MARYLAND REVAMPS DENTAL CARE FOR CHILDREN

Volume 29, Issue 515 May 12, 2008

Anna C. Spencer

Maryland children have a new reason to smile. A year after Maryland youngster Deamonte Driver died from a tooth infection that spread to his brain, the General Assembly has approved sweeping legislation to overhaul the state’s Medicaid dental health system.

Despite a sluggish economy, lawmakers voted to include millions of dollars in the FY 2009 budget to expand dental care for low-income children, mostly by increasing Medicaid reimbursement rates, expanding the dental care workforce by granting new powers to dental hygienists, and creating a "single vendor."

The barriers to dental care are multifaceted, but one factor has been the shortage of dentists willing to accept Medicaid patients. A state-by-state analysis from the federal General Accountability Office found that Medicaid payments in Maryland for common dental procedures range from 37 percent to 73 percent of the market rate, leaving many providers unwilling to participate in the program.

The General Assembly chose to incrementally raise Medicaid dental reimbursement rates, authorizing the appropriation of $7 million a year over the next three years. Ultimately, it's expected that the increases will provide $42 million in state and federal funds, bringing Maryland's Medicaid dental-care reimbursement rates up to the median community rate for the Mid-Atlantic region. Reimbursement rates also will be indexed to inflation to maintain their rank at the 50^th percentile.

Raising reimbursement rates is expected to result in a “dramatic increase in the number of preventive and diagnostic exams kids receive,” said Harry Goodman, chief of the Office of Oral Health with the State Department of Health and Mental Hygiene. In the first year reimbursement for preventive procedures and exams will be raised, and in the coming year payments for restorative dental work also will be boosted.

As per a recommendation (see box) from the Dental Action Committee, a single dental services vendor will be established. Currently, seven Medicaid managed-care organizations subcontract with dental service vendors to provide services. The health department plans to issue a request for proposals to award a contract to a single vendor which, says Goodman, will simplify the administrative aspects and improve transparency and accountability. “We want to show providers we are truly serious about working with them,” he added. “We’re not just modifying the [Medicaid dental program], we’re blowing up the system and totally redoing it.”

The state budget also includes $1.4 million to increase the capacity of local public health clinics to provide dental care, particularly in underserved areas of the state, such as southern Maryland and the Eastern Shore. "Forging (long-term) private-public partnerships” with providers throughout the state will help ensure that no child ever dies again from a lack of access to dental care, Goodman said. Driver died after his family repeatedly but unsuccessfully sought to find a dentist who would him as a Medicaid patient.

New Powers for Dental Hygienists

In addition to spending increases, lawmakers also voted to allow dental hygienists to perform cleanings, fluoride treatments and sealants in public health clinics and in schools without a dentist being present or requiring their sign-off. The budget allocates $700,000 annually to establish school-based programs and a mobile van program, staffed by hygienists. Scheduled to go into effect October 1, the Public Health Dental Hygiene Act (HB 1280/SB 818) is “a more cost-effective way to get treatment to kids who are underserved,” said Goodman.

Nearly 500,000 children in Maryland are enrolled in HealthChoice, Maryland's Medicaid managed-care program. Children can enroll in HealthChoice if their families make up to 300 percent of the federal poverty level; families over 200 percent must pay a monthly premium. According to the nonprofit Advocates for Children and Youth, fewer than 30 percent of children in HealthChoice see a dentist in a given year.

Dental Action Committee

The overhaul of the Maryland Medicaid dental program is based, in part, on the recommendations put forth by the Dental Action Committee (DAC), which was formed by the Maryland Department of Health and Mental Hygiene in June 2007 in response to the death of Deamonte Driver and mounting concerns about access to dental services in the state.

In December 2007, the DAC released a report that included seven key recommendations for improving access to dental care for low-income people, particularly children. To a large extend, all the recommendations were addressed by the General Assembly. The recommendations included:

establishing a statewide single vendor for dental services;

increasing dental reimbursement rates;

ensuring that each local jurisdiction has a local health department dental clinic and a community oral health safety net clinic;

establishing a public health-level dental hygienist to provide screenings, prophylaxis, fluoride varnish, sealants, and x-rays in public health settings;

developing culturally appropriate oral health campaigns to educate caregivers of young children about oral health and the prevention of oral disease;

incorporating dental screenings with vision and hearing screenings for public school children or requiring dental exams prior to school entry;

providing training to dental and medical providers to conduct oral health risk assessments, educate parents/caregivers about oral health, and assist families in establishing a dental home for all children.