KDA Today

KDA Today

For Immediate Release

Date: Jun 16th, 2014
Contact: Dr. John Thompson
Phone: 800-292-1855
Email: info@kyda.org

YOU HAD TO BE THERE!

As the Interim Executive Director I am discovering new policy every day. There are many things I hope to share with you in component meetings, but this is something I would only do in writing. I recently attended a meeting I felt necessary to help me define the socioeconomic and political environment into which this job has thrust me. All I can say is …

YOU HAD TO BE THERE!

The last Friday in April the University of Louisville School of Dentistry sponsored a lecture entitled AFFORDABLE CARE ACT (ACA) IMPLEMENTATION: IMPACT ON DENTISTRY. This presentation was to a full auditorium and I am reasonably certain that no one left feeling better than they did on arrival. This presentation either sustained or exacerbated many of the concerns I have shared in commentary over the last two years. The greatest benefit of attending this meeting was the clarity and accuracy of the material presented. Like it or not the brave new world of medicine was explained in this four plus hour symposium. Did I say medicine? Well, if you don’t believe that dentistry is rapidly becoming a sub-specialty of medicine don’t bother to read this synopsis. 

There was too much material to even attempt to detail material provided by each of the presenters. Instead, I am going to try to share bullet points gleaned from the ten pages of notes I took during this meeting. Each of the five speakers presented a perspective and I will be very limited in selections from each.

Thomas J. Spangler, Esquire representing the American Dental Association as Senior Director on Legislative and Regulatory Policy:

Regarding the Pediatric Vision and Dental requirement that satisfies the Essential Health Benefit (EHB) mandated by the ACA:

v  Only three states, Kentucky, Nevada and Washington require that the benefit be purchased.    

  • All other states require only that it be offered.

v  Embedded plans have a distinct advantage in pricing nationally.

  • A Stand Alone Dental Plan (SADP) with a 70% low actuarial value averages about $30 per month in premium for a one child CHIP or FEDEP pediatric dental plan.
  • A SADP with an 85% high actuarial value averages about $39 for the same coverage.
  • A Pediatric Dental Plan that is embedded in the medical plan is averaging about $5.11
    • The SADP is not subject to the medical deductible and the annual Maximum Out OF Pocket (MOOP) expenses are clearly limited and defined in these plans.
    • The embedded plan has a much lower cost but in many policies is subject to the medical deductible before any pediatric dental benefit is covered. (Not in Kentucky at this time)

¨       A dental office must know each policy in order to explain the benefit to a patient and this is going to be a complicated process with many variables.

¨       These policies do not look like and expected costs to patients do not apply in ways that reflect dental policies of the past.

v  Market forces will demand that you know the plans being offered in your region.

  • For SADP you must know the carrier and have a contract as most all will be closed panel networks.
    • There is a 90 day grace period before the premium must be paid and you will need to know if there is coverage if that premium is not paid. If service is provided inside of that grace period you may find you worked for no fee.
    • For an embedded plan the same applies but in addition:
      • You must know how the deductible is applied and if it does apply to preventive benefits that would be covered at 100% for the first dollar in a SADP.

v  PATIENT COMMUNICATION IS GOING TO BE EXTREMELY CRITICAL!

Tony Cook, CEO Dental Care Plus, HMO Dental Plan

Regarding trends and how it affects existing dental plans:

v  The ACA provides a definition of an EHB for dental plans that provide a pediatric dental benefit.

  • This benefit ranges from 19 to 21 year olds (21 in Kentucky)
  • The Kentucky plan is based on the KCHIP menu of services and the KCHIP definition of Orthodontic qualification.
    • Orthodontic coverage is provided under the qualifier as Medically Necessary or Handicapping Malocclusion.
      • Under this definition 0.5 to 1.5% of a population will be covered.

v  There is now no annual maximum, but there is an annual MOOP expense.

  • In Indiana and Ohio the MOOP expense is $700 for the first child and $1400 for two or more children.
  • In Kentucky the MOOP expense is $1000 for the first child and $2000 for two or more children.
    • IT IS IMPORTANT TO NOTE that the higher the MOOP the lower the monthly premium.
    • There is a Federal move to lower the MOOP significantly and Kentucky will apply for a waiver to maintain the level we have now. (the Premium effect will be addressed later)

v  Perhaps Tony’s most dramatic presentation was focused on HEALTH CARE TRENDS and this synopsis will not do justice to the depth of these concepts:

  • Dentistry used to be different.
    • It is now all about the lowest cost for the highest quality.
    • There is the trend to make the mouth part of the body.
      • The profession has been working hard to demonstrate the effect oral health has on systemic health and the message has been heard.
      • Employers are trending toward a strategy of defined contribution for employee healthcare.
        • Instead of offering a health plan and a dental plan as an employee benefit, provide the employee a defined amount (i.e. $10,000) per year to purchase their own health and dental policies from a public or private exchange/marketplace and not suffer annual increases in premiums as drains on the bottom line of the business.

