macpac session brief medicaid and chip payment and access ... · medicaid and chip payment and...
TRANSCRIPT
MACPAC Session Brief Medicaid and CHIP Payment and Access Commission April 11, 2013 www.macpac.gov
1
Session 1 Thursday, April 11: 10:30-11:45 am Oral Health Services for Adults Enrolled in Medicaid
• Terry Dickinson, DDS, Executive Director, Virginia Dental Association • Mina Chang, PhD, Chief, Health Research and Program Development, Ohio Office
of Medical Assistance • Paul Glassman, DDS, Professor of Dental Practice, Director of Community Oral
Health at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco
ISSUE: Good oral health has been shown to positively impact an individual’s overall health. Dental disease is connected with other health conditions such as cardiovascular disease, diabetes, and bacterial pneumonia. Studies have also reported an association between untreated dental disease and the increased risk of preterm delivery and low birthweight babies. Even so, access to oral health services for adults on Medicaid is limited. Adult dental services are an optional benefit; only a small number of states cover comprehensive dental care. Most states provide a limited set of benefits, most often for conditions associated with trauma or disease or for emergency dental-related services. Some states limit oral health services to specific Medicaid adult populations, such as pregnant women or persons with disabilities. Moreover, dental services are often cut during budget shortfalls and sometimes restored during budget surpluses, making coverage unpredictable for both enrollees and practitioners. With limited coverage, many adults on Medicaid seek dental care in hospital emergency rooms. A study by the Pew Center on the States estimated that preventable dental conditions were the primary diagnosis in more than 830,000 visits to ERs in 2009. For patients, ER care often can only provide short-term relief. For Medicaid, this is an expensive and inefficient source of treatment. Some individuals with disabilities and the elderly have conditions that impair their oral care at home and their ability to access care in dentist offices. People with disabilities have more dental disease, more missing teeth, and more difficulty obtaining dental care than other members of the general population. KEY POINTS: Although few states are currently covering comprehensive oral health benefits for adults on Medicaid, there are a number of promising initiatives underway that strive to better meet the oral health needs of low-income adults and to improve the coordination of medical and oral health care. Two programs which will be highlighted in this session focus on:
MACPAC Session Brief Medicaid and CHIP Payment and Access Commission April 11, 2013 www.macpac.gov
2
• Multi-stakeholder partnerships that bring together hospitals, dental providers, and managed care plans to identify dental needs, fast-track treatment, coordinate care to reduce avoidable ER visits, and improve patient awareness of available services.
• Using new types of dental professionals to provide oral health services in non-traditional settings such as residential facilities for persons with disabilities and long term care facilities to eliminate barriers to care for populations most at risk of future dental disease.
The session will also highlight the importance of good oral health and the negative consequences of both poor oral health and no or limited dental benefits on adults enrolled in Medicaid. ACTION: As staff prepares next steps on oral health, Commissioners should provide insights on issues of particular interest to be explored at subsequent meetings. STAFF CONTACT: Lois Simon, [email protected]
Consequences The good, the bad, the ugly
Terry D. Dickinson, D.D.S.
Executive Director, Virginia Dental Association
0
5
10
15
20
25
30
35
40
45
50
Federal Poverty Level (FPL) Below 100% of FPL At/Above 100% of FPL
Percent US Adults with Any Dental Visit by Income (MEPS 2009)
A quarter mile of uninsured people
Status of State Adult Medicaid programs (2012)
2002 2012 Full services- 13 0 Limited services- 13 26 Emergency only- 17 17 No services- 8 8
0
10
20
30
40
50
60
70
80
At/above 100% of FPL
% US Adults with Self-‐reported Unmet Dental Need by Income
Below 100% of FPL
Challenges for success } Payment (reimbursement) } Administrative challenges } Paperwork } Patients in and out of system } Multiple vendors } Pre-authorizations } Provider frustrations } Literacy/education } No show rate } Educating providers
0
10
20
30
40
50
60
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Percent of Medicaid Enrolled Children with a Dental Visit in VA
INTENTION
MANDATED
SFY Members Over 21 Receiving Dental Services Amount Paid For Dental Services
2006 2,989 $658,404.32
2007 4,652 $1,466,494.85
2008 8,030 $3,004,309.50
2009 13,338 $5,123,747.70
2010 21,009 $9,885,194.40
2011 32,921 $10,974,518.30
2012 36,945 $11,333,009.02
Success brings danger…..
