Oficiales intervinientes: análisis institucional

a. Adequate reimbursement rates. The literature, our key informant interviews, and discussions with dentists and other experts all indicate that without adequate reimbursement, as well as simplified billing and administration, dentists will not increase their levels of Medicaid participation. Currently, the dental fees paid by Medicaid are estimated at 55-60% of the UCR rate, many groups indicate that fees nearer 70 to 75% of UCR may be needed to attract dentists. However, even with these

improvements, studies show that dentists’ increases in participation may be modest. While adequate reimbursement and simplified billing and administration are crucial, addressing these issues may be called a necessary, but not sufficient, policy solution.

b. Outreach to enroll new dentists in Medicaid Targeted efforts should be continued to reach more dentists and their office staff to inform them about positive changes with Doral as the Medicaid dental

intermediary, such as current fees, simplified billing, and shortened payment cycles. Dentists who already participate in Medicaid could validate these improvements. Information on the number of dentists enrolled in their area could be provided as a way to allay concerns about being the only Medicaid dentist in the area and, consequently, being overwhelmed with Medicaid patients. A substantial number of eligible children are enrolled under the CHIP program and dentists should be aware that this population differs from the Medicaid population (Byck, 2000) and they may behave more like private pay or privately insured dental patients in terms of keeping appointments and complying with treatment.

Research shows that older, more established dentists are less likely to participate in Medicaid. Outreach efforts can be designed to target dentists with the greatest likelihood of participation.

Conversely, outreach conducted to dentists who seem less likely to participate can still be undertaken, but new strategies are needed to increase the effectiveness of these efforts.

c. Increase participation levels of currently participating dentistsOutreach efforts should also be directed at enrolled dentists with the goal of increasing their participation and asking about problems with the program. Perhaps innovative incentives or awards could be developed for dentists with greater service volumes; of course, this would need to be balanced by concerns of encouraging “Medicaid mills” for children’s dental care.

Policy Recommendation 2: Consider options to increase the dentist supply in under-served areas of Illinois.

For several regions of Illinois, the dentist supply, based on ADA data, is quite low, notably the Marion region, and to a lesser extent Peoria and Champaign regions. The markedly reduced output of new graduates from Illinois dental schools will make it difficult for these communities to recruit new dentists. This situation should be further assessed and key groups should review findings of this and other studies. At a minimum this review should include the dental schools, the Illinois State Dental Society, the regional dental societies, Doral and IDPA, as well as other groups that are community stakeholders, such as businesses, and educational institutions. These discussions may require consideration of expanding dental school enrollments to produce more Illinois dentists. Also,

consideration should be given to efforts to increase the diversity of providers since minority providers may be more likely to treat a minority and under-served populations.

Other options include the development of State loan forgiveness programs for dentists willing to practice in under-served areas or those willing to provide care to a certain level of Medicaid patients. For example, the State of Maryland recently offered a loan assistance repayment plan for dentists who commit to treat Medicaid patients as at least 30% of their practice patient load.

Policy Recommendation 3. Explore the feasibility of maintaining or expanding the capacity of dental clinics known as safety net providers, such as dental school clinics, community health centers, local health departments and others.

While our study had only limited information on the dental services provided by these clinics, they represent places where dental services are now provided and where high-risk children are found (schools, community health centers, local health departments, community centers, and dental training sites). The Illinois Department of Public Health is collecting information on these sites and this is an

important first step. Further assessment of the issues these clinics encounter in recruiting staff, equipping their sites, receiving payments for services, all need to be considered.

Other states are exploring ways to increase dental care capacity in these sites and this experience may be useful to Illinois. Healthy People 2010 sets a target of increasing to 75% the proportion of local health departments and community health centers that have an oral health component. More start-up funds and grants to existing and new safety net providers are needed, as are incentives to improve the success of recruiting and retaining dentists. In addition, greater use of existing facilities may be possible. For example, many community colleges have dental hygiene and dental technician programs and accompanying clinical facilities. It may be possible to use these facilities outside of class time, which would alleviate the barrier relating to expensive equipment and facilities.

