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North Carolina Medicaid Dental Program Update
CMS Oral Health Workshop Arlington, VA November 10, 2010
Governor Beverly Eaves Perdue Lanier M. Cansler, DHHS Secretary Dr. Craigan L. Gray, DMA Director
A Word From My Sponsor……
l Customer-focused l Anticipatory l Collaborative l Transparent l Results Oriented
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My Other Sponsor-- GO DUKE!!!
Presentation Objectives
l Define one problem and identify NC’s solution
l Discuss the design and origins of “Into the Mouths of Babes” (IMB)
l Summarize IMB research findings l Continuing challenges l Future opportunities
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Problem: Access to Care for Preschool Medicaid Recipients
l Up to 60% of low-income children enter kindergarten in North Carolina having experienced tooth decay, much of this is untreated decay l ECC widely prevalent l Profound social and economic effects for children and their
families l Preschoolers have significant barriers that prevent
them from accessing dental care l Behavior management concerns l Lack of general dentists trained to treat infants/toddlers l Shortage of pediatric dentists in NC
l Low income children (Medicaid) have more difficulty accessing care than other groups
Solution: Policy Initiative
l Goals of the IMB l Increase access to preventive dental care
for low income children 0-3 years of age l Reduce the incidence of ECC in low-income
children l Reduce the burden of treatment needs on a
delivery system stretched beyond its capacity to serve young children
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Design of IMB
l Utilize more robust NC primary care medical provider (PCP) network to deliver important preventive oral health services
l Design program services to be administered with successful NC EPSDT well child visit program (Health Check)—services needed to be easily integrated into PCP practice
l To qualify for participation, providers receive enhanced CME training—face-to-face l Taught infant/toddler oral exam procedure, caries risk
assessment, preventive counseling with the parent/caregiver, application of topical fluoride varnish
l Training initially provided by NCAFP and NC Peds Society; currently provided by the Division of Public Health—Oral Health Section
Origins of IMB
l Pilot project started in Western NC Appalachian counties in 1998—core group of PCPs and Early Head Start personnel noted significant problems with ECC
l Application to DHHS for statewide implementation developed in 2000
l Funding l Partial funding by ARC l Continued Federal funding first from CMS, later
from HRSA/MCHB and CDC l $ used for staff to develop the training curriculum,
conduct training, oversee the program and generate the research conducted to support the program
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IMB Visit
l Who’s eligible for the service? l Recipients age 6 months to 3½ years
l Who provides services? l PCPs and extenders who have completed
the CME training can provide IMB services l How often can the treatment be done?
l Every 60 days with a maximum of six (6) IMB visits before age 3½
IMB Visit
l What is an IMB Visit? l D0145—periodic oral evaluation of a patient under
three years of age and counseling with the primary caregiver (current reimbursement = $36.35)
l Early caries screening and detection & report of other notable findings like obvious pathology of hard and soft tissues
l Preventive oral health and dietary counseling with the primary caregiver including development of an age appropriate preventive oral health regimen
l Prescription of a fluoride supplement if indicated, per the guidelines of the AAP
l Referral to a dentist, if appropriate
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IMB Visit
l What is an IMB Visit (cont’d)? l D1206—topical fluoride varnish; therapeutic application for
moderate to high caries risk patients (Reimbursement = $16.04)
l Many studies demonstrate that FV is the safest and most effective form of topical fluoride for this age group
l FV dose:response relationship (Weintraub et al., J Dent Research, 2006)
l Claims filed on CMS-1500 using CDT codes listed above (D0145 and D1206)—must be reported together on the same claim form to receive reimbursement
l Render at WCV, sick child or separate visit l Well accepted in busy PCP practice by staff and parents—
physicians want to provide a valuable service for children at risk
IMB Research Findings
l Increase in access to preventive dental services for infants and toddlers of 30-fold
l By four years of age, children who had received at least four IMB services demonstrated a statistically significant cumulative reduction in the number of restorative treatments needed for anterior teeth of 39%.
