Topic:
DENTISTS; HEALTH INSURANCE; LEGISLATION; SOCIAL SERVICES; CHILD HEALTH; JUVENILES; MEDICAID; STATISTICAL INFORMATION;
Location:
DENTISTRY; INSURANCE - HEALTH;

OLR Research Report


February 23, 2006

 

2006-R-0107

DENTIST PARTICIPATION IN HUSKY

By: Robin K. Cohen, Principal Analyst

You asked what the state is doing to improve dentist participation in the HUSKY program, in particular pediatric dentists.

Please see earlier OLR Reports (2004-R-0175, and 2003-R-0831) for additional information on the topic. You can also find related information on the Department of Public Health's Office of Oral Public Health website (http://www.dph.state.ct.us/bch/oralhealth)

We do not know to what extent pediatric dentists are serving the HUSKY population. We have asked the Department of Social Services (DSS) for such a breakdown and will provide it to you once we receive it.

SUMMARY

For years, both advocates for the poor and dentists have asserted that the state needs to do more to ensure that low-income children, in particular HUSKY recipients, have access to dental care. A 2005 Voices for Children study of HUSKY A dental care reported that just 47% of children ages three to 19 had any dental care in 2004. That year also marked an end to a steadily rising percentage of children receiving preventive dental care, which had begun in 2000.

A declining number of dental providers willing to serve these children has been one of the main barriers to access. There are many reasons for the lack of providers, with the main ones being low reimbursements and high no-show rates. The state reimbursement has not been changed since 1993. At that time they were set at 80% of the prevailing fee, according to the Connecticut Health Foundation; now it is less than 20% of what dentists typically charge for their services. And Medicaid managed care (HUSKY A) transferred reimbursement for pediatric dental care from a fee-for-service to a monthly capitation model, with the managed care organizations (MCO) subcontracting with dental MCOs to serve clients.

To address these access concerns, the 2003 legislature directed DSS to hire an administrative services organization (ASO) to manage HUSKY dental services beginning in late 2004. But in early 2005, DSS abandoned its plan to do this, believing such a move would not improve access. At around the same time, legal aid advocates sued the state for a general failure to provide adequate and timely access to dental care to the poor, but a U.S. District court recently ruled in favor of DSS's motion for summary judgment to dismiss most of the suit's counts.

The governor's FY 07 budget adjustment includes nearly $3 million for “enhanced” dental services in HUSKY, but no hikes in reimbursement for services. The budget write up calls for a pilot program under which pediatricians will examine children's teeth at regular intervals before age three and apply topical fluoride treatments. It will also cover sealants for premolars, which are believed to reduce the potential for tooth decay. A proposed bill calls for an increase in dental reimbursements.

In a recent report on the dental care “safety net,” which includes community clinics, hospitals, public schools, and dental schools, the Connecticut Health Foundation writes that utilization rates for even these providers are low (they serve only 10% of HUSKY A children) and need to be boosted with higher Medicaid payments. They also suggest a new dental care delivery model that relies on dental hygienists and public schools. The foundation recently awarded a grant to Middletown's Community Health Center to provide a mobile dentistry program for that community's low income children. (A news account of the grant said that no private dentists in Middlesex County were serving HUSKY recipients.) The Public Health Committee has raised a bill to carry out many of the foundation's recommendations.

LACK OF DENTAL PROVIDERS

A lack of dental providers, in particular dentists, is cited as the main reason HUSKY families are finding access to dental care for their children difficult. In late 2003, we reported a downward trend in the number of individual dentists enrolled in the Medicaid program as fee-for-service providers. (We do not know the figures for HUSKY A but we believe these dentists also serve HUSKY A children.) This downward trend has continued, as shown in Table 1. (It should be noted that even though dentists are identified as being HUSKY providers, many of them are not accepting new patients, or the wait to see them is up to three months, according to Dr. Kenneth Lambert of DSS.)

Table 1: Medicaid Fee-for-Service Dental Providers (2000-2005)

Provider

2000

2003

2005 [1]

Individual dentists

289

188

141

Dental groups

40

40

29

Orthodontist groups

21

21

Unavailable

Oral surgeons

17

9

12

Oral surgeon groups

9

4

3

Dental clinics

34

35

36

Dental hygienists

0

1

Unavailable

Dental hygienist groups

0

1

Unavailable

[1] DSS provided aggregate data for 2005, rather than by provider categories. We did not receive orthodontist or hygienist data. We placed providers in categories based on our best judgment.