¨       As inflation erodes the defined contribution, how much will be left for the traditional family dental plan when only the pediatric benefit is mandated?

  • At the congressional level there has always been the question of, “Why is dentistry separate?” That distinction is becoming harder to sell as medicine continues to integrate.
    • Health Exchanges are creating health consumers.
      • Consumers demand information on quality as well as cost.
      • Exchanges allow consumers to demand low cost for high quality.

Dr. Ken Rich (our own KDA Past President and Past ADA Trustee) in his role as Kentucky Medicaid Dental Director and through his involvement with the Dental Quality Alliance.

Regarding emerging paradigms and strategies within the profession:

v  In 2010 48% of healthcare in the United States was paid with tax dollars and we spend more than any other developed country on healthcare as a percent of the GDP.

  • Internationally healthcare in the US is not the best, just the most expensive.

v  The current national healthcare services strategy is to:

  • Improve health
  • Improve patient experience
  • This is to occur at a lower cost

v  The paradigm is that only 10% of an individual’s overall health is due to healthcare services.

v  The old standard of care in dentistry is being replaced by Evidence Based Dentistry (EBD)

v  The fee for service model for reimbursement is disappearing and being replaced by:

  • Value based reimbursement and that progression has been from
    • Fee for service toward>
    • Physician and Hospital pay for performance toward>
    • Patient centered medical homes toward>
    • Bundled payments toward>
    • Accountable Care Organizations (ACO) and Delivery System INTEGRATION.
      • WE ARE MOVING INTO A FULLY INTEGTATED MEDICAL MODEL

Dr. Fred L. Sharpe AVESIS Chief Dental Officer

Observations from the perspective of the Managed Care Model:

v  There are three managed categories of dental healthcare.

  • Children’s dental diseases, primarily caries
  • Adult dental care; continued  breakdown and periodontal diseases
  • Senior Adult advanced caries and periodontal disease associated with dry mouth

v  CDC reports increasing dental disease in the youngest population, under 5 years

  • The greatest dollar expenditure for all of Medicaid is on the 4 Year Old and hospital based dental services due to advanced caries.

v  The group with the least services is seniors.

  • No Medicaid of significance
  • No Medicare dental
  • Most retirement dental plans have disappeared with the Great Recession.
    • Almost all dental services are family financed.

v  The US population is about 330,000,000 and of those 140,000,000 are in Federal healthcare programs.

  • 61,000,000 Medicaid and CHIP
  • 49,000,000 Medicare
  • 30,000,000 TriCare

v  At the end of last year there were 715,000 souls enrolled in Medicare in Kentucky

  • 141,000 have been added with Medicaid expansion to a level of 856,000 Medicaid enrollees.
    • 20% of all Kentuckians and
    • 50% of all Kentucky children
      • Only 36% of children on Medicaid ever access the system

¨       No personal fiscal investment on the part of the parents.

  • 50% of KCHIP qualified children receive services.

¨       Shared fiscal responsibility with the parents.

  • Diet is a disaster in this population with low pH / high sugar soft drinks being a major contributor to poor dental health.

Carrie Banahan, Executive Director of the Kentucky Health Exchange, Cabinet for Health and Human Services.

Discussing the success of the implementation of the Kentucky Health Exchange, KYNECT

v  Kentucky’s Health Benefits Exchange is an indisputable success with 420,000 enrollees which was more than expected.

  • Of these 380,000 were enrolled in Medicaid and most by the expansion
  • 75% did not have insurance previously.
  • 50% of existing health plans were renewed by early reenrollment and these plans will be enrolled through the exchange beginning November 15th of next year.
  • There were 22,000 dental plans placed through the exchange.
    • The average monthly premium in Kentucky was $25-$28 in this enrollment period.
      • This was the target range for premiums based on our MOOP expense levels for Kentucky plans. (Considerably lower than the national average.)
  • There was one embedded dental plan and in this plan the medical deductible was not applicable to the dental benefits as in other states.

Following these well done presentations there was a time for Questions and Answers. While there were a significant number of well-presented questions and appropriate responses that were seldom what the respondent would like to have been able to say, I had only one question.

v  Our Health Care Exchange has been phenomenally successful in bringing the uninsured Kentuckians to the table. Medicaid has expanded coverage to adults, but these adults are largely in terrible oral health and their needs are great. These needs are not limited to dental health.

v  Medicaid dollars are allocated for a much healthier population than is being presented in Kentucky.

v  Our Medicaid provider network is limited and Medicaid only works for the typical dental practice if Medicaid patients are less than 35% of the patients seen in that practice. That number is being pushed to 65% in many dental practices today.

v  Medicaid dollars for dentistry are very limited and the reimbursement is one of the lowest in the country and made lower by a 10% MCO withhold.

The question is: How long will dentists be able to provide dental services to this population in this environment because there is not enough on the table to serve the need.

 

To this question there was no reply.

 

 

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