C A L I FOR N I A H EALTH C ARE F OU NDATION Managing California’s Medicaid Dental Program: Lessons from Other States July 2009 Managing California’s Medicaid Dental Program: Lessons from Other States Prepared for California HealthCare Foundation by Caroline Davis Gretchen Brown Health Management Associates July 2009 About the Authors Caroline Davis and Gretchen Brown are senior consultants with Health Management Associates (HMA), an independent national research and consulting firm specializing in complex health care program and policy issues. Davis has served as a member of the senior leadership team for California’s Medicaid program and as the senior Medicare analyst and deputy branch chief at the U.S. Office of Management and Budget. Brown has served on the leadership team for CalOptima, the Medi-Cal managed care program for Orange County. Acknowledgments The authors wish to thank the representatives of the following state programs, dental benefits managers, and managed care plans for their assistance and participation in this project: Arizona Health Care Cost Containment System California Department of Health Care Services California Managed Risk Medical Insurance Board CenCal Health Delta Dental of California Delta Dental of Michigan, Ohio, and Indiana Doral Dental USA, LLC Health Choice Arizona Michigan Department of Community Health New Jersey Department of Human Services, Division of Medical Assistance and Health Services Rhode Island Department of Human Services United/AmeriChoice Virginia Department of Medical Assistance Services Finally, they wish to thank their colleague, Barbara Coulter Edwards, for her insights and assistance. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Introduction 3 II. Background: A Nationwide View 4 III. Medicaid Dental Access in California Program Administration Denti-Cal Program Dental Managed Care Program Lack of Dental Coverage in Medi-Cal Managed Care 6 IV. Medicaid Dental Administration in Selected States State Contracts with Dental Benefits Manager for a Fee-For-Service Dental Program State Contracts with Managed Care Plans to Provide Dental Benefits 1 1 V. dditional Model: Healthy Families Dental Program A 1 2 VI. Common Themes Active Stakeholder Involvement Is Important for Program Reform Payment Issues Are Critical for Dental Providers Administrative Issues Are Also Important for Providers Pent-Up Demand Delays Cost Savings Integration of Services Is in Infancy 1 4 VII. Considerations for California Transition from Payer to Purchaser Establish High-Level Task Force Align Dental Access and Program Integrity Goals Use Dental FI Reprocurement as Opportunity Measure Dental Program Performance Partner with Medi-Cal Managed Care Improve Outreach and Education of Beneficiaries and Providers 1 8 VIII. Conclusion 1 9 IX. Methodology 2 1 Endnotes I. Introduction There is growing evidence that A ccess to oral health services is an important underpinning of good health overall. It has been shown to reduce the better integrating physical and oral incidence and severity of a range of serious diseases and conditions, health services improves health and to enhance functionality. Because there are significant disparities in oral health care between low-income and other Americans, federal outcomes and reduces costs. and state policymakers have long been concerned about ensuring access to dental services for Medicaid beneficiaries. In recent years, a number of states have examined their Medicaid dental programs and implemented reforms to improve oral health care for beneficiaries. In some states, these reforms have included changes in the administration of the Medicaid dental program, with the goal of improving both access to and use of services. To learn from these states’ experiences, Health Management Associates (HMA) was asked by the California HealthCare Foundation to examine how several states administer their dental programs and to share insights. The purpose of this project was to identify key considerations that could help California improve access to oral health care services for the Medi-Cal population. 2 | C alifornia H ealth C are F oundation II. Background: A Nationwide View T he disparities in oral health care Dental care has long-term cost implications. between low-income and other Americans are well Research suggests that access to dental services documented. The U.S. Government Accountability reduces the incidence and treatment costs of a Office reported that three in five children enrolled variety of diseases and conditions. A 2004 study of in Medicaid had experienced dental decay, one in preschool-age children eligible for North Carolina’s three had untreated tooth decay, and roughly one Medicaid program found that delaying the first child out of nine had untreated tooth decay in three preventive dental care visit increased the chance that or more teeth.1 Further, lower-income populations a child would require more restorative and emergency use fewer dental services than their higher-income dental services in the future, compared with a child counterparts: Nearly a third of people from poor who received a preventive visit before age 1.6 and low-income families had an annual dental visit Moreover, there is growing evidence that compared with 58 percent of individuals in high- better integrating physical and oral health services income families.2 A 2000 report by the U.S. surgeon improves health outcomes and reduces costs. Such general characterized such disparities as a “silent findings spurred Aetna to implement a Dental/ epidemic” of dental and oral disease among low- Medical Integration Program for its commercial income populations.3 plan beneficiaries. This program offers enhanced Under Medicaid, the Early and Periodic educational services and dental benefits to Screening, Diagnostic, and Treatment (EPSDT) commercial beneficiaries with diabetes, coronary program (known as the Child Health and Disability artery disease, and/or cerebrovascular disease.7 Prevention program in California) requires that For Medicaid beneficiaries, however, dental all states provide dental services to beneficiaries coverage does not equal access to services. under the age of 21. Even so, states report relatively Nationally, less than half of all dentists enroll as low levels of access and utilization for Medicaid- Medicaid providers.8 Burdensome administrative eligible children, especially preventive services. For requirements, the challenges of working with most adults, dental care is an optional benefit, and Medicaid beneficiaries, and low payment rates, about one-third of states provide a comprehensive particularly when compared with commercial rates, dental benefit for adult beneficiaries.4 Most states are commonly cited as issues that limit Medicaid opt to provide only limited, emergency-related participation by dentists.9 dental services for Medicaid-eligible adults. A 2005 survey found that, even among states that offer a comprehensive Medicaid dental benefit, only about half of beneficiaries reported having a check-up during the 12 months prior to the interview.5 Managing California’s Medicaid Dental Program: Lessons from Other States | 3 III. Medicaid Dental Access in California U ntil recently , C alifornia ’ s M edi -C al 85 percent of higher-income children reported program offered comprehensive dental services to all having a dental visit in the last year compared with full-scope Medi-Cal beneficiaries. During 2004, more just over 75 percent of lower-income children.13 than 8.5 million people were eligible at some point Only 40 percent of the state’s dentists in private for Medi-Cal-covered dental services, and Medi-Cal practice accept Medi-Cal patients, and the majority payments were