Improving Oral Health: Improving Oral Health: Strategies for Strategies for

Increasing Available Increasing Available ProvidersProviders

H. Bryan Tomlinson, II, Director of Health Care Services

Virginia Department of Medical Assistance Services

National Association of State Medicaid Directors2007 Fall Conference

Washington, DCNovember 13, 2007

2

Virginia Virginia Medicaid/SCHIP Medicaid/SCHIP Dental BenefitsDental Benefits

Approximately 490,000 eligible childrenApproximately 490,000 eligible children

Dental benefits for children in Dental benefits for children in Medicaid/SCHIP include:Medicaid/SCHIP include: Diagnostic, preventive, restorative/surgical Diagnostic, preventive, restorative/surgical

procedures and orthodonticsprocedures and orthodontics

Dental benefits are not covered for Dental benefits are not covered for Medicaid adults, except for limited oral Medicaid adults, except for limited oral surgery (e.g. extraction of infected teeth surgery (e.g. extraction of infected teeth complicating a medical condition, etc.)complicating a medical condition, etc.)

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Access to/Utilization of Access to/Utilization of Dental Services Needed to Dental Services Needed to

ImproveImprove

In FY 2003, 23.4% of In FY 2003, 23.4% of eligible children eligible children received servicesreceived services

Low participation of Low participation of all VA licensed all VA licensed dentists (620 of dentists (620 of 4,786) in the 4,786) in the Medicaid/ FAMIS Medicaid/ FAMIS programprogram

87%

13%

Not Participating

Participating

Dentist Participation in Medicaid/FAMIS*

*FY 2003

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DMAS Dental SurveyDMAS Dental Survey

Survey was developed to identify the Survey was developed to identify the reasons providers did not want to reasons providers did not want to participate in the Medicaid/FAMIS participate in the Medicaid/FAMIS dental programdental program

Survey was mailed to all licensed Survey was mailed to all licensed dental practitioners in Virginia (over dental practitioners in Virginia (over 4500) in 20044500) in 2004

Over 1000 surveys were completed and Over 1000 surveys were completed and returned to DMAS. (22% response rate)returned to DMAS. (22% response rate)

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Barriers to ParticipationBarriers to Participation

ReimbursementReimbursement Claim SubmissionClaim Submission Prior authorizationPrior authorization Timeliness of paymentTimeliness of payment Availability of specialistsAvailability of specialists Patient behaviorsPatient behaviors

Broken appointmentsBroken appointments Non-complianceNon-compliance

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Would you consider Would you consider participating if fees participating if fees

increased?increased?

0

10

20

30

40

50

60

70

80

Per

cent

age*

Yes

Yes, if other changesmadeNo

* Percentage of those that answered particular question

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Program GoalProgram GoalImprove Access to Quality Dental

Care to Medicaid/SCHIP Recipients

Increase Provider Participation

Increase Pediatric Dental Utilization

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Stakeholder Stakeholder Engagement Engagement

Advocacy Groups

MCOs

Organized

Dentistry

Medicaid/SCHIP Agency

Governor

Legislature

New Medicaid/ FAMIS Dental

Program

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A New Day for Dental! A New Day for Dental! Smiles For ChildrenSmiles For Children

Effective date: July 1, 2005Effective date: July 1, 2005

New program was labeled New program was labeled Smiles For ChildrenSmiles For Children with a new logo and registered service markwith a new logo and registered service mark

All children (Medicaid & FAMIS) were enrolled All children (Medicaid & FAMIS) were enrolled in a single program administered by Doral Dental in a single program administered by Doral Dental USAUSA

Limited medically necessary services for adultsLimited medically necessary services for adults

Medicaid/SCHIP retains policymaking authority and Medicaid/SCHIP retains policymaking authority and closely monitors contractor activitiesclosely monitors contractor activities

New program is fee-for-service and non-riskNew program is fee-for-service and non-risk

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Fee-for-Service with a Fee-for-Service with a Commercial FlareCommercial Flare

Many principles of a managed care Many principles of a managed care product were adopted:product were adopted:

Coordination of Care Coordination of Care Provider CredentialingProvider CredentialingNetwork DevelopmentNetwork DevelopmentMember OutreachMember OutreachQuality Improvement Quality Improvement ProgramsPrograms

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Key Program Key Program EnhancementsEnhancements

Old Program Multiple Vendors

Multiple credentialing processes

Complicated Administration

Limited local representation on program policy decisions

Enrollee transfer between plans disrupted care

Smiles For Children Single Vendor (Doral)

Streamlined Credentialing

Easy, Industry-Standard Administration

VA Based Peer Review Committee/Dental Advisory Committee

All enrollees in Smiles for Children program

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ResultsResults

Increased Provider Increased Provider NetworkNetwork

387 new dentists are 387 new dentists are participating (62% participating (62% increase)increase)

Percentage of Percentage of contracted providers contracted providers who are billing for who are billing for services has services has increased from 50% increased from 50% to 83%to 83%

620

1007

500

600

700

800

900

1000

1100

1200

Jul-05 Sep-07

Participating Providers

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Incentives to Attract Incentives to Attract ProvidersProviders

Increased ReimbursementIncreased Reimbursement Improved ease of administrationImproved ease of administration Conformed to commercial practices Conformed to commercial practices Reduced broken appointmentsReduced broken appointments Offered superior provider relationsOffered superior provider relations Provided flexible levels of Provided flexible levels of

participationparticipation Collaborated with dental communityCollaborated with dental community

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……..And Increased Access ..And Increased Access to Careto Care

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Ages 0-20 Ages 3-20

SFY 2005 SFY 2006 SFY 2007

Percentage of Children Receiving Dental Care

24%

29% 29%

36%

Source: CMS 416 Report for Virginia

35%

43%46%48%

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Lessons LearnedLessons Learned Reduce program requirements for Reduce program requirements for

providers who uphold high standards of providers who uphold high standards of carecare

Centralize and standardize processes Centralize and standardize processes through advanced web based servicesthrough advanced web based services

Promote best practicesPromote best practices Acknowledge dental community Acknowledge dental community

participation to state legislators and participation to state legislators and public policy groupspublic policy groups

THANK providersTHANK providers

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On-Going ChallengesOn-Going Challenges

ReimbursementReimbursement Prior program experiencePrior program experience Provider attitude towards Provider attitude towards Medicaid Medicaid enrollees enrollees

Payor environmentPayor environment Recruitment in rural areasRecruitment in rural areas

1-888-912-3456http://www.dmas.virginia.gov/dental-home.htm

http://www.doralusa.com

THANK THANK YOU!!!!!YOU!!!!!