.
Ms. Mann. You're absolutely right, and that would have been
a very different story. That's exactly right.
Mr. Kucinich. So we understand that there are certain
circumstances where you have to become involved in encouraging
States with respect to their--to provider networks, but there
are areas where they have providers, and we're wondering about
corrective action in those areas.
Now, Dr. Crall's letter also recommends uniform eligibility
and benefits regardless of State of residency.
Could you tell us what challenges CMS faces to creating
such a system?
Ms. Mann. In the Medicaid program, actually, there is
uniform benefit eligibility for children. That is the EPSDT
program, and it is the guarantee that every child get that
uniform eligibility, which is, simply stated, all the medical
care that they need, that's deemed necessary. So we have a lot
of variations for adults in Medicaid but not for children.
The question is do we get it enforced, and do we have
providers taking the children, and do families know about the
availability; and that's why we're setting up this listening
session and doing this EPSDT work group. We have a problem
beyond oral health. We have a larger problem making sure that
EPSDT benefit is observed for every child in the Medicaid
program.
Mr. Kucinich. Thank you very much.
Mr. Jordan.
Mr. Jordan. Thank you, Mr. Chairman.
Just a couple of basics I was curious about.
What is the average time a child is enrolled in Medicaid?
Ms. Mann. Generally, in any given year, about 9 months.
Mr. Jordan. So they're in 9 months, out? I mean, is there a
back-and-forth a lot? Just tell me the typical scenario.
Ms. Mann. There's a fair amount of back and forth. If you
look at----
Mr. Jordan. Over their lifetime, what is the average? I
mean, the lifetime of the child from 0 to 18. What's their
lifetime?
Ms. Mann. I don't know. Over the lifetime, if you look at a
cohort of uninsured children, about a third of them have
actually been on Medicaid in the last year or so. So there's a
lot of turning in and out, and one of the important advances, I
think, that we can do to help children get access to care is to
keep that coverage continuous.
Mr. Jordan. But my point is--so some of these kids who
aren't getting coverage--I mean do your numbers account for
this one-third we've determined that are getting the dental
care? Is it because--could they be, in fact, moving out of
Medicaid and getting care from a private--you know, a private
source?
Ms. Mann. They could be moving out of care and getting care
from private sources. They could be moving out of coverage in
Medicaid and simply being uninsured, but not have a card to
then go to the dentist; and for Medicaid patients, it's
probably more the latter, but it could be either.
Mr. Jordan. What's the percentage of eligible Medicaid
children, the percentage who are eligible who aren't enrolled--
or the number? Give me those numbers.
Ms. Mann. About 7 out of 10 of all uninsured children are
eligible for either Medicaid or CHIP but not enrolled. Some
have been enrolled in the past, but they've been churned
through the program; but at any given time, about 7 out of 10
of eligible children--of uninsured children--could be enrolled
through either Medicaid or CHIP. They're eligible.
Mr. Jordan. OK.
Ms. Mann. That's why enrollment and continuous enrollment
is a very important piece of the quality puzzle.
Mr. Jordan. OK. OK.
Thank you, Mr. Chairman.
Mr. Kucinich. I thank the gentleman.
The Chair recognizes Mr. Cummings.
Mr. Cummings. Ms. Mann, the Government Accountability
Office reported in September 2008 that the extent of dental
disease in children had not decreased between 1994-2005, which
means that kids were estimated to have untreated tooth decay.
Information from that report showed that about one in three
children ages 2 through 18 in Medicaid had untreated tooth
decay, and one in nine had untreated decay in three or more
teeth.
Compared to children with private insurance--and you know,
you know the stats--how much funding was lacking and what was
the cause of unavailability, do you know?
In other words, what is CMS doing about the urgency of the
need for the treatment of these children, some of whom may be
adults now, and how are we addressing that? How do you plan to
address that?
Ms. Mann. I'm sorry. The treatment of adults?
Mr. Cummings. Yes.
Ms. Mann. In the Medicaid program under Federal law,
coverage of dental services for adults is optional with the
States, and as you look through what's going on in the States
now and during a recession, it's one of the first set of
benefits that States will cut out if they're looking to reduce
their Medicaid budgets, so it is not a requirement nor is the
standard, even once they cover an adult in Medicaid, nearly as
robust as the standard is for children.
Mr. Cummings. Ms. Iritani, you were talking about barriers
and what the State folks said were the barriers, and you said
that one of the things that was talked about the most was the
failure to make appointments; is that right?
Ms. Iritani. That's correct.
Mr. Cummings. Did you all have any recommendations as to
how to deal with that?
Ms. Iritani. Our recommendations aimed at CMS were to
conduct more reviews of the States with low access rates.
They--CMS' reviews looked at a number of different access-
related problems, including inadequate provider networks, and
we also advised CMS that they should take action to ensure that
any State found with an inadequate provider network to
corrective action.
Mr. Cummings. Ms. Mann, you know, when Ms. Iritani was
talking about this earlier, I was thinking about how important
it is that parents understand the relationship between teeth
and the rest of the body. I think a parent--any parent wants
their kid to be healthy, but I don't think a lot of parents
have a clue of the relationship between the teeth and the body;
and I'm just wondering did you have any thoughts on that with
regard to making sure that we get that information out there?
We--well, I was the author of an amendment to SCHIP where
we were able to do some things in that regard, but I'm just
wondering: Is that on your list? Because, you know, that's one
of the things that--it might cost some money getting the
information out, but the benefits would be phenomenal compared
to the money that we put out because then you'd have all these
agents call parents, who--you know, it's just like I think of a
parent who thought that their kid had a fever. They would do
everything in their power to address that when, certainly,
tooth decay could lead to something far worse than a fever, and
so I'm just wondering what your feeling is on that.
Ms. Mann. I think you're absolutely right. Prevention is a
key to moving forward. There is a provision--and perhaps this
is the one you're referring to--in the CHIP legislation that
requires education for pregnant women and parents of newborns,
and we are working on developing an education campaign. We're
partnering--we plan on partnering with the Centers for Disease
Control. We've been reaching out to some of the philanthropic
organizations around the country and to look at other
mechanisms to get information out to pregnant women and to
newborns about what they can do.
We also find that the dental utilization rate is much lower
for adolescents, and I think that's also a lack of information
about how important dental care is for teenagers, so I think
coming up with a campaign that helps to provide some
information to parents as well as to teenagers, themselves,
will be really important.
Mr. Cummings. Can you assume--give us a deadline on that,
give us some type of timetable on that since it's such an
important and potentially beneficial and cost-saving thing? We
want to really followup on that, and I have a tremendous
personal interest in that, all right?
Ms. Mann. I would be glad to provide you with a plan and a
timetable attached to it.
Mr. Cummings. Very well.
Thank you, Mr. Chairman.
Mr. Kucinich. I thank the witness for her responsiveness
and the GAO for their report. This committee appreciates your
attendance, and we will be in touch with you regarding our next
meeting. Thank you very much.
The first panel is dismissed. We will now go to the second
panel.
While our staff is concluding its work, this is the
Domestic Policy Subcommittee of Oversight and Government
Reform. Today is Wednesday, October 7, 2009. The title of
today's hearing is ``Medicaid's Efforts to Reform since the
Preventable Death of Deamonte Driver.''
We have heard from witnesses from the GAO and also from the
new director for the Center for Medicaid and State Operations.
We are fortunate to have an equally outstanding group of
witnesses on our second panel.