in excess of $600 million.10 Since are general practitioners; specialty access is even 2006, budget constraints have limited adult dental more limited.14 Group dental practices, as well as benefits to $1,800 per beneficiary per year (although community health centers, provide a significant a number of procedures and eligibility categories amount of the services available to Medi-Cal are exempted from the cap), and most adult dental beneficiaries.15 Low provider participation rates are benefits were eliminated effective July 1, 2009. driven, in part, by Medi-Cal’s low reimbursement The majority of Medi-Cal beneficiaries receive rates, which are one-third to one-half of dentists’ services through Denti-Cal, the state’s fee-for-service usual fees.16 Efforts to increase reimbursement to dental program. California’s Department of Health dental providers have been stalled by ongoing budget Care Services (DHCS) also operates dental managed constraints.17 care programs in Sacramento and Los Angeles counties. Enrollment in these programs is mandatory Program Administration for Medi-Cal beneficiaries in Sacramento County Within DHCS, the Medi-Cal Dental Services and voluntary for beneficiaries in Los Angeles Branch (MDSB), a part of the Fiscal Intermediary County. and Contracts Oversight Division, is responsible for As in other states, California’s Medicaid (Medi- managing the Medi-Cal dental program. MDSB Cal) dental access and utilization rates are low. In manages Medi-Cal’s two dental programs differently 2004, only 26 percent of beneficiaries used dental because of their different structures. services, with children, pregnant women, and seniors using the least. Thirteen percent of Medi-Cal Denti-Cal Program beneficiaries had never been to a dentist, compared DHCS administers Denti-Cal through a contract with 5 percent of people with commercial health with Delta Dental of California (Delta California). insurance.11 A 2007 survey found that 44 percent of The Denti-Cal contract is structured in a manner adult beneficiaries reported not having Medi-Cal typical of Medicaid fiscal intermediary (FI) dental benefits even though Medi-Cal provides contracts. Delta California operates the program them.12 Among California’s children, those in using the California Dental Medicaid Management higher-income households (with family incomes Information System.18 This system supports above 300 percent of the federal poverty level) were functions such as eligibility verification, beneficiary more likely to have seen a dentist within the past services, provider services, utilization review, claims 12 months than lower-income children: About processing, and reporting. Delta California also 4 | C alifornia H ealth C are F oundation operates a call center with an integrated voice Lack of Dental Coverage in Medi-Cal response system, conducts quality management Managed Care Contracts activities, notifies beneficiaries of coverage decisions, It is important to note that about half of all Medi- and participates in fair hearings. Cal beneficiaries are enrolled in Medi-Cal managed DHCS establishes the criteria for services care plans, but dental services are not included in provided, and Delta California conducts the the plans’ contracts with the state and the plans’ treatment authorization request process and pays responsibility for dental services is limited.21 As a claims using these criteria on the state’s behalf.19 result, there is limited coordination of Medi-Cal It should be noted that a number of these criteria managed care beneficiaries’ physical health and dental and processes have been enacted in state statute to care services. Over the years, some Medi-Cal health counter fraud and abuse in the program, and leave plans have indicated an interest in including dental DHCS, and thus Delta California, with limited coverage in their contracts. Discussions with DHCS discretion in the way they are implemented. have generally faltered around the issue of rates. DHCS pays Delta California for administrative Most recently, CenCal Health (CenCal), the County services on a per-member-per-month basis tied Organized Health System serving Santa Barbara and to program enrollment. Under the terms of the San Luis Obispo counties, identified dental care as contract, Delta cannot lose or gain more than $4 a critical unmet need for its members. The plan has million per year. Delta California pays providers on a approached DHCS on an exploratory basis to discuss fee-for-service basis using the Medi-Cal fee schedule. issues related to the possible assumption of this benefit by CenCal, but no decision has been made.22 Dental Managed Care Program In Los Angeles and Sacramento counties, DHCS contracts with nine Knox-Keene-licensed dental managed care plans to provide dental services to Medi-Cal beneficiaries.20 The dental plans assume full financial risk for providing the Medi-Cal dental benefit in return for a negotiated monthly capitation payment. While the plans are required to offer the same services as Denti-Cal, they are provided within a managed care model that allows plans to manage utilization. Managing California’s Medicaid Dental Program: Lessons from Other States | 5 IV. edicaid Dental Administration in M Selected States HMA identified five states  — A rizona , State Contracts with Dental Benefits Michigan, New Jersey, Rhode Island, and Virginia  Manager for a Fee-For-Service Dental — that use administrative models that differ from Program California’s. Through interviews with state officials, Michigan, Rhode Island, and Virginia contract with dental benefits managers, and health plans, HMA dental benefits managers to help the state administer explored how these models operate to identify fee-for-service dental programs, including organizing potential lessons for California. Michigan, Rhode dental provider networks and actively managing Island, and Virginia have implemented major beneficiary utilization. Each of these states enrolls changes in their programs’ administrative structures many Medicaid beneficiaries in managed care health and contract with dental benefits managers (DBMs) plans for physical health care services, but dental to manage their fee-for-service dental programs. benefits are administered separately. The states moved Arizona and New Jersey include dental services to a DBM arrangement as a part of larger reforms of in their managed care health plan contracts and their Medicaid dental programs. The focus of reform have worked with the plans to improve access and has been on services for children; none of these states utilization. provides comprehensive dental benefits to adults. A number of common elements emerged across these states’ efforts, including: Key Findings The states studied in-depth — Arizona, Michigan, New Jersey, Rhode Island, and Virginia — as well as the Healthy Families Program (HFP), use different models to administer their dental programs. Arrangements include: contracting with dental benefits managers (DBMs) for administrative services only; contracting with dental managed care organizations; and contracting with full-risk managed health care plans for both physical and oral health services. Some of the study states rely on a single administrative model, while others use more than one model across their programs. Some states significantly restructured the Medicaid dental program, while others made incremental changes. Other findings: • Stakeholder involvement and buy-in is critical to the success of any reform effort. Senior-level executive and legislative branch leadership is also important. • Reforming the Medicaid dental program does not lead to cost savings in the short term due to beneficiaries’ unmet needs and resulting