Alex Severance 2013 Legislative Sessin Representative Barbara Bllier Oral Health Care and Methds t Increase Effectiveness f Dental Healthcare in Kansas There has been much discussin regarding the ral health landscape in Kansas. This reprt will examine key issues that Kansas faces in regards t ral health and the state s dental healthcare system. Amng the questins being addressed are: Dental Deserts - areas r ppulatins in Kansas that are underserved The lw number f Medicaid dental prviders The current Extended Care Permit. The prpsed Registered Dental Practitiner license prpsed in HB 2280 and SB 192. Dental Deserts A study cnducted by the University f Kansas Medical Center fr Cmmunity Health Imprvement fund that that there are key issues that Kansans face regarding ral health. Fr example, in 2009, 54 percent f practicing dentists in rural cunties were planning n retiring in the next three t five years with mst nt having interested buyers f their practices. These rural prviders accept Medicaid patients at a much higher percentage than their urban cunterparts. But 93 f Kansas 105 cunties, r 88 percent f ur cunties, face dental wrkfrce shrtages. (Kimminau, 2011) This KU Medical Center study identified three ppulatins wh are currently nt being served by the ral health system. These grups are: Peple wh cannt easily travel fr services (frail and elderly) and thse with limited mbility Thse withut dental insurance wh cannt pay ut-f-pcket Medicaid enrllees wh cannt find a dental prvider willing t accept patients with public reimbursement The study als identified gegraphic areas that lack primary care dental ffices -- A Dental Access Desert. The five cunties in which peple currently have a 30-minute r lnger drive (the definitin f a Dental Access Desert) t reach their primary care prvider are Gray, Wallace, Cmanche, Barber, and Ness cunties. The study als predicted that many mre areas will becme Dental Deserts in the near future because f the increasing retirement rate f dentists in the cming years. This means that there are currently 57,000 Kansans wh live in Dental Care Service Deserts with that number grwing in the cming years (Kimminau, 2011). Medicaid Reimbursement Currently, Kansas is ne f the 33 states t prvide sme frm f Medicaid reimbursement fr ral health services prvided by primary care prviders. The state f Kansas currently reimburses $17 fr each applicatin f fluride varnish, but it des nt reimburse the primary care prvider fr any ther services (Cantrell, 2009). Washingtn State has begun an
innvative prgram in which prviders are reimbursed fr bth an ral exam/screening and caregiver educatin; a cmbined reimbursement f $57.04 fr the tw services as ppsed t the $13.25 reimbursement fr just the applicatin f fluride varnish. The study nted that reimbursing all f these services as a cmbined sum has been instrumental in increasing medical prvider participatin in Medicaid reimbursed fluride varnish applicatin (Hanln, 2010). Thugh required by the Early and Peridic Screening, Diagnsis and Treatment Prgram, The Natinal Academy fr State Health Plicy has fund that nly 1 in 5 Medicaid-Enrlled children receive regular screenings r the treatment needed frm medical, dental, r visin prviders. Many dental prviders are reluctant t becme Medicaid prviders because the reimbursement rates are ften well belw the cst f prviding the service. Furthermre, care-seeking behavir amng Medicaid recipients is lw and there is a high n-shw rate fr dental appintments. This is likely due t burdensme prgram administratin requirements that are nt required by ther insurance carriers and lack f patient educatin (Brchgrevink, 2008). There have been imprvements in the state run Medicaid prgrams f specific states. Examples include Michigan, which entered int a Managed Care Organizatin (MCO) cntract with Delta Dental in 2000 t administer t children in nn-urban cmmunities. The state pays Delta per enrllee per mnth but Michigan sets reimbursement rates fr Medicaid prviders at 100% f Delta Dental Premier rates. In each f the states examined in the study cnducted by The Natinal Academy fr State Health Plicy, reimbursements were increased t cver mre than the administrative cst and this saw increases in Medicaid participatin amng prviders frm 62 percent t 150 percent (Brchgrevink, 2008). Natinally, mst states Medicaid payment rates are substantially belw market rates, and belw the cst f prducing care itself. A natinal analyses shws that average natinal Medicaid reimbursements