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Improving Oral Health: Strategies for Increasing Available ... Improving Oral Health: Strategies for Increasing Available ... Presentation Transcript

  • Improving Oral Health: Strategies for Increasing Available Providers H. Bryan Tomlinson, II, Director of Health Care Services Virginia Department of Medical Assistance Services National Association of State Medicaid Directors 2007 Fall Conference Washington, DC November 13, 2007
  • Virginia Medicaid/SCHIP Dental Benefits
    • Approximately 490,000 eligible children
    • Dental benefits for children in Medicaid/SCHIP include:
      • Diagnostic, preventive, restorative/surgical procedures and orthodontics
    • Dental benefits are not covered for Medicaid adults, except for limited oral surgery (e.g. extraction of infected teeth complicating a medical condition, etc.)
  • Access to/Utilization of Dental Services Needed to Improve
    • In FY 2003, 23.4% of eligible children received services
    • Low participation of all VA licensed dentists (620 of 4,786) in the Medicaid/ FAMIS program
    Dentist Participation in Medicaid/FAMIS* *FY 2003
  • DMAS Dental Survey
    • Survey was developed to identify the reasons providers did not want to participate in the Medicaid/FAMIS dental program
    • Survey was mailed to all licensed dental practitioners in Virginia (over 4500) in 2004
    • Over 1000 surveys were completed and returned to DMAS. (22% response rate)
  • Barriers to Participation
    • Reimbursement
    • Claim Submission
    • Prior authorization
    • Timeliness of payment
    • Availability of specialists
    • Patient behaviors
      • Broken appointments
      • Non-compliance
  • Would you consider participating if fees increased? * Percentage of those that answered particular question
  • Program Goal
    • Improve Access to Quality Dental Care to Medicaid/SCHIP Recipients
        • Increase Provider Participation
        • Increase Pediatric Dental Utilization
  • Stakeholder Engagement Advocacy Groups MCOs Organized Dentistry Medicaid/SCHIP Agency Governor Legislature New Medicaid/ FAMIS Dental Program
  • A New Day for Dental! Smiles For Children
    • Effective date: July 1, 2005
    • New program was labeled Smiles For Children
    • with a new logo and registered service mark
    • All children (Medicaid & FAMIS) were enrolled
    • in a single program administered by Doral Dental USA
    • Limited medically necessary services for adults
    • Medicaid/SCHIP retains policymaking authority and closely monitors contractor activities
    • New program is fee-for-service and non-risk
  • Fee-for-Service with a Commercial Flare
    • Many principles of a managed care product were adopted:
          • Coordination of Care
          • Provider Credentialing
          • Network Development
          • Member Outreach
          • Quality Improvement Programs
  • Key Program Enhancements
    • Old Program
    • Multiple Vendors
    • Multiple credentialing processes
    • Complicated Administration
    • Limited local representation on program policy decisions
    • Enrollee transfer between plans disrupted care
    • Smiles For Children
    • Single Vendor (Doral)
    • Streamlined Credentialing
    • Easy, Industry-Standard Administration
    • VA Based Peer Review Committee/Dental Advisory Committee
    • All enrollees in Smiles for Children program
  • Results Increased Provider Network
    • 387 new dentists are participating (62% increase)
    • Percentage of contracted providers who are billing for services has increased from 50% to 83%
    Participating Providers
  • Incentives to Attract Providers
      • Increased Reimbursement
      • Improved ease of administration
      • Conformed to commercial practices
      • Reduced broken appointments
      • Offered superior provider relations
      • Provided flexible levels of participation
      • Collaborated with dental community
  • …..And Increased Access to Care Percentage of Children Receiving Dental Care 24% 29% 29% 36% Source: CMS 416 Report for Virginia 35% 43% 46% 48%
  • Lessons Learned
    • Reduce program requirements for providers who uphold high standards of care
    • Centralize and standardize processes through advanced web based services
    • Promote best practices
    • Acknowledge dental community participation to state legislators and public policy groups
    • THANK providers
  • On-Going Challenges
      • Reimbursement
      • Prior program experience
      • Provider attitude towards Medicaid enrollees
      • Payor environment
      • Recruitment in rural areas
  • 1-888-912-3456 http://www.dmas.virginia.gov/dental-home.htm http://www.doralusa.com THANK YOU!!!!!