l IMB has led to an increase in access to restorative treatment services in the dental office through the effect of referral of children with existing disease at the time of the IMB visit to the dental care system
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010
2030
Exp
ecte
d D
enta
l Pro
cedu
res
Per
Mon
th
0 10 20 30 40 50Age in month
(mean) noimbtp (mean) imbtp
Anterior teeth: Kids with 0 IMB vs 4 or more IMB
IMB Research Findings (cont’d)
l No reduction in visits to dentists for preventive care for the 0-3 age group
l Opposite effect—preventive care in the dental office for infants and toddlers under age 3 has increased substantially as IMB has grown l Not displacement of preventive care from dental
offices, but rather supplementation l Implication--service is reaching recipients who truly
face barriers to seeking care in dental offices l Cost effectiveness?—the truth is still out there
l Need larger sample size to follow children as they age out of IMB
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IMB Facts and Figures
l More than 3000 physicians, PAs, nurse practitioners, nurses, office staff et al. have been trained since statewide inception of the program in 2001
l Approximately 450 public and private billing providers
l Children from every county have received services; in about one-third of the state’s counties, no Medicaid child in this age group received any preventive care in dental offices before IMB
Number of Unduplicated Recipients Ages 0-3 Receiving IMB Services
010,00020,00030,00040,00050,00060,00070,00080,00090,000
SFY2001
SFY2003
SFY2005
SFY2007
SFY2009
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# Annual Preventive Dental Visits in NC Medical Offices, 2000-2010
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Trends in provision of preventive dental services in NC primary care medical offices
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
Q12000
Q42000
Q32001
Q22002
Q12003
Q42003
Q32004
Q22005
Q12006
Q42006
Q32007
Q22008
Q12009
Quarter/Year
Amou
nt p
aid
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
No. o
f visi
ts
Amount paidNo. of visits
* Effective 1/1/07 claims codes changed from four D-codes for initial and follow-up visits, fluoride application and instruction, to two D-codes for oral evaluation and fluoride application. The frequency interval also changed at that date from every 90 days to 60 days, and the upper age limit from 3 years of age (36 months) to 42 months. Consequently, some recipient duplication may be present in the quarterly estimates beginning in 2007.
*
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Percent of Annual Health Check Screenings (WCVs) Receiving IMB Services *
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
• For years 2000-2007 includes 1-2 yr olds only, for 2008 on includes 1-3 year olds.
2008 represented by 1st and 2nd quarter data only.
Barriers to Adoption of IMB
l Funding l Some opposition from provider community
l Although, NCDS and NCAPD have been supportive
l Organized medicine including the NCAFP and NC Peds Society have been extremely supportive
l Staffing concerns l Coding and claim form issues
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Ongoing Challenges for IMB
l Opposition to medical providers rendering oral health care l Question effectiveness l Medicolegal issues l Off label use of FV
l Reimbursement issues l Exam covered under EPSDT well child visit? l Prior to May 2008, PCPs were paid more than dentists for oral
evaluation and fluoride varnish
l Making the connection from medical home to dental home—particularly for children at high risk for ECC
l Funding and staffing in a difficult economic climate
Obstacles to Growth and Effectiveness
l Licensing boards l Number of eligible children in practice l Evaluation l Dental referrals l Physician knowledge of oral conditions,
confidence in diagnostic abilities l Reluctance to refer high risk children without
disease
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Lessons Learned in NC
l Necessity is the mother of invention (and, often times, innovation)
l All stakeholders have to be at the table --organized medicine and dentistry, health care policy makers, academicians from UNC SoD and SPH, EHS, etc.
l Reimbursement and equity issues are important
l TEAMWORK!—Need a dedicated core of individuals willing to sacrifice time and money
Next Steps—Carolina Dental Home
l HRSA Workforce Grant initiative in Eastern NC- “Carolina Dental Home” l Development of risk assessment tool for PCPs to
use to identify high risk preschool children and facilitate referral to dentists (general or pediatric dentist) based on risk factors/needs
l Possibly test PORRT as part of CHIPRA Quality Demonstration grant
l Care coordination/health navigation to facilitate referrals
l Education and training of providers both IMB PCPs and participating dental providers
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Next Steps—Zeroing Our Early Childhood Tooth Decay (ZOE)
l Overall goal is to determine whether oral health education is effective
l To help reduce the growing disparities in dental disease in targeted low-income children and their families in NC EHS programs. l Provide education for teachers and staff
l Teach motivational interviewing techniques l Provide educational resources l Provide technical advice l Link EHS families with IMB practices l Evaluate how it works
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Division of Medical Assistance NC Medicaid Dental Program
www.ncdhhs.gov/dma/dental.htm
Mark W. Casey, DDS, MPH
Dental Director [email protected]
919-855-4280