pent-up demand for oral health care services. However, cost-effectiveness improves as utilization moves away from restorative services and toward preventive care. • Administrative and payment issues are critical for providers and contribute to low rates of provider participation. The study states reduced or streamlined administrative requirements and, in many cases, increased reimbursement rates to improve participation. • Integration of physical and oral health services has not been a priority, although some states and health plans are beginning to focus on this. 6 | C alifornia H ealth C are F oundation Changes were guided by a high-level oral DBM for the state’s CHIP program. In contracting health task force that included legislative and with a DBM, the state was particularly interested in executive branch officials, dental associations, and obtaining access for Medicaid beneficiaries to a larger, consumer groups; commercial network of dental providers. Accordingly, dentists participating in Delta Michigan’s commercial The states are committed to streamlining network must see Medicaid beneficiaries unless administrative requirements for providers; they are not accepting new patients. This has The states look to their dental benefits managers increased access significantly for Michigan’s Medicaid to provide administrative services only, and retain beneficiaries because Delta Michigan’s network financial risk for their dental programs; includes about 95 percent of the state’s dentists. In addition, Delta Michigan uses the same policies and The DBMs pay their dental providers on a fee- procedures across both its commercial and Medicaid for-service basis; and lines of business, which providers find easy to The states work with their DBMs to monitor navigate. beneficiary access and utilization of services. The state pays Delta Michigan a fixed payment per beneficiary per month for both administrative As described below, each of the three states has services and payment of provider claims. The state some unique aspects to it program. reconciles claims paid annually with Delta Michigan. To pay providers, Delta Michigan uses a statewide fee Michigan’s Healthy Kids Dental Program schedule that is higher than the traditional Medicaid Implemented in 2000, Michigan’s Healthy Kids dental fees. Dental program now operates in 61 of the state’s Michigan tracks selected process measures to 83 counties. These counties are primarily rural and monitor the impact of the Healthy Kids Dental serve about one-third of eligible children under age Program. Since the program started: 21. Children in the remaining 22 counties, including Dental visits for enrolled children are 50 percent the Detroit metropolitan area, receive care through higher than for children in the traditional the state’s fee-for-service dental program. Medicaid dental program; Provider participation was a key problem for Michigan. Prior to 2000, less than 20 percent of the Geographic access to dentists has improved for state’s dentists participated in the Medicaid program, enrolled patients; and which spurred the state to convene the Medicaid Parents reported high rates of satisfaction with the Dental Task Force to evaluate it. The task force program, and 92 percent reported improvements recommended building on the success of Michigan’s in their children’s health as a result of Healthy Children’s Health Insurance Program (CHIP) Kids Dental.23 dental program, which is modeled on a commercial program. Healthy Kids Dental is administered through a Rhode Island’s RIte Smiles Program contract with Delta Dental of Michigan, Ohio, and Rhode Island’s RIte Smiles program was Indiana (Delta Michigan), which also serves as the implemented statewide in 2006 in response to the Managing California’s Medicaid Dental Program: Lessons from Other States | 7 recommendations of a senate commission on oral Virginia’s Smiles for Children Program health. In addition to focusing on access, the state Started in 2005, Virginia’s Smiles for Children has sought to increase the use of preventive dental program serves all Medicaid- and CHIP-eligible services and reduce the use of emergency departments children under age 21. for dental care. To maintain budget neutrality, only Provider participation was a key consideration children born on or after May 1, 2000, are enrolled for Virginia. Prior to 2005, Virginia offered dental in the program. Children born prior to this date up services to Medicaid beneficiaries through the health to age 21, continue to receive dental services through plan contracts in managed care regions of the state or the state’s fee-for-service system. through the fee-for-service program in the remainder Rhode Island contracts with UnitedHealthcare of the state. Dental providers objected to following Dental (United) as its dental benefits manager. The administrative procedures that varied by health plan company provides dental administration and care and found it difficult to keep track of beneficiaries management services, is responsible for developing who transitioned between different types of coverage and maintaining a provider network, and pays (managed care and fee-for-service) and between claims. To facilitate participation, providers may elect health plans. to participate only in RIte Smiles rather than the In 2004, on the recommendation of an oral entire Medicaid dental program. health task force led by the Medicaid director, the Rhode Island pays United a fixed payment per general assembly approved consolidating Medicaid enrolled child per month. The contract includes a dental services for children into a single, statewide risk-sharing and gain-sharing arrangement designed program managed by a DBM, and approved an to ensure the monthly payment adequately covers unprecedented 30-percent increase in program the cost of services provided, while limiting United’s funding. profit margin. Virginia selected Doral Dental USA (Doral) as Access to and utilization of dental services has the Smiles for Children dental benefits manager. improved after the program’s inception. Since 2006, The state pays Doral a fixed payment per enrolled provider participation has increased from 27 to 217 child per month to cover administrative services. providers, including every pediatric dentist in the Doral pays providers on a fee-for-service basis state.24 Within the first year of implementation, using a single, statewide fee schedule, and the state 34 percent of RIte Smiles patients had visited a reimburses Doral for claims paid. dentist, compared with 21 percent of fee-for-service The state tracks performance measures that participants. Rhode Island also monitors the use of align with Smiles for Children goals and has seen preventive care and has found that 27 percent of improvements in both utilization and provider children enrolled in RIte Smiles receive a preventive participation: visit, compared with 17 percent of fee-for-service In 2005, less than one-quarter of children under participants.25 age 21, and less than a third of children ages 3 to 20, received dental services. By 2007, utilization rates had increased to 35 percent for children under age 21 and to 43 percent for children ages 3 to 20. 8 | C alifornia H ealth C are F oundation In 2005, only 13 percent of Virginia’s licensed Like other states, Arizona has made changes to dentists participated in Medicaid, and only increase participation by dental providers. These 50 percent of providers who participated efforts started in 1997 when the legislature created submitted claims. By 2007, 23 percent of the Interim Study Committee on Dental Care Virginia’s dental providers participated in the to assess dental care services provided to children program and 83 percent submitted claims. 