AMERICAN ACADEMY OF

PEDIATRIC DENTISTRY

“Filling Gaps” Task Force Visit to

Michigan Healthy Kids Dental Program

NOVEMBER 12-13, 2001

In 1999, the American Academy of Pediatric Dentistry (AAPD) was awarded a four-year Children’s Health Insurance Program Partnership Grant by the HRSA Bureau of Maternal and Child Health. The purpose of the grant is to identify and develop “best practice” protocols and training materials designed to increase the access of preschool children to dental care and to improve their overall dental health. A Task Force of AAPD members was formed to carry out the mission of this grant, entitled “Filling Gaps: Integrating Service Systems to Improve Children’s Access to Oral Health Care.”

In November 2001, the Filling Gaps Task Force conducted a site visit to Michigan to examine elements of the State’s Healthy Kids Dental (HKD) initiative (the dental program for Medicaid beneficiaries under 21) and to a lesser extent the MIChild program (the State’s CHIP dental program). During the site visit, the Task Force met with a variety of advocacy organizations, program officials and staff, dental providers, as well as a state legislator and a parent with a child enrolled in HKD. These meetings provided the Task Force with the opportunity to learn more about the history of HKD and MIChild as well as the perceived strengths, challenges, and opportunities of the programs.

A BRIEF SUMMARY AND HISTORY OF THE HEALTHY KIDS DENTAL PROGRAM

HKD is a state-wide demonstration program in which commercial-like insurance is provided to Medicaid beneficiaries under the age of 21. Modeled after the MIChild program, HKD became effective in May 2000 and is


currently operating in 37 of the state’s 83 counties. Under HKD, Medicaid providers are reimbursed at commercial rates equivalent to Delta Dental Premier and beneficiaries carry a Delta Dental card identical to those carried by private subscribers. HKD is noteworthy in that the program uses a commercially administered plan with benefit and reimbursement levels that are widely accepted by the majority of area dentists. As such the features of the plan minimize or eliminate the major problems that have been widely cited by dentists as barriers to their participation in publicly financed or publicly administered dental programs. Michigan appears to be unique in the country with this state-private insurance partnership that allows beneficiaries an insurance card without the “stigma” of Medicaid, and handles administrative claims processing for providers with the efficiency of a respected private insurer.

HKD is the product of years of intense negotiations and advocacy driven by both the primary care and dental communities, hand in hand. As a result of this unprecedented cooperation and focus, and several other forces (including a class action lawsuit) and increased interest at the State level to address the “oral health crisis”, the Michigan legislature embraced the issue and enacted HKD as a pilot in 1999 at a cost of $5 million the first year.

MAJOR PERCEIVED STRENGTHS OF HKD

[Note: When HKD was enacted, there was a provision in the legislation requiring the collection and reporting of data on utilization rates, provider participation rates and overall satisfaction. This has been critical both parochially in terms of sustaining and expanding the program, and nationally in terms of promoting the program as a model to be replicated in other states.]

· Eight month data shows utilization has improved 78.7% among Medicaid eligible children. More recent data suggests that this trend is continuing and that HKD will close the gap between children’s utilization of dental services under the traditional Medicaid program and levels of utilization by commercially insured children by 50% in a mere 12 months. [1] [footnote to details in Dan’s data]

· Eight month data shows provider participation in the Medicaid program has increased by 43%. The State achieved this through its contract with Delta Dental who offered its entire network of providers to HKD eligible patients. In essence, the State purchased a provider network.

· Dentists are reporting much higher levels of satisfaction with HKD in terms of increased reimbursement, claims processing and overall program operation.

· Beneficiaries are reporting higher satisfaction rate with HKD than traditional Medicaid in terms of the overall program, finding a dentist that will accept their child, traveling less distance to get to a dentist, and improving their child’s overall health and the quality of treatment received.

STRENGTHS OF ACTUAL PROGRAM:

· Provider fees are paid at commercially established rates which are equivalent to Delta Premier or Delta PPO rates.

· Claim submission procedures for dentists are identical to Delta’s private pay counterparts.

· No services, co-pays, deductibles or prior approvals are necessary in order for care to be delivered.

· Beneficiaries are issued cards identical to private patients and thus have essentially equal access to providers.

· Treatment costs for the vast majority of beneficiaries are modest and stable across all ages.

· Beneficiaries receive a welcome packet in the mail from Delta Dental educating them about the new program, which includes a list of participating providers in their area.

· Culturally competent informational brochures posted in multiple languages.

· The state and Delta Dental were satisfied with their risk-based agreement that features a guarantee or “hold harmless” provision for both parties.[2]

FACTORS IN ESTABLISHING THIS INITIATIVE:

· Significantly enhanced awareness of oral health problems in young children and increased enthusiasm among state program officials and state legislators to do something about it.

· Developed an advocacy effort among a broad base of interests. The success was due in large part to broadening the base of support beyond organized dentistry to include the primary care community.

· The state dental association and the state’s academy of pediatric dentistry worked together to create this initiative.

· Advocates capitalized on the Michigan Department of Community Health’s interest in oral health and a state-wide lawsuit to establish a Dental Medicaid Task Force.

· Stakeholders focused on developing a consensus product through the Task Force.

· Stakeholders worked hand in hand to find a champion(s) in the state legislature and to seek out a funding opportunity to implement the consensus product.

· Stakeholders engaged the media.

