Press Releases

September 7, 2005

Medicaid Dental Programs - It's more than just money

Recently, much attention has been focused on Medicaid dental programs and their level of success as measured through member access. Recently, The Center for Medicare and Medicaid Services (CMS) and The Oral Health America National Grading Project have published reports dealing with this subject. CMS has advised State Medicaid Directors that any dental program not meeting an annualized 50% utilization target will be subject to review.

Doral Dental USA, is currently involved in administering Medicaid dental programs in 21 states and as such, has an intimate and diversified knowledge of the real world operational models currently in place. While the conventional wisdom might be that a high enough reimbursement will solve the access issue, Doral Dental USA believes the problem is much more complex as are the solutions. Since Medicaid dental programs as, in essence, insurance programs underwritten by Federal and State Governments, it would be helpful to evaluate these targets in relationship to the general population that has commercial dental insurance.

Dental Reimbursement

There has been much said about the adequacy of dentist reimbursement as it relates to dental access. Organized dentistry has advocated that higher reimbursement will equate to higher access. In some states such as Georgia and Indiana where the reimbursement now exceeds 70 - 75% of prevailing fees, the number of dentists participating in the program has increased substantially. However, in Indiana, the actual increase in patient access was minimal and has not exceeded 35% annually. Clearly, in the current environment, increasing reimbursement will not guarantee a proportional increase in patient access.

The explanation for this has to do with the definition of access. In the dental world, access means more dentists available to treat patients (i.e. network access). In the Medicaid world, access means unique patients being treated or as it is called in the dental insurance environment, utilization. The result of increasing reimbursement to the dentists beyond a certain point is that you may very well have enough dentists, but the availability of a dental office does not guarantee that patients will access.

To compare this to the general population that has dental insurance, assume the dentist network is all practicing dentists within a geographic area. Over the past 25 years, the access (utilization) for this population has averaged 50% with a range of 20 - 90% by group.

For example, there may be a factory group that only 20% of the insured patient's access services within a given year whereas there could be a different factory group where 90% of the patient's access services in the same year. The explanation for this variability has more to do with a population's average understanding of the necessity of services or a "dental IQ" than only the number of available dentists.

The conclusion on the reimbursement question is that, yes, it will be necessary to provide reimbursement levels to the dentists that approach 70 - 75% of the prevailing fees to sustain a network providing reasonable dentist availability to patients over time.

The actual reimbursement level, whether it comes in above or below that number, will be a function of the number of practicing dentists in a region, the network access requirements, the distribution of Medicaid eligibles and the efficiencies of the individual dental offices. In the future, the already shrinking pool of practicing dentists will have an increasing impact on the reimbursement levels throughout the country and even more so in rural locales. However, increasing dentist reimbursement to an adequate level in and of itself will not resolve the patient access issue.

Dental IQ

Assuming, reimbursement is at adequate levels and the network is in place, what about the access issue? Average access levels in Medicaid populations throughout the country are around 20% as recently reported by CMS based on straight administration. There has not been significant fluctuation in these levels over the past decade. In other words, this access is largely dependent on the Medicaid patient's voluntary compliance to visit the dentist. Compared to the average 50% access rate for the general population having dental insurance, this level is less than half.

Assuming the adequacy of the network was in place, the explanation for the difference will reside in differences in aforementioned "dental IQ". Recent studies have shown a correlation in dental access with the social-economic level of the patient. Based on these studies, the expectation would be that there is a higher average awareness of the importance of preventive and routine dental care with the insured population than the Medicaid population. There has been some thought that the insured population has a greater economic ability to pay for dental care and hence the higher access rate.

However, the standard Medicaid dental program has no insured patient co-insurance payments and, in fact, no patient payment whatsoever. Therefore, in reality, the Medicaid population has a much lower economic barrier to access than the insured population.

Given this fact, the impact of higher access for the insured population has more to do with the ability to obtain the information and education needed to increase and sustain a higher "dental IQ" rather than merely the economic ability to pay for services.

