Presented at the UCSF Dental Public Health Seminar January 29, 2013

1. Presentedat the UCSF Dental Public Health Seminar January 29, 2013 WITHOUT CHANGE IT’S THE SAME OLD DRILLImproving Access to Denti-Cal Servicesfor California Children ThroughPrivate Dentist Participation

2. Study Team: Barbara Aved, RN, PhD, MBA Principal Investigator BAA President Ron Inge, DDS, Vice President Delta Dental, Washington Larry S. Meyers, PhD BAA Research Associate Funders: LIBERTY Dental Plan Health Net Purpose: Examined: Challenges in the CA Medicaid (Medi-Cal) Dental fee-for-service (FFS) program Extent of private practice DDS participation in the program Factors that account for DDS willingness to accept patients with Denti-Cal in their practices Looked at: Access, utilization, quality Project Period: May 2012 – October 2012 The Study

3. Primary Study Questions • Who is serving the Medi-Cal population and at what levels? • What are the main reasons for unwillingness of private practice dental practices to take or restrict the number of children with Medi-Cal, and what would it take to increase their likelihood of participating? • To what extent do children with Medi-Cal utilize the ED for dental conditions considered preventable? • How do practices that accept Medi-Cal successfully offset any negative aspects of the program? • What is the FFS complaint/grievance system for families when they experience access or quality problems, how many use it (on their own and with help from advocates), and with what results? • What performance requirements are there for FFS providers concerning quality and cost containment?

4. Background • 45% of CA children ages 0-17 are covered by public insurance, primarily Medi-Cal. • 23,318 DDSs in active practice in CA in 2008. • In 2008, ~24% of CA private practice DDSs accepted Medi-Cal (down from 40% in 2003). • Of the DDSs with at least 1 paid Medi-Cal claim in 2008, only 33% had paid claims of >$10,000. • Medi-Cal Dental is primarily FFS (managed care only in 2 counties); CA dropped general adult coverage in 2009. • CA has one of the lowest Medicaid dental reimbursement levels in the U.S.

5. Methods • Review of past, related studies • Confer with Medi-Cal Dental staff(CA Department of Health Care Services) • Secondary data collection (mostly from DHCS, 2011) • Claims data from rendering providers (i.e., encounters/procedures); comparison data from child-only commercial dental plan • Utilization data • Pt. grievances (filed with State; contacts to advocacy organizations) • Emergency dept. use • Interviews (key informants—policymakers, advocates, dental experts)

6. Methods, Cont. • DDS Survey(local General and Pediatric DDSs) • Developed detailed survey (review by DHCS, CDA) • 5-County Sample • Local dental society involvement (~80% DDSs are members) • Mailing lists for paper version + Cover Letter • Hosted survey on website for online response • ~ 2,000 surveys mailed • $10 Starbucks gift card as incentive

7. Methods (cont.) Study Limitations: • Focus on urban areas(where majority of Medi-Cal pop. lives) • DDS survey based on sample pop. (not statewide) • Paid claims level info not available (DHCS wouldn’t provide it) • Dental services provided in community clinics not included in analysis (they have their own reimbursement model)

8. Utilization Utilization of Medi-Cal FFS Dental Services, Children Ages 0-20, 2011 Source: Department of Health Care Services, Medi-Cal Dental Services Division, August 2, 2012. Children continuously enrolled in FFS for at least 11 months during Calendar Year 2011. California lags behind 39 other states re. proportion of children receiving any dental services, and 37 other states of those receiving preventive dental services under the EPSDT dental benefit. Key Findings

9. Utilization Findings (cont.) • Main Reasons Parents Reported for No Dental Visit Source: 2009 California Health Interview Survey, UCLA

10. ED Findings • In 2010, CA children ages 0-18 made 19,766 ED visits due to one of the 10 primary diagnoses of an oral condition; • Two-thirds (13,282) of these considered preventable. • 51.3% of the ED visits were made by children ages 0-5. Percent of Children’s ED Visits for Oral Conditions Considered Preventable, 2010

11. ED Findings (cont.) Percent of Preventable ED Visits by Payer Source, Ages 0-18, 2011 Percent of ED Visits with Public Payer Source, Ages 0-18, 2007 2011

12. DDS Survey Findings • Study Sample • N=322 (16.2% response rate) • Online responses = 14.6% of total surveys. • Proportion received from general (83.3%) and pediatric (16.7%) DDSs generally equivalent to proportion of surveys sent to each group. • Proportion sent to each county representative of surveys mailed. • Business and personal characteristics mostly matches CA dentist profile (see next slide)