fr dental care are $14-$20 per member per mnth while premiums run $17-25 per member per mnth (Crall, 2011). But, raising rates can be a twstep prcess that sees a tw-fld increase in the cst fr the state. First, the state is paying mre fr the services thrugh reimbursements prvided, smetimes even dubling payment fr services s reimbursements align mre with the dentist s usual rates. Next, if the state is successful in attracting mre dentists and expanding the cverage, expenditures will rise further (Brchgrevink, 2008). Hwever, dental spending is under tw percent f ttal Medicaid spending. Even with large grwth in expenditures, it will still be a relatively small part f spending cmpared t ther services such as nursing hme care r prescriptin drugs. Increasing this dental care as part f Medicaid spending wuld nly bring dental Medicaid spending clser in line t natinal dental health expenditures f five percent f ttal spending (Cantrell, 2009). But it is imprtant t nte that access t dental care is nt entirely dependent n spending. A majrity f experts interviewed in a study cnducted by the Natinal Academy fr State Health Plicy said that adequate reimbursement rates (meaning rates that at least met the verhead expenses) were necessary, but nt sufficient t imprve access t Medicaid dental services (Brchgrevink, 2008). Dentists frequently cite frustratins with brken appintments amng Medicaid patients and administrative hassles as significant prblems when wrking with Medicaid users.
The Extended Care Permit The Kansas Extended Care Permit was created in 2003 t imprve access in these underserved lcatins. While sme Extended Care Prviders (ECPs) have been delivering services in underserved lcatins, very few wrked in the mst underserved lcatins. Currently, an Extended Care Permit can be btained by Dental Hygienists with varying levels f the permit with different tasks and respnsibilities: Extended Care Permit I -- 1,200 hurs f dental hygiene care within the past there years Practice f dental hygiene may be perfrmed with the cnsent f a parent r legal guardian n children in nn private-practice settings Remving stains and debris frm teeth Applicatin f tpical anesthetic if the hygienist has cmpleted a require curse Applicatin f fluride Dental hygiene instructin Assessment f patient s need fr further evaluatin by a dentist Extended Care Permit II -- must have 1,800 hurs f practice in the past three years under the supervisin f a dentist and 6 cntinuing educatin hurs n the care f special needs patients All the tasks f ECP I May perfrm practice f dental hygiene in cmmunity setting r in dental clinics withut the presence f a dentist. May prvide hygiene service t persns with develpmental disabilities and n persns wh are residents in an adult care hme, elderly in subsidized husing, hspital lng-term care unit, state institutin. Extended Care Permit III -- must have 2,000 hurs f practice in the past three years under the supervisin f a dentist All the tasks f ECP I and II May practice dental hygiene n children wh are cnsidered t be dentally underserved (Oral Health Kansas, 2010) Currently, there are 35 dentists per year influx in the state and The University f Kansas Medical Center fr Cmmunity Health Imprvement recmmends an increase in the number f dentists becming newly-licensed in Kansas. Other suggestins include acquiring additinal seats frm neighbring dental schls such as UMKC, University f Nebraska/Cllege f Dentistry, Creightn University, and the University f Oklahma Cllege f Dentistry. The study als suggests increasing the cmmunity invlvement such as state lan repayment prgrams (such as KIND) that nt nly repay student lans fr new dentists wrking in under-served areas but als prvide funds fr ffice csts/start-up fr dentists as part f lcal ecnmic develpment. Anther idea is t require that new dentists fulfill a scial bligatin rle such as requiring that they participate in Medicaid and take Medicaid patients. Prpsed Legislatin (HB 2280 and SB 192) This cntinuing lack f access t dental services has led t the push fr Registered Dental Practitiners (RDPs) in Huse Bill 2280 and Senate Bill 192. But the questin remains, if these RDPs are licensed, hw can they be mst effectively placed in underserved areas and with underserved peple? In Huse Bill 2280 and Senate Bill 192 which are currently being debated, Dental hygienists (wh are licensed and have an Assciates degree) culd cmplete an additinal 18 mnths f training t becme Registered Dental Practitiners.
