For Immediate Release
Date: Feb 20th, 2014
Contact: Dr. John Thompson
Medicaid: An Example of Missing the Goals for Oral Health in Kentucky
To say that the Kentucky Dental Association opposed the implementation of the Managed Care Organization (MCO) model for the Medicaid program in 2011 for Kentucky would be an understatement. We could find no logic for the imposition of another layer of bureaucracy in an already bureaucratically-burdened system. We pointed to a desperately low service reimbursement rate as the primary problem, not fraud and abuse. We said that deficiencies in access to care could be solved by increasing dentist participation. We argued that the money dedicated to paying the MCOs could be used to increase reimbursement and that would increase participation and that would drastically improve access to care. We had only logic to defend our position and no matter how we presented this, it came across as “self-serving the dental profession”.
Fast forward to 2014 and how much has the situation regarding the dental Medicaid program in Kentucky improved? I wrote in 2011, in my tongue in cheek commentary, “I HAD AN UNCLE”, for KDA TODAY as I was looking forward to the result of this implementation, “I could now spell FIASCO! For some reason, this had not worked out too well and now the Not Doing Well cousins are saying they can’t get their teeth fixed. Little cousins have tooth aches and they have to wait for the outside cousins to say they can go to the tooth fixers for treatment. To make matters worse, the tooth fixers are screaming mad because they say the outside cousins are keeping the coins for the teeth they have already fixed. Some cousins are now writing editorials about access to care for our Not Doing Well cousins and calling for another change. Nobody was very happy before and now they are all getting mad as hell!” I am not an oracle, but I think it is an accurate assessment!
It is, however, very unfair of us to say, “I told you so” with regard to what has happened. In 2010 the annual cost for Kentucky Medicaid services was spinning out of control. The federal government was pressuring states to adopt this model and states that had adopted this model were pointing to success in cost control for their overall Medicaid expenses. Kentucky had been using the same management model for Medicaid year after year and was getting the same dismal results. To keep doing the same things and expecting a different result is the definition of insanity was the argument Governor Steve Beshear used to drive for change in the management of Kentucky Medicaid.
Here is the crux of the problem. The MCO model has been successful for cost savings in medical Medicaid programs. In the rush to implement the MCO model over the last three months of 2011, dentistry was swept into the web of the entire Medicaid program and budget. Medicine and Dentistry have very different primary care delivery models and dentistry has its projected expense line item. In 2012, the overall Medicaid Claims budget was $4.8 BILLION and of this amount for dental services was $86 MILLION. The cost of MCO operation is minimal when factored against such a large overall budget and the savings are real. The cost of MCO operation when factored against the small projection for dentistry is a significant cost. The MCOs have, in fact, provided a savings in dental Medicaid expense dollars, but what has been the REAL cost?
That answer comes to us through the efforts put forth by Dean Sharon Turner and Dr. Raynor Mullins, a “semi-retired” dental public health faculty member at the University of Kentucky College of Dentistry. Dean Turner is the principal investigator and Dr. Mullins is the project leader for the University of Kentucky as a sub-contractor for an Appalachian Regional Commission (ARC) planning grant project that included as the lead university, Morehead State University. Gerald Demoss, PhD is the project director for MSU. The project is titled APPALACIAN RURAL DENTAL EDUCATION PARTNERSHIP (ARDEP). Currently, UK and MSU are in the initial year of implementation of ARDEP that includes development of a campus-wide oral health literacy program and campaign linked to the MSU Student Health Service.
It is important to have a sense of the mission of this ARDEP project and the ARC goals. ARC goal one is to “increase job opportunities and per capita income in Appalachia to reach parity with the nation; and General Goal Three: develop and improve Appalachia’s infrastructure to make the region economically competitive.” The “ARC State Objective 2.6: Provide access to health care professionals that can increase the availability of affordable, accessible and high quality health care to meet the needs of Kentucky’s Appalachian communities. Additionally, this project addresses the ARC state strategy 2.6.1: Support educational institutions and programs that train health care professionals who will practice in the region.”
The ARDEP planning grant required a dental needs assessment and database to provide clear, objective information about the number of dentists who practice in Kentucky, and the number of dentists who participate in the Medicaid and KCHIP programs in Appalachia and state-wide. A team from the UK Center for Oral Health Research (Jeff Ebersole, Pam Stein, Robert Kovarik, Jackson Brown and Joanna Aalboe) worked on the dental needs assessment that also included dental practice information developed from the ADA Survey of Dental Practice data for Kentucky and an assessment of the economic impact of dental practices with the UK Center for Business and Economic Research, Gatton College. This necessary database provides for a direct comparison of the year before the MCO experiment took place and the year after it was installed. That comparison, a natural experiment, provides eye-opening results.
Workforce assessment questions that were asked included:
* How many dentists practice in Kentucky?
* General Dentists
* Dental Specialists
* Distribution across the Commonwealth
* Gender and Age Characteristics?
The study has many interesting findings that bear consideration in any attempt to define a problem. I will limit this commentary to only a small segment of the data sets. There are 2,063 general dentists practicing in Kentucky, 30% are female, 52% are 50 or older and 24% are 60 or older. From 2008-2011 there was a net gain of 224 dentists in Kentucky and interestingly 145 were educated at out of state colleges. This is statistic is called in-migration and may represent the growth of corporate dentistry in Kentucky and dental faculty recruitment at Uof L and UK. In the years 2008-2011, 41% of the new dentists licensed were trained out of state.
Questions that were asked to define the outcomes of Medicaid Managed Care for the year 2012:
- What was the level of participation?
