KDA Today

KDA Today

For Immediate Release

Date: Aug 21st, 2014
Contact: Compiled by John A. Thompson, DMD as Editor and Interim Executive Director for the Kentucky Dental Association
Phone: 800-292-1855
Email: info@kyda.org

KENTUCKY HEALTH NOW: The GOALS of our GOVERNOR

Governor Steve Beshear recently announced a set of seven goals for improving the health of Kentuckians. Lt. Governor Jerry Abramson is heading up the task force charged with making this happen. Goal number six is directed at improving oral health for Kentuckians. The Kentucky Dental Association was not consulted as to what this goal would be and we applaud the inclusion of oral health as a major goal. We would have had some edits that would help focus on specific impact areas related to dentistry. The KDA Medicaid Workgroup has provided the Cabinet for Health and Family Services and the Kentucky Medicaid Department a variation of this document to provide solutions aimed at achieving these goals. This workgroup has some difficulty with a number of the recommendations. We do recommend that goals be vetted against evidence based dentistry processes. It still appears that one of the greatest barriers remain as inadequate commitment of resources i.e. funding. 

Goal: “Reduce the percentage of children with untreated dental decay by 25% and increase adult dental visits by 10%.

Kentucky’s dental problems have long been a source of ridicule, and have real and detrimental impacts on schoolchildren, the workforce and families. In fact, Kentucky ranks 41st in annual dental visits, 45th in the percentage of children with untreated dental decay (34.6%), and 47th in the percentage of adults 65+ missing 6 or more teeth (52.1%). Gov. Beshear proposes to tackle this problem with a number of strategies, including:

1. Increase pediatric dental visits by 25% by the end of 2015.
2. Partner with Managed Care Organizations to encourage increased utilization of dental services.
3. Create public-private partnerships to increase to 75% the proportion of students in grades 1-5 receiving twice yearly dental fluoride varnish application.
4. Increase by 25% the proportion of adults receiving fluoride varnish during an annual dental visit.
5. Increase by 25% the percentage of adults receiving medically-indicated dental preventive and restorative services, including fillings and root canals, in accordance with evidence-based practices.
6. Partner with stakeholders to increase the number of dental practitioners in Kentucky by 25%.”

What is SUCCESS? “SUCCESS is the progressive realization of a worthwhile goal” Earl Nightingale.

SOLUTION:
Kentucky dental professionals and the Kentucky Dental Association do not believe there is any chance of achieving these goals if we continue to do what we are doing now. A cross sectional workgroup that includes active Medicaid enrolled dentists from across the entire state, both rural and urban, and public health experts from both of our state dental colleges developed these recommendations. We are submitting these recommendations with the objective being SUCCESS in achieving these goals.

KENTUCKYHEALTHNOW’s recommendations are numbered 1 through 6. The Kentucky Dental Association’s responses are the red bullet points we offer as solutions.

RECOMMENDATIONS:

1. Increase pediatric dental visits by 25% by the end of 2015.

· The number of four-year-olds who require hospitalization for significant dental services is a very expensive embarrassment to this state. Kentucky’s children have one of the highest rates of dental disease in the United States. Nutrition as well as cultural oral health illiteracy is root causes. DentaQuest Foundation’s Oral Health for All provides a plan outline that deals with oral health literacy, early childhood caries risk assessment and models using appropriate fluoride application to prevent gross dental disease and will reduce operating room treatment for a significant number of low socioeconomic at-risk children. Risk assessment and early interception costs will be more than offset by the reduction in hospitalizations.
· Incentivize comprehensive school-based oral health treatment delivery models.*
· Add health literacy curriculum in all K-12 classes to include oral health.
· Oral health literacy is a major barrier in both access to oral health care and actually seeking services. In cooperation with advocacy groups such as the KENTUCKY ORAL HEALTH COALITION promote the implementation of COMMUNITY DENTAL HEALTH COORDINATORS in all service districts throughout the Commonwealth.
· Transportation is often a significant barrier to care for Medicaid dependent children. Allowing dental treatment to be accomplished the same day that a dental examination code is recorded would facilitate access to care for these children and reduce unnecessary trips to the dentist.
(An example of a dental action plan is presented as EXHIBIT A, below.)

