Adult Medicaid Dental is Key to Overall Health, Requires Increased Access

Medicaid programs are well-positioned to prioritize optimal oral health in their states through adult dental benefits, but systematic changes are necessary to fully address barriers to dental care.

Although Medicaid programs are required to provide pediatric dental coverage for low-income children, extending those benefits to the adult population is optional. Currently 15 states offer extensive dental coverage for low-income adults on Medicaid, while 17 states only provide coverage for dental emergencies or provide no coverage at all.

Robust adult dental benefits can have tremendous impacts on state Medicaid populations:

·         Individuals with dental benefits are 42 percent more likely to have a dental checkup within the year than individuals who don’t have coverage. Additionally, when parents receive care, their children are more likely to go to the dentist as well.

·         Reducing or eliminating Medicaid adult dental benefits has led to significant increases in dental-related emergency department visit and associated costs in states like California.

·         Ensuring low-income adults have access to comprehensive dental coverage can improve employability, as adults lose millions of work hours each year due to dental disease.

·         Increasing access to dental coverage can help to reduce disparities as well because untreated dental disease disproportionately afflicts racial and ethnic minorities.

·         Treatment of gum disease can lead to better health management — as evidenced by lower health care costs and fewer hospitalizations — among people with common health conditions, such as type 2 diabetes, heart disease, and pregnancy. These links to improved overall health management are particularly critical for Medicaid beneficiaries.

The economic, oral health, and overall health outcomes above are tremendous arguments for states to invest in a Medicaid adult dental benefit, but access challenges will persist without systematic approaches to oral health.

In this month’s publication of Health Affairs, research conducted by the DentaQuest Institute and the American Dental Association shows that emergency department utilization for oral health conditions rose in Kentucky after Medicaid expansion, which included a dental benefit for adults.

In the emergency department, patients generally receive palliative and costly care. A combination of pain-management (usually opioids) and infection management for preventable conditions costs the U.S. health care system an estimated $1.6 billion annually.

Presumably, increasing coverage under Medicaid would have reduced emergency department utilization and associated costs. Why didn’t this happen for Kentucky?

Although Kentucky expanded dental coverage to adults in Medicaid, the state still faced many challenges:

• 23 percent of low-income individuals cited inconvenient locations or time as a reason to avoid going to a dentist.
•  Kentucky’s reimbursement for dental services was 44 percent of commercial rates.
•  Due to few dental providers in the state, Kentucky had 99 dental health provider shortage areas, and only 39 percent of Kentucky dentists participated in the Medicaid program.

Coverage is a critical first step to ensuring access to dental services for adults served by Medicaid, but it cannot be the only step. 

While information in Kentucky suggests that an increase in emergency department use following the addition of an adult Medicaid dental benefit is likely temporary, strategies to improve oral health in a state must go beyond coverage alone.

Key strategies that states must consider include:

• provider capacity and support, 
• reimbursement rates,
• dynamic oral health education, and 
• the integration of oral health screenings and/or referrals into primary care are. 

These factors are critical to ensure that patients receive the most appropriate care in a timely manner and in the most appropriate setting.

Fortunately, organizations like DentaQuest are creating multi-pronged approaches to these systemic oral health challenges.

At DentaQuest, we align philanthropy, science, coverage and care to improve the oral health of all. DentaQuest Foundation delivers millions of dollars in grant funding to hundreds of initiatives across the nation, fostering oral health innovation at the grassroots level. Ideas that prove most promising are leveraged by the DentaQuest Institute, which develops innovative clinical care and practice management solutions to help providers deliver optimal care.

Programs and initiatives that prove to be both effective and scalable by the DentaQuest Institute are then integrated in a broader fashion by DentaQuest Benefits Administration and the DentaQuest Care Group, fueling a comprehensive disease management approach toward health that is prevention-focused and outcome-driven. 

We are more than just a dental administrator. We are an incubator of innovation and a proving ground for pioneering initiatives in the oral health space that improve health.

