Chf Oral Health Policy1
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p o l i c y b r i e f HUSKY A DENTAL CARE: AVOIDING THE
HUSKY A Dental Care: third in a series February 2007
BARRIERS TO RECEIVING DENTAL SERVICES
REPERCUSSIONS OF POOR DENTAL CARE FOR CHILDREN ON MEDICAID
Private Provider Participation Is Limited Due to Low Reimbursement Rates Children on HUSKY A cannot access dental care because of the small number of private dentists participating in the program, due to low dental reimbursement fees. Less than 15 percent of all Connecticut providers participate.1 Dental fees for HUSKY A enrollees were set in 1993, at the 80th percentile of prevailing fees then. But they have not been adjusted since. As such, Connecticut’s HUSKY A fees are now in the lower 1st to 7th percentiles of dental fees in the New England states.1 Limited Dental Safety Net Meanwhile, Connecticut’s dental safety net system — made up of dental clinics owned and operated by public and volunteer organizations — is not sufficiently robust to satisfy the need. The safety net provides only about one-third of the dental care that HUSKY A children receive, while Connecticut’s private dentists participating in the Medicaid program provide two-thirds of the care.3
SUMMARY FINDINGS • Because current Medicaid fees to providers are too low, the majority of children on HUSKY A in Connecticut do not have access to dental care. • The state currently pays approximately one-third the amount per child for HUSKY A dental coverage than it does for coverage of state employees and their children. • Raising Medicaid reimbursement rates to the 70th percentile has resulted in increased access to dental care in other states.
Oral Health Services for Children on HUSKY A Approximately one-quarter of all children in Connecticut are enrolled in Medicaid, also known as HUSKY A. Among these approximately 250,000 enrollees, two-thirds receive no dental services at all.1 This dental utilization rate is the lowest among the New England states and is less than half that of privately insured children nationally.2 The repercussions of this neglect are significant. Acute dental problems cause three days of lost school per 100 children.2 In fact, dental decay is the single most common chronic childhood disease — five times more common than asthma.2
Connecticut’s HUSKY A fees are now in the lower 1st to 7th percentiles of dental fees in the New England states.
POTENTIAL SOLUTIONS
Increasing access to dental care for children on HUSKY A requires a multi-pronged approach. One solution with demonstrated success: raising reimbursement fees to an adequate level, so more dentists can participate. This will expand services for children in need by maximizing the efficiencies of the private sector, as well as utilizing the unique skills and reach of safety net providers.
Specifically, if Connecticut raises the reimbursement level to the 70th percentile (provided that orthodontic fees are not raised1), the cost would total $21 million in the first year, which would be eligible for a 50 percent federal match. It will also be necessary to improve and simplify administration of the program for providers, to ensure efficient and easy participation.
PUTTING CHANGES IN CONTEXT
Table 1
Current and Projected Costs of HUSKY A Children’s Dental Services for All Services and Modified Services1 It is important to evaluate these proposed changes in light of the current environment. Connecticut now pays a per-member-per-month cost of $84 for children on HUSKY A — only about one-third of the $225 per-member-per-month cost for state employees and their children. It is not surprising, therefore, that only 33 percent of the state’s HUSKY A recipients can locate and visit a dentist in a year, compared to 75 percent of state employees. By raising HUSKY dental reimbursement rates to the 70th percentile (Table 1), the per-member-per-month cost for Medicaid recipients will have to be raised to $15 — a cost that is still considerably lower than the state employees plan.
Total Program Cost: All Fees Except Orthodontics Raised*
Current Utilization (33%) Projected Rates (50%)
Number of Children Receiving Services Current HUSKY A Fees 2005 NDAS Fees at 70th Percentile
88,876
133,974
$16,360,526 $37,092,983
$24,639,346 $55,862,926
*Fees of two orthodontic procedures (8080 and 8670) maintained at 2004 HUSKY A levels. Analysis based on data from the Connecticut Department of Social Services, analyzed by Connecticut Voices for Children for CHF, and data from the National Dental Advisory Service.
