ADHA Offers Testimony at CMS National Medicaid Dental Town Hall

Baltimore, MD – On April 6, 2009 the Centers for Medicaid and Medicare Services (CMS) convened a Town Hall Forum to explore access to dental care for Medicaid-eligible children.  The event brought together a host of oral health stakeholders and marked the first Town Hall forum on dental CMS has hosted.  ADHA had the opportunity to offer testimony to highlight the important role dental hygienists play in the delivery of care to Medicaid-eligible populations.

The Town Hall sought to open dialogue among interested stakeholders to determine what can be done to improve the delivery of oral health care services to children enrolled in Medicaid.  Medicaid provides eligible low-income children with coverage for health care services, including dental services.  In spite of federal mandates for dental care, at the national level less than one-third of all children enrolled in Medicaid received any preventive services dental services in 2007.

The event featured presentations from CMS, the National Association of State Medicaid Directors and the American Dental Association.  Interested parties were able to offer testimony at the Town Hall to address issues related to reimbursement, delivery systems, and patient and provider education. 

ADHA’s District III Trustee Pam Quinones, RDH, and Washington DC Counsel Karen Sealander offered testimony on behalf of ADHA.  Quinones noted, “It is important for ADHA to participate in national events like the CMS Town Hall to make others aware of the impact that dental hygienists have on Medicaid-eligible populations.  As an association ADHA is committed to working in partnership with other stakeholders to break down some of the barriers that prevent Medicaid children from receiving the dental care they need to maintain healthy mouths and bodies.”

CMS Dental Director Dr. Conan Davis indicated that the feedback solicited from the Town Hall would be used by CMS staff in their efforts to develop solutions to improve delivery of care to Medicaid-eligible children.  Additional information about the Town Hall and CMS programs is available at: http://www.cms.hhs.gov/MedicaidDentalCoverage/.  

The written version of ADHA testimony offered at the Town Hall is posted below/at the following link.  If you have any questions about ADHA’s efforts regarding the Town Hall please contact Governmental Affairs Division Staff at 312.440.8925 or gov.affairs@adha.net.

Remarks of Pam Quinones, RDH, ADHA District III Trustee
CMS National Medicaid Dental Town Hall Forum
April 6, 2009

Good afternoon.  On behalf of the American Dental Hygienists’ Association, I would like to extend thanks to CMS for convening this Town Hall meeting.  This forum provides us with an opportunity to address the lack of access to dental services for Medicaid-eligible children and to facilitate dialogue about how disparities in the delivery of care can be overcome.

My name is Pam Quinones and I am licensed dental hygienist who lives and works in Maryland.  I represent ADHA here today as a member of ADHA’s Board of Trustees.  

As we are all aware, oral health is a vital component to total health.   Virtually all dental disease is preventable, yet in spite of that tooth decay remains the most common chronic childhood disease.   At the national level, ADHA is committed to advocating for solutions that increase coverage for and access to oral health care services.  ADHA is also committed to working with other health care stakeholders, the American Dental Association in particular, to work collectively on issues impacting oral health.

In recent years, ADHA has had the opportunity to work in collaboration with a host of oral health care stakeholders to advocate in support of access initiatives.  ADHA worked alongside ADA, the Children’s Dental Health Project, the American Dental Education Association and others as part of the Dental Access Coalition to advocate for the recent passage of legislation to reauthorize the Children’s Health Insurance Program (CHIP).  As a result, CHIP now includes a guarantee for dental benefits and offers states the option to offer dental-only wrap around coverage for those who have medical, but not dental coverage, and are eligible for the program.

As the member of the dental care team focused on prevention, dental hygienists are well-placed to play a key role in the delivery of services that prevent decay and help treat oral disease while it is still manageable.  Dental hygienists throughout the country play an active role in the delivery of care to Medicaid populations in a range of settings—schools, public health clinics, mobile dental units, and private dental offices are just some examples.  As one of the top ten fastest growing health professions in the country, the dental hygiene workforce is a great resource for states to draw upon as they seek to increase and streamline the delivery of oral health care services. 

Fourteen states currently recognize dental hygienists as providers who can be directly reimbursed for services delivered to Medicaid patients.  It is expected that Massachusetts will join that list shortly as a result of recently passed legislation allowing direct reimbursement for dental hygienists.