LEGISLATIVE ACTIONS TO INCREASE ACCESS

Carve Out of Dentists in HUSKY

PA 03-155 directed DSS to administer the dental portion of the Medicaid managed care program (HUSKY A), taking it out of the overall managed care system. It also called on DSS to simplify the application process for dental providers and streamline the renewal forms for providers whose information had not recently changed. DSS never implemented the “carve out,” claiming that it would not increase access.

To a limited extent, the department implemented the application and renewal process changes, according to DSS.

Dental Hygienists as Dental Providers and 2005 Changes

State law permits dental hygienists to practice under the general supervision of a dentist, even if the dentist is not actually on the premises. This arrangement is quite common among safety net providers.

In 2005, the legislature changed the scope of practice for a number of dental providers and took other steps to improve access. For example, hygienists are now permitted to administer certain kinds of anesthesia, with proper training. The new law requires dentists to show they have completed a minimum number of continuing education “contact” hours, which they can do by volunteering in public health facilities. It also allows a person to use successful completion of a year of postgraduate training as a dental resident, which often involves public clinic work, to qualify for a dental license, without having to take the practical portion of the licensing exam.

The act also (1) eliminates the $100 license renewal fee for dentists who provide at least 100 hours of free care at licensed health care institutions and (2) allows foreign-trained dentists to obtain both state dentist and hygienist licenses (thus increasing the number of dental practitioners) (PA 05-213).

LAWSUIT

In 2003, legal aid lawyers sued DSS, alleging that DSS had failed to comply with the Medicaid law and this created a critical shortage of dental providers willing and able to serve children and adults receiving Medicaid. DSS asked a U.S. District Court for summary judgment on the suit.

In January 2006, the court granted summary judgment to DSS with respect to the allegations that it had failed to comply with the following Medicaid requirements: (1) “equal access” and “quality of care,” (2) statewide availability, (3) timely care, (4) comparable care among recipients, and (5) prompt and efficient payments to providers. But the court denied judgment on most of the counts that alleged that DSS had failed to inform recipients of, and provide access to, the Medicaid program's Early and Periodic Diagnosis, Screening and Treatment provisions as they pertain to dental services for children. It is unclear what the ramifications of this latter finding will be for DSS.

GOVERNOR'S PROPOSAL

Governor Rell has proposed $2.95 million in FY 07 budget adjustments to enhance dental services in the HUSKY program. The budget narrative calls for an “Access for Baby Care” pilot program, in which pediatricians examine children until age three and apply fluoride to prevent tooth decay. It also calls for teaching mothers and children better oral hygiene practices. Finally, it requires DSS to pay for dental sealants in the HUSKY program; currently, these are not covered.

SAFETY NET PROPOSAL

The Connecticut Health Foundation has been studying the issue of dental access for poor children. In a series of recent reports, it makes the following observations:

1. the size of the dental work force in Connecticut is declining,

2. HUSKY A fees are below the 7th percentile of fees for all of New England,

3. safety net clinics are short of dental equipment and auxiliary staff, and

4. HUSKY A children have the lowest dental utilization in New England and less than half of that of privately insured children

The co-authors of the reports looked at the diminishing dental work force (retirements are outpacing new dentists) and assert there is a deficit of 532 dentists by 2015, with a continuing, uneven distribution across cities and towns.

The authors focused primarily on safety net providers, which include the community health centers. But even these providers, who presently serve only 10% of HUSKY children but could potentially serve more, are struggling financially.

The authors made these recommendations they say will double dental utilization rates among HUSKY A-eligible children. First, Medicaid fees need to be raised. The authors cite Michigan, where in an experimental program, the state turned Medicaid in 37 counties over to a private insurer and paid dentists the same rates that private insurers paid, which resulted in increased utilization.

The second recommendation is to increase the ability of the safety net providers to serve these children. They suggest increasing auxiliary staff and operatories (dental chairs), which would raise productivity of both private practices and safety net clinics. The authors point to the dentists' limited ability to employ more hygienists because of the community colleges' current lack of capacity to train them.

A third recommendation is a model plan where a dental hygiene team provides screening and preventive services to HUSKY A children in public schools and coordinates with private practices for needed restorative or other care. The model is based on the fact that 76% of services used by HUSKY children can be provided by such teams using portable equipment in schools. The plan calls for the dentist or hygienist to do the initial screening; preventive services are provided by a hygienist, supported by a dental assistant, community aide, school aide, and driver, should the child need any additional services.

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