The conclusion to the "dental IQ" question is that, yes, the availability of dental education and information can have a profound impact on patient access and future utilization. Raising the "dental IQ" is essential in changing the patient's perception as to the importance of preventive and routine dental care. Hence "Dental IQ" has contributed to the low access levels seen for Medicaid populations over time.

Raising this level will be gradual at best due to the cumulative impact of dental education over time. It is therefore unlikely that any State having an access rate of 20% will reach 50% in the next year or two through raising the "dental IQ" alone.

Passive Program Administration

Currently, the dominant model of Medicaid administration is one of administering benefits either through the State Medicaid Department or through a contracted vendor, generally a Health Plan or Third Party Administrator (TPA). Usually, the main focus of such an arrangement is for the purpose of paying claims and maintaining networks. The level of the administrator's involvement in programs that are either aggressive or mandatory in terms of increasing access may be minimal to non-existent.

As discussed earlier, providing information and support to programs increasing the "dental IQ" are an essential component to increase access levels beyond the 20% national average. At some point, with these programs and other initiatives in place, access may approach the 50% average of the general population having dental insurance.

An example of another program that would immediately accelerate access would be mandatory dental screenings as a part of school enrollment or mandatory dental screenings as a part of participating in a Medical Assistance program.

Medical screenings are a common requirement for school enrollment but the corollary dental screening is often not required It should be pointed out that, the oral cavity represents the first stage of the digestive process, and as such can have a significant impact on the later stages of digestion from a medical sense.

In the era of budgeted Medicaid Programs, the triaging afforded by a dental screening of Medicaid eligible recipients will offer an efficient method to evaluate the general oral health as well as provide for referral and provision of necessary care. Early recognition of dental disease has been the hallmark of cost effective preventive dental care. Voluntary compliance leaves the recognition of early detection and prevention of dental disease to the "dental IQ" of the member, the result of which has contributed to the result of historically low access levels.

In conclusion, passive administration of a Medicaid dental program without aggressive or mandatory initiatives such as dental screenings, etc. will likely result in little if any increase in access over time. It is crucial that the administrative entity has experience in design and implementation of such programs as well as the support of the State Medicaid Department or contracted vendor to do so.

The Doral Solution

With the above facts in mind, how does Doral Dental USA increase access and by what means.

Dental Reimbursement

Doral Dental USA continues to support efforts to provide adequate reimbursement to participating dentists. While every State has a U&C level characteristic of their market, typically 70-75% of U&C appears to be a range that can help achieve a compliant network in urban regions. Reimbursement in rural regions will necessarily be higher.

"Dental IQ"

To address the "dental IQ" issue, Doral Dental has formulated and implemented various programs designed to both educate and improve access to Medicaid populations. These programs serve the dual purpose of providing a dental screening and triaging as well as giving the member valuable educational materials designed to increase "dental IQ".

Outreach programs utilizing phone and mail correspondence have increased "dental IQ" and encouraged the preventive dentistry concept to members. Mobile dental clinics have been used to provide dental screening and education to remote regions.

Passive Program Administration

Doral Dental has developed and utilized numerous methods to help its clients increase access. As such, Doral Dental philosophy is not one of passive program administration, but one of active integration of initiatives to achieve these goals of increased access and care.

School and Health Clinic based screenings offer excellent opportunities to increasing access. However, experience has shown that voluntary compliance of schools in these programs has limited the total potential in terms of both the ease of entry into the schools and thus the ultimate utilization by patients.

Coupled with dental education and other programs, school based and mobile dental screenings can provide a significant increase in access over the traditional passive administration of a Medicaid program.

Doral Administration

At the core of the successful administration of a Medicaid program lies the efficient distribution and cost effective administration of State budgeted dollars. Doral integrates all of the components necessary to satisfy the State, Health Plans, members and dentists.

Among these are:

1. Second generation UM/QI programs designed to distribute dollars appropriately.



2. Utilization reporting flexible enough to meet changing State and Federal requirements.



3. Coordination with Health Plan objectives relative to both medical and dental program administration.



4. Superior member services and appeals process.



5. Timely and accurate claims payment to dentists.



6. Coordination and execution of education, outreach and screening programs to increase access.



7. Data management and its analysis to provide consultative feedback to State and Health Plans as to program design and performance.