26 enrolled in Medicaid. The study committee directed AHCCCS to convene a task force to improve the While Virginia cannot attribute these availability and delivery of dental services to children. improvements solely to the transition to a dental As a result of the task force’s recommendations, benefits manager, the state believes Doral has AHCCCS made a significant change in how the played a key role in improving access and provider Medicaid health plans pay their dental providers. satisfaction. After many years of allowing plans to determine how to do this, AHCCCS explicitly prohibited capitating State Contracts with Managed Care dental providers and now requires that the plans pay Plans to Provide Dental Benefits providers on a fee-for-service basis. Additionally, Two of the studied states, Arizona and New Jersey, AHCCCS has strengthened contractual requirements contract with managed care plans to provide both to ensure they are consistent with the standard of care physical health care and dental services to Medicaid in the dental community, and has established dental beneficiaries. In each state, the health plans are paid network requirements. For example, AHCCCS a capitated monthly fee and are at financial risk updated the health plan contracts to clarify that for services provided. Some of the plans choose to beneficiaries can see a dental provider at least twice provide the dental benefit themselves by contracting a year for preventive care. With these changes as a directly with providers, while others subcontract with foundation, the state and the plans have conducted dental benefits managers. Both states work closely outreach to providers to increase participation in the with the health plans to address access and utilization program. issues and monitor performance. To monitor dental access and utilization, health Unlike the three DBM states discussed above, plans are required to report results of the HEDIS Arizona and New Jersey have not elected to make annual dental visit measure, and AHCCCS works wholesale changes in the way they administer their with plans on dental-related quality improvement Medicaid dental programs. Instead, they are tackling projects. For example, in the early 2000s, health issues related to access and utilization through their plans implemented a number of interventions existing administrative structures. designed to encourage annual dental exams for children age 3 to 8. Interventions implemented Arizona by one or more of the health plans as part of this Arizona’s Medicaid program — the Arizona Health quality improvement project included: (1) pay- Care Cost Containment System, or AHCCCS —  for-performance strategies to reward primary care contracts with 18 health plans to provide all physicians or dentists who meet specified oral health Medicaid-covered benefits to beneficiaries, including performance targets; (2) education of Head Start dental services (either comprehensive or emergency and Special Supplemental Nutrition Program for services). Managing California’s Medicaid Dental Program: Lessons from Other States | 9 Woman, Infants, and Children (WIC) staff about with 43 percent of children between the ages of 4 and the importance of oral health; (3) follow-up activities 6),28 and the state continues to work with the plans conducted with beneficiaries who miss appointments; to improve the program. For example, in 2007, the and (4) development of utilization profiles to provide Center for Health Care Strategies partnered with the feedback to providers about visit rates or to identify state to create New Jersey Smiles. Under this quality specific members requiring services. In one year, collaborative, stakeholders, including the health utilization for this group of children increased from plans, work with pediatric primary care providers 52.2 to 57.7 percent.27 and dentists in urban areas to improve integration of medical and oral health services by enhancing access New Jersey to pediatric dental care among children age 5 and Similarly, New Jersey’s Medicaid program (known younger.29 as NJ FamilyCare) contracts with five health plans to provide physical and oral health services on a capitated basis to the majority of beneficiaries. The health plans generally reimburse dental services providers on a fee-for-service basis. As in Arizona, the health plans are responsible for recruiting dental providers (including specialists), negotiating provider payment rates, conducting member outreach, and establishing and managing prior authorization requirements. Significantly, New Jersey is exploring how to integrate physical and oral health care services for Medicaid beneficiaries. NJ FamilyCare uses an integrated medical/dental model that provides coordinated, interdisciplinary care for beneficiaries with complex health issues. For example, in organ transplant cases, medical providers work closely with dental providers to ensure that all dental issues are addressed so transplant opportunities are not delayed or missed. The Medicaid health plans are required to track EPSDT-related utilization rates and to report on utilization using the HEDIS dental measure. While New Jersey credits its model with improving provider networks, access and utilization remain a concern (2006 HEDIS results indicate that about 21 percent of children between the ages of 2 and 3 received at least one dental visit in a 12-month period, compared 10 | C alifornia H ealth C are F oundation V. dditional Model: Healthy Families A Dental Program In addition to examining various states’ ranges set for those counties by MRMIB. However, initiatives for improving access to oral health services Delta has retained its existing beneficiaries and for underserved populations, the researchers also accepted their siblings when the plan is closed to new looked at California’s Healthy Families Program enrollment. (HFP), which provides dental services to low-income To monitor dental access and utilization, children. The Managed Risk Medical Insurance MRMIB collects data reported by dental plans and Board (MRMIB) administers the program. conducts satisfaction surveys. MRMIB found that To provide services to HFP subscribers across between 1999 and 2004, the percentage of HFP the state, MRMIB contracts with six dental plans, subscribers receiving an annual dentist visit or a including two dental exclusive provider organization prophylaxis treatment remained relatively constant (EPO) plans and four dental maintenance (ranging from 53 to 58 percent, and from 42 to 53 organizations (DMOs). Delta Dental and Premier percent, respectively).30 Access serve as the EPOs, and the DMO plans In 2007, MRMIB approved the use of eight new include Access Dental Plan Inc., SafeGuard Dental dental quality indicators, several of which focus on Plan, Health Net Dental Plan, and Western Dental access and use of services. These measures include: Plan. the HEDIS annual dental visit measure; overall MRMIB negotiates plan-specific capitation rates utilization of dental services; utilization of preventive with the participating plans, which are responsible dental services; use of dental treatment services for delivering services to their subscribers. Three of (to compare preventive and restorative services); the plans pay their contracted dental providers on a examinations/oral health evaluations conducted; capitated basis, two pay providers on a fee-for-service treatment/prevention of caries; ratio of fillings to basis, and one plan’s providers are salaried employees. preventive services; and continuity of preventive care To expand the choice of plans available to provided from year to year.31 Plans will report these subscribers, MRMIB has allowed