Raising reimbursement to an adequate level will expand services for children by maximizing the efficiencies of the private sector as well as utilizing the unique skills and reach of safety net providers.
RAISING MEDICAID REIMBURSEMENT – THE EXPERIENCE OF OTHER STATES
By comparison, nine other states have increased Medicaid reimbursement to the 75th percentile or a comparable market-based rate. Because of the change, all of these states have shown substantial increases in private provider participation (Table 2), and dental access has improved significantly.
Table 2
Increase in Provider Rates Among States That Have Increased Fees to Market Rates
State Year of Change New Rates Approx. # Dentists in State Numerical Increase in Participating Providers* % Increase in Participating Providers
Alabama 20004, 6, 7
100% of Blue Cross rates4, 6, 7 85% of dentists normal submitted charges4 75% to 85% of UCR4 75th percentile4, 10 100% of Delta Dental Premier Rates10 85% of UCR4
1,9127, 8
308 to 4567
48%
Delaware 19984
3028, 9
1 to 1089
> 1000%
Georgia 20004 Indiana 19984,10 Michigan (Select Counties) 200010 Nebraska 19984
4,0004 3,58310 N/A
259 to 1,3554 770 to 1,09610 115 to 35110
423% 42% 205%
1,0778
798 to 96412 231 to 387**12 644 to 855**14
21% 68%** 33%**
North Carolina 200313
73% of University Faculty rates13 75th percentile4, 15 75th percentile4, 16
3,50013
South Carolina 20004, 15 Tennessee 20024, 16
1,5618 2,8618
619 to 8864 380 to 70016
43% 84%
*Change reported after a period of 2-3 years from the rate increase except for Delaware which was 5 years. **Providers billing greater than $10,000 per annum. UCR = Usual and Customary Rates
Table 3
Comparison of Current Connecticut Medicaid Fees and Proposed New Fees1
DESCRIPTION CURRENT HUSKY A FEES Initial exam Cleaning Sealant Amalgam - 2 surface Stainless steel crown Extraction single tooth 2005 NDAS FEES AT 70TH PERCENTILE
$24 $22 $18 $38 $85 $33
$65 $52 $42 $126 $207 $122
It is not surprising, therefore, that only 33 percent of the state’s HUSKY A recipients can locate and visit a dentist in a year, compared to 75 percent of state employees.
Source: Connecticut Department of Social Services and National Dental Advisory Service.
CONCLUSION
One-quarter of Connecticut’s children have no routine access to dental care and, as a result, a large proportion have significant untreated dental disease.
By raising Medicaid reimbursement rates for dentists to the 70th percentile, the state will significantly increase the number of private practitioners participating in the program, safety net providers can expand their reach, and access to care for children on HUSKY will improve.
REFERENCES 1. Beazoglou T, Douglass JM. HUSKY A Dental Care: Financial Strategies. Policy Brief. Connecticut Health Foundation, January 2006. 2. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Rockville, Md.: U.S. Public Health Service, Department of Health and Human Services; 2000. 3. Beazoglou T, Bailit H. HUSKY A Dental Care New Directions. Policy Brief. Connecticut Health Foundation, January 2006. 4. American Dental Association. State Innovations to Improve Access to Oral Health Care for Low Income Children: A Compendium Update. Chicago: American Dental Association: 2005. 5. State of Connecticut. 6. Al Agili D et al. Access to Dental Care in Alabama for Children with Special Needs. JADA 2004:135:490-5.12. 10. Hughes RJ et al. Dentists’ Participation and Children’s Use of Services in the Indiana Dental Medicaid Program and SCHIP: Assessing the Impact of Increased Fees and Administrative Changes. JADA 2005:136:517-23. 11. Ekland SA, Pittman JL, Clark SJ. Michigan Medicaid’s Healthy Kids Dental Program: As Assessment of the First Twelve Months. JADA 2003:134:1509-15. 16. Berthold M. Tennessee Winning: Dental Medicaid Provider Network up 80 Percent. ADA News Article. May 2004. Retrieved at: http://www.ada.org/prof/resources/ pubs/adanews/adanewsarticle.asp?articleid=895. 9. American Dental Association. Medicaid Reimbursement — Using Marketplace Principles To Increase Access to Dental Services. Policy Brief. 