MAJOR PERCEIVED CHALLENGES AND OPPORTUNITIES:

· Sustainability will continue to be an issue because the pilot relies on annual appropriations from the state. The economic forecast in the near term suggests that this may be a greater challenge than originally anticipated. However, the fact that HKD survived the latest round of severe budget cuts in the state is impressive and suggests that at least, currently, there is a strong base of support in the legislature.

· For the same reasons above, statewide expansion will also be a challenge. Currently, the program operates in 37 of the states 83 counties. It was suggested that the cost of operating the program in the Detroit metro area would double the current operating budget, meaning that these counties might be the last to be covered.[footnote: to issue of Detroit receives other subsidies on health care and apparently legislators are not demanding that these 3 counties be next or else] There did not seem to be an aggressive plan in the pipeline to address the challenges of extending the program to beneficiaries in this region.

· To date, there has not been a formal effort to engage the non-dental community about the HKD program. There may be an opportunity through HKD to enhance the interest of the dental and medical groups to work together at the community level to integrate services and develop adequate referral systems.

· While the program is dramatically improving utilization rates among children older than three, it is less clear how effectively it is improving access for children under three. Part of the issue may relate to general dentists’ discomfort with caring for very young children. A professional education program focused on providing basic dental services to infants and very young children is being developed and will be implemented within the upcoming year.

· The data clearly show that access to preventative care among beneficiaries is improving substantially. The data also show that early treatment patterns suggest beneficiaries have accumulated needs. Preliminary analyses suggest that HKD children are seeking recall examinations (continuous care) and that their subsequent service utilization profiles are similar to commercially insured children. It is unclear at this juncture whether the entire scope of their treatment needs are being met.

A BRIEF SUMMARY OF MICHIGAN CHIP DENTAL PROGRAM: MIChild

MIChild was implemented in May 1998, two years before the HKD pilot and a year after the U.S. Congress passed the Child Health Insurance Program (CHIP) which gave states funding assistance to provide health insurance coverage for low-income children. MIChild dental coverage is capped at $600 annually per beneficiary. Families are required to pay a $5 per month per FAMILY annually and there is no co-pays for any services.

MIChild, which became the model for the HKD pilot, utilizes commercial dental insurance programs. Like HKD, MIChild beneficiaries are issued private insurance cards. Unlike the arrangements for HKD, dentists are not required to be Delta Dental Premier participants to provide services for MIChild enrollees. However, because the vast majority of Michigan dentists are Delta Dental participating dentists, using Delta Dental commercial programs has the positive effect of engaging large numbers of dentists in these public programs. Utilization rates for dental services by MIChild children have been similar to commercially insured children. The cost of running the dental program has been comparable to commercial levels with expenditures running at about $14 per child per month.

MIChild’s success in terms of attracting providers served as a model and springboard for the HKD imitative. The Task Force did not spend sufficient time examining the elements of the MIChild program to detail the program’s perceived strengths, challenges and opportunities. However, enough information was shared both anecdotally and through data for the Task Force to provide the following observations:

MAJOR PERCEIVED STRENGTHS OF MIChild

· Designed like a commercial dental insurance program in terms of reimbursement and administration.

· Provides beneficiaries with about the same access to dental providers as that which the commercial population has.

· Issues beneficiaries a card identical to those carried by the privately insured.

· Very high levels of provider participation, reduced travel time for beneficiaries due to better geographic distribution/access of dentists.

· Preliminary estimates suggest that costs have stabilized at $14 per child per month.

MAJOR PERCEIVED CHALLENGES AND OPPORTUNITIES

· As with HKD, there was little evidence that MIChild has led to increased communication and integrated services between the medical and dental communities. The Task Force inquired but did not hear of any formal effort to engage the non-dental community and educate them about MIChild. Efforts to disseminate information about the changes in access brought about through the HKD and MIChild dental programs could further enhance EPSDT and other referrals for children who need special services.

· Although the state has not received claims in excess of the $600 annual cap, anecdotal evidence suggests that the cap might be a barrier for some beneficiaries. Individual providers reported that a subset of their patients required restorative work that cost well beyond the $600 annual limit. As a result, they are “balance billing” patients. State officials appeared to be unaware of this potential problem. Thus there appear to be no current efforts to address this issues -- e.g., by providing some flexibility in the program so that providers can recoup their costs for this subset of children with unusually high treatment needs without placing too severe of a financial burden among the beneficiaries. Alternative approaches for “staging” care to capitalize on the annual “renewal” of benefits (i.e. $600 annually) could also be explored.

CONCLUSION

Michigan has made tremendous progress towards improving access to and utilization of dental services among low-income children. The preliminary evidence indicates that the Michigan “model” should be closely explored for development in other states. Central to the success of Michigan’s HKD program is the fact that it uses a commercially administered plan with benefit and reimbursement levels widely accepted by a majority of the state’s dentists.

The efforts behind the Michigan program are as noteworthy as the “model” itself. A coalition of health advocates, providers, legislators and community activists have dedicated themselves to raising the quality of oral health among Michigan’s children. The coalition paved the way for the initial pilot program and will be instrumental to HKD’s sustainability as well as its expansion to the rest of the state.

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[1] Briskie, Daniel. “Improving Access to Care for Children in Medicaid: The Michigan Model,” a study.

[2] The state protects Delta against higher than expected costs; conversely, Delta is allowed only a minimal profit to ensure that the state will not overpay for benefits. This reflects the fact that Delta of Michigan is a non-profit dental corporation with a mission to improve oral health care.