November 1, 2000
DENTAL SERVICES IN NURSING HOMES
By: Helga Niesz, Principal Analyst
Robin Cohen, Principal Analyst
You asked us to survey a sampling of nursing homes about any problems they have getting dentists to come to the homes and take care of their residents.
We surveyed 100 nursing homes regarding your question and 58 of them responded. Two-thirds of the respondents said they were having or sometimes had difficulty obtaining dental services for their residents. Seventeen percent experienced service disruptions or cancelled visits. Nearly all of them attributed their difficulties to low Medicaid reimbursement, although other factors appear to play a role. Some of those who are currently having no difficulties also added that they had past difficulties or anticipated potential future problems.
Most respondents reported that local dentists provide routine procedures at the home, such as oral exams, diagnosis, cleanings, and denture adjustments and fittings and residents are sent out for more serious procedures. Dental hygienists also come to 17% of the homes. A significant number of respondents (40%) were served by HealthDrive, a Massachusetts-based company that contracts with nursing homes to provide dental, podiatry, audiology, and other services. Almost half the respondents said that the dental professionals provide services monthly or more frequently. Only four homes (7%) indicated they currently have to send their patients out for all dental care. Half the respondents indicated that dental care took place in a timely fashion, but 43% expressed some concern that the wait was too long. The wait for non-emergency service ranges from less than a week to up to six months. For emergency services, the range is from the same day or within 24 hours to several days.
We have enclosed OLR Report 99-R-0428, which provides additional details on dental services in the Medicaid program generally, associated difficulties, and potential solutions.
Of the 58 respondents, 23 (40%) were served by Health Drive, 34 (59%) were served by other local dentists (of these, one dentist was listed as serving nine nursing homes, three other dentists were named as serving two homes each), and one had an in-house dental clinic staffed by several local dentists.
Frequency of Care
When asked how often the care is provided, 27 homes (47%) responded that it is provided monthly, or monthly and as needed, or more frequently. Eight homes responded that care is provided yearly and as needed. Seven reported care is provided at intervals between monthly and annually. Five homes responded it is provided “as needed.'' One answered “as per regulations.” Ten (17%) responded to this question by reporting some disruption or cancellation of scheduled visits.
Location of Care
Thirty-five homes (60%) said the dentist comes to the home. Another 19 (33%) said they both have a dentist come to the home and send patients out. Four (7%) said they currently have to exclusively send the residents out of the home for dental care. Ten of the homes (17%) indicated that a dental hygienist also came to the home in addition to the dentist.
Types of On-Site Services
In 42 of the homes (74%), dentists provide routine procedures at the home, such as oral exams, diagnosis, cleanings, denture adjustments, and fittings. (Of these, 10 report that the dentists also provide fillings on-site, 13 report that they provide simple extractions, and two report that they provide some other services.) Five homes said the dentist provided all but the most difficult procedures on-site. In an additional five homes, the dentists do only oral exams on-site. Four homes said they currently provide no dental services on-site and one did not respond to the question. Nearly all of the homes sent residents out for difficult procedures such as oral surgeries, root canals, or multiple or difficult extractions.
Difficulty Obtaining Services
When asked whether they had difficulty obtaining dental services for their residents, 38 (66%) answered “yes.” Of the 20 (34%) homes that answered “no,” a number said although they have a dentist now, they have had difficulties in the past or would have difficulty finding a new dentist if this one left. Several of those who had contracts with HealthDrive anticipated difficulty in the future because HealthDrive is having difficulty recruiting dentists and is asking the nursing homes to pay them a fee for providing services. Thirty-four of the 38 who responded “yes” attributed the difficulty mainly to low Medicaid reimbursement. Even some of those that currently have no difficulty attributed their past or feared future problems to this factor. Other reasons given were dentists' reluctance to come to the homes, paperwork, state inspectors second-guessing dental decisions, difficulty of residents, time it takes to travel to the home, and confusion regarding the pending HealthDrive contract. In a telephone conversation, one administrator mentioned difficulty in providing an appropriate space for the dentist to do his work (i.e., a space that meets proper standards for a sterile environment and anti-infection safeguards) as a factor in getting dentists to do invasive work at the home.
Length of Wait for Treatment
When asked how long people have to wait for dental treatment, 29 (50%) of the respondents indicated that it took place in a timely fashion and 25 (43%) expressed some concern that the wait was too long. The wait for non-emergency service ranged from less than a week to up to six months. For emergency services, the wait ranged from the same day or within 24 hours to several days. But often respondents just said the services were provided in a timely fashion or that the wait was too long without providing more specifics.
Some homes also commented that because they have difficulty getting local dentists, especially specialists, to accept Medicaid patients, they have to use dental clinics at hospitals, which results in a very long wait. Some also expressed concern about HealthDrive's proposal to charge the nursing homes an annual non-reimbursed fee to provide the services. A number emphasized the large gap between dentists' fees on the private market and the reimbursement they receive from Medicaid and expressed their opinion that there is a need for equitable reimbursement for professional services. One respondent stated that many people enter the nursing home with poor dentures or problems with their teeth, which can affect their ability to eat.
State Dental Requirements in Nursing Homes
State public health regulations require a dental examination and evaluation within 30 days after someone enters a nursing home unless such an examination has taken place within the last year. After that, the nursing home must provide an annual exam and evaluation (Conn. Agencies Reg. Sec. 19-13-D8t (n)(4)(A)(iii), (n)(9)(B)(v). Federal law requires the home to assist residents in obtaining routine and 24-hour emergency treatment (42 C.F.R. § 483.55).
Although the regulations only require nursing homes to provide examinations once a year, Medicaid pays for cleanings twice a year, dentures every five years, relining dentures every two years, and other services as needed.
Medicaid reimbursement for adult dental services has not changed in at least 11 years (rates for children increased in 1994). For instance, Medicaid currently reimburses the dentist $13 for an initial oral exam and only $9.75 for a periodic oral exam. Reimbursement for an adult cleaning is $19.50. We have enclosed a complete reimbursement schedule.
We have also enclosed a copy of the 1999 Connecticut Medicaid Study, which surveys dentists' attitudes toward participation in Medicaid.
Dental Advisory Council
PA 00-2 June Special Session established a Dental Advisory Council to examine dental care access for Medicaid recipients to, among other activities, review the fees that Medicaid pays for dental services, recommend adjustments, and recommend ways to expand access.