Improving Oