Fiscal Fitness: How States Cope: Analysis: States must expand dental services to low-income residents to improve overall health
October 1, 2008
Fiscal Fitness: How States Cope
Analysis: States must expand dental services to low-income residents to improve overall health
While dental services often have not received the attention given some other health care disciplines, many communities now are attempting to provide more services targeted to vulnerable, low-income residents. That's the conclusion of an analysis of the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative U.S. metropolitan communities.
It's known that lack of dental care is the key contributor to oral health problems, and poor oral health may contribute to other health problems, including heart and lung disease, stroke, and premature births. Low-income peopleand some racial and ethnic minoritiesreceive fewer dental services than higher-income people and whites, according to the Agency for Healthcare Research and Quality.
Recognition of the importance of oral health has grown since a 2000 Surgeon General's report highlighting the prevalence of poor oral health among low-income groups and stressing that oral health is essential to overall health.
HSC researcher Laurie Felland¸ site visit analysis report co-author, says the site visits found that dental care is one of the most difficult health care services for low-income people to obtain, largely because it's hard for them to find dentists who will accept public insurance or provide charity care.
At an Alliance for Health Reform/Kaiser Family Foundation briefing on dental care, Kaiser Commission on Medicaid and the Uninsured executive director Diane Rowland said as a result of low provider participation, children who have coverage through Medicaid are not getting the kind of services that they need. "There has been a really low awareness among many of the importance of oral health and the need for an oral health infrastructure," she says. "It is particularly important when we think about children, as we probably enter into the next reauthorization debate over the SCHIP program, to look at the importance of dental benefits for that population. Today, if you look at the use of services by children, you find that 78% of those with insurance actually access dental visits compared to only 48% of the uninsured, so that is affecting how people use the system."
Reimbursement rates are too low
"Reimbursement is the largest concern," Ms. Felland tells State Health Watch. "Many dentists seem to have so many patients with private insurance or who have high incomes and can pay out-of-pocket that they can operate outside of the health care system and not concern themselves with public programs like Medicaid and SCHIP. This is a huge barrier to finding Medicaid safety net dentists or charity care."
American Dental Association associate executive director for government affairs William Prentice told the Alliance for Health Reform briefing that the "starting point and ending point [for any solution] has to be funding. There are a number of different things that can be done, but we have to convince policy-makers of the importance of improving access to oral health. If we cannot get them to see the importance by devoting funding to improving Medicaid and SCHIP, then I think the other things we can do are not going to be enough to do the job."
Mr. Prentice said he has been telling members of Congress that too often politicians are very good at promising coverage and very bad at paying for care. "What we need them to do is to recognize that it is not good enough to just pass legislation expanding coverage and expanding programs if you are not going to provide the financial commitment to ensure that these mandates and these coverages can be provided by health care professionals," he said.
Additional barriers for low-income people may include a lack of awareness of the importance of dental health to overall health and perceptions that dental care is more of a luxury than a necessity, she says. Given the barriers to care, many low-income people don't receive preventive dental care or treatment for an oral health problem until an infection or other urgent condition develops. And then diseased teeth are often pulled rather than restored.
Policy role
State Medicaid and SCHIP policy plays a significant role in access to dental services in communities. Although states are required to provide comprehensive dental coverage to children enrolled in Medicaid, dental coverage for children in SCHIP and for adult Medicaid enrollees is optional. And while most states include some level of dental coverage in SCHIP, Medicaid coverage for adults varies greatly by state and often is limited to emergency services.
And, Ms. Felland says, even when Medicaid and SCHIP provide dental coverage, low reimbursement rates often impede dentists' participation. Thus, although Michigan restored a previous cut in routine dental services for adults in 2006, dentists' participation had declined significantly, leaving only 15% of the state's dentists accepting adult Medicaid patients.