additional DMOs measures to MRMIB for the first time based on the into the program over time. Overall, MRMIB 2008 calendar year. has found contracting with dental maintenance organizations to be more cost-effective than the exclusive provider organization model, and this has become increasingly important as California’s growing fiscal crisis puts increased pressure on the program’s budget. However, MRMIB has also found that member satisfaction is significantly lower in the DMOs than in the dental EPO plans. Delta Dental has been closed to new enrollment in a number of counties because its rates did not fall within the Managing California’s Medicaid Dental Program: Lessons from Other States | 11 VI. Common Themes S everal common themes emerged from able to reimburse providers at rates equal to those the research on the administration of the studied of commercial plans, but the case study states also state programs and Healthy Families Program. acknowledge that providers also must be able to cover their costs. Michigan, Rhode Island, and Virginia Active Stakeholder Involvement Is each increased provider reimbursement as part of Important for Program Reform their reform efforts. Nearly all of the case study states emphasized the Among the study states, providers are typically importance of stakeholder involvement in developing paid on a fee-for-service basis. Arizona, Michigan, and implementing changes to their programs. Rhode Island, and Virginia all commented that this Medicaid directors or interested legislators formed is necessary to promote provider participation. In or called for task forces to conduct studies, review contrast, several of the HFP dental maintenance options, and make recommendations about improving organizations pay providers on a capitated basis, the Medicaid dental programs in their states. which MRMIB noted could reflect the prevalence Senior-level executive branch or legislative leaders of dental managed care in some of California’s larger played prominent roles in several states. Virginia’s counties, such as Los Angeles. efforts were led by the state Medicaid director, Additionally, several case study states indicated who played an active role. In Arizona, senior-level that dental providers are willing to be paid a lower members of the executive branch, including the amount if claims are paid accurately and in a timely governor’s office and the Medicaid director, led the manner. To this end, New Jersey is planning to move project. Rhode Island’s reform was led by the chair of to one-day turnarounds for clean claims submitted the Special Senate Commission on Oral Health, who electronically by a specific time. has since become the state’s lieutenant governor. None of the case study states reported using pay- To ensure the programmatic reforms were for-performance incentives to encourage improved well-received and reflected a state’s individual access and utilization, although some Medicaid characteristics, all of the study states emphasized health plans in Arizona have used this strategy. the need to actively engage a range of dental stakeholders, including state dental associations, Administrative Issues Are Also dental schools, dental plans, dental professionals, Important for Providers physicians, Head Start representatives, schools, and All of the study states agreed that provider consumer advocates. participation is the backbone of ensuring access. In addition to increasing reimbursement rates, Payment Issues Are Critical for streamlining or reducing administrative requirements Dental Providers is important in increasing participation. Most case study states indicated that dental The study states noted that most dentists work providers understand Medicaid programs are not as sole practitioners or in small groups, and some 12 | C alifornia H ealth C are F oundation commented that dentists find it challenging to have Integration of Services Is in Infancy in-office expertise to manage contracts. Virginia and Among the study states, the focus to date has been Michigan both indicated that dentists prefer to work on increasing access and utilization of dental services with a single entity (e.g., a dental benefits manager) rather than integrating physical and oral health care. rather than with multiple health plans with differing Several states noted that the link between dental administrative requirements. To address these health and physical health is not strong, citing the concerns within a managed care structure, Arizona dearth of research on the benefits of integration or has changed health plan contracts to promote documented savings. One of the health plans noted procedural consistency across plans. that integration of physical and oral health services To ease one of dentists’ most commonly cited is not part of traditional medical or dental training, concerns about working with Medicaid beneficiaries, and Doral Dental commented on the challenge of several study states highlighted the importance of developing information systems capable of efficiently addressing “no-show” rates. Virginia works with sharing information between medical and dental providers to identify, track, and trend no-show providers. rates for enrollees, and patients are contacted about However, some of the study states are exploring the importance of keeping appointments.32 Rhode limited integration strategies. For example, Michigan Island’s DBM assists providers with no-shows and is considering training primary care physicians on the credits this with significant improvement in provider importance of having a first dental visit by age 1 and satisfaction. Arizona requires plans to work with providing fluoride varnish applications. Rhode Island dental providers to address and monitor no-shows. recently modified its Early and Periodic Screening, For example, Health Choice Arizona’s member Diagnostic, and Treatment periodicity schedule services department sends follow-up letters to to include a dental visit by age 1; the state’s dental members who have missed appointments. benefits manager is charged with informing dentists and primary care physicians about the requirement. Pent-Up Demand Delays Cost Savings The health plans interviewed for this project Most of the case study states cautioned that pent- also are focused on integration. In New Jersey, up demand for dental services delays cost savings AmeriChoice trains medical care providers in the associated with program changes. However, several early recognition of dental problems in children and states noted they are beginning to see increased cost- reimburses physicians for these services. The plan effectiveness due to reform efforts. While Michigan reimburses providers for dental referrals that result has yet to realize any cost savings, state officials cited in a dental visit (providers receive 40 percent of evidence of increased cost-effectiveness as member their original reimbursement amount for successful utilization moves away from costly restorative care to referrals), and AmeriChoice data indicate that preventive and primary care services. Rhode Island dental utilization doubles in medical practices that also anticipates that spending on dental services participate in the referral program. Finally, the plan will decline over time with the shift to a preventive reimburses dentists to screen for diabetes as part of care model. Similarly, MRMIB has found the initial the dental exam. years following expansion of access to dental services can be expensive, but costs decrease over time as utilization patterns change. Managing California’s Medicaid Dental Program: Lessons from Other States | 13 VII. Considerations for California Like other states, California is struggling the value of