Policy Recommendation 4. Encourage the integration of oral health care with primary health care.

Several reports have recommended a stronger link between oral health care and primary medical care. Studies have shown that children who had preventive medical visits are more likely to have had dental visits. National data also indicate that the proportion of children who had a medical visit in past year is much higher than the proportion who had a dental visit (74% vs. 43%). Thus, children who may not see a dentist in one or more years may see a medical care provider; this is particularly true for children under three years of age.

This represents an opportunity to reach children and their parents to discuss oral and dental health. The dental community could work with children’s primary health care providers – pediatricians, family practice physicians, nurse practitioners – and their representative organizations (e.g., American

Academy of Pediatrics) to address the problem of children’s oral and dental health. This is particularly important for high-risk children (low-income or minority children), the groups least likely to see a dentist and at higher risk for having untreated dental caries. Primary medical care providers need to learn more about the importance of oral health, how to talk to parents about their children’s oral health needs, and how to perform basic oral health screenings. They could be encouraged to include oral health in well-child visits. In addition, they should have information for Medicaid and uninsured children on where to obtain dental care in their community.

Policy Recommendation 5. Enhance dental school training to include population-based studies of oral and dental disease among the high-risk groups, the problems with access to dental care, and public health dentistry. Expose students to community based private practices and safety net clinics where high-risk children are receiving care.

Dental schools could broaden their curriculum to include more information on public health dentistry, issues regarding access to dental care, and varied utilization patterns of different population groups. Through both classroom and offsite experiences, dental students could be exposed to successful private dental practices with a large number of Medicaid patients, as well as to safety net clinics (e.g.,

community health centers, hospital outpatient clinics) – practices and clinics that are outside the traditional model of private practice dentistry. The intent of this exposure during dental school is to foster a greater awareness of dental access problems and of successful practice model that provide access to care.

Policy Recommendation 6. Expand the role of dental hygienists in the care of Medicaid children.

Dental hygienists are an important component of the dental workforce in Illinois and their expanded role in the care of Medicaid children should be seriously considered and tested.

Over one quarter of Medicaid dental expenditures and a larger percent of all procedures were for preventive care services (cleanings, fluoride, sealants). Hygienists are trained to provide these services. Hygienists are also trained to counsel children and their families on oral health and dental self-care. Dentists who employ a hygienist have a substantially larger capacity to provide services. The State could consider testing programs which expand dental hygienists’ provision of certain services (e.g. cleanings, fluoride, sealants, and screening exams. If properly designed, this would allow for the testing of conditions that would enable under-served children to have access to preventive dental care – and possibly reduce dental problems in the future and thus prove cost-effective. Access to dental providers is a critical barrier to oral health care; access could potentially be improved by expanding the use of dental hygienists.

Policy Recommendation 7. Establish a statewide oral health surveillance system.

Currently, in Illinois as well as nationally, there are limited data available to inform health

professionals, policy makers, health advocates, and others about the oral health needs of a population. There are a few states that have regular surveillance activities in place to assess oral health status of children, thus, providing a picture of oral health status (i.e., caries experience) over time. At least one state (North Carolina) collects data on workforce characteristics of dentists and dental hygienists as part of the licensure renewal process.

A comprehensive oral health surveillance system will enable Illinois to collect and analyze oral health data in order to monitor the oral health status of the population and subgroups, identify needs, make decisions, influence policy makers, secure program resources, and evaluate programmatic success in improving oral health. The oral health surveillance system could have the capacity to assess oral health workforce capacity and characteristics, oral disease burden, population trends, oral health status, health behaviors related to adverse oral health, and dental insurance coverage.

Policy Recommendation 8. Expand community based preventive programs.

Prevention of oral disease is key in decreasing the demand for services among low-income children. School based oral health education programs, community based sealant programs, and programs that raise awareness and educate low-income families about the importance of oral health care and influence their behavior in seeking oral health care for their children should be developed and or expanded.

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Appendix A

Illinois Center for Health Workforce Studies

Dental Advisory Group – Members & Invited Guests