Burton L. Edelstein, who is a D.D.S. and an M.P.H., is a
professor of Clinical Dentistry and Clinical Health Policy and
Management at Columbia University's College of Dental Medicine
and Mailman School of Public Health. He is founding director
and board Chair of the Children's Dental Health Project--a
D.C.-based nonprofit policy and strategic consulting
organization that advances policies to improve children's oral
health.
Mary G. McIntyre, M.D. and M.P.H., is medical director of
the Office of Clinical Standards and Quality for the Alabama
Medicaid Agency. She received an award from the Alabama Dental
Association's House of Delegates in 2004 for outstanding
leadership and championing the cause for improved oral health
for Alabama's children. Dr. McIntyre served as chairman of the
Robert Wood Johnson Foundation National Advisory Committee
State Action for Oral Health Access.
Joel Berg, D.D.S. and M.S., is professor and Lloyd and Kay
Chapman Chair of the Lloyd and Kay Chapman Chair for Oral
Health. He serves as the Chair of the Department of Pediatric
Dentistry at the University of Washington and dental director
at Seattle's Children's Hospital. He is author of a multitude
of manuscripts, abstracts and book chapters regarding a variety
of subjects, including restorative materials for children and
other work related to bio materials and is coeditor of a
textbook on early childhood oral health.
We have Doctor--or Frank Catalanotto; is that right?
Dr. Catalanotto. Yes.
Mr. Kucinich. D.M.D. He is professor and Chair of the
Department of Community Dentistry and Behavioral Sciences,
University of Florida College of Dentistry. He has chaired a
number of committees in the American Academy of Pediatric
Dentistry. He has served on the editorial board of the
Academy's journal, ``Pediatric Dentistry.'' In addition, he was
a member of the National Affairs Committee of the American
Association for Dental Research from 1989 to 1995. This
committee works with the Federal congressional delegation to
increase funding for dental research, particularly for the
National Institute of Dental Research. He is currently a member
of the Legislative Affairs Committee of the American Dental
Education Association, which advises and lobbies on Federal
policies and appropriations related to dental education and
practice.
I want to thank all of you for appearing before our
subcommittee. It's the policy of our Subcommittee on Domestic
Policy of the Committee of 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. Thank you very much.
Let the record reflect that each of the witnesses answered
in the affirmative.
As with panel one, I would ask each witness to give an oral
summary of his or her testimony. Please keep this summary under
5 minutes in duration, and your complete statement will be
included in the hearing record.
Again, thanks to each and every one of the witnesses for
being here. I would like Dr. Edelstein to begin as the first
witness on this panel.
You may proceed, sir.
STATEMENTS OF BURTON EDELSTEIN, D.D.S., M.P.H., CHAIR,
CHILDREN'S DENTAL HEALTH PROJECT; MARY McINTYRE, M.D., M.P.H.,
MEDICAL DIRECTOR, OFFICE OF CLINICAL STANDARDS AND QUALITY,
ALABAMA MEDICAID AGENCY; JOEL BERG, D.D.S., M.S., CHAIR,
DEPARTMENT OF PEDIATRIC DENTISTRY, UNIVERSITY OF WASHINGTON;
AND FRANK CATALANOTTO, D.M.D., PROFESSOR AND CHAIR, DEPARTMENT
OF COMMUNITY DENTISTRY AND BEHAVIORAL SCIENCES, UNIVERSITY OF
FLORIDA, COLLEGE OF DENTISTRY, REPRESENTING AMERICAN DENTAL
EDUCATION ASSOCIATION
STATEMENT OF BURTON EDELSTEIN
Dr. Edelstein. Thank you, Mr. Chairman, Ranking Member
Jordan and members of the subcommittee. I appreciate the
opportunity to come before you today to testify about the
Federal Government's role and responsibilities in ensuring that
children in Medicaid have access to the dental care that is
entitled to them by Federal law.
I am Dr. Burton Edelstein, Columbia University professor
and Chair of Children's Dental Health Project here in D.C.
The founding of the Children's Dental Health Project in
1997 was a direct response to congressional enactment of the
State Child Health Insurance Program because I, as a pediatric
dentist who treated children on a daily basis, was shocked by
the lack of attention that in 1997 was given to children's oral
health. It was not until the death of Deamonte Driver that so
much attention has been brought to this issue, and the
subsequent work by this subcommittee and others has ensured
that policymaking simply, as you've demonstrated today, will
not leave this issue to fester any longer.
The result of the attention that you have brought to this
issue led to significant improvements in provisions in CHIP
through CHIPRA. I commend the chairman and the committee on
this issue, and I cannot think of a better example of how far
we have come than to have Cindy Mann as the CMSO director with
her personal commitment to children and to children's oral
health.
Clearly, Mr. Cummings, I agree with the statement you made
earlier that we may need to do something different, and I think
we need to explore the limits of what CMS can and cannot do as
well as what it can do in partnership with other agencies
across the Federal Government.
Clearly, all of the progress that has been made has still
left a number of challenges. So, 2\1/2\ years after the
subcommittee launched its investigation, we still have Deamonte
Drivers out there, and we need to consider some of the more
structural and fundamental issues that limit the access to
health care.
At the time that CDHP was founded, subsequent to SCHIP, the
vast majority of advocacy on behalf of oral health for children
was made by organizations of dentists. This makes sense, of
course, because it's dentists who are on the front line of
providing care to children. However, dentists, parents and the
program all both contribute to and can help solve the woeful
inadequacy that you've highlighted today.
When asked about how to improve the program, dentist
organizations typically respond with the very items that we
heard featured today: low payments, complex paperwork and
noncompliant patients. Unfortunately, we have seen in States
across the Nation that addressing these three issues alone--and
many States have taken significant actions on these three
issues--has not led to the kinds of increases that we would
hope for. Research has shown that increasing reimbursement
absolutely is a necessary but not a sufficient condition for
improving dental access.
For example, an analysis done by the California Health Care
Foundation in four States shows that raising reimbursements did
significantly kick up the percentage of kids receiving care but
only from a quarter of children to a third, which is that level
that we're stagnating at today.
Studies currently underway by my research group at Columbia
University indicate that, during the period 1999 to 2006, 41
States did increase fees; 25 showed no increase in utilization
primarily because those increases didn't bring them into the
market. However, amongst the 25 that did have an increase in
both fees and utilization, about half--13--still only reached a
level of 33 percent or more. Overall, in 2006, 20 of our States
still provided care to fewer than one-third, and no State has
broken the 50 percent level yet. A variety of factors
contribute to this problem, which I've detailed further in my
written testimony.
Based on the complexity of this issue, CDHP has advocated
for a holistic approach to improving children's oral health--an
approach that combines both public health and patient-focused
interventions. In my written testimony, I lay out solutions
that can be pursued by a variety of agencies--by CDC, NIH,
HRSA, WIC, Head Start, AHRQ, as well as CMS.
CMS, of course, plays a particularly pivotal role because
it is both the funder and the regulator of so much of this
care, and the suggestions that we've made fall under the three
categories that have been featured already today--leadership,
technical assistance and oversight--which I believe CMS is now
fully committed to pursue. My colleagues and I at the
Children's Dental Health Project look forward to continuing to
work with this committee, with CMS and with all who are
concerned about dental care for Medicaid beneficiaries.
When CDHP was founded, we called it ``a project.'' We
specifically called it ``a project'' with the realization that
the problem we're addressing is solvable. Tooth decay in
children is preventable. The irony is that we're putting so
much effort into chasing after disease that can be prevented in
the first place.