the oral health services purchased on with how to improve access and utilization of services behalf of beneficiaries. These metrics could include: for Medicaid beneficiaries. While program funding is Percentage of beneficiaries who have at least one clearly important, how the program is administered visit per year; also affects the provision of services. The experiences of the study states and the Healthy Families Program Distribution of services (i.e., preventive, provide insights for California to consider in diagnostic, and other dental treatment services) weighing alternative approaches to administering the provided to Medi-Cal beneficiaries; Medi-Cal dental program. Ratio of fillings to preventive services provided; Transition from Payer to Purchaser Amount of dental-related services provided in The study states have transitioned, or are the emergency department and inpatient hospital transitioning, from being payers of Medicaid dental setting; and claims to purchasers of services by actively partnering Number of California dentists participating in with vendors to improve access and utilization. the program and number providing services to This change is similar to the shift that many states Medi-Cal beneficiaries. (including California) have made over the past decade for their Medicaid managed care programs. In a similar way, Medi-Cal could become a “value-based Establish High-Level Task Force purchaser” for the dental program. Changes made by most of the study states were Under such a framework, Medi-Cal would focus guided and supported by a high-level task force that on the services purchased and the results achieved. was actively involved in framing goals and objectives, Rhode Island provides an example. Its reform efforts assessing options, and developing recommendations were guided by the legislature’s intent that the state and implementation strategies. become a “prudent purchaser” of dental care services. California could establish a similar task force that This led the state to contract with a dental benefits would include a range of dental care stakeholders. manager and developing process and outcomes Likely members might be: Department of Health measures to track the DBM’s performance. Care Services staff (including representation from Medi-Cal could develop a standard set of metrics the Medi-Cal Dental Services Branch; Medi-Cal based on the findings from the California HealthCare Managed Care Division; and Child Health and Foundation’s Denti-Cal Facts and Figures report Disability Prevention program), MRMIB staff, in 2007 and HFP’s dental quality indicators. The dental associations including the California Dental metrics could then be used to monitor the dental Association, community clinics, consumer advocacy program, make programmatic decisions, and gauge groups, Delta California, the dental managed care 14 | C alifornia H ealth C are F oundation plans, dental and health care professionals, and the they could be modified to be less burdensome for Oral Health Access Council. dental providers in good standing with the program. Ideally, the task force would be initiated and led by a senior-level representative from the executive Use Dental FI Reprocurement as branch (e.g., a member of the Governor’s staff or the Opportunity Medi-Cal director) or a member of the legislature After exercising available contract extensions, interested in oral health issues. Senior-level leadership DHCS will need to have a new dental FI (fiscal would be particularly important for California intermediary) contract in place in 2012. To meet this because any changes that lead to improved access and timeline, the procurement process would begin in greater utilization would likely result in increased late 2009 or early 2010. Reprocurement of the dental costs and could require changes in statute. FI contract presents DHCS with the opportunity to The task force could be charged with both short- restructure the contract to focus on improving access, term and long-term goals. A short-term goal might utilization, and outcomes. Suggestions from the be to examine options associated with the upcoming study states: reprocurement of Denti-Cal’s fiscal intermediary (FI) Incorporate access and utilization performance contract. Longer-term goals may focus on developing measures as well as administrative measures; and implementing a road map to improved oral health for all eligible Medi-Cal beneficiaries. Lessons Track beneficiary utilization of dental services from other states and the HFP could inform this over time and telephone or email beneficiaries process, but options and recommendations should who do not access dental care services within a reflect the Medi-Cal context. specified time frame; Design and implement initiatives with Align Dental Access and Program participating dentists and beneficiaries to address Integrity Goals appointment no-shows; and Program integrity is a significant concern for the Medi-Cal dental program because of past fraud and Secure access to a commercial dental network to abuse. This history has led to significant controls supplement the Medi-Cal dental network. on utilization, many of which are statutory and/or more stringent than those found in the commercial In addition to reviewing other states’ contract market. Dental providers find these requirements language, DHCS may want to solicit input and burdensome, which may limit their participation in information from possible vendors, including the Medi-Cal program. Delta California, through a request for information It will be important for Medi-Cal to align its regarding approaches that could be used to address access goals with its program integrity goals to ensure key issues in California. Information gathered they are complementary rather than working counter through this process could be used to structure to one another. A first step could be an analysis of the the request for proposals that DHCS will issue to statutorily required provisions to determine whether reprocure this contract. they are having their intended impact and whether Managing California’s Medicaid Dental Program: Lessons from Other States | 15 Measure Dental Program Performance reach out to Medi-Cal beneficiaries about the dental In the interim, DHCS may want to incorporate program and the importance of good oral health. performance measures into its existing FI and dental In addition, MDSB and MMCD could work more managed care contracts. The study states and the closely to ensure compliance with existing health HFP include performance measures in their dental plan requirements regarding dental benefits. For benefits manager or managed care plan contracts, and example, although MMCD notified its health plans several states commented on the importance of doing in 2007 that the topical application of fluoride is a so as part of managing their dental programs. covered benefit for members under the age of 6,34 the Currently, DHCS is exploring whether to include Medi-Cal Dental Services Branch indicated that the the HFP performance measures, or a similar set of benefit has not been monitored closely or enforced. measures, in the FI and dental managed care plan MDSB and MMCD could work with the health contracts.33 Performance measures used by other plans to track implementation of this requirement. states may provide additional metrics appropriate While these activities could require an enhancement for the Medi-Cal dental program. Medi-Cal should in the managed care capitation rates, they also offer continue to evaluate the best set of performance the opportunity to reach roughly half of all Medi-Cal measures for the dental program and work with the beneficiaries. FI and dental managed care plans to