In my home state of Maryland, the untimely and tragic death of Deamonte Driver focused a national spotlight on the barriers that too many children face in accessing oral health care services.  In the wake of that tragedy, the state of Maryland has made some significant strides in improving patients’ ability to access care, for Medicaid-eligible children in particular.  In Maryland in 2007, less than 30 percent of all Medicaid eligible children received any preventive dental services. The Governor convened a Dental Action Committee (DAC), which included members from all of the oral health stakeholder groups in the state. DAC members developed seven major recommendations to improve access to oral health care access in the state. Three of those recommendations had a direct impact on advancing the increased utilization of dental hygienists in public health programs.  The first, which passed into law last October, allows for more effective use of dental hygienists working in public health settings by allowing hygienists working in public health settings to implement their full scope of practice without the direct supervision of a dentist.   DAC also recommended the launch of a statewide “oral health literacy campaign” targeting pregnant women and parents with core messages about the importance of good oral health.  A third recommendation from DAC related to mandatory dental screenings in public schools. 

Yet another opportunity to optimize the existing dental hygiene workforce is through the development of the Advanced Dental Hygiene Practitioner, a Master’s level provider focused on the provision of educational, preventive, therapeutic, and minimally invasive oral health care services to underserved populations.  Mid-level oral health providers are in practice in over 50 countries internationally.  The introduction of advanced nursing providers and other medical mid-levels has bolstered the health care workforce and increased patients’ abilities to access quality health care services.

ADHA looks forward to developments in states like Minnesota where the state legislature is considering legislation to establish a mid-level oral health provider. 

ADHA fully recognizes the importance of implementing a host of solutions to address the oral health care crisis—from raising Medicaid reimbursement rates, to expanding patients’ understanding of the importance of oral health, to increasing grant and loan forgiveness opportunities for dental providers who work with underserved populations—a myriad of policies must be considered and applied. 

ADHA looks forward to working with CMS, organized dentistry, and others on efforts to increase access to vital oral health care services.  As national efforts to improve the delivery of health care services get underway, oral health stakeholders have another opportunity to collectively support the inclusion of dental benefits in any comprehensive health reform effort. 

Thank you for the opportunity to speak about these issues on behalf of ADHA.

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Remarks of Karen Sealander, Washington DC Counsel, ADHA
CMS National Medicaid Dental Town Hall Forum
April 6, 2009

I’m Karen Sealander, an attorney with McDermott Will & Emery, long-time Washington Counsel to ADHA.  I join with Trustee Quinones and other ADHA members here today in expressing ADHA’s appreciation to CMS for highlighting the importance of improving access to Medicaid dental services for children by holding this Forum.  We look forward to positively participating in the ongoing open dialogue that this event seeks to create. As we go forward, we hope that all of us will try to step outside of our comfort zones and think creatively and innovatively to achieve the improvements to the dental Medicaid delivery system that we all are committed to attaining. 

The death of Deamonte Driver provided all of us a tragic reminder that lack of access to oral health services for Medicaid children can have serious – even fatal – consequences.  We have heard today about many ways to improve access.  ADHA believes that two key ingredients to any successful strategy to improve access to dental services for Medicaid children are 1.  opening up additional entry points into the delivery system through the increasing provision of Medicaid dental services at schools, CHCs, Head Start Centers, and other public health settings; and 2.  enhancing dental workforce capacity and flexibility through the exploration of new provider models.  Merging these strategies, ADHA is working to shape a future in which Medicaid children and other vulnerable populations will be able to directly access dental services from advanced practice hygienists who will be providing services in schools and other public health settings and who will be working collaboratively with dentists.  

A quick look at four trends across the country will confirm that states are better utilizing the growing dental hygiene workforce to improve access to Medicaid dental services and that real progress is being made to bring an advanced practice dental hygienist to fruition.

1.  Hygienists as Medicaid Providers – In 1998, California and Washington became the first two states to recognize and reimburse hygienists as Medicaid providers.  As Pam noted, today, little more than a decade later,14 states recognize and reimburse hygienists as Medicaid providers.  (These states are:  Arizona, California, Colorado, Connecticut, Maine, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, Oregon, Washington, and Wisconsin.)  Soon, Massachusetts will make 15.  CMS could encourage other states to adopt this approach. 