I look forward to continuing to work with you and with all
who care about children's oral health to solve this problem.
That concludes my testimony. I look forward to your questions.
Mr. Kucinich. Thank you very much, Dr. Edelstein.
[The prepared statement of Dr. Edelstein follows:]
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Mr. Kucinich. Dr. McIntyre, you may proceed for 5 minutes.
STATEMENT OF MARY McINTYRE
Dr. McIntyre. Mr. Chairman, Ranking Member Jordan and
members of the subcommittee, thank you for the opportunity to
speak on behalf of the Alabama Medicaid Agency and the
population that we serve.
My name is Dr. Mary McIntyre, and I serve as medical
director, and I'm not a dentist, but a physician, board
certified in public health and general preventative medicine. I
appreciate the opportunity to testify before you today on the
progress that we have made. This has been a 10-plus-year
journey, and it isn't over yet. The vision statement for our
State Oral Health Coalition and for our Smile Alabama!
initiative is to ensure every child in Alabama enjoys optimal
health by providing equal and timely access to quality,
comprehensive oral health care, where prevention is emphasized,
promoting the total well-being of the child.
I have been asked to address the programmatic aspects of
the Smile Alabama! initiative that have, No. 1, improved access
to and the utilization of pediatric dental services and, No. 2,
increased provider enrollment and participation.
More than 10 years ago, the Alabama Medicaid Agency
recognized that significant growth in the number of children
eligible for Medicaid dental services and a decrease in dental
provider participation in the Medicaid dental program had
combined to create a dental access crisis. The dental
utilization rate in 1998 was approximately 25 percent, due
largely to the low number of Medicaid participating providers
but also because of the widespread belief that preventative
dental care for children, especially very young children, was
unimportant. Providers complained of low reimbursement rates,
uncooperative patients and families, and a cumbersome claims
filing process.
A decade later, Alabama Medicaid's dental utilization is up
by more than 62 percent, and there has been a 216 percent
increase in the number of dentists who see more than 100
patients per year. There is greater public awareness that good
oral health is essential to overall health.
What made this possible is the collective determination of
many people in both the public and the private sectors to find
solutions and the willingness of dental providers, State
leaders and others to implement steps necessary to bring about
meaningful change.
While the initiative known as Smile Alabama! was the
primary catalyst to this important public health achievement,
there were several important milestones that laid the
groundwork for its success. These include the formation of a
dental task force, increases in the dental reimbursement rate,
major claims processing changes, dental outreach efforts,
formation of a public-private alliance, creation of an oral
health strategic plan and policy leadership team, convening of
two State dental summits, and finally, the successful funding
and implementation of the Smile Alabama! initiative.
In February 2001, the Alabama Medicaid Agency received a
grant of $250,000 to enhance dental outreach efforts through
the Smile Alabama! initiative. Funding for the grant was
provided through the Robert Wood Johnson Foundation's 21st
Century Challenge Fund--a component of the Southern Rural
Access Program--and was matched by Federal, State and private
funds to total more than $1 million.
In summary, the Smile Alabama! initiative was composed of
four components--a dental reimbursement increase, claims
processing simplification, patient outreach in education and
provider outreach.
In conclusion, in order to improve access to and the
utilization of oral health care services, a focus on prevention
and early care is important. A multi-pronged approach must be
taken for a complex multifaceted issue. Efforts must be
ongoing. None of us want any child to suffer. I, personally,
know what it is to be a child in severe pain from a dental
abscess because my parents lacked the means to obtain care.
States are struggling to maintain services in the light of
severe budget shortfalls. We are currently experiencing
increased enrollment due to the present state of the economy,
with shrinking budgets, while trying to increase utilization.
These factors will limit our ability to push utilization up,
and must be considered in any discussion surrounding finding
the solution to the dental access issue.
It is important that everyone understand that improving the
oral health status of this most vulnerable population will
require an understanding of all of the factors that result in
underutilization.
Thank you for this opportunity to speak today on behalf of
the Alabama Medicaid Agency and the recipients that we serve.
Mr. Kucinich. Thank you, Dr. McIntyre.
[The prepared statement of Dr. McIntyre follows:]
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Mr. Kucinich. Dr. Berg, you may proceed.
STATEMENT OF JOEL BERG
Dr. Berg. Good afternoon, Mr. Chairman and members of the
subcommittee. I thank you for the invitation to testify today.
My name is Joel Berg, and I am the Chair of the Department
of Pediatric Dentistry at the University of Washington, dental
director at Seattle Children's Hospital, as well as the
secretary-treasurer of the American Academy of Pediatric
Dentistry. I am a practicing pediatric dentist, and I care for
a large number of Medicaid eligible children. I am honored to
appear before you today to represent and to share the success
of Washington State's Access to Baby and Child Dentistry [ABCD]
program.
The goal of ABCD is to expand access to oral health
services by Medicaid eligible children from birth through their
6th birthday. More than a dozen nationally publicized articles
and published articles have clearly demonstrated that early
prevention reduces future dental costs and that ABCD is an
effective, cost-saving method of improving the oral health
status of children enrolled in Medicaid. The first ABCD program
was established in 1995 in Spokane, Washington as a
collaborative effort between public and private sectors. The
community agreed that something needed to be done to address
the severe lack of dental access among high-risk, low-income
preschool children.
ABCD programs are locally administered by a health
jurisdiction or a community agency that contracts with the
local health department. The administrator then works with an
identified ABCD dental champion, who is a leading pediatric
dentist or general dentist who is selected and trained by the
University of Washington to identify, recruit, train, and
mentor other local general dentists. ABCD encourages general
dental offices, not just pediatric general offices, to provide
a positive dental experience and a dental home by age 1. The
ABCD program is embedded in many local Head Start and Early
Head Start programs, now both under the American Academy of
Pediatric Dentistry Leadership.
In Washington State, ABCD is a collaborative effort of
Washington Dental Service Foundation, the University of
Washington School of Dentistry, the Department of Social and
Health Services, the Washington State Dental Association, the
Department of Health, local dental societies, and local health
jurisdictions.
ABCD-certified dentists receive enhanced Medicaid
reimbursement for selected procedures on enrolled children.
Dental office staff receive training and communication in
culturally appropriate followup with families, and the billing
staff learns how to work with the Medicaid program.
With the growth of the ABCD program, an increasing number
of Washington physicians is now addressing oral health during
well child checks because ABCD-trained dentists serve as
referral sites. Medicaid reimburses trained and certified
primary care providers for delivering oral screenings, health
education, employed varnish applications during well child
checks, and they make the necessary referrals to dentists.
Today, 31 of Washington's 39 counties--more than 1,000
dentists--participate in ABCD, and several other States have
expressed interest in adopting this successful program. ABCD
has more than doubled the number of young Medicaid children in
Washington to receiving dental care from 40,000 to 107,000--a
utilization increase from 21 to 39 percent.
The ABCD program is reducing overall dental costs.
Education/prevention is most cost-effective during the first 2
years of life, and ABCD is making progress toward increasing
the number of children who receive care before their 2nd
birthday. In 2008, nearly 22,000 children under age 2--19
percent of eligible children--received dental services. When
the program began in 1997, only 3 percent, close to what is
probably the national average today of eligible infants and
toddlers, received dental care.
