Jim Gillcrist - Oral Health


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Jim Gillcrist - Oral Health

  1. 1. TennCare’s Dental Program: Before & After the Carve-Out NASMD November 14, 2008 James A. Gillcrist, DDS, MPH Dental Director, TennCare
  2. 2. Oral Disease versus Medical Disease <ul><li>To be an insurable risk, a condition should be: rare and random, irreversible, with significant financial consequences </li></ul><ul><li>Medical disease is an insurable risk </li></ul><ul><li>Oral disease is not an insurable risk </li></ul><ul><li>80% of practicing dentists are general practitioners and the rest are specialists </li></ul><ul><li>Conversely, 80% of physicians are specialists and 20% are generalists </li></ul><ul><li>In dentistry, most care is provided by a single dentist at a single location </li></ul><ul><li>In medicine, care is provided by multiple practitioners at different locations </li></ul>June 2006 JADA publication by Albert H. Guay, DMD entitled, “ The differences between dental and medical care Implications for dental benefit plan design”
  3. 3. Prior to the dental carve-out, a medical managed care model existed with integrated dental services <ul><ul><li>Dentists were frustrated by different administrative requirements associated with multiple MCOs </li></ul></ul><ul><ul><li>Different provider credentialing processes </li></ul></ul><ul><ul><li>Different fee schedules </li></ul></ul><ul><ul><li>Low reimbursement rates </li></ul></ul><ul><ul><li>Different provider pools </li></ul></ul><ul><ul><li>Different enrollee benefit packages offered </li></ul></ul><ul><ul><li>Different provider agreements /contracts </li></ul></ul><ul><ul><li>Different provider manuals </li></ul></ul><ul><ul><li>Different prior-authorization requirements </li></ul></ul>
  4. 4. Other Concerns <ul><ul><li>Multiple MCOs with TennCare members enrolled in different plans </li></ul></ul><ul><ul><li>Most dentists contracted with 1 plan only </li></ul></ul><ul><ul><li>Therefore, members did not have access to the entire network of dentists just to those contracted with their individual plan </li></ul></ul><ul><ul><li>Access to dental care affected by medical model </li></ul></ul>
  5. 5. What is a Carve-Out ? <ul><li>A carve-out delivers a single benefit (i.e., dental care) by separating it out from other Medicaid Managed Care services </li></ul><ul><li>Establishes a “dental” budget (dedicated dental funds allocated) </li></ul><ul><li>Uses a single benefits manager (DBM) to administer dental services. </li></ul>
  6. 6. “ Dental Carve-Out” <ul><li>On May 14, 2002, following a competitive bid process, Doral Dental was awarded the original DBM contract with Tennessee. </li></ul><ul><li>Implementation began in the Fall of 2002 following a report of readiness and approval by a EQRO and TennCare. </li></ul>
  7. 7. Dental Carve Out Achievements <ul><li>Establishment of a TennCare Dental Advisory Committee (TDAC) </li></ul><ul><li>Support & promotion by organized dentistry </li></ul><ul><li>Growth of dental provider network </li></ul><ul><li>Reduction of “Hassle” factor </li></ul>
  8. 8. Dental Carve Out Achievements <ul><li>Active provider participation </li></ul><ul><li>Access improvements </li></ul><ul><li>Utilization improvements </li></ul><ul><li>Collaboration among key stakeholders </li></ul><ul><li>Intensive outreach (enrollee & provider) </li></ul>
  9. 9. TennCare Dental Advisory Committee <ul><ul><li>Comprised of Tennessee dentists, dental specialists and non-dentists </li></ul></ul><ul><ul><li>Member vs. provider focus </li></ul></ul><ul><ul><li>Empowered to make recommendations to TennCare </li></ul></ul><ul><ul><li>Non-binding, yet frequently adopted </li></ul></ul>
  10. 10. Promotion of the dental carve-out by organized dentistry occurred once: <ul><ul><li>A single DBM was awarded the contract, </li></ul></ul><ul><ul><li>An adequate fee-for-service reimbursement schedule for providers was instituted, </li></ul></ul><ul><ul><li>TDAC was constituted, </li></ul></ul><ul><ul><li>Contract analysis was completed by ADA, </li></ul></ul><ul><ul><li>Dentists were assured they could participate at a level that accommodated their practice </li></ul></ul><ul><ul><li>A dentist was hired as the first dental program director </li></ul></ul>
  11. 11. Growth of dental provider network <ul><ul><li>Between October 2002 and September 2008: </li></ul></ul><ul><ul><ul><li>Dental Network statewide grew by 135% </li></ul></ul></ul><ul><ul><ul><li>Network includes 909 contracted dentists: </li></ul></ul></ul><ul><ul><ul><ul><li>630 General dentists </li></ul></ul></ul></ul><ul><ul><ul><ul><li>78 Pedodontists </li></ul></ul></ul></ul><ul><ul><ul><ul><li>201 other dental specialists </li></ul></ul></ul></ul><ul><ul><ul><li>27% of licensed Tennessee dentists participate in the TennCare program </li></ul></ul></ul>
