States diverge in caring for the teeth of the poor

What do you call a dental insurance plan that lets you file claims online quickly and efficiently, confirm patients' eligibility instantly, get timely authorization for treatments, receive reimbursement in two weeks or less, and get paid at a rate that lets you make a profit? Now, what do you call the plan that provides all that for low-income kids?

In Michigan, one name covers both: Healthy Kids Dental (HKD), the program for Medicaid children that has replaced traditional Medicaid in 69 of the state's 83 counties. It is administered by Delta Dental, a well-established private network, and already it has 90% of dentists in those counties participating.

It's a rare story of progress in a nation where the oral health problems of millions go untreated. Michigan's program still falls short of offering dental care for all those in need. Uninsured children whose families earn more than the federal poverty limit ($21,200 a year for a family of four) don't qualify; neither do any adults. But such state initiatives may provide the biggest change you'll see in dental care over the next few years.

The need is pressing. "Oral health should be at the table for healthcare reform," said Jay Gershen, D.D.S., Ph.D., executive vice chancellor of the University of Colorado Health Sciences Center. "There are 133 million Americans who don't have dental insurance. Many medical conditions express themselves in the oral cavity. Americans need equitable access to affordable care, including dental care."

The problem got some attention a year ago when Maryland 12-year-old Deamonte Driver died from an untreated dental abscess -- even though his family was eligible for Medicaid. But reforms introduced in Congress remain stuck in a partisan standoff.

Historic divide

In general, dental care gets less government support because it has been left out of general healthcare programs. Medicare doesn't include dentistry, and Medicaid reimburses dentists as little as 43% of reasonable and customary fees. "Medicaid only offers a promise of dental care for children," said William Prentice, who directs the ADA's Washington, DC, office. An estimated 70% of eligible kids nationwide receive no dental services because in most places so few dentists participate in the program.

Members of Congress last year introduced several pieces of legislation aimed at expanding the number of people eligible for government-subsidized dental care. Most efforts focused on a reauthorization of the State Children's Health Insurance Program (SCHIP), which provides care to children from families too poor to afford private insurance but not poor enough to qualify for Medicaid. The legislation would have made dental care a mandatory part of the program. But President George W. Bush vetoed the bill.

So far the candidates vying for President Bush's job have not explained how they might extend dental care to patients who can't afford private insurance. The ADA and the American Dental Education Association are currently working on policy statements, which they hope to have ready in time for the new president. "We intend to have a very specific and hopefully strong statement," said Jack E. Bresch, associate executive director of the American Dental Education Association.

The ADA has traditionally favored market-based approaches and keeping dentistry separate from medicine in health reform, according to policies listed on its Web site. But it has made an exception for the indigent. "We want the government to focus its time, attention, and funding on those with least resources," Prentice said. "Rather than promising coverage to many, let us focus on getting care to those most in need."

Three states -- Maine, Massachusetts, and Vermont -- recently enacted comprehensive healthcare reforms aimed at covering the uninsured, but all treat oral healthcare separately. "Dental care has always been delivered through a different delivery system from medical care," Prentice said. "It is an accident of history."

But not a complete accident, according to Bresch. Congress excluded dental from Medicare when it established the program over 40 years ago. "That was not an oversight," he said. "The ADA lobbied successfully not to have oral health included in Medicare."

That policy seems to have shaped the approach of state dental organizations as well. Covering dental care did not even enter the conversation leading to Maine's Dirigo Health plan, according to Frances Miliano, executive director of the Maine Dental Association.

Vermont legislators included in the state's Catamount Health plan only what health insurance policies regularly cover, which excludes dental services, according to Peter Taylor, executive director of the Vermont State Dental Society.

And Massachusetts's Commonwealth Care health reform is too new to consider adding anything beyond medical benefits, said Karen Rafeld, assistant executive director of the Massachusetts Dental Society.

Increasing dentists' participation

States that have made progress in addressing oral health have acted outside of general healthcare reform. In Michigan, "the maze of red tape, along with woefully inadequate reimbursement rates, was the main reason for poor dental provider participation," said Dale Nester, D.D.S., a general practitioner in rural Ithaca, MI.

A 2001 nationwide survey by the National Conference of State Legislatures (NCSL) confirms Nester's observation. It also mentions that many low-income families don't understand the importance of oral health and are unfamiliar with making and keeping appointments. "These obstacles still persist in 2008," said Shelly Gehshan of NCSL, one of the study's authors.

Plans like Michigan's, which have attracted dentists to treating Medicaid children, share three important features, according to Congressional testimony by Jane Perkins of the National Health Law Program of Chapel Hill, NC, in May 2007. They reimburse dentists a lot more, streamline administration, and provide case management to address appointment no-shows.

Under the Michigan plan, participating dentists agree to accept whatever Delta Dental reimburses as payment in full. Typically, this amounts to at least 66% more than Medicaid would pay for the same services.

"Reimbursement far exceeds that of the state government Medicaid program and, with the efficient turnaround times for payment, will allow an office a small to moderate profit," said general practitioner Raymond Gist, D.D.S., of Flint, MI, who is eagerly awaiting July 1, when his county will join HKD.

In the first five years of HKD, dental visits by children in the program were 50% higher than for children in traditional Medicaid, according to University of Michigan researcher Stephen A. Eklund, D.D.S., Ph.D.

A handful of other states have also recently improved access to dental care:

• Delaware's fee-for-service Medicaid plan pays 85% of dentists' "reasonable and customary" fees, in contrast to only 43% typically reimbursed through the Medicaid system. Almost 60% of Delaware's licensed dentists now participate.

• Medicaid children in Rhode Island's RIte Smiles program present the same card as private subscribers to UnitedHealthcare Dental insurance plans. RIte Smiles pays more, and more promptly, than fee-for-service Medicaid (which still enrolls kids born before 2000). Participating practices can receive special training in pediatric dentistry. Participation quintupled in the first year.

• South Carolina raised reimbursements to the 75th percentile (meaning that 75% of dentists in that region are charging that amount or less for a particular service). The state also improved administration and case management. The number of participating dentists nearly doubled.

• Tennessee established a single fee schedule, provider contract, and claims procedure, as well as electronic systems. Payments rose from about 40% of dentists' costs to the lesser of the 75th percentile ADA-surveyed regional fees or the charges billed. The number of participating dentists more than doubled.

• Virginia raised fees nearly 30% and turned administration over to a private network. In the first year, 190 dentists joined, a 30% increase. A quarter of the state's licensed dentists now participate.

Elsewhere, however, efforts to expand dental care for those most needy have stalled. Faced with a budget deficit, California Gov. Arnold Schwarzenegger proposed cutting reimbursements for indigent California dental patients by 10%.

And state efforts alone can't ensure that poor kids will get dental care. When higher rates and administrative changes go into effect, "dentists need to step up to the plate and participate in the programs," Perkins said. Otherwise, she warns, state officials have no incentive to make reforms and "will say, rightly, 'Wait a minute, dentists were crying out about this, so we increased the rates and they didn't join.'"