While targeted enhanced reimbursements for increased
frequency of preventative interventions for young Medicaid
children are extremely important, other elements must be
present to ensure the success of ABCD. The Washington Dental
Service Foundation coordinates the program at the State level,
and provides 3-year startup grants to launch the program
locally so that outreach to families, case management, support
services for the dentists, and other critical activities are
included.
In the years ahead, the ABCD program will be expanding the
use of risk assessment tools as exciting technologies are
emerging. This combined with increasing incentives for earlier
intervention and for higher risk children, an expanding
partnership to refer the highest risk children--the highest
risk and low-income children--to a dentist as early in life as
possible will further improve the oral health of the program's
children.
We must combat the growing crisis in childhood dental
disease and increase access to care to some of our country's
most vulnerable patients. ABCD is a proven best practice that
is working in Washington State. I thank you for the opportunity
to share the success, and we look forward to working with
others States across the country to increase access to dental
care.
Thank you.
Mr. Kucinich. Thank you, Dr. Berg.
[The prepared statement of Dr. Berg follows:]
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Mr. Kucinich. Dr. Catalanotto, you may proceed.
STATEMENT OF FRANK CATALANOTTO
Dr. Catalanotto. Thank you.
Good afternoon, Mr. Chairman and Ranking Member Jordan and
members of the committee.
My name is Dr. Frank Catalanotto. I am Chair of the
Department of Community Dentistry and Behavioral Science at the
University of Florida College of Dentistry. I am here today on
behalf of the American Dental Education Association [ADEA].
ADEA's membership consists of academic dental institutions
who serve as dental homes for a broad array of racially and
ethnically diverse patients, many of whom are uninsured,
underinsured or reliant on public programs such as Medicaid and
the Children's Dental Health Program.
The American Dental Education Association is grateful for
the opportunity to share our perspectives and recommendations
for improving the children's dental program and Medicaid.
First, a couple of comments about academic dental
institutions as safety net providers, and this is the answer to
some of your questions, Mr. Jordan.
Academic dental institutions include dental schools and
dental hygiene schools that provide dental care reduced fees
and provide millions of dollars of uncompensated care in our
clinics each year.
All 59 U.S. dental schools and over 200 schools of dental
hygiene operate clinics that teach students how to treat a
broad array of patients and conditions as part of our
educational mission.
On average, over 53,000 patient visits were conducted
annually at each U.S. dental school, totaling more than 3
million patient visits; and over 50 percent of those patients
were on public assistance programs. At the University of
Florida college clinics, we had over 101,000 patient visits in
2008; and 76 percent of those patients were at 200 percent of
the poverty level or below.
A couple of comments about Medicaid dental benefits and
academic dental institutions.
Safety net dental programs and community health centers,
local departments and academic dental clinics operating at full
capacity are only able to meet about 8 percent of all the unmet
dental needs in this country. There are few public subsidies
that are available to academic dental institutions to help pay
for the uncompensated care we provide.
Medicaid dental reimbursement levels have also been
historically low. On average, they equal the lowest 10 percent
of market rates in many States. In Florida, for example, our
Medicaid reimbursement fees rank at 49th of the States.
Therefore, 74 percent of the 18,000 children we saw in the
University of Florida college and university clinics were at or
below poverty level. In other words, they were on Medicaid. And
the low reimbursement rates we receive put considerable strain
on our ability to continue providing these services.
I would like to give you two examples of how academic
dental institutions can help improve access to care in the
United States.
The University of Florida College of Dentistry has a
Statewide network for community oral health that operates five
dental clinics and is affiliated with nine other clinics
throughout the State of Florida, from Miami to the border of
the western part of the State; and these partners include
federally qualified community health centers, county health
departments, and a mobile dental van. The network serves
Florida's most vulnerable populations and provides
comprehensive dental care in the areas of greatest need around
the State.
The second example, in 2002, the Robin Wood Johnson
Foundation and the California endowment funded a program to
promote community based dental education in 23 dental schools
with grants totaling approximately $38 million. One of the
dental schools funded was the Ohio State University College of
Dentistry. The College's goal with the Robin Wood Johnson money
was to reach populations in need of dental care across the
State. Starting in 2003, when they first received the grant,
the dental school had 10 community based sites. By 2007, they
had expanded to 46 sites where their dental students and
residents provide dental care to underserved and low-income
minority income patients.
So what are the recommendations we have? My written
testimony provides eight specific recommendations that ADEA
would suggest, but I would like to focus on just three of them.
First, fund the expansion of community based dental
education learning programs with academic dental institutions,
and the Robin Wood Johnson pipeline project is an example of
the kind of funding that maybe could be provided at both the
Federal and at the State level.
Second, develop standards and protocols for models of care
that allow other primary care professionals to help gather
data, detect clinically pathological conditions, dental
conditions, triage, and refer patients to appropriate dental
professionals for care.
One of the questions asked earlier was about the role of
physicians in providing oral health services. You may have
noticed in my background that I have a grant from HRSA to
actually train physicians to provide such care to provide oral
health preventive services that are funded by Medicaid, and
involving other members of the health care team is a critical
step in this process of addressing access to care.
No. 3, provide Federal funds to States for school-based
oral health promotion, education, and prevention programs.
School-based sealant programs are another example. In other
words, bring care to the K-12 school system where the children
are.
In conclusion, the American Dental Education Association
believes it is critical for Congress to preserve basic medical
services for Medicaid beneficiaries and safeguard essential
Medicaid dental benefits in any reform of the U.S. health care
system. ADEA and its member institutions are prepared to work
with Congress and other health care advocates to identify
programs and policies that will increase access to care for
underserved patients in Medicaid.
That is my testimony. Thank you very much.
[The prepared statement of Dr. Catalanotto follows:]
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Mr. Kucinich. Thank you, Doctor.
Now you gave us three out of eight.
Dr. Catalanotto. There were two, sir--my apologies--two of
the ones I wanted to assess. My error.
Mr. Kucinich. I just wanted to make sure that you feel that
you communicated your major points.
Dr. Catalanotto. The other six are provided in detail in
the written testimony.
Mr. Kucinich. OK. I just want to make sure that you had a
chance to note that. It sounded like you were on a roll there.
I didn't want to cut you off.
Dr. Catalanotto. Thank you.
Mr. Kucinich. Let's go to questions for the witnesses.
Dr. Edelstein, in your prepared testimony, you address the
situation that occurred in Georgia where vendors cut providers
from their networks to ward off utilization increases imposed
by the States. This is clearly an unintended consequence of
reform that was intended to increase access to care.
In your opinion, what does the evidence suggest about the
consequences of relying upon Medicaid managed care
organizations to provide dental coverage to children?
Dr. Edelstein. What I am referencing there is specifically
placing managed care companies at financial risk. And, as was
mentioned earlier, depending upon the quality of the contracts
and the degree of oversight, it is possible to have a variety
of relationships between a State and a managed care company and
still have a satisfactory outcome.
However, in the case of dentistry per se, there is very
little that managed care companies concurrently do to manage
the care in order to effectuate savings; and so the primary
technique that they have left to rely upon in order to protect
their profit line--because these are for-profit at-risk
companies--is to control utilization. And that means that
there's a perverse incentive built into the concept with regard
to dentistry, because there's very little else that the managed
care company can do to protect its bottom line.
Mr. Kucinich. Thank you, Doctor.
Drs. Berg and McIntyre, if you could both give a try at
answering this one.