} Optional enhances and exacerbates systemic diseases
} Optional creates burden on ER’s } Optional creates a less effective work force } Optional creates a less employable work force } Optional is not fair in trying to make healthier
communities } Optional creates a less ready military } Optional is medically inappropriate } Optional destroys hope
IIMMPPRROOVVEE Statewide Collaborative
Dental Fast Track Referral To Reduce Avoidable ER Use by the Medicaid Population
Medicaid and CHIP Payment and Access Commission
April 11, 2013 Washington, DC
Mina Chang, Ph.D., Chief Health Research and Program Development
• Five IMPROVE interven0ons: Dental, URI, and Ultra-‐u0lizers with chronic back pain, severe mental illness, or non-‐mental health condi0ons
• Community collabora0ons to iden0fy issues and solu0ons
• 18 month Rapid-‐Cycle Quality Improvement Trial (Ins0tute for Healthcare Improvement framework)
• Issues and solu0ons are pa0ent-‐centered and “up-‐stream”
2
Background
• Reasonably homogeneous popula0on
• Large enough volume to warrant interven0ons
• Ac0onable QI interven0ons on health status • Prac0cal measurement strategies
• Clearly iden0fiable boundaries ü Diagnosis (chest pain, chronic diseases)
ü Age (newborns, elderly)
ü Day of week (weekends)
ü Ethnic background (cultural barriers)
PaAent PopulaAon IdenAficaAon Strategy
3
• Inner-‐city/urban dental hot spot issues • Adult Medicaid managed care plan (MCP) members
• Seeking dental care in the emergency department
• EDs located in inner-‐city
Dental PaAent PopulaAon
4
• Tooth pain • Pa0ents experienced symptoms more than a week before
seeking ED care and had dental problems for a long 0me
• Pa0ent perceived geZng a den0st appointment was inconvenient, or did not have den0st
• Convenience of ED • Perceived a need for an0bio0cs • Not aware of dental benefits
Dental Deciding Factors to Seek Care at ED
5
Fast Track Dental Appointments
Business Hours • Medicaid managed care members presen0ng with dental
condi0ons are iden0fied at the ED
• EDs call par0cipa0ng dental providers and secure a fast-‐tracked dental appointment for the pa0ent
• EDs forward the iden0fying informa0on of sample pa0ents to the appropriate MCP
• MCPs follow-‐up with the member
AGer-‐Hours • ED staff distribute a card lis0ng the MCP contact informa0on and
instruct the pa0ent to call the MCP during business hours for a fast-‐tracked dental appointment
6
Fast Track Dental Appointments
7
• Successful real-‐0me appointment scheduling at the ED with par0cipa0ng dental providers
• Regularly scheduled communica0on between test sites and MCPs
• On-‐going communica0on and training between senior level and opera0onal staff within each organiza0on
• A useful resource for EDs to make fast-‐tracked dental appointments for Medicaid members and connect them with MCP resources
• Improved provider and consumer sa0sfac0on and community awareness
Fast Track Dental Appointments Key Findings
8
9
Key Lesson Learned
“Sustainable solu.ons are possible when stakeholders and community
leaders are involved”
– Dr. Roger K. Resar, Senior Fellow IHI
Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Den@stry San Francisco, CA
The Surgeon General’s Report
• “Although there have been gains in oral health status for the popula@on as a whole, they have not been evenly distributed across subpopula@ons.”
• Profound health dispari@es exist among popula@ons including: – Racial and ethnic minori@es – Individuals with disabili@es – Elderly individuals – Individuals with complicated medical and social condi@ons and situa@ons
The 2011 IOM Reports on Oral Health
4
Dental Medicaid’s Track Record • Only 40% of children enrolled in Medicaid had a dental visit in
2010 with children under 3 averaging only 8%1,2
• In 2008, fewer than half of the den@sts in 25 states treated any Medicaid pa@ents2,3
• “Op@onal” adult Medicaid benefits have resulted in very few states with adult coverage. – When parents with Medicaid coverage do not make at least one dental visit annually, their children are 13 @mes less likely to visit a [email protected]
– Providing dental care for adults, par@cularly those with disabili@es and chronic medical condi@ons, could save money for state Medicaid programs through reducing the “Costs of Neglect”5,6
1. Children’s Dental Health Project. Dental Visits for Medicaid Children: Analysis and Policy Recommenda@ons. Issue Brief June 2012. 2. GAO. Efforts Under Way to Improve Children’s Access to Dental Services, but Sustained A`en@on Needed to Address Ongoing Concerns. Report
to Congressional Commi`ees. November 2010. 3. Pew Children’s Dental Campaign. Two Kinds of Dental Shortages Fuel One Major Access Problem. Issue Brief . February 2011. 4. Bonito AJ, Gooch R. Modeling the Oral Health Needs of 12-‐13 Year Olds in the Bal@more MSA: Results from One ICS-‐II Study Site. American
Public Health Associa@on (APHA) Annual Mee@ng; November 12, 1992. 5. Blue Sky Consul@ng. The Benefits of Preven@ve Dental Care. h`p://[email protected]/storage/
Impact_of_the_Virtual_Dental_Home_Project.pdf. April 2013. 6. Pew Children’s Dental Campaign. A Costly Dental Decision. Hospital Care Means States Pay Dearly. Issue Brief. February 2012.
Themes from the 2011 IOM Reports on Oral Health
Improve access to services and oral health through: • Chronic disease management • Delivery Systems
– Bring care to where undeserved people are – Telehealth – Workforce expansion
• Drive change and accountability through – Incen@ves based on measures of health outcomes 6
Dental Care and People with Disabili@es and Chronic Medical Condi@ons
• The most underserved of the underserved • Lack of access to care in the tradi@onal system
– Den@st training – Loca@on and availability of services – Low income -‐> No Medicaid coverage – Oral health not integrated in general health services
• More severe disease • Greater medical/personal/economic consequences • Need to rethink how to deliver services
1. Glassman P, Harrington M, Namakian, M, Subar P. The Virtual Dental Home: Bringing Oral Health to Vulnerable and Underserved Popula@ons. CDA Journal: 2012: 40(7)569-‐577.
Radiographs
Photographs
Radiographs
Radiographs
Photographs
Photographs
Community-‐based Preven@on and Early Interven@on Procedures
The Virtual Dental Home Sites
Oral Health Systems for Underserved Popula@ons
Opportuni@es to Improve Medicaid/CHIP for People with Disabili@es
and Chronic Medical Condi@ons
• Cover adults! – Priori@ze those with disabili@es and chronic medical problems as well as pregnant women
• Recognize new delivery systems – Pay for telehealth enabled services – Incen@vize preven@on ac@vi@es – Recognize community delivery systems – Incen@vize integra@on of oral health and general health services
• Establish federally supported pilot programs to create innova@ve and cost saving models of care
Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Den@stry San Francisco, CA