implement Given the interest the Medi-Cal health plans have them. shown in carving dental services into their contracts over the years, MDSB and MMCD should continue Partner with Medi-Cal Managed Care to explore the potential to pilot a dental carve-in with Over the past 10 years, the Medi-Cal Managed CenCal. This would give the state and the plans the Care Division (MMCD) has implemented value- opportunity to assess how this model would work based purchasing strategies on behalf of more under the Medi-Cal managed care program and than 3 million Medi-Cal beneficiaries. MMCD evaluate this approach in terms of access, utilization, requires plans to measure health plan performance outcomes, and cost. and member satisfaction and provides incentives (both financial and non-financial) to improve the Improve Outreach and Education of quality of services provided. For example, MMCD Beneficiaries and Providers publishes the annual HEDIS results for the health DHCS could work with the California Dental plans; publicly recognizes high-performing health Association (CDA) and other provider groups, plans at the MMCD annual quality conference; and consumer advocacy organizations (e.g., Western uses performance data to help determine health plan Center on Law and Poverty), schools, clinics, enrollment for members who do not voluntarily WIC (Special Supplemental Nutrition Program select a health plan. for Women, Infants, and Children) sites, Delta Given California’s sustained experience with California, and the dental managed care plans to Medi-Cal managed care, there may be partnership develop strategies to proactively conduct Medi-Cal opportunities for the state to explore with the health beneficiary and provider outreach and education plans. For example, MDSB could coordinate with the about the importance of oral health care and how Medi-Cal Managed Care Division and the plans to to obtain services. As in other states, MDSB could 16 | C alifornia H ealth C are F oundation analyze enrollment and utilization data to identify beneficiaries who are not using dental services and implement strategies to encourage them to do so. It should be noted that the current FI contract neither requires nor prohibits Delta California from undertaking such activities and would need to be revised. In addition, Medi-Cal could work with health care providers, including via the Medi-Cal managed care plans, to provide training on the dental program and the importance of preventive dental care for overall health. DHCS could look to other initiatives in California as models for outreach and education. For example, the First Smiles program was a four- year, statewide initiative funded by First 5 California designed to provide education and training to medical and dental professionals and education to community-based organizations (e.g., WIC and Head Start programs) aimed at increasing access to preventive oral health services for young children.35 Similarly, Alameda County’s Healthy Kids, Healthy Teeth demonstration project offered training to dental and medical providers to increase access to dental services and improve the oral health of children age 5 and younger eligible for Medi-Cal.36 Managing California’s Medicaid Dental Program: Lessons from Other States | 17 VIII. Conclusion States that have struggled with dental care access and utilization offer valuable insights and models for California to consider. These states have tackled reform from various angles that have included reducing or streamlining administrative requirements and, in some cases, increasing provider reimbursement. Some also have pursued new administrative approaches (such as contracting with a dental benefits manager) while others have implemented incremental approaches within the context of their state environment. Despite California’s current fiscal crisis, which limits the amount of new funding available, California should chart a course to improve the Medi-Cal dental program. In particular, the reprocurement of the Denti-Cal FI contract offers an opportunity to begin to change the way Medi- Cal provides dental benefits and to introduce managed care principles into the Denti-Cal program. Simultaneously, a Medi-Cal dental task force could develop a vision and approach for longer-term changes to improve access and utilization within the dental program. 18 | C alifornia H ealth C are F oundation IX. Methodology The information included in this issue brief is based Michelle Marks on HMA interviews with state Medicaid officials in Chief, Medi-Cal Dental Services Branch five states: Arizona, Michigan, New Jersey, Rhode California Department of Health Care Services Island, and Virginia. The researchers interviewed Janette Lopez representatives from two dental benefit managers Chief Deputy Director (Delta Dental of Michigan, Ohio, and Indiana, and California Managed Risk Medical Insurance Board Doral Dental USA) and two managed care health plans (United/AmeriChoice and Health Choice Michigan Arizona) that contract with state Medicaid programs Christine M. Farrell, R.D.H., M.P.A. to provide health and dental services. Officials from Program Specialist, Medical Services the California Department of Health Care Services Administration (DHCS), which administers the Medi-Cal dental Michigan Department of Community Health program, and the Managed Risk Medical Insurance Board (MRMIB), which administers the Children’s New Jersey Health Insurance Program (CHIP), known as Margaret M. Bennett, M.S.N., R.N., A.P.N. Healthy Families, were interviewed. In addition, Director, Office of Quality Assurance representatives from Delta Dental of California, Division of Medical Assistance and Health which serves as the fiscal intermediary for the Services Medi-Cal fee-for-service dental program, were also New Jersey Department of Human Services interviewed. Carol Grant State Interviewees Chief of Operations Division of Medical Assistance and Health Arizona Services Robert L. Birdwell, D.D.S. New Jersey Department of Human Services Dental Director Clifford Green, D.M.D. Arizona Health Care Cost Containment System Assistant Director, Office of Quality Assurance Division of Medical Assistance and Health California Services Robert Isman, D.D.S., M.P.H. New Jersey Department of Human Services Dental Program Consultant Medi-Cal Dental Services Branch California Department of Health Care Services Managing California’s Medicaid Dental Program: Lessons from Other States | 19 New Jersey, cont. Dental Benefits Manager/ Valerie J. Harr Health Plan Interviewees Deputy Director Allen Finkelstein, D.D.S Division of Medical Assistance and Health Chief Dental Officer Services United/AmeriChoice New Jersey Department of Human Services Robert Freeman Bonnie Stanley, D.D.S. Deputy C.E.O. Chief, Bureau of Dental Services CenCal Health Division of Medical Assistance and Health Michael Kaufmann Services Senior Vice President of Government Programs New Jersey Department of Human Services Delta Dental of California Rhode Island Kevin Kline Martha Dellapenna, R.D.H., M.Ed. Vice President, Client Services Oral Health Access Project Manager Doral Dental USA, LLC Center for Child and Family Health Richard Lantz Rhode Island Department of Human Services Manager of Government Relations Delta Dental of Michigan, Ohio, and Indiana Virginia Sandra Brown Garrett Leaf Dental Program Manager Vice President, Denti-Cal Virginia Department of Medical Assistance Delta Dental of California Services Nancy McEwen Dental Program Manager Health Choice Arizona 20 | C alifornia H ealth C are F oundation Endnotes 1. U.S. Government Accountability Office. September 2008. 