These types of collaborative solutions that incorporate a wide array of stakeholders are imperative to successfully improve oral health in a state and to achieve the Triple Aim – reduce healthcare costs, improve the patient experience, and achieve better health outcomes. 

Why are dentistry and oral health care practices seemingly easy to question?

The topic of evidence in dentistry and oral health care has been in the news a lot recently, with articles like this column in the New York Times by a professor of pediatrics.

In his column, Aaron Carroll discusses the differences he sees between his own and his wife’s dental journeys, as well as what little rigorous research has been done to support certain generally recommended dental practices.

What is interesting is that articles like this one and the popular flossing article from the Associated Press, among others, imply that recommendations made by dentists are based solely on limited or weak evidence – or worse, based simply on what the dentist will get paid for by an insurance company.

They also leave readers feeling that plaque removal and cavity prevention/treatment are the only elements necessary to address for good oral health.

Ultimately, Carroll suggests in his column that while lack of evidence doesn’t mean oral health prevention efforts don’t work, we should invest in research to ensure that those things we do are evidence-based.

For those of us in the business of improving oral health, we couldn’t agree more with that conclusion. But let’s take a closer look at some of the points that may have gone overlooked by recent press coverage.

We know that evidence something works for populations doesn’t directly translate into solutions for a specific individual – that is in fact why Carroll and his wife have such dramatically different dental journeys.

Carroll notes he has had just one filling in his life and doesn’t religiously care for his mouth, while his wife has “more fillings than [he] can count” but is fastidious in her oral care routines.

This underscores two important points:

1. Every person is different. Individualizing care is critical to improved oral health.

While evidence-based research informs standards of care, it is the dental team that must develop the best care plan for any given person’s situation. That is why DentaQuest invests in the development and adoption of evidence-based care protocols that focus on prevention, early intervention and disease management.

Our investments in disease management and risk assessment help provide dental teams with the knowledge and tools they need to best serve their patients.

For instance, across a five-year period, the DentaQuest Oral HealthCenter demonstrated that risk assessment and intense preventive efforts (including sealants and fluoride varnish) directly resulted in a reduction in the need for invasive surgical procedures.

Sealants are one of the most cost-effective strategies for protecting teeth, as noted in another recent New York Times column. This is because they provide a physical barrier against cavities. They can even be applied to teeth that are just starting to show signs of new cavities, and stop them from getting bigger.

The best time to seal a tooth is immediately after it erupts in the mouth, and so the DentaQuest Oral Health Center strives to set aside extra time at visits for children ages 6 and 11 since the permanent molars are usually erupting at that time. It is also why the DentaQuest Foundation collaborates so closely with school-based health alliances working to improve access to oral health care – and sealants – among children in grade school.

Additionally, with a patient population of over 10,000, the DentaQuest Oral Health Center works in collaboration with the DentaQuest Institute to refine strategies that make patients healthier. And when these best practices are implemented, they actively improve peoples’ health.

2. Prevention and oral health improvement do not take place solely in the dental chair.

Preventive dental visits provide an important opportunity for people to check in on their oral health habits and get evaluations for early signs of not just dental disease, but also chronic diseases like diabetes and hypertension.

Most of us spend two hours a year in a dental office. And, if we are to reconsider the benefit of two annual preventive visits as Carroll suggests, some of us might end up spending even less time with a clinician. So what about the other 8,758 hours?

The differences in the oral health of Carroll and his wife are not because he brushes with an electric toothbrush every day or because she is doing something “wrong” in her routine. Oral health care is more than just brushing and flossing. In fact, it is about more than your teeth and gums.

To make an impact, we have to take a look at how we pay for oral health care, how our public policies enable it, and how our communities prioritize it, in addition to how we provide it.

Addressing just one of those will not improve oral health care on the larger scale or reduce health care costs, as Carroll aims to do with his recommendations. We know oral health care is indeed critical for overall health. This is why we at DentaQuest look far beyond the dental chair.

For example, as part of Oral Health 2020, the DentaQuest Foundation is investing in efforts to incorporate oral health into the primary education system. Oral health education, screenings, assisted referral, and delivery of preventive care through our schools provide equitable, reliable entry into long-term oral health care.