2.  Direct Access to Dental Hygiene Services - Currently, 29 states enable direct access to hygiene services, meaning patients can access preventive services provided by hygienists without a prior visit to or authorization from a dentist.  Direct access efficiently streamlines care by providing additional entry points into the delivery system, while also striving to ensure that referrals to dentists are made for those patients in need of additional care. In 1995, five states allowed direct access to hygiene services, in 2000, nine states allowed direct access, and today 29 states allow direct access to hygiene services.  One direct access success story is an innovative public private partnership in South Carolina, which provides dental hygiene services in 341 schools in 38 targeted school districts.  Importantly, the program has 12 restorative partners, dentists who agree to see referred children in their private offices, thus promoting the receipt of comprehensive services.

The positive impact of the program is evident in the 2007/2008 South Carolina Children’s Oral Health Needs Assessment, which revealed that in the five years time since the program was effectively in place –
1.  untreated caries rates declined;
2.  treatment urgency rates declined; and
3.  sealant usage rates increased.  Indeed, the Needs Assessment showed that there are presently no disparities between black and white third grade children for sealant use in South Carolina.  

3.  Workforce Demographics - According to the Bureau of Labor Statistics (BLS), the number of dental hygienists is expected to grow by more than 30 percent between 2006 – 2016, making dental hygiene one of the fastest growing health care professions in the country.  By contrast, the population of dentists is growing at a much slower rate and according to the BLS; the projected growth in the number of dentists is not anticipated to keep pace with the need for dental care in coming years.  These workforce realities must be reflected in solutions to the oral health access crisis for Medicaid children.  We need to answer the question, what do we do if a dentist can’t be there?

4.  Increasing State Interest in New Dental Providers - States are performing their traditional role of serving as laboratories of change.  In Minnesota, for example, a Safety Net Coalition worked to pass legislation in 2008 creating a work group to establish an Oral Health Practitioner, a new oral health provider with a scope of practice very similar to the ADHP.  Follow-on legislation is now pending to launch the OHP and another new dental provider model.  Expert testimony at a Minnesota hearing last month reminded us that the Minnesota OHP concept is neither new nor untested.  Alaska and 53 countries utilize non-dentists to provide restorative and other dental services.  Rigorous research shows these primary care dental professionals perform their duties as competently as do dentists.  However and importantly, these non-dentists do not provide the full array of services that dentists provide.  Neither the OHP nor the ADHP nor any other non-dentist provider will replace or seeks to replace the dentist.  Rather, new providers will work collaboratively with dentists and put patients in pipelines to see dentists. 

The nation’s first Masters program based on ADHP competencies will begin at Metropolitan State University in St. Paul, MN this fall.  Eastern Washington University in Spokane is working toward enrollment of ADHP students in the fall of 2010.  Other states are evaluating what new provider models would work in their states.  The CMS National Dental Summary released in January of this year calls for further review of alternative providers.  A forthcoming GAO report, mandated in the CHIPRA bill, will examine dental access issues including the feasibility and appropriateness of using qualified mid-level dental health providers, in coordination with dentists, to improve access for children to oral health services and public health overall.           

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In closing, ADHA welcomes the opportunity to work with CMS, the ADA, the entire dental community and all those who care about the nation’s oral health to work toward solutions to improve access to dental services for Medicaid children.  Despite clear links between oral and systemic health, oral health is still not accorded the same importance in health care policy as is general health.  Dental concerns and unmet dental treatment needs, especially among the vulnerable populations we are talking about here today, persist and won’t be eliminated until oral health is increasingly integrated into overall health. 

As the new Administration and the new Congress undertake to reform the nation's medical care delivery system, the nation's oral health care delivery system rightly should be reformed as well.
The efforts to achieve health system reform presents an historic opportunity to create an integrated health care delivery system that truly reflects the fundamental fact that the mouth is part of the body and oral health is essential to overall health and general well-being.  ADHA is committed to working collaboratively with everyone here and all who want to make oral health part of total health.