Increased payments that approach private insurance rates or dentists' charges have contributed to an increase in dentist participation in some communities, including Little Rock, AR; Phoenix; and Syracuse, NY. The researchers report that while New York's 250% increase in dental reimbursement rates initially had little impact, it eventually prompted a few Syracuse dental practices to participate in Medicaid. In particular, a dental practice chain that focuses on treating Medicaid and SCHIP children opened two Syracuse facilities. And in New Jersey, which traditionally has had among the lowest Medicaid rates in the nation, a 350% increase in reimbursement for children's dental services put Medicaid rates on par with private rates.
Simplify administrative chores
The site visits also found that in addition to raising reimbursement rates, simplifying administrative processes such as claims processing also helps improve dentists' participation in Medicaid and SCHIP and access to care.
Meanwhile, some local communities are taking the initiative to expand dental services for low-income people, with efforts ranging from providing preventive services to filling cavities and providing other restorative services and even rehabilitative services such as orthodontics and periodontics. Those efforts depend on local funding and the support of dental students and professionals.
Communities often rely on dental hygienists to support their preventive programs with school children as they are less expensive and typically more available than dentists. A number of states now allow dental hygienists to provide certain preventive services to low-income people in public facilities without the direct supervision of a dentist.
But preventive programs still need resources in place to treat dental problems identified during examinations. A Cleveland school-based program has attempted to address this issue by partnering with local dental societies to generate a list of dentists willing to provide follow-up treatment. Unfortunately, community programs that coordinate physicians and dentists willing to volunteer their services for low-income people generally have very limited capacity. Thus, through such a program in Little Rock, the wait for a dental appointment reportedly is several years.
Federally qualified health centers and other community clinics are increasingly offering dental services, including preventive, restorative, emergency, and sometime rehabilitative services, Ms. Felland reports. Health centers or community clinics in half of the 12 communities visited reported increasing capacity by opening new dental clinics, expanding clinic sessions, and/or hiring new dental staff over the last few years. The federally qualified clinics receive enhanced Medicaid reimbursement, which helps generate the revenues needed to support the expansions. But they still report that their level of expansion has not kept pace with the need, and the waits for appointments remain long.
Respondents in northern New Jersey and Seattle reported that the wait for an adult to see a dentist often is two to three months, even for extractions of diseased teeth. And federal dental expansion grants to community health centers have dropped in recent years.
Need far exceeds local resources
Ms. Felland says community efforts to meet the dental services needs of low-income residents face an uphill battle because demand for services far exceeds available resources. She says policy-makers could consider a number of options to improve access to dental care through both public and private providers.
"Additional state efforts to improve Medicaid and SCHIP payment rates and reimbursement processes could help expand the number of dentists willing to serve low-income people," she says. "Recent gains in dentists' participation in some communities could erode if public payment rates are not adjusted as private fees increase. Yet state spending on dental services is threatened by competing priorities and the current economic downturn and decline in tax revenue in many states. Policy-makers also might examine whether targeted incentives to large dental practices that specialize in the particular needs of low-income patients, as seen in Syracuse, could help expand access in a cost-effective way."
Additional National Health Service Corps dentists, dental expansion grants for community health centers, and other federal efforts could help build capacity. Some federal legislation is pending, including bills prompted by the death of a Maryland boy, Deamonte Driver, whose abscessed tooth ultimately led to an infection that went to his brain and killed him. It's not known when or if those bills will be adopted and funded to increase the number of pediatric dentists and to expand community health center dental capacity.
Collaborating among policy-makers, safety net providers, national and state dental associations, and dental schools could help address gaps in the dental work force. And the debate continues about the level of care dental hygienists should be allowed to provide without direct dentist supervision and whether other nondentist professionals could safely fill cavities and extract teeth.
Download the issue brief at http://www.hschange.org/CONTENT/1000. Contact Ms. Felland at (202) 484-4833. Information on the Alliance for Health Reform dental briefing is available online at http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2900.
While dental services often have not received the attention given some other health care disciplines, many communities now are attempting to provide more services targeted to vulnerable, low-income residents.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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