2. Partner with Managed Care Organizations to encourage increased utilization of dental services.

· Appoint a “DENTAL COORDINATOR or DIRECTOR” whose primary responsibility will be to reduce conflicts and overlaps in dental services provided by public funding. It is of interest that the number one priority in the 2011 Access to Care Report of the California Dental Association was to hire a dental director. States that have a dental director have much better outcomes than states that do not. The charge would include maintenance of a burden-of-disease report for comparative outcomes in conjunction with the Kentucky Health Information Exchange. Leading the collaborative process, such as this, to create a state oral health plan. This role will/should include establishing oral health literacy projects and funding for prevention-focused oral health and essential disease prevention services, particularly for children. We envision this position would require a licensed dentist with experience in epidemiology.
· Require Medicaid recipients to have both medical and dental preventive/wellness activities on an ongoing basis.
· Recognize the contribution of oral health to overall systemic health.
· Recognize that a small investment in oral health could dramatically improve the oral health of Kentuckians, especially when preventive practices are inculcated.
· Add health literacy curriculum in all K-12 classes to include oral health.
· Oral health literacy is a major barrier in both access to oral health care and actually seeking services. In cooperation with advocacy groups such as the KENTUCKY ORAL HEALTH COALITION promote the implementation of COMMUNITY DENTAL HEALTH COORDINATORS in all service districts throughout the Commonwealth.

3. Create public-private partnerships to increase to 75% the proportion of students in grades 1-5 receiving twice yearly dental fluoride varnish application. **

· Add health literacy curriculum in all K-12 classes to include oral health.
· Oral health literacy is a major barrier in both access to oral health care and actually seeking services. In cooperation with advocacy groups such as the KENTUCKY ORAL HEALTH COALITION promote the implementation of COMMUNITY DENTAL HEALTH COORDINATORS in all service districts throughout the Commonwealth.

4. Increase by 25% the proportion of adults receiving fluoride varnish during an annual dental visit.

· This is not a valid goal in our opinion.
· There is an essential lack of evidence that this goal as stated would be of impact.
o Fluoride varnish will not cure dental decay and all significant research has been focused on pediatric applications.
· Add health literacy curriculum in all K-12 classes to include oral health.
· Recognize the contribution of oral health to overall systemic health.
· Improve oral health literacy with the help of the Oral Health Coalition.
· Dentist’s cannot afford to treat the adult population based on the current fee reimbursements.

5. Increase by 25% the percentage of adults receiving medically-indicated dental preventive and restorative services, including fillings and root canals, in accordance with evidence-based practices.

· Develop a mechanism for Kentucky to participate in the Kentucky Information Exchange so that dentistry and medicine can be integrated for optimal patient care outcomes. The return on investment in appropriate dental services cannot be tested without an integrated data base.
· Implement a tax on high sugar content soft drinks to increase revenue for dental education.
· Adults and children seeking pain relief by going to the Emergency Room for dental treatment is an incredible waste of scarce resources. The Journal of the American Dental Association has published estimates that these ER visits average $760 each and are averaging one billion dollars annually in the United States. The Kentucky Dental Association in conjunction with other healthcare provider associations is seeking to develop an Emergency Room Diversion plan which has as its objective to initiate pilot programs in select locations to find ways to reduce / eliminate this problem. The savings potential of this effort could certainly offset cost of certain other recommendations. An immediate reduction in dental ER visits can be attained by the elimination of rules that do not allow more than one visit to the dentist per month for adult non-emergent treatment. This will require the cooperation of the MCOs and most likely a single phone number to facilitate this program.
· Shift the above recommendation into “high gear” by incentivizing the MCOs to invest in this program.
· Aggressively promote statewide participation by dentists in the Dental Lifeline Network aka Donated Dental Services. This pro bono service can provide immediate dental care to eliminate chronic and acute oral health impediments to emergency life threatening health crises.

6. Partner with stakeholders to increase the number of dental practitioners in Kentucky by 25%.
(This should say, increase the number of dental practitioners participating in Kentucky Dental Medicaid by 25%)

· The administrative burden that has been placed on individual dental practices is not appreciated by CMS. The simple acquisition of a Medicaid service number required to begin providing services takes a minimum of forty six working days if the application is perfect. That alone is a barrier to even providing services. Information technology should be improved to institute “real time” patient enrollment as well as provider and facility credentialing and concurrent posting of treatment as it is delivered the patient.*** Set an absolute goal of presenting a Medicaid Provider Number within two working days to encourage participation instead of this being a barrier.
· Review demand issue before determination is made about the need for more dental workforce. Patients often have needs for services, but do not demand them for any number of reasons, including lack of finances, lack of transportation, inability to get off of work without losing pay, or fear.
· Increase state support for and investment in higher education in the health sciences in order to improve the health of Kentuckians in the most cost-effective manner.
· Increase pipeline activities to recruit Kentucky residents into Kentucky dental schools (can only occur if there is increased state support).
· Lift the cap on enrollment of Kentucky students (can only occur if there is increased state support).
· Implement a rural tax credit for dental practitioners.
· Create a tax incentive for practitioners who treat Medicaid patients.
· Establish funding for loan forgiveness for new graduates going to rural or underserved areas to practice.
· Provide low interest loans for dentists to open new practices in rural or underserved areas.
· Counties that are certified as economically depressed have both, high numbers of unemployed and Medicaid dependent populations. Dental practices in these communities must see higher proportions of Medicaid patients. The reimbursement, even if increased twenty five percent, does not support the sustained operation of a dental practice when fifty percent is exceeded. These practices will fail and there will not be replacement. Access to care will be nonexistent. Allow the MCOs the ability to pay up to 1.5 times the posted Medicaid rate in counties where certain criteria has been established. This would require a regulatory change to allow the MCOs to have this discretion.
· The Kentucky Board of Dentistry allows a significant number of dental procedures to be performed under the direct supervision of the dentist. Kentucky has led the nation in leveraging the workforce to allow for delegated duties. There remains significant elasticity in this utilization.
· The Kentucky Board of Dentistry has licensed a new category for dental hygiene. The Public Health Hygienist is a developing role that has untapped potential. The addition of telemedicine technology to this practice modality has tremendous potential in ways yet to be conceived.