Patient compliance is often cited as a barrier to improving
outcomes in State Medicaid dental programs. Both of your
programs have a case management component. And what are some of
the specific interventions of case management?
Before you answer that question--Ms. Mann, I just want to
note something. First of all, you may be one of the only
administration official who has actually stayed to hear
witnesses on the next panel. It's very rare and refreshing.
Thank you.
So, Dr. McIntyre and Dr. Berg, what are some of the
specific interventions of case managers in your programs that
increased patient compliance?
Dr. McIntyre. I want to start first with a regional--
because we kind of redesigned things with our First Look
Program, but we originally wanted to address the issues that
the providers themselves talked about, which was the missed
appointment. And what the care coordinators provided was the
means of actually contacting patients to assist them with
getting into their providers' offices. You know, they address
issues such as the care of the other children, which is
something that a lot of times people didn't think about. Well,
what did they do with the other kids when they really have an
appointment to see the dentist for maybe one or two of those
children, issues such as transportation to the dental office.
And sometimes there were issues that didn't have anything
to do with the transportation. There were issues concerning,
well, I don't know how I am going to pay rent tomorrow, so I am
not really worried about keeping a dental appointment next
week. So that the care coordinators had to get into not just
the issues of the dental appointment themselves but also the
other issues that were surrounding the reasons why these
patients wouldn't keep appointments.
And then one of the things we had to deal with was also to
address the dental provider's problem about behavior in the
office, and we did that also as part of this program. We are
trying to educate them on, you know, taking one child and
making sure that you are on time for your appointments.
Mr. Kucinich. Thank you, Dr. McIntyre.
Dr. Berg, would you like to respond?
Dr. Berg. Yes, Mr. Chairman.
I think you were pointing out that one of the most
important aspects of the ABCD is the local ABCD coordinator. It
is a county specific--or local health jurisdiction specific
program. And we found, indeed, that in the smaller local health
jurisdictions it's easier to get access to care through the
ABCD program because it's easier in the smaller communities to
coordinate efforts. We found, actually, that we had lower no-
show rates than some of the ABCD programs in most jurisdictions
then with the non-Medicaid populations. We have evidence to
show that.
So these care coordinators are absolutely critical in the
scheme of things to make things work. We have evidence of that
in different counties.
Mr. Kucinich. Thank you, Dr. Berg.
The GAO study reveals that States overwhelmingly would like
additional guidance from CMS. So if we could again hear from
Drs. McIntyre and Berg, from the State perspective, what
specific suggestions do you have for CMS to improve the
guidance they provide to State Medicaid systems?
Dr. McIntyre. Well, as a State that I think we had a
relatively--what could I say--a very good relationship with our
regional office when it came down to getting assistance, we
didn't have any problems recalling. But specifically when it
comes down to recommendations, the main thing is to communicate
specifically what we can and cannot do from a State standpoint.
And I think a lot of times States are under the, I guess,
misinformation as far as with misunderstandings about what
policies will allow them to do or not do.
But we didn't have it, that particular issue, because we
got clear communication about, well, you know, when it came
down to Smile Alabama!, no one told us that we couldn't go
after outside funding, so we did. We did a check, and it was
OK. So we went after funding in order to do the program.
But I think there's something that other States need to
know, that you don't have to deal with just the money that you
have, you know, within the State coffers, that you can look
beyond that and identify private-public partnerships in order
to do some of the programs that you want to do from a State
standpoint.
Mr. Kucinich. Thank you, Doctor.
Dr. Berg, if you could answer. My time has expired, but
please just give a brief answer.
Dr. Berg. Yes, please. I will give specific
recommendations.
The State of Montana just adopted an ABCD-like program
modeled after Washington State's program. They actually did
what we would have liked to have done this year, but it wasn't
fundable in the current legislature, and that is to incentivize
earlier intervention where we can separate the highest-risk
children.
We know that, as was stated earlier, 80 percent or
something of the cost is spent on 25 percent of the children,
and that starts at about age 2\1/2\ or 3. If at age 1 we can
identify who they were and segregate them and have more
aggressive intervention for the higher-risk children, we can
save money. We have actually done an economic modeling of this
through our health economist and have shown that it can work.
So I would absolutely look right now at earlier
intervention, incentivizing earlier intervention, incentivizing
higher risk, more aggressive interventions.
Mr. Kucinich. Thank you very much.
The Chair recognizes Mr. Jordan.
Mr. Jordan. Thank you, Mr. Chairman.
Let me thank the witnesses, too, and for your commitment
for helping these children.
You know, the goal is, as Dr. Berg just said, to treat them
as early as possible so we save on costs in the long term and,
obviously, hopefully avoid any type of tragedies like with
Deamonte. And I appreciate the work that the universities are
doing. It was great to hear that. I think I got the numbers, 3
million you said.
Dr. Catalanotto. Three million dental visits across the 59
dental schools. That does not include any visits that might
have occurred at----
Mr. Jordan. In a year.
Dr. Catalanotto [continuing]. Dental hygiene programs.
Mr. Jordan. Wow. You said at your university you had
100,000 last year.
Dr. Catalanotto. 100,000 visits, 76 percent of which were
patients at 200 percent of the poverty level or below.
Mr. Jordan. 100,000 children?
Dr. Catalanotto. No, 100,000 dental visits. There were
26,000 children of that 100,000.
Mr. Jordan. We appreciate all that.
Dr. Edelstein, in your comments you said three things--
paperwork, low reimbursement rates, and noncompliant patients--
make it tough for certain providers to do this care. Which of
the three is the one that--if you had to rank order those
three, which is the one that is the most difficult for dentists
to deal with?
Dr. Edelstein. The one that is perceived and reported to be
the most difficult is the low reimbursement, and the point I
had hoped to make clear is that sufficient funding is a
necessary but not sufficient condition.
Mr. Jordan. Would it help--let me ask you this question. I
am going to ask some fundamental questions here.
Would it help if dentists would be able to--for those
families who can pay something, would it help if they could
say, OK, Medicaid covers this much and would you as a family be
willing to pay X amount of dollars to cover the cost of the
care? Would that help?
Dr. Edelstein. I have no idea, except to suggest that it
would create a significant--as small business people, it would
create significant billing hassles and problems trying to deal
with the copayments. As a practitioner who actively
participated in both Medicaid and CHIP in Connecticut where
copays were allowed for some CHIP patients in Connecticut, we
did confront significant problems with trying to manage that
cost-sharing portion.
Mr. Jordan. OK.
So, again, you started--I think you were starting to say
that what you hear typically is low reimbursements is the
single biggest reason given for not accepting these patients.
But it sounds to me like that's not what you believe. What do
you believe?
Dr. Edelstein. Well, the ``but'' was that our study nearing
completion now tried to assess the impact of different levels
of fee increase on utilization; and what we discovered were a
couple of things. First off that with the increases, generally,
you have the same providers who were already seeing Medicaid
patients seeing many more Medicaid patients, rather than
bringing a lot of new providers into the actual provision of
care.
Now, that's when fees are the primary intervention. As Dr.
McIntyre mentioned, in Alabama, there was additionally some
case management and reductions in paperwork with prior
authorizations. So a multi-pronged approach did help.
On the other hand, even in Alabama, with all of its
tremendous effort, we see that relative increase was
tremendous, but we still hit the same sort of barrier, hitting
the top levels that any States have hit in the 40 to 45 percent
range. And it's tempting to think that barrier really
represents parents' failure to pursue care, but, in fact,
parents are able to obtain significantly higher levels of
medical care, raising the question about whether the doors to
the dental offices are truly open.