15. Nietert PJ, Bradford WD, and Kaste LM. The Impact of an Innovative Reform to the South Carolina Dental Medicaid System. Health Services Research 2005:40:1078-90. 8. National Center for Chronic Disease Prevention and Health Promotion. Oral Health Resources. Synopses of State and Territorial Dental Public Health Programs. http://apps.nccd.cdc.gov/synopses. 14. Modifi M. Dentist Participation in Medicaid: Key to Assuring Access for North Carolina’s Most Underserved. NC Med J. 2005:66:456-9. 7. Cuadro R, Scanlon A. Does Raising Rates Increase Dentists’ Participation in Medicaid? The Experience of Three States. National Conference of State Legislatures. Promising Practices Issues Brief 2004. 13. Mofidi M. Background Paper for Recommendation Section I: Increasing Dentist Participation in the Medicaid Program. North Carolina Oral Health Summit, April 8, 2005. 12. Gehshan S, Hauck P, Scales J. Increasing Dentists Participation in Medicaid and SCHIP. National Conference of State Legislatures. Promising Practices Issues Brief.
Joanna Douglass, B.D.S., D.D.S., is an associate professor of pediatric dentistry at the University of Connecticut School of Dental Medicine and the Oral Health Consultant at the Connecticut Health Foundation.
Joanna Douglass, Author UCONN School of Dental Medicine Monette Goodrich, Editor-in-Chief Connecticut Health Foundation Don Heymann, Editor E.K. Weymouth, Designer Hitchcock Printing, Printer
This brief is available on our website at www.cthealth.org or by calling 860.224.2200. RETURN SERVICE REQUESTED 74B Vine Street New Britain, CT 06052 www.cthealth.org
NON PROFIT ORGANIZATION U.S. POSTAGE PAID NEW BRITAIN, CT PERMIT NO.16
p o l i c y b r i e f HUSKY A DENTAL CARE: AVOIDING THE
HUSKY A Dental Care: third in a series February 2007
BARRIERS TO RECEIVING DENTAL SERVICES
REPERCUSSIONS OF POOR DENTAL CARE FOR CHILDREN ON MEDICAID
Private Provider Participation Is Limited Due to Low Reimbursement Rates Children on HUSKY A cannot access dental care because of the small number of private dentists participating in the program, due to low dental reimbursement fees. Less than 15 percent of all Connecticut providers participate.1 Dental fees for HUSKY A enrollees were set in 1993, at the 80th percentile of prevailing fees then. But they have not been adjusted since. As such, Connecticut’s HUSKY A fees are now in the lower 1st to 7th percentiles of dental fees in the New England states.1 Limited Dental Safety Net Meanwhile, Connecticut’s dental safety net system — made up of dental clinics owned and operated by public and volunteer organizations — is not sufficiently robust to satisfy the need. The safety net provides only about one-third of the dental care that HUSKY A children receive, while Connecticut’s private dentists participating in the Medicaid program provide two-thirds of the care.3
SUMMARY FINDINGS • Because current Medicaid fees to providers are too low, the majority of children on HUSKY A in Connecticut do not have access to dental care. • The state currently pays approximately one-third the amount per child for HUSKY A dental coverage than it does for coverage of state employees and their children. • Raising Medicaid reimbursement rates to the 70th percentile has resulted in increased access to dental care in other states.
Oral Health Services for Children on HUSKY A Approximately one-quarter of all children in Connecticut are enrolled in Medicaid, also known as HUSKY A. Among these approximately 250,000 enrollees, two-thirds receive no dental services at all.1 This dental utilization rate is the lowest among the New England states and is less than half that of privately insured children nationally.2 The repercussions of this neglect are significant. Acute dental problems cause three days of lost school per 100 children.2 In fact, dental decay is the single most common chronic childhood disease — five times more common than asthma.2
Connecticut’s HUSKY A fees are now in the lower 1st to 7th percentiles of dental fees in the New England states.