  12. 12. “ Active” Participation By Contracted Dentists <ul><ul><li>For the 12-month period from 1/1/2007 Through 12/31/2007: </li></ul></ul><ul><ul><ul><ul><li>85% of participating dentists were paid claims ≥ $10,000 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>70% of participating dentists treated ≥ 100 children </li></ul></ul></ul></ul>
  13. 13. “ Hassle” factor reduction <ul><li>Streamlined administration by DBM </li></ul><ul><ul><ul><li>One provider credentialing process </li></ul></ul></ul><ul><ul><ul><li>One provider pool </li></ul></ul></ul><ul><ul><ul><li>One provider agreement </li></ul></ul></ul><ul><ul><ul><li>One provider manual </li></ul></ul></ul><ul><ul><ul><li>One maximum allowable fee schedule </li></ul></ul></ul><ul><ul><ul><li>One set of prior authorization requirements </li></ul></ul></ul><ul><ul><ul><li>Electronic claims submission thru DBM </li></ul></ul></ul>
  14. 14. Member Utilization <ul><li>From FY 2002 (year prior to carve-out) Through FY 2007, utilization of dental services increased by 42%*. </li></ul>* Calculation of dental participant ratio specific to TN
  15. 15. Outreach <ul><ul><li>DBM contractual outreach initiatives </li></ul></ul><ul><ul><li>Dept. of Health contractual initiatives </li></ul></ul><ul><ul><ul><li>School-Based Dental Preventive Project (SBDPP) </li></ul></ul></ul><ul><ul><li>Voluntary initiatives with organized dentistry (TDA, Pan-TDA) & Palmolive Colgate </li></ul></ul><ul><ul><ul><ul><li>“ No Child Overlooked” </li></ul></ul></ul></ul>
  16. 16. DBM Outreach Initiatives <ul><ul><li>Reminder notices </li></ul></ul><ul><ul><li>Newsletters </li></ul></ul><ul><ul><li>Collaboration </li></ul></ul><ul><ul><li>Post Card and Outbound Call Campaign </li></ul></ul><ul><ul><li>Member Education </li></ul></ul><ul><ul><li>At - Risk Populations </li></ul></ul><ul><ul><li>Child Development Centers </li></ul></ul><ul><ul><li>Prenatal & Coordination </li></ul></ul><ul><ul><li>Provider Network Expansion </li></ul></ul><ul><ul><li>Provider Education and Outreach </li></ul></ul>
  17. 17. DBM Utilization Review Process <ul><li>Evaluates a provider’s treatment practice compared with the norm for peers </li></ul><ul><li>Controls for normal statistical variability (noise) </li></ul><ul><li>Significant deviation from peer norms elicits a thorough analysis and chart review </li></ul><ul><ul><li>Incorporates professional panel review </li></ul></ul><ul><ul><li>Requires corrective action intervention by DBM </li></ul></ul><ul><ul><ul><ul><li>Behavior Modification </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Recoupment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Termination </li></ul></ul></ul></ul>
  18. 18. TennCare’s Dental Program <ul><li>Has a specific budget </li></ul><ul><li>Includes comprehensive dental benefits for over 726,000 children </li></ul><ul><li>Includes “medically necessary” services </li></ul><ul><li>Cosmetic dental services excluded </li></ul>
  19. 19. Dental Workforce <ul><li>Dentists with TN license is ≅ 3,426 </li></ul><ul><li>Licensed dentists participating in TennCare = 909 </li></ul><ul><li>General population-to-dentist ratio in children and young adults in TN is ≅ 500:1 </li></ul><ul><li>TennCare population-to-participating general dentist ratio for ages 3-20 ≅ 800:1 </li></ul><ul><ul><li>* These ratios don’t include student providers treating TennCare enrollees through university affiliated dental programs (Univ. Tenn., Meharry, and Vanderbilt) </li></ul></ul>
  20. 20. TennCare Service Expenditures for Children 2008 <ul><ul><li>Dental service expenditures for children </li></ul></ul><ul><ul><ul><li>$137,702,497 </li></ul></ul></ul><ul><ul><li>All TennCare service expenditures for children </li></ul></ul><ul><ul><ul><li>$1,639,704,309 </li></ul></ul></ul><ul><li>Dental service expenditures as a percentage of all TennCare service expenditures for children was 8.40% </li></ul>
  21. 21. TennCare Dental <ul><li>Average annual dental expenditure per child who received dental services in SFY 2007 was $422.00 </li></ul>
  22. 22. Foundation for Program Success <ul><li>“ Member” vs “dentist” focus </li></ul><ul><li>“ Dental” vs “medical” model </li></ul><ul><li>Utilization of a single DBM experienced in Medicaid/SCHIP programs </li></ul><ul><li>Incorporates streamlined administrative processes </li></ul><ul><li>Incorporates a reasonable dental fee schedule and provider fee-for-service reimbursement </li></ul><ul><li>Active participation of “community-based” dentists </li></ul><ul><li>Strong collaboration among key stakeholders </li></ul><ul><li>Input through a “dental” advisory committee </li></ul><ul><li>Incorporates an education and outreach component </li></ul>