Mr. Jordan. OK. What--you mentioned noncompliant patients
as one thing here. Do you think that's a real problem or not?
Dr. Edelstein. Well, the noncompliance has to do with
appointment keeping; and I think Dr. McIntyre explained how
complex some of these individuals' lives are. But there's an
excellent example that I cite in my written testimony from New
York State, Tompkins County, where a county level care
coordinator liked what the American Dental Association has
suggested, as the community dental health coordinator acted as
a case manager.
Mr. Jordan. Let me just ask this question of all of you and
see what you thought. And I brought this up, I think, in the
very first round of our first panel.
You know, there are all kinds of taxpayer assistance that
the typical Medicaid-eligible family receives. I kind of come
from the school of thought that says, if you want responsible
behavior, you should reward it and irresponsible behavior,
there should be some kind of penalty for it.
Do you think it would make some sense if, in fact, parents
aren't complying with the appointments that they have, aren't
doing what needs to be done for their kids relative to dental
care, if there was some kind of sanctioning or some kind of
penalty in--you know, typical families getting nine or ten
different types. They are getting TANF. They are getting
housing. They are getting food stamps. On and on it goes.
Some kind of sanctioning process, do you think that would
be helpful, along with what Dr. McIntyre, I think, and Dr. Berg
referred to in a previous answer, the care coordinator and the
case manager approach as well?
Let's go down the line.
Dr. Edelstein. I personally am more of a carrot than a
stick person, thinking that as soon as there is a clear
understanding of what the child's needs are that there be an
effort to engage the family in a positive way. My concern is
the child and recognizing the complexity of some of these lives
to get to whatever benefits the children.
Mr. Jordan. Yes. It seems to me--look, I know we did well
for reform in the State of Ohio. I was the guy who did the
language on the time limits component, and we said we are going
to make sure kids get health care. We are going to make sure
kids get, you know, the food they need. But at some point, if
an individual is not willing to work and they are an able-
bodied adult, they are no longer going to receive cash from the
taxpayers. And it was a long period of time, and we gave them
job training and everything else.
But at some point if you don't have that deadline, if you
don't have--I would say deadlines influence behavior. And if
you don't have that out there as some kind of thing that
everyone has to think about--we all have to function. Everyone
in the world has to function under those kinds of responsible
things and those kinds of deadlines. It seems to me there might
be an approach in there that can work and still make sure that
these kids get what they need.
Dr. Edelstein. Perhaps when dental access is readily
available, when those office doors really are open and parents
can have success in pursuing their desire to find treatment for
their kids, then perhaps it would be time to think about the
sticks.
Mr. Jordan. Mr. Chairman, if I could, real quick----
Mr. Kucinich. If you can give a quick answer.
Mr. Jordan. I thank the chairman's indulgence.
Real quick----
Mr. Kucinich. Just give a brief answer.
Dr. McIntyre. From the standpoint--I am like Burt. I look
at the carrot versus the stick. And the reality is that
sanctions will really hurt the children. Because what we are
looking at is you are sanctioning the parents for behavior that
the kids have no control over. And then what happens is they
don't get into care. So really it would only hurt them.
Mr. Jordan. The only thing I would say is----
Dr. Berg. I would agree with the last part of Dr.
Edelstein's statement as well, that when the access problem is
solved and there is much more readily available access, then we
could look at some pilot projects perhaps to study that. I
think we don't have enough information to know if it's
effective or not. I would want to study it on a small scale to
see what kind of effectiveness we have.
Dr. Catalanotto. Just to emphasize that, in Florida, for
example, only 10 percent of Florida dentists see Medicaid
patients. Our numbers are worse than the rest of those States.
We only have 25 percent of children achieving any kind of
dental visit.
So until you solve the access problem, it's not--I don't
think it's appropriate to talk about punishment for the
parents, which ultimately punishes the child. We need to fix
the access problem first.
Mr. Kucinich. I thank the gentleman.
The Chair recognizes Mr. Cummings.
Mr. Cummings. Dr. McIntyre--thank you, Mr. Chairman.
Tell me, what part did--first of all, the folks who you all
hire, are these a lot of community people? In other words, that
have the kind of sensitivity that you are talking about?
I think they first have to understand--it really reminds me
of Healthy Start. In other words, you have people who
understand the complexity of people's lives. They understand
that punishment is--I could have answered that question. That's
not going to get it, because then they will drop out of the
system.
Dr. McIntyre. They will.
Mr. Cummings. But so you must be--you must look at a
certain type of worker who has a certain level of sensitivity.
Dr. McIntyre. We didn't hire anyone. Let me get that
straight. This is--remember when I talked about public-private
partnerships? We actually worked with the Health Department to
get care coordinators in the community.
Mr. Cummings. I see.
Dr. McIntyre. So that many of these people were folks that
knew people already, that people were comfortable with. They
were at the community level. They were on a county level. So
that when you are calling to get a child in that a lot of times
these people really know who the children are.
Mr. Cummings. I see.
Dr. McIntyre. So I think in that standpoint we didn't go
out and hire a bunch of people. We worked with the Health
Department to get care coordinators at the county level in
order to work to put this program into place.
And that's the whole thing about working together with all
of the different entities within the State. It's not just a
Medicaid issue. It's an issue that involves the entire State,
and it involves all the people that are there coming together
to try to come up with a solution.
Mr. Cummings. Dr. Edelstein, we were talking about the
whole idea of--you were here earlier when we talked with the
other panel about this whole idea of a campaign to educate
parents with regard to the significance of dental care for
their children. Tell us, how do you feel about that? I mean, do
you think that is very significant?
Dr. Edelstein. Yes. The parents clearly have a critical
role, particularly, as Dr. Berg mentioned that the disease
onset is very early in life. And so we need to get to parents
very early in life, as required now by CHIPRA.
But one of the roles for the parents is the day-to-day,
moment-to-moment decisions that they make that either
predispose their kids to have this problem or predispose their
kids to avoid this problem. And so the education needs to be
about more than dental care but has to be about managing the
risk factors for developing the disease in the first place.
Mr. Cummings. You know, I visited Kennedy Krieger in my
district. They have this clinic for severe dental problems for
kids, and they showed me some kids who had had phenomenal
damage as little kids. I mean, who literally had to go through
major surgery as a little kid--I mean, like 3 years old--
because of things like a bottle with sugar, like juice bottles,
and the sugar gets to the tooth. And a lot of people don't
realize how significant those little things are. And I just
think that education is so significant.
The other thing I was going to ask you about is these
federally qualified health centers. One of the things that I
pushed hard for is making sure that they could contract with
dentists. Because a lot of times that's a missing piece, and
those help centers are located smack dab in the middle of
places where people would not normally be able to get health
care.
You might want to comment on that, too, Dr. McIntyre----
Dr. Edelstein. Well, if I might reflect on the value of
that contracting, it has so many values. The first is that it
allows dental practitioners who are not Medicaid providers to
contract with FQHCs to see Medicaid patients and thereby become
familiar with the patients as people, as patients who they can
become more comfortable with and discover really face the same
kinds of dental issues that others do and can be readily
accommodated in their practices.
The second is that it expands the capacity of the federally
qualified health center. So many of the health centers are
limited either by not having dental facilities themselves or
having facilities and no dentists, because there is a shortage
in the FQHC system. So that allows them to contract with
dentists to expand their capacity.