The 50% Question

Doral has proven time and time again that it can increase access over time in markets where it has assumed administration of Medicaid dental programs. The Tennessee "TennCare" program is an example of how the Doral Dental USA has provided an integrated solution to the access issue. Doral has significantly increased access in Tennessee from the low 20%'s to well into the 40%'s.

If reimbursement is increased to the recommended levels to provide enough dentist participation, "dental IQ" is increased, school and health clinic programs expand, then annual access can approach the 50% target. However, to reach and sustain this 50% access level over time as well as provide for the increase in follow-up care that will occur, Doral believes additional steps must be taken.

Mandatory Dental Screenings

Because school and health clinic programs rely on voluntary participation by either the school or the member, numerous administrative and political components come into play that can slow up and even defeat the process of providing these programs especially the school based ones.

Doral Dental USA's experience has shown that even with aggressive mature school based screening programs, such as the one in Illinois, total Medicaid access may still not match that of the general population at 50%. Again, the experience has shown that gaining voluntary approval by schools boards, etc. has been an impediment to rapid expansion and contribution to access.

Only a mandatory dental screening as a pre-requisite to school enrollment, much the same as certain medical requirements will guarantee an annualized 50% access rate. State and local government agencies should treat dental screenings the same way they treat medical screenings with respect to school enrollment.

Increased Supply of Dental Professionals

The current shortage in practicing dentists has been recognized by both CMS and the American Dental Association. With the advent of the "baby boomer' generation reaching retirement age, this situation will only be exacerbated due to the fact that this generation represents the largest segment of practicing dentists.

In addition, over the past 15 years, the number of dentists practicing part time has increased substantially. As a result, the trend is moving towards fewer dentists per 1000 patients as the absolute number of dentists decrease and the general population increases.

Federal government involvement in both encouraging the increase in dental school enrollment and their disposition into underserved areas through economic incentives is essential. Doral Dental USA, by virtue of dentist contacts throughout the country, has determined that specialty dentist shortages, particularly the pediatric dentists who serve the largest percentage of children, are even worse than general dentistry.

In a number of current Medicaid markets, this shortage has driven up the cost of care significantly to where specialty care is being reimbursed at 100% of the dentist's billed charges. Programs in dental hygiene and assisting, which can add significant efficiencies to the dental delivery model, are in short supply as well. Current State Medicaid dental budgets need to be reviewed to reflect these changes.

Reaching and maintaining the 50% access rate not only means there needs to be enough dentists to triage patients but to provide follow-up care as well.

Increased Emphasis on Passive Prevention

The impact of fluoridation has been well documented. However, The Oral Health America National Grading Project indicates several states with the largest number of Medicaid children did not have widespread fluoridation. The cost effectiveness and passive nature of this preventive component needs to be incorporated everywhere.

The next generation preventive materials such as plaque reducing tooth paste and rinses are proving very effective as adjuncts to fluoridation. Their incorporation into Medicaid programs in tandem with appropriate education as to benefits and use should be considered. Again federal and state economic assistance is essential.

Federal Government support of the development of additional pharmacological components that, like fluoride, do not rely on voluntary compliance should be increased. Examples would be food additives and vaccines.

In Conclusion

The delivery of Medicaid dental services represents a part of the overall delivery of dental care to the population in general. As such, Medicaid is affected by a number of common factors influencing the availability of care to the general population such as geographic, economic, and available dentists.

Of these, the number of available dentists in the future represents the largest threat to access to dental care for all individuals regardless of their method of payment. Doral Dental USA can provide integrated solutions to reach and sustain these access targets that are both cost effective and efficient. However, the long-term success of Medicaid dental programs in improving oral health requires Federal and State initiatives that recognize and compensate for the changes in the dental delivery model as it applies to all individuals.

If you would like more detailed information regarding Doral Dental, please contact Amy Nelson at 262.834.3727.

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