POTENTIAL SOLUTIONS
Increasing access to dental care for children on HUSKY A requires a multi-pronged approach. One solution with demonstrated success: raising reimbursement fees to an adequate level, so more dentists can participate. This will expand services for children in need by maximizing the efficiencies of the private sector, as well as utilizing the unique skills and reach of safety net providers.
Specifically, if Connecticut raises the reimbursement level to the 70th percentile (provided that orthodontic fees are not raised1), the cost would total $21 million in the first year, which would be eligible for a 50 percent federal match. It will also be necessary to improve and simplify administration of the program for providers, to ensure efficient and easy participation.
PUTTING CHANGES IN CONTEXT
Table 1
Current and Projected Costs of HUSKY A Children’s Dental Services for All Services and Modified Services1 It is important to evaluate these proposed changes in light of the current environment. Connecticut now pays a per-member-per-month cost of $84 for children on HUSKY A — only about one-third of the $225 per-member-per-month cost for state employees and their children. It is not surprising, therefore, that only 33 percent of the state’s HUSKY A recipients can locate and visit a dentist in a year, compared to 75 percent of state employees. By raising HUSKY dental reimbursement rates to the 70th percentile (Table 1), the per-member-per-month cost for Medicaid recipients will have to be raised to $15 — a cost that is still considerably lower than the state employees plan.
Total Program Cost: All Fees Except Orthodontics Raised*
Current Utilization (33%) Projected Rates (50%)
Number of Children Receiving Services Current HUSKY A Fees 2005 NDAS Fees at 70th Percentile
88,876
133,974
$16,360,526 $37,092,983
$24,639,346 $55,862,926
*Fees of two orthodontic procedures (8080 and 8670) maintained at 2004 HUSKY A levels. Analysis based on data from the Connecticut Department of Social Services, analyzed by Connecticut Voices for Children for CHF, and data from the National Dental Advisory Service.
Raising reimbursement to an adequate level will expand services for children by maximizing the efficiencies of the private sector as well as utilizing the unique skills and reach of safety net providers.
RAISING MEDICAID REIMBURSEMENT – THE EXPERIENCE OF OTHER STATES
By comparison, nine other states have increased Medicaid reimbursement to the 75th percentile or a comparable market-based rate. Because of the change, all of these states have shown substantial increases in private provider participation (Table 2), and dental access has improved significantly.
Table 2
Increase in Provider Rates Among States That Have Increased Fees to Market Rates
State Year of Change New Rates Approx. # Dentists in State Numerical Increase in Participating Providers* % Increase in Participating Providers
Alabama 20004, 6, 7
100% of Blue Cross rates4, 6, 7 85% of dentists normal submitted charges4 75% to 85% of UCR4 75th percentile4, 10 100% of Delta Dental Premier Rates10 85% of UCR4
1,9127, 8
308 to 4567
48%
Delaware 19984
3028, 9
1 to 1089
> 1000%
Georgia 20004 Indiana 19984,10 Michigan (Select Counties) 200010 Nebraska 19984
4,0004 3,58310 N/A
259 to 1,3554 770 to 1,09610 115 to 35110
423% 42% 205%
1,0778
798 to 96412 231 to 387**12 644 to 855**14
21% 68%** 33%**
North Carolina 200313
73% of University Faculty rates13 75th percentile4, 15 75th percentile4, 16
3,50013
South Carolina 20004, 15 Tennessee 20024, 16
1,5618 2,8618
619 to 8864 380 to 70016
43% 84%
*Change reported after a period of 2-3 years from the rate increase except for Delaware which was 5 years. **Providers billing greater than $10,000 per annum. UCR = Usual and Customary Rates
Table 3
Comparison of Current Connecticut Medicaid Fees and Proposed New Fees1
DESCRIPTION CURRENT HUSKY A FEES Initial exam Cleaning Sealant Amalgam - 2 surface Stainless steel crown Extraction single tooth 2005 NDAS FEES AT 70TH PERCENTILE
$24 $22 $18 $38 $85 $33
$65 $52 $42 $126 $207 $122
It is not surprising, therefore, that only 33 percent of the state’s HUSKY A recipients can locate and visit a dentist in a year, compared to 75 percent of state employees.