So, on both sides, it benefits the patients, it benefits
the dentist, it benefits the health centers. And we anticipate
that experience the dentists will have will lead them more
likely to become active Medicaid providers.
Mr. Cummings. Dr. McIntyre, did you have a comment on that?
And thank you.
Dr. McIntyre. Yes, I wanted to comment that, in looking at
the public-private partnership, the FQHCs are vital in making
sure that we identify all of the resources available.
And some of the things we did was also identify not just
the Medicaid dentists per se but also for uninsured--because a
lot of our uninsured go on and off, you know, their own
Medicaid; then they have no insurance at all--to make sure that
those resources are available for them.
But there is a shortage. When we talk about addressing
access issues, one of the things I wanted to bring out was
this: Overall, in our State, as of May, we had a shortage of
288 dentists. Now this is not Medicaid dentists. This is a
shortage in dentists in the counties.
So, in addressing the issue, we have to address the work
force in order to--like, he was talking about are their doors
really open? Well, the doors are open, but who gets in it to
see is something that you have to consider when you are looking
at that. Because the work force itself is part of this problem.
Mr. Cummings. Thank you.
Mr. Kucinich. I thank the gentlewoman.
The Chair recognizes Mr. Issa.
Mr. Issa. I thank the gentleman.
I thank the chairman for holding this hearing, because I do
believe it is important that we as a committee that looks at
waste, fraud, and abuse also look at government efficiency; and
that's, I think, a great deal of what we want to work on here
today.
Before I do my comments, I would like to yield to the
gentleman from Ohio for his question.
Mr. Jordan. Well, just a quick comment, and I do have to
run to an RC thing.
I could tell the panel didn't particularly like my
suggestion about holding parents more accountable. But I would
just point out this. We heard from the previous panel that the
number was one in three kids, 33 percent, were getting the
treatment, according to the study done in 2008. And since that
time Ms. Mann's answer was it has been improved all the way up
to 36 percent now.
So, obviously, what we are doing isn't working. Maybe it
makes sense, you know, to try the same old, same old, giving us
the big increase of 3 percent. Maybe it makes sense to try
something different and go the route that I suggested. That's
my only point. I know it's worked in other parts of welfare
reform. It has worked in the State of Ohio.
So I would just offer that and thank the gentleman for
yielding me a few seconds.
Mr. Issa. Now I am going to take a slightly different line
of questioning.
I guess I have an MD, a DMD, and two DDSs, so that probably
gives me all of the passel of opinions.
When I was growing up in Cleveland, Ohio, right next to but
slightly down the street from the chairman, we still had a
great deal of, if you will, the public health care system; and
a lot of the services at that time were delivered through
nonprivate means if they were going to be delivered. I got my
shots through the public system and so on. And that delivery
system for the working poor and even up tiptoeing through the
middle class and certainly for what we would call the most
indigent among us today was an accepted part of society.
It appears to me as though, as we have divested ourselves
of that, and the Medicaid system has been about money being
delivered, often, often not at the same rate, haven't we moved
away from--at least germane to today--if preventive medicine,
recognizing that dentistry expands to fill the amount of money
you have, that if you have enough money--and we here on the
dais don't have a dental plan--or at least it's not standard in
our program. If you have enough money, you don't get amalgam.
If you have enough money, you don't get false teeth; you get
implants. If you have enough money, you go through a series of
much more expensive levels of care. And I think you are all
aware of just how phenomenal dentistry can be if you have the
dollars for it.
But aren't we here today talking fundamentally about the
least--trying to find the most efficient, least expensive, most
universal for the poor delivery of evaluation, cleaning, and
prevention? And isn't our system somewhat broken in that if
that's what you wanted to provide, would you provide it the way
you do today? And this is regardless of 3 percent more money, 6
percent less money.
I would like your comments on that. Because, for this
committee, we do try to think in the sense of organization of
government.
I will go right down the line. Thank you, Doctor.
Dr. Edelstein. Interestingly, this problem is not unique to
the United States; and underserved populations having lack of
dental care is a global phenomenon. So if we look at other
countries like ours--Great Britain, New Zealand, Australia, the
Netherlands--to see how they have approached this, they do it
primarily with the advent of different kinds of providers. I
wouldn't say that it's necessarily a public delivery system, as
opposed to a private delivery system, but it's a more readily
accessible, more limited in scope provider who is more like the
vulnerable population being treated.
And there are a number of ideas, from the American Dental
Hygienists Association, the American Dental Association, new
legislation in Minnesota, experiments and new programs in
Alaska, a variety of approaches that bring dental therapists to
increasing the capacity for the delivery of services. So,
looking at other countries, that might be one direction of
particular value.
Mr. Issa. As you go down the list, the reason I said
``public'' is that I understand that dental practice and State
regulations tend to predetermine certain things such as a
hygienist being able to work on their own or not, an assistant
work on their own or not. I used the term ``public'' because
it's a preemption for the poor potentially that would allow us
to find the most efficient way to provide preventive medicine
that might not be universally available in some States. Being
in California now, I am aware of that.
Please, Doctor.
Dr. McIntyre. Well, as a physician, one of the things that
I started out with our group, when we first formed our task
force in our coalition, was that the mouth is part of the body
and that for some reason we have kind of separated it out and I
think a lot of problems came from that.
But we have actually started using our primary care
providers, physicians, more because dental caries is a disease
and, like any disease, in order to get away from the disease
later, we have to prevent it. So if we can start early, when
children first get their teeth--you know, when they get those
first two in the mouth, even before they get their teeth, we
start educating mothers when they are pregnant about what they
need to do. They get brochures and information from the care
managers about how to take care of the teeth and the babies
aren't here. They are more likely to listen before the babies
are born. Then when they get here, then doctors who see
children and give them their shots is an ideal opportunity to
educate, assist, and refer; and that's what we are trying to do
to utilize the system.
Mr. Issa. If we could narrow the answer just to the
organizational one, because I am testing the chairman.
Mr. Kucinich. Please respond, the gentleman's time has
expired.
Dr. McIntyre. And that is part of the organization.
Mr. Issa. Thank you.
Dr. McIntyre. Using physicians to do part of the work, OK.
Dr. Berg. My comment is a summary of what has been stated
before. That dental caries, cavities in kids is almost entirely
preventable; and the earlier you intervene, the more
preventable it is. And the other nondental providers who aren't
treated in the surgical aspects of dentistry can assist us in
the risk assessment of prevention. You know, the fluoride
varnish is not the cure. But the risk assessment, determining
who is at greatest risk and providing more aggressive and
frequent interventions, that is the solution.
So I think we need to segregate the surgery and not think
about dentistry as surgery. We have dentists who can do
surgery. We need some assistance in the earlier intervention
for those folks, as mentioned, who do see the children earlier.
Mr. Issa. Thank you. Please.
Dr. Catalanotto. The other part that I would mention about
this is that there is a fundamental problem, though, in the
dental public health infrastructure. What I mentioned in my
testimony is that, assuming you had, at full capacity, the
existing public health infrastructure, the dental institutions,
county health departments, federally qualified community health
centers, they can only address about 8 percent of the dental
need that's out there.
So part of your solution that you need to look at is
improving the dental public health infrastructure.
Mr. Issa. Thank you. Thank you for your indulgence, Mr.
Chairman.
Mr. Kucinich. Thank you.
The Chair recognizes Ms. Watson.