9. U.S. General Accounting Office. September 2000. Medicaid: Extent of Dental Disease in Children Has Not Oral Health: Factors Contributing to Low Use of Dental Decreased, and Millions are Estimated to Have Untreated Services by Low-Income Populations Tooth Decay (www.gao.gov/new.items/d081121.pdf). (www.gao.gov/archive/2000/he00149.pdf ). 2. Manski, R. J., and E. Brown. 2007. Dental Use, Expenses, 10. California HealthCare Foundation. May 2007. Private Dental Coverage, and Changes, 1996 and 2004. Denti-Cal Facts and Figures: A Look at California’s MEPS Chartbook No. 17. U.S. Agency for Healthcare Medicaid Dental Program (www.chcf.org/documents/ Research and Quality (www.meps.ahrq.gov/mepsweb/ policy/DentiCalFactsAndFigures.pdf). data_files/publications/cb17/cb17.pdf). 10. Ibid. 3. U.S. Department of Health and Human Services. 2000. 12. California HealthCare Foundation. November 2008. Oral Health in America: A Report of the Surgeon General Drilling Down: Access, Affordability, and Consumer (www.surgeongeneral.gov/library/oralhealth). Perceptions in Adult Dental Health 4. McGinn-Shapiro, Mary. October 2008. State Health (www.chcf.org/documents/policy/ Policy Monitor: Medicaid Coverage of Adult Dental Services. DrillingDownAdultDentalSurvey2008.pdf). National Academy for State Health Policy 13. 2007 California Health Interview Survey. UCLA Center (www.nashp.org/files/Adult Dental Monitor.pdf). for Health Policy Research (www.chis.ucla.edu). 5. Haley, J., G. Kenney, and J. Pelletier. July 2008. Access 14. See note 10. to Affordable Dental Care: Gaps for Low-Income Adults. The Kaiser Commission on Medicaid and the Uninsured 15. See note 10. (www.kff.org/medicaid/upload/7798.pdf). 16. California HealthCare Foundation. March 2008. 6. Savage, M.F., J.Y. Lee, J.B. Kotch, and W.F. Vann, Jr. Increasing Access to Dental Care in Medicaid: Does Raising October 2004. “Early Preventive Dental Visits: Effects Provider Rates Work? (www.chcf.org/documents/policy/ on Subsequent Utilization and Costs.” Pediatrics 114(4): IncreasingAccessToDentalCareInMedicaidIB.pdf ). e419 – e423 17. For a summary of the Clark v. Kizer settlement, see (www.pediatrics.org/cgi/content/full/114/4/e418). Clark v. Coye, 967 F. 2d 585 (9th Cir. 1992) at 7. See Albert, D.A., D. Sadowsky, P. Papapanou, M. caselaw.lp.findlaw.com/scripts/getcase.pl?court=9th& Conicella, and A. Ward. August 16, 2006. “An navby=case&no=9315930&exact=1. Examination of Periodontal Treatment and Per Member 18. The California Dental Medicaid Management Per Month (PMPM) Medical Costs in an Insured Information System is a state-owned information system. Population.” BMC Health Services Research The system consists of an integrated set of procedures and (www.biomedcentral.com/1472-6963/6/103); Aetna. computer processing systems capable of claims processing October 30, 2006. “Aetna Launches Dental/Medical as well as storing and retrieving information. States are Integration Program that Includes Specialized Pregnancy required to have these CMS-approved systems unless Benefits.” Press release (www.aetnaushealthcare.com/ this requirement is waived by the federal government, news/2006/pr_20061030a.htm). and states generally contract with a fiscal agent or 8. U.S. House of Representatives, Oversight and intermediary to operate the system. Government Reform Committee, Domestic Policy 19. Medi-Cal-covered dental services are defined in the Subcommittee. September 23, 2008. Testimony of California Welfare and Institutions Code and in Title 22, Burton L. Edelstein, DDS, MPH (www.cdhp.org/ California Code of Regulations. downloads/Oct2008_CDHP Testimony.pdf). Managing California’s Medicaid Dental Program: Lessons from Other States | 21 20. Knox-Keene refers to the Knox-Keene Health Care Health Care Strategies and New Jersey Smiles, New Jersey Service Plan Act of 1975. Health care service plans Smiles: A Medicaid Quality Collaborative to Improve Oral or specialized health care service plans operating in Health in Young Kids (www.chcs.org/usr_doc/NJ_Smiles_ California are required to obtain a Knox-Keene license Fact_Sheet.pdf). granted by the California Department of Managed 29. Ibid. Health Care. This license ensures that such organizations meet certain minimum standards and gives them the 30. California Managed Risk Medical Insurance Board. right to conduct business in the state. July 19, 2006. Dental Plan Quality Measurement Report for Services Provided in 2004 (www.mrmib.ca.gov/ 21. Dental requirements for health plans participating in MRMIB/HFP/2004DentalRpt.pdf ). the Medi-Cal Managed Care Program include referring members to the Medi-Cal dental program beginning at 31. California MRMIB. September 19, 2007. Meeting age 3 and providing an oral health assessment as part minutes (www.mrmib.ca.gov/MRMIB/Agenda_ of the member’s initial and periodic health assessments Minutes_091907/091907min.pdf ). as required under the Child Health and Disability 32. Virginia Department of Medical Assistance Services. Prevention program. December 2007. Annual Report on the Dental Program. 22. Personal communication with Robert Freeman, deputy 33. California Department of Health Care Services. October chief operating officer, CenCal, September 30, 2008. 2008. California’s Response to the American Dental 23. U.S. House of Representatives Committee on Energy Association 2008 Compendium Update: A Survey of and Commerce, Subcommittee on Health. March 27, Medicaid and State Children’s Health Insurance (SCHIP) 2007. Testimony of Christine Farrell, Medicaid policy Dental Programs for Children and Adults. specialist, Medical Services Administration, Michigan 34. On April 18, 2007, DHCS issued MMCD All Plan Department of Community Health (energycommerce. Letter 07008 to inform the Medi-Cal health plans that house.gov/images/stories/Documents/Hearings/PDF/110- the topical application of fluoride, up to three times in he-hrg.032707.Farrell-testimony.pdf). a 12-month period, is a covered benefit for members 24. Dellapenna, Martha M., October 6, 2008. “The RIte under the age of 6. Plans were instructed to inform Smiles Program and Its Effects on Children with Special members about the new benefit, train providers to Healthcare Needs.” Presentation at the National Academy ensure applications are documented in the member’s for State Health Policy Annual Meeting: Tampa, FL record, monitor the utilization rate of fluoride varnish, (www.nashp.org/Files/Dellapenna_NASHP2008.pdf). encourage providers to schedule visits that include application of fluoride varnish, and promote the use of 25. Dellapenna, Martha M. August 28, 2007. OMB Site fluoride varnish through provider training and quality Visit. improvement activities (www.dhcs.ca.gov/formsandpubs/ 26. Virginia Department of Medical Assistance Services. Documents/MMCDAPLsandPolicyLetters/APL2007/ December 2007. Annual Report on the Dental Program. MMCDAPL07008.pdf ). 27. Arizona Health Care Cost Containment System 35. Barbara Aved Associates. March 2008. First 5 Division of Health Care Management. August 2005. California Oral Health Education and Training Project, Arizona Health Care Cost Containment System CYE Final Evaluation Report (www.first5oralhealth.org/ 2003 Performance Improvement Project: Children’s downloads/0/1589/First 5 Oral Hlth Final Eval Reprt for Oral Health Care Visits, First Remeasurement of CDAF-DHF.pdf ). Performance (www.azahcccs.gov/reporting/Downloads/ 36. For information on Healthy Kids, Healthy Teeth, PerformanceImprovementProjects/dentalvisits2005.pdf ). see the Alameda County Public Health Department 28. 2007 New Jersey Medicaid health plan HEDIS data Web site (www.acphd.org/user/services/AtoZ_PrgDtls. as reported by the health plans, included in Center for asp?PrgId=39). 22 | C alifornia H ealth C are F oundation C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org