Source: Connecticut Department of Social Services and National Dental Advisory Service.
CONCLUSION
One-quarter of Connecticut’s children have no routine access to dental care and, as a result, a large proportion have significant untreated dental disease.
By raising Medicaid reimbursement rates for dentists to the 70th percentile, the state will significantly increase the number of private practitioners participating in the program, safety net providers can expand their reach, and access to care for children on HUSKY will improve.
REFERENCES 1. Beazoglou T, Douglass JM. HUSKY A Dental Care: Financial Strategies. Policy Brief. Connecticut Health Foundation, January 2006. 2. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Rockville, Md.: U.S. Public Health Service, Department of Health and Human Services; 2000. 3. Beazoglou T, Bailit H. HUSKY A Dental Care New Directions. Policy Brief. Connecticut Health Foundation, January 2006. 4. American Dental Association. State Innovations to Improve Access to Oral Health Care for Low Income Children: A Compendium Update. Chicago: American Dental Association: 2005. 5. State of Connecticut. 6. Al Agili D et al. Access to Dental Care in Alabama for Children with Special Needs. JADA 2004:135:490-5.12. 10. Hughes RJ et al. Dentists’ Participation and Children’s Use of Services in the Indiana Dental Medicaid Program and SCHIP: Assessing the Impact of Increased Fees and Administrative Changes. JADA 2005:136:517-23. 11. Ekland SA, Pittman JL, Clark SJ. Michigan Medicaid’s Healthy Kids Dental Program: As Assessment of the First Twelve Months. JADA 2003:134:1509-15. 16. Berthold M. Tennessee Winning: Dental Medicaid Provider Network up 80 Percent. ADA News Article. May 2004. Retrieved at: http://www.ada.org/prof/resources/ pubs/adanews/adanewsarticle.asp?articleid=895. 9. American Dental Association. Medicaid Reimbursement — Using Marketplace Principles To Increase Access to Dental Services. Policy Brief. 15. Nietert PJ, Bradford WD, and Kaste LM. The Impact of an Innovative Reform to the South Carolina Dental Medicaid System. Health Services Research 2005:40:1078-90. 8. National Center for Chronic Disease Prevention and Health Promotion. Oral Health Resources. Synopses of State and Territorial Dental Public Health Programs. http://apps.nccd.cdc.gov/synopses. 14. Modifi M. Dentist Participation in Medicaid: Key to Assuring Access for North Carolina’s Most Underserved. NC Med J. 2005:66:456-9. 7. Cuadro R, Scanlon A. Does Raising Rates Increase Dentists’ Participation in Medicaid? The Experience of Three States. National Conference of State Legislatures. Promising Practices Issues Brief 2004. 13. Mofidi M. Background Paper for Recommendation Section I: Increasing Dentist Participation in the Medicaid Program. North Carolina Oral Health Summit, April 8, 2005. 12. Gehshan S, Hauck P, Scales J. Increasing Dentists Participation in Medicaid and SCHIP. National Conference of State Legislatures. Promising Practices Issues Brief.
Joanna Douglass, B.D.S., D.D.S., is an associate professor of pediatric dentistry at the University of Connecticut School of Dental Medicine and the Oral Health Consultant at the Connecticut Health Foundation.
Joanna Douglass, Author UCONN School of Dental Medicine Monette Goodrich, Editor-in-Chief Connecticut Health Foundation Don Heymann, Editor E.K. Weymouth, Designer Hitchcock Printing, Printer
This brief is available on our website at www.cthealth.org or by calling 860.224.2200. RETURN SERVICE REQUESTED 74B Vine Street New Britain, CT 06052 www.cthealth.org
NON PROFIT ORGANIZATION U.S. POSTAGE PAID NEW BRITAIN, CT PERMIT NO.16