These RDPs wuld be supervised by Dentists in ne f tw types f supervisin: direct and general. Under direct supervisin, the RDP wuld wrk in the same setting as the Dentist and under general supervisin, the RDP wuld wrk in a different setting after receiving permissin frm their supervising dentist. The services that a RDP may prvide include all f the services that Registered Dental Hygenist prvides plus additinal services such as fillings, cavity preparatin, extractin f lse permanent teeth, extractin f already lse baby teeth, and perhaps mst imprtantly, the ability t diagnse and refer patients t dentists fr further treatment. The bill stipulates that RDPs wuld have t meet ne f the fllwing cnditins: wrk at a safety-net clinic; be emplyed in federally designated wrkfrce shrtage area; r wrk at a private practice in which 20 percent r mre f the revenues cme frm Medicaid (HB 2280 and SB 192, 2013). The Natinal Academy fr State Health Plicy has identified three methds fr preventively imprving ral health: Oral Examinatin/Screening/Risk Assessment- Primary care physicians wh are trained t wh are trained t identify signs f dental disease during a child s rutine well-child check-up and then referring them t a dentist. Anticipatry Guidance/Caregiver educatin- Primary care prviders alng with dental prviders can serve as ral health advcates and educatrs during visits. Applicatin f Fluride Varnish- A study frm the Wiscnsin Medicaid prgram fund that allwing prviders t be reimbursed fr applying fluride varnish increase the applicatin in 1-2 year ld children. This is a quick and easy prcedure that can be that can be administered by auxiliary staff and integrated int the well child visit. The mid-level prviders specified in HB 2280 and Senate Bill 192 culd ptentially address these appraches utlined by the Natinal Academy fr State Health Plicy. But wuld it fix the ral healthcare prblems Kansas is facing? Cnclusin: There are clearly many issues at hand here and nt all prblems can be slved with a single slutin. Lack f access can take multiple different frms (gegraphic, mnetary, etc.) and a multi-prnged apprach is needed t address them. The main questins t cnsider in reviewing HB 2280 and SB 192 are: Quality f care Is the training f RDPs adequate t maintain the level f care we are accustmed t? Are there particular prcedures that are best left t dentists? Fiscal Cnsideratins Placement: Hw much des it cst t train RDPs with prgrams being develped at Frt Hays State University? The Extended Care Prvider is a mid-level that has seen varying results. What can be dne t ensure that RDPs are placed in underserved areas and wrk with underserved ppulatins? Can Kansas achieve the same gals by imprving the Extended Care Prvider by better placing these mid-levels, as well?
References: Brchgrevink, et all. The Effects f Medicaid Reimbursement Rates n Access t Dental Care. Natinal Academy fr State Health Plicy. March 2008. Cantrell, Chris. Engaging Primary Care Medical Prviders in Children s Oral Health. Natinal Academy fr State Health Plicy. September 2009 Crall, James J. The Search fr Successful Strategies t Imprve Oral Health. Natinal Cnference f State Legislatures and Center fr Health Care Strategies Inc. April 2007. Gehshan, Shelly and Matt Wyatt. Imprving Oral Health Care fr Yung Children. Natinal Academy fr State Health Plicy. April 2007. Hanln, Carrie. Reimbursing Medical Prviders Fr Preventative Oral Health Services: State Plicy Optins. Natinal Academy fr State Health Plicy and the Pew Center n the States. February 2010. Kansas Huse f Representatives. Cmmittee n Health and Human Services. HB 2280. 2013 Kansas State Senate. Cmmittee n Ways and Means. SB 192. 2013 Kimminau, Kim and Anthny Wellever. Mapping the Kansas Rural Dental Wrkfrce: Implicatins fr Ppulatin Oral Health. University f Kansas Medical Center fr Cmmunity Health Develpment. September 2011 Oral Health Task Frce: Findings and Recmmendatins. Kansas Bard f Regents. June, 2012