Oral Health: Strategies to Improve Access

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Oral Health Strategies to Improve Access
2008 Fall NASMD Meeting
Washington, DC
Oral Health Session November 14, 2008
Mary G. McIntyre, M.D., M.P.H. Medical Director,
Office of Clinical Standards and Quality Alabama
Medicaid Agency
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Whats The Problem?

• Tooth decay is the most common chronic childhood
  disease, five times more common than asthma.
• 80 percent of pediatric dental disease is
  concentrated in 25 percent of children, primarily
  those from low-income and minority households.
• Adults lose 164 million work hours per year
  because of dental problems.

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State of Alabama

• Population of 4.7 million
• 67 counties / 45 non-MSA
• Medicaid eligibles 988,678
• State/Federal match of about 30/70
• In Alabama, about 20 of population is Medicaid
  eligible
• About 47 of all Medicaid eligible children are
  from working families

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Demographics

• Medicaid covers
• 20 of Alabamas total population (includes all
  eligibility categories)
• 50 of all deliveries in Alabama
• 38.9 of Alabamas children (under 19)
• 21.2 of Alabamas elderly (65 and above)
• Source 2006 Annual Report

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Alabama Medicaid Dental Program
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Vision StatementDental Program

• 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

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Smile Alabama! Initiative

• Public/Private Partnership
• Robert Wood Johnson Foundations 21st Century
  Challenge Fund supported matching grants program
• Dental Outreach Initiative-Official Start,
  February 2001

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Goals

• Increase the number of dental providers
  participating in the Medicaid program by 15
  during the 3-year grant period
• Increase the number of children receiving dental
  care by at least 5 (Annual Dental Visit Rate)

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Premise

• Good oral health prevents pain, suffering, missed
  days of school or work and unnecessary costs due
  to dental treatment.

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Why Is Good Oral Health Important?

• Dental related illness causes poor children to
  miss 12 times more school days than children
  from higher income families
• Poor oral health has been associated with other
  medical problems including heart disease and
  premature births

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Where We Started

• Identification of Key Individuals who could make
  the difference...
• Dentists (ALDA)
• AL Medicaid Agency
• AL Department of Public Health
• Governor
• Legislature
• Dental School

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We Listened

• Formation of Dental Task Force
• Non-Medicaid and Medicaid dentists
• Alabama Dept of PH and UAB School of Dentistry
• Dental Task Force discussed Medicaid issues
• Dental Surveys done
• 1 Issue - Low Reimbursement
• 2 and 3 Claims Processing

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Timeline

• Formed Dental Task Force Jan 1998
  
• Targeted Rate Increase Jan 1999
• Coordinate with State Dental Association
• Survey of state dentists 1999 and 2000
• Develop educational materials for dentists
• Provider enrollment
• User friendly billing manual Aug/Sept 1999

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Timeline

• Streamline claims payment Oct 1999
• ADA approved claim forms
• Scanning technology
• Free software for electronic claims submission
  (Windows Based)
• Proclamation April 2000
• Educate legislature
• Enlist Governors Support Spring 2000
• Governors Letter to Dentists Oct 2000
  

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Timeline

• Establish Multidisciplinary Workgroup
  Evaluate state needs for all March 2000
  
• Outreach program
• Provider visits July/Aug 1999
• Visit all participating dentists March
  2000
• Attend state and regional meetings
  Ongoing
• Speak to dental students yearly
  Ongoing
• Dental Outreach Specialists June 2001-
  2004

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Timeline

• Grant applications RWJ April Nov 2000
  NGA Oct 2000
• Targeted Case Management (TCM)
  March 2000
• Increase in Fees Oct 2000
• Developed patient education materials
  May 2001-Ongoing
• Public education campaign Nov 2001, April 2003
• Video and Public Service Announcements (TV
  Radio)

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Working Together

• Establishment of Additional Teams
• Dental Initiative Workgroup evolved into current
  Oral Health Coalition of Alabama (OHCA)-Initial
  focus on AL Medicaid oral health strategies, now
  work to implement strategies for AL OH Strategic
  Plan
• AL NGA Policy Academy Team now AL Oral Health
  Strategic Team (AOHST)

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Oral Health Policy Team (NGA)

• Alabama Dental Association
• Alabama Department of Public Health
• Alabama Medicaid Agency
• Alabama Primary Health Care Association
• Child Health Insurance Program
• CMS Regional Office
• Governors Office
• Legislator
• Office of Primary Care Rural Health
• Private dentist
• UAB Dental School

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Oral Health Coalition of Alabama (OHCA)

• Alabama Office of the Governor
• Alabama Legislature
• Alabama Extension Service
• Alabama Medicaid Agency
• Alabama Department of Public Health
• Department of Rehabilitation Services
• Department of Childrens Affairs
• Department of Education
• Department of Human Resources
• Department of Mental Health
• UAB School of Dentistry

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Oral Health Coalition of Alabama (OHCA)

• Alabama Academy of Family Physicians
• Alabama Academy of Pediatrics
• Alabama Arise
• Alabama Association of School Nurses
• Alabama Hygienists Association
• Alabama Dental Association
• Alabama Dental Society
• Alabama Hospital Association
• Alabama Pediatric Dental Association
• Alabama Primary Health Care Association