DentaQuest also champions efforts to include innovative financing models for dental in person-centered approaches to care enabled by the Affordable Care Act (ACA).

Over the last decade, we’ve seen significant movement to transform our health care system into one that improves quality, lowers costs, and makes people healthier. In fact, on the medical side the Triple Aim is starting to be supported by alternative payment and care delivery models that are person-centered and focus on prevention.

Why did that happen? Because experts and advocates knew there had to be a better way forward for a healthier America.

The same is true for oral health. We are beginning to see that it is possible to live in a world where optimal oral health is the expectation, not the exception. We must continue to invest the same transformative energy into improving the oral health of all because you cannot have optimal overall health without optimal oral health.

 

Let’s improve oral health with provider-focused, patient-centric Medicaid dental partnerships

States and managed care organizations face real challenges when it comes to running a successful Medicaid program and helping people get and stay healthy. Medicaid leaders find themselves faced with extremely difficult decisions about how best to prioritize critical needs of the population – often times there are no silver bullets. Yet, Medicaid dental partnerships are a great step forward.

In the past, the dental component of a Medicaid program has fallen victim to tough decisions, receiving fewer resources and lagging behind when it came to ensuring access to needed care. And people suffered.  

Recognizing this, states started to look at their Medicaid dental programs differently. They began seeking out industry experts like DentaQuest to help work directly with Medicaid agencies or to support managed care organizations to implement best practices. 

The result was that more people got access to the medically necessary oral health they needed.

   

Rapidly expanding regulatory requirements and Medicaid budget pressures, as well as the tidal wave of value-based payment and care models initiated by the Affordable Care Act, mean states once again find themselves at a crossroads when it comes to their Medicaid dental programs.  

Forward thinking states are moving past the notion that access to treatment is all it takes to improve the oral health of all. They recognize that an effective Medicaid dental program must achieve the Triple Aim: lower costs, improved population health, and better patient experiences.  

Tennessee is a perfect example of a dental partnership focused on the triple aim. 

In 2012, state Medicaid leaders recognized they were no longer meeting the oral needs of the people they served and set out to create a new Medicaid dental program model. They also recognized that they needed a new partner, not just a vendor, to help develop and implement a holistic approach to oral health.   

Today, DentaQuest partners with the state to administer the TennCare Medicaid dental program and through this partnership, more children have access to preventive care at a lower cost to taxpayers.  

Since partnering with TennCare in 2013, DentaQuest has saved the state $27.5 million by prioritizing preventive care, which helps to avoid extensive, costly future procedures. In the second year of the program, the number of children participating in the program increased by 8 percent to 810,000 enrollees. Through our dental home program, we’ve made sure that each and every one of the 810,000 children is connected to a dentist who is willing and able to provide care.  

TennCare has been able to handle the influx of patients thanks to a provider participation increase of 31 percent. DentaQuest has focused on easing the administrative burdens placed on providers and facilitating transparent communications.  

This successful model is built upon the idea that aligned incentives can improve outcomes.  

DentaQuest has a shared responsibility when it comes to improving outcomes and reducing costs. This challenge should not fall on providers and states alone. DentaQuest must meet outcome benchmarks—set by the state—related to access, network adequacy, outreach, and cost.  

DentaQuest met or exceeded benchmarks in all categories during the first two years and is poised to demonstrate success again in year three.   

The results of this model are encouraging: 

• Average distance to a provider is 3.7 miles, compared to a benchmark of 30 miles 
• Wait times for routine, urgent, and emergency care are significantly lower than the state’s thresholds 
• 100 percent of beneficiaries have patient-centered dental homes—providing accessible, comprehensive, and coordinated care to enrollees 

 

DentaQuest has been able to succeed in part by educating and engaging patients and families—even hosting over 80 community events last year.  

This type of patient-centric program should serve as a model for other state Medicaid programs and partners. Change and innovation should not mean complexity and burden. 

There is a better way forward and DentaQuest has a roadmap to get there.