13. DDS Survey Findings, cont.

14. DDS Survey Findings, cont. • Age When Child is First Seen (all DDS survey respondents) • 58% of general DDSs start seeing children at age 3 or older

15. DDS Survey Findings, cont. • Participation in Medi-Cal FFS Dental Program (called “Denti-Cal”) • Total sample: 26.8% • General DDS: 24.8% • Ped DDS: 37.0% • Those who accept M-C see a low volume • 38% of general DDSs had 15% or fewer M-C kids in their practice. • 56.3% ped DDS had <5% M-C in their practice • Provider satisfaction level

16. DDS Survey Findings, cont. Reasons for Not Accepting Medi-Cal by Rankings

17. DDS Survey Findings (cont.) • Typical wait times for M-C appointments: • <2 weeks for a no-problen appt • 2-3 week wait for a treatment visit (reported by 50% of ped DDSs) • Most of the 24.8% who accept M-C report they do so without restriction. • 90% of general DDSs said it was “very difficult” or “somewhat difficult” to find a ped dentist for M-C problem referrals.

18. DDS Survey Findings (cont.) The characteristics of DDSs less likely to accept M-C are:* In practice for more than 20 years In solo practice Male White, non-Hispanic *Statistically significant (chi square analysis)

19. DDS Survey Findings (cont.) • A small proportion of general DDSs reported they have the interest/capacity to see more kids with Medi-Cal. Characteristics of General Practices Wanting to See More Medi-Cal Children with the Capacity to do so

20. Claims (Procedures) Data Findings The number of participating DDSs has been declining over the last 5 years (table). Ratio of general DDS access points to eligible children of 1:178 is w/in industry standards. From there, however, ratios vary significantly for pediatric and other dental specialties. Ratios camouflage important issue of provider distribution and access within CA counties, particularly for specialty care. Source: Medi-Cal Dental Services Division. Source: Medi-Cal Dental Services Division.

21. Claims (Procedures) Findings, cont. • 82% participating in M-C served <100 new children with M-C in 2011. • Service category concerns (anomalies with certain categories of claims): • High frequency of restorative and endodontic services may indicate a lack of preventative services for children. • Claims for dental sealants—a proven strategy to prevent decay—not submitted in expected numbers given that kids with M-C are at higher risk for decay than kids in the general population. • High submissions of claims for extractions suggest the children’s teeth were unsalvageable at the time of the visit.

22. Similar submissions by payers – Diagnostic-Oral Exams; Preventive; Restorations. Dissimilar submissions by payers (significant differences) – Diagnostic-Radiographs/ Diagnostic Imaging; Endodontics; Periodontics. Contribution of Categories of Care to the Total Number of Claims submissions for Medi-Cal Compared with Commercially Insured Child Population. Claims (Procedures) Data Findings, cont.

23. Lessons from Other States • Implementing strategies that increase access and utilization: • Increase in provider rates • Targeted provider recruitment • Reduction of the administrative burden associated with Medicaid (e.g., streamline enrollment) • Outreach to beneficiaries regarding how to best access and utilize services • Education of parents to better understand the importance of preventive services • Education of providers

24. Recommendations • Make Medi-Cal more attractive to encourage participation. Streamline and expedite the dental provider enrollment process. • Simplify claims submission to reduce provider burden and lower costs. • Raise Medi-Cal dental FFS rates. • Recruit more dentists into the Medi-Cal dental program by targeting those most likely to enroll. • Adopt more quality measures for the FFS program. • Monitor Medi-Cal dental utilization rates, provider participation and providers-to-eligibles ratios. • Monitor Medi-Cal dental claims for patterns linked to over utilization and patient safety. • Sponsor more trainings for general DDSs to increase their comfort and skill level in seeing younger children.

25. Recommendations (cont.) • Expand outreach and education to families on the availability and importance of early, regular dental care for children. • Make Medi-Cal dental data more easily accessible and in more usable formats for studies like this one. • Collect EPSDT dental data from federally funded clinics that allow more accurate reporting of utilization rates. • Support the collection of more recent and consistent CHIS (California Health Information Survey) data on oral health. • Identify a “legislative champion(s)” willing to be visible in taking on an oral health leadership role. • Examine more closely the reasons why more parents do not fully utilize Medi-Cal dental benefits for their children. • Outreach to women whose pregnancies are covered by Medi-Cal to educate women about the importance of getting a dental visit for themselves and their children.

26. Thank you! Questions? Full report available at: www.barbaraavedassociates.com