- Measured monthly and annually
- Paid dental claims volume in dollars
- The number of patients served
- The age categories of these patients
- The number of patient visits
- Measured monthly and annually
- What is the level of Medicaid/KCHIP participation in the 2012 MCO model?
- How many dentists participate in Medicaid Managed Care?
- Best measure is dentists who are paid for one or more dental claims in a given time period based on the unique NPI number
- Monthly / annual
- Analysis by general dentists, dental specialists, gender, practice sector and regional distribution
We have to start with what has happened to utilization as the target of the MCO model was to control cost and increase access to care. Dr. Mullins discovered that during 2012, the numbers of Medicaid/KCHIP patients who actually received dental care dropped substantially, with nearly 35,000 fewer Kentuckians receiving dental services compared to 2011, the year prior to implementation of the MCO model.
Interestingly the total Medicaid enrollment only increased by a few hundred individuals from 2011 to 2012 and the decrease in patients receiving care was noted in all age groups from 0-4 through age 70. The shame is that the most dramatic drop in utilization was for children age 0-4 years. While the enrollment for this age group increased substantially by nearly 30%, the number of these young children that actually received dental services in this same period declined 12.74%.
For all of Kentucky in 2011, age 0-20, there were nearly 600,000 enrolled in Medicaid/ KCHIP and only 46% had an actual contact for some dental service. For all of Kentucky in 2012, age 0-20, was an increase in enrollment by 3.4% and a decrease in services to only 40% of the eligible children. In 2011 the total Medicaid/KCHIP paid claims were $124 million and decreased in 2012 to $86 million, a decrease of $38 million or a decrease of 30.5% in claim reimbursement. There can be no question that Kentucky’s experiment with Managed Cost (excuses me, Care) Organization has been very successful in reducing expenditures. It is of interest that the dental MCO’s actual fees for managing the Kentucky Dental Medicaid/KCHIP programs is considered proprietary and that information is not available.
It is my opinion that dentist participation has also been adversely affected by increased MCO administrative burden and decreased reimbursement rates from 2011 to 2012. In 2011 there were 849 general dentists with paid claims. In 2012 there were 169 who filed no claims and dropped from the program, while 81 new enrollees participated for a net loss of 88 general practitioners. Similarly, there are 110 oral surgeons in Kentucky and of these only 53 were providing services in 2012.
Our Kentucky pediatric dentists are the real examples of altruistic care in this data analysis. While there are 86 pediatric dentists across this state, 74 were participating in Medicaid/ KCHIP. Thus, this small group is providing a very significant volume of the care in this state. The question or problem is how close they are to maximum participation, with little room to grow to fill the documented needs.
The data for year 2013 has not all been analyzed at this time, but there is currently no indications that there will be any significant variance from the trends in 2012. It is now 2014 and the Affordable Care Act has become a reality (albeit a fractured resemblance to its projections). The estimates for Kentucky seem to be fairly accurate in that Medicaid eligibility will be expanded by 308,395 souls. KYNECT (Kentucky Health Care Exchange) will add 55,632 with some form of federal subsidy and 288,046 as newly insured. I cannot tell you how many will be children seeking dental care, but the net effect is an expanding population with oral health care needs. “We have a big problem and unless changes occur in the current managed care model, this problem will increase”, is the conclusion of the ARDEP report.
The ARDEP report is specific for dentist participation by specialty, by region, by county and service. The consolidated reports have been provided and distributed to state government. Governor Steve Beshear has seen the data and has expressed his concern to me, as it is not the result he sought. The Cabinet Secretary for Human Services, Audrey Tayse Haynes, has been told that the current state model for managing and providing oral health care for the underserved population is failing. She is responsive to the problem. We have Dr. Ken Rich in the Medicaid Services Department who has assisted in gathering data sources and is seeking to work with Commissioner Kissner. They all know that these problems are compounded in rural Kentucky, particularly Appalachia and the Mississippi Delta. A new dental care management model is needed.
The greatest problem that we face in securing any improvement in the management model is the simple fact that dental care is such a small fraction of the overall Medicaid claims (approximately 0.02%). The changes that the ACA has brought to the overall Medicaid program are overwhelming state government personnel. Their ability to focus on this problem is compromised by the onslaught of unintended complications involving line items with much greater fiscal significance.
There is a very real possibility that with the current increase in the Medicaid population, the trend in decreased dental provider participation and increase to five MCOs, we may soon have more people involved in cost management of the Medicaid dollars than are actually providing dental care. That is one unintended consequence that will be very hard to justify by government or the profession.
We must look at this problem from this perspective:
- It is OUR Commonwealth
- It is OUR state government
- It is OUR dental profession
- They are OUR children
- They are OUR future
- It is OUR problem
WE must be part of the solution!
Editor’s note: For the last two years I have been privileged to follow development of a significant collaborative designed to improve oral health literacy and outcomes in Eastern Kentucky. Dr. Raynor Mullins has shared data as it has been collected, screened, purged and collated. The data has been gleaned from public sources, but never before put into truly meaningful spreadsheets. The collated data is property of the University of Kentucky College of Dentistry, Morehead State University and the APPALACIAN RURAL DENTAL EDUCATION PARTNERSHIP (ARDEP). The data sets and the information these data sets have provided has now been fully disclosed and shared with the government agencies of the state of Kentucky prior to distribution to any other entity. I have used these data sets and reports generated by Dr. Mullins as my sole source for this commentary. The Kentucky Dental Association and all members of the dental profession owe a debt of gratitude to ARDEP for developing this statistical look at oral health care services in Kentucky. The span of this report goes well beyond what I have cited and there will be following articles and interviews to provide additional findings contained in the report.