Ms. Watson. Thank you very much, Mr. Chairman.
I want to address this particularly to Dr. McIntyre and Dr.
Berg. I think your two States have participated in some
promising practices that were posted by CMS; and, in a survey
that was taken by GAO, there were 37 States who indicated a
need for more information on other States' efforts. And have
you then shared that information? Have you been part of it,
Promising Practices, that was initiated by CMS? And can that
Web site then be promoted to other States that need this
information?
Dr. McIntyre.
Dr. McIntyre. Well, we have actually provided information
to a number of people, including CMS.
Now, as far as whether it's part of the Promising, I know
that we have actually published articles. We put out
information on our Web site. We mailed out brochures to all 50
States. It's, you know, basically in the past, to actually give
them the information about what we were doing. So--and we
actually put the information where it is accessible, and we are
willing to share it with anyone.
Ms. Watson. One of the things that concerns me is that many
of the dentists kind of look at the Medicaid beneficiaries and
say, I really don't want them. What's with that attitude?
Dr. McIntyre. I mean, I think that's a matter of education
as well; and it goes on both sides. Part of what we did as part
of our provider education and outreach was to educate providers
that it was a two-way street. And that in order to receive, you
know, the behavior that they were expecting, they also needed
to be willing to treat people with respect. So we came up with
a dental rights and responsibilities sheet that addressed the
provider on what they could expect and what the patient could
expect from the provider and for both of them to sign it.
And the reason for that is--and I am saying this because,
as a child who grew up with no insurance and no access to
health care, OK, and people a lot of times are looking down on
people just because of their income levels, is something that
we have to go beyond. And that is one of the things that we
address with the providers, that, you know, if you expect
people to behave a certain way, you have to treat them so that
they will behave that way. If you expect bad behavior, you will
get bad behavior. So that's part of the education that we deal
with our dental task force.
Ms. Watson. Dr. Berg.
Dr. Berg. Yes, I think, part of the success of ABCD is
training and cultural sensitivity. That's a big part with the
staff, and it's effective. You know, that there are unique
needs of this different population, their circumstances are
different, and that has been critical to the success. So I will
just add that statement.
Ms. Watson. Well, let me give you a pet peeve of mine.
I had a bill for the last 8 years to look at dental
amalgams. Amalgams are, as you know silver fillings. They are
50 percent mercury. Mercury is the No. 1 toxic element. And I
have been getting to the dentists. In fact, the minority
dentists came in, and they are adamantly opposed to it because
they say it's cheaper to put an amalgam filling in.
Well, the research shows that when you have mercury in your
fillings, it is constantly--gases are constantly escaping,
particularly with children. So I find a real problem with the
dentist that says to me, it's a matter of cost. And, you know,
we have now, in your States, Medicaid providing dental health
care; and then we don't have this kind of patient result.
However, when you get the industry saying to you, it's a matter
of cost, black people don't like to go to the dentist, so this
is the cheapest we can give, I think that's a violation of
ethics. How do we continue to educate these dentists? Anybody
want to take a swipe at that?
Dr. Berg. You are talking about the amalgam question
specifically?
Ms. Watson. Yes.
Dr. Berg. I think, first of all, to remind them that only
about 6 percent of their total cost is materials, including
amalgam and other materials; and the real cost is how efficient
they are at running their practice. And I think there are best
practices and ABCD has an annual meeting where our champions
come together and talk about how do I run efficiently in my
office. And by changing those behaviors in their office, they
can do well by doing good and be much more efficient. So I
think that's the focus we give.
By the way, I think, in our State, I wouldn't say there's
any differentiation in any population in terms of who gets
what, restorative procedure. We don't happen to do many
amalgams, because there are alternatives today. Some do. But I
think we like to educate that it's the efficiency of running
the practice where they are going to save the money, not--
difference of materials are really minuscule compared to staff
costs and other costs in the practice.
Ms. Watson. Thank you.
Thank you, Mr. Chairman.
Mr. Cummings [presiding]. Thank you very much.
We are going to conclude this hearing. But I want to thank
all of you for your testimony.
As a representative from the State where Deamonte Driver
died, this hearing means a lot. I have often said that Deamonte
Driver was a little boy who was suffering from an infected
tooth, and he died in one of the richest States in one of the
richest counties in one of the richest countries in the world.
There is something wrong with that picture, and we can do
better.
Dr. McIntyre, I was just thinking, as you were talking
about this whole idea of people just getting respect, a lot of
times people don't realize it, but people feel so often that
folks are talking down to them, and they don't--so they don't--
they feel that they are not respected.
When we look at health care disparities, for example, one
of the things that is clear is that there is a divide and some
type of misunderstanding between, sometimes, those people who
are trying to treat and those who need treatment. And so I
think it's very important that, when we look at the Deamonte
Drivers, we look at all the kinds of things you have talked
about here today.
And I was glad that Ms. Mann stuck around to hear some of
this.
One of the things that Ms. Mann said was--not Ms. Mann but
our gentlelady, Ms. Iritani, said was that they wanted--these
other States wanted to know best practices. Duh. I mean, this
is not rocket scientist stuff. This is basic common sense and
trying to work things out and treating human beings as human
beings.
So I just kind of think--I know we made a lot of headway,
but I just wanted to take the time to thank all of you all
every day because you are affecting children.
I mean, and I say over and over again, children come on
this Earth with gifts. They bear gifts. Every one of them bears
gifts. They are born on the day that they are born to deliver
gifts at certain points in their lives. But what happens is
that, if we don't treat them right and we don't nurture them
and nourish them and help them develop, they will never deliver
those gifts. And if they are sitting, as I did as a little boy,
sitting in elementary school thinking that cavities was a part
of life. It wasn't a question of--it was like a headache. You
are supposed to have cavities. And a lot of people are still
thinking that today.
That's why this whole education thing is so significant,
letting people know. And that whole idea of letting them know
there is a direct relationship between the body and teeth, they
don't think it.
So I think all of us--I mean, the testimony that you all
have provided today is basics. And, hopefully, somebody is
listening, somebody will come to you all--because you all seem
to know where you are going, and you are on the right path--and
allow you to help others to get it.
Now, the question becomes sometimes not whether people get
it but whether they want to get it, whether they have the will
to do what's necessary; and that's where we are going to come
in. We are going to try to do everything in our power to make
sure that our children, that the providers, that the States,
and that all others have the kind of information they need so
they can touch our children in a positive way and look out for
generations yet unborn.
Finally, let me say this. This is about--this is bigger
than us. This is bigger than us. When you were talking--Dr.
McIntyre talked--you know, it's a great idea to educate mothers
before they give birth. Because, you know, all that excitement
you have when you find--you know, I am not a woman, so I don't
know, but folks get real excited about their first birth in
particular. And they go and they prepare the room and all that
kind of good stuff.
And then the question becomes, you know, shouldn't part of
that preparation be making sure that you are prepared for the
teeth of that child and the dental health?
And what I was telling my aide, you know, was that the
wonderful thing about it was that if you then educate, first,
the mother delivering the first child, then that sets a pattern
for the other children that may come. But it does something
else. It then teaches the child as the child grows up how to
take care of their teeth and then hopefully generations--you
have generational cycles of good teeth, taking good care of
your teeth. That's what it's all about.
So thank you all very much. This hearing is now adjourned.
[Whereupon, at 5:05 p.m., the subcommittee was adjourned.]
[Additional information submitted for the hearing record
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