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OHCA (Continued)

• Alabama State Medical Association
• Alabama Power
• Business Council of Alabama
• Blue Cross and Blue Shield of Alabama
• Consumer Representatives
• Faith Based Organization
• FOCAL
• Head Start
• Medical Association of the State of Alabama
• Medicaid Dental Task Force
• VOICES

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Target Populations Identified

• Medicaid children and caregivers
• Practicing dentists
• Stakeholder or partner associations and groups

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Interventions

• Claims Processing Simplification
• Dental Rate Increase
• Provider Outreach and Education
• Consumer and Patient Education

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Educational Tools

• Healthy teeth, healthy mouth, healthy you!
• Head Start OH Lesson Plans (Initially with most
  recent use by Office of School Readiness for
  Pre-K programs
• Take a 1st Look
• Primary Care Physician (focus on OH risk
  assessment and referral by age 3)
• Revised 1st Look (Effective Jan 2009, added
  fluoride varnishing reimbursement for 1st Look
  certified physicians and requirement for referral
  to care coordinator for establishment of dental
  home for all high risk children assessed through
  1st Look, ages 6 through 35 months of age)
• Obstetrical Early Intervention
• Pregnant women (Taking Care of Babys Teeth)

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Ill have water, please! Going to bed with a
bottle of milk or juice can cause a problem
called baby bottle tooth decay. A tooth with
decay can cause great pain and can cost a lot of
money to fix. To prevent this problem

• Put water in nap or bedtime bottles.
• Dont let baby carry around a bottle or
  sippy cup filled with a sweet drink.
• Dont dip pacifiers in anything sweet.
• By the first birthday,teach your baby to drink
  from a cup.
• Clean babys mouth with a clean, damp cloth
  after each feeding and before bed.

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Your Rights and Duties As a Dental Patient Read
this and find out what you need to know!
Having healthy teeth is an important part of your
good health. Medicaids dental program is set up
to help you get good dental care. In order for
you to get good dental care, there should be
respect and trust between you and your
dentist. When you signed up for
Medicaid, you agreed to be a part
of Medicaid and to follow Medicaids rules. This
also means you have the following
rights and duties when you go for
dental care on the Medicaid program
You have the right To be told what your
dental problem is, if you have one, and what the
dentist thinks is the best way to treat it To
decide about your dental care and to give your
permission before the start of any
treatment To have the personal information in
your dental records kept private To report to
Medicaid any complaint or grievance about your
doctor or your medical care and To be treated
with respect, dignity and privacy.
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You need to know . . . Your dentist has
the right to ask you to follow the rules for the
office or clinic. This also applies to any
visitors or relatives who come with you or your
child. If you or others with you do not follow
the rules, your doctor has the right to ask that
your child go to another dentist. Serious
problems, such as refusing to keep appointments,
or acting in a rude, mean or threatening way to
the dentist or to a person who works for the
dentist, may result in your losing your Medicaid.
This includes fighting, using profanity or other
abusive words, carrying a weapon or being under
the influence of drugs or alcohol while at the
office or clinic. To be signed by the
patient I have been told about my rights and
duties as a Medicaid dental patient. I have been
told what the rules are for my dentists office
or clinic. I have been given the chance to ask
questions about any rules I do not understand. I
have been told that if I miss appointments, do
not follow the dentists directions or do not
follow the rules for Medicaid, my dentist can ask
that my child go to another dentist. I
understand that if I or someone who comes with me
acts in a rude, mean or threatening way to the
dentist, employees of the office or clinic and/or
other patients and visitors, I can lose my
Medicaid. I have been told that I have a right
to complain to Medicaid and get an answer to my
complaint. Signed ___________________________ D
ate _____________________________
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Baseline Data

• In FY 1999, 82,585 of 317,214 Medicaid eligible
  children received dental services (26)
• 436 Medicaid enrolled dentists
• Of these, 328 were participating (75.2)
• Total dental expenditure of 11.6
• 19 counties had 1 or no Medicaid participating
  dentist

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Where We Are Now

• FY 2007, 187,613 of 460,525 Medicaid eligible
  children received dental services (41)
• 778 Medicaid enrolled dentists for FY 07
• Of these, 748 participating (96)
• Total dental expenditures of 54 million
• 6 counties with 1 or no Medicaid participating
  dentist as of February 2008 (there were no
  counties with no Medicaid participating dentist)

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FY1998-FY2007

• RESULTS

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Figure 1. Alabama Dental Medicaid Utilization,
1998-2007
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Figure 3. Performing Dentists, Alabama Dental
Medicaid, 1998-2007
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Figure 2. Enrolled and Performing Dentists,
Alabama Dental Medicaid, 1998-2007
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Figure 4. Percent Medicaid Eligibles Receiving
Any Dental Service, by age category, U.S. and
Alabama, FY 2006
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Figure 4. Percent Medicaid Eligibles Receiving
Any Dental Service, by age category, U.S. and
Alabama, FY 2006
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What Can You Do?

• Assist in the distribution of information to
  increase knowledge on the importance of good oral
  health to overall health
• Support funding for Medicaid and ALL-Kids
• Encourage dentists to participate in serving
  low-income children

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• If you always do,
• What you always did,
• You always get,
• What you always got.
• Jackie Moms Mabley