The American Dental Association ACTION FOR DENTAL HEALTH initiative was begun in 2013 and is a national blueprint for improving oral health in the United States.

COMMENTS:
* Prophy and fluoride are preventive therapies and not dental treatment. Dental vans providing dental treatment without x-ray evaluation is not a best practice procedure.
** A fluoride varnish treatment without a dental exam, a parent present, or a dental home is not the answer that addresses this problem. The primary problem we are seeing is with early childhood decay, i.e. before they reach the primary grades. Fluoride varnish is a very good preventive measure, but it does not cure decay that already exists.
*** Many times an MCO website can be used to determine patient eligibility for services, only to find that a mobile unit provided a service at an earlier date, but delayed claim submission. The MCO then pays the earliest date submitted. Many Medicaid subscribers have no idea what services have been provided and have moved from one dental provider to another as they do not have a dental home.

NOTE: KDA Medicaid Work Group members are: Drs. Garth Bobrowski, Fred Howard, Beverly Largent, Susie Riley, Raynor Mullins and Lee Mayer.

EXHIBIT A: Plan for reaching age groups:

KEY ASSUMPTIONS:
A) There is a need for increased access for children of all ages, but especially those ages 0-4. There are both short term actions and long term actions to work toward a solution for this issue.
B) There are critical differences between the communication and outreach for each of the four age groups described herein.
C) There is a contrast between the issue of access and the issue of communication and persuasion. The short term actions are focused on communication and persuasion, while the longer term actions are addressing access.
D) Without some increase in dental access, the success over years for Kentucky Medicaid will be limited. Along with increased dental access, we must also address medical access for the youngest ages regarding dental health awareness.

SHORT TERM ACTION PLANS:
A) Members’ ages 0-4. This group has the least utilization of dental preventive services.
Management and control: Strictly with parents and guardians.
Access: Mix between physician offices and dental offices.

Plan: Part 1 – promotional campaign to reach out via letter, e-mail, social workers and dental and medical healthcare providers. Use of literature and narrative concerning the importance of oral health and proper home care. Part 2 – renewed efforts to get all pediatric physicians and family practitioners within KY Medicaid to be part of the early detection and fluoride varnish program.

B) Members ages 5-9. This group has the best current utilization of dental preventive services.
Management and control: Parents and guardians, along with teachers.
Access: Mix between fixed dental offices and mobile/portable programs.

Plan: Part 1 – promotional campaign to reach out via teachers and dental and medical healthcare providers. Use of literature and narrative concerning the importance of oral health and personal oral care. Try to get this incorporated into regular teaching by schools. Part 2 – Work with portable dental program to have a regular school program with recall and restorative services.

C) Members ages 10-14. This group has the second best utilization of dental preventive services.
Management and control: Mostly with students themselves – along with coaches and parents and guardians.
Access: Mix between fixed dental offices and mobile/portable programs.

Plan: Part 1 – promotional campaign to reach out via teachers, coaches and dental and medical healthcare providers. Use of literature and narrative concerning the importance of oral health and proper home care. Part 2 – a free sports mouth guard program sponsored by KY Medicaid and featuring a mobile going directly to football practices and basketball practices to perform dental examinations and the sports mouth guards. Part 3 – a web and social media based program directed at adolescents and teens featuring a local sports figure from a college or university. The sports figure could be used in humorous and informative videos that would be featured on web sites, Twitter and Facebook to reach the social media used by these age groups.

D) Members ages 15-20. This group has the second worst utilization of dental preventive services.
Management and control: Nearly all with students themselves – along with some coaches, teachers and parents and guardians.
Access: Mix between fixed dental offices and mobile/portable programs.

Plan: Part 1 – promotional campaign to reach out via teachers, coaches and dental and medical healthcare providers. Use of literature and narrative concerning the importance of oral health and proper home care. Part 2 – a free sports mouth guard program through local Medicaid dental offices to perform dental examinations and the sports mouth guards. Part 3 – a web and social media based program directed at adolescents and teens featuring a local sports figure. This “spokesperson” would be used in humorous and informative videos that would be featured on web sites, Twitter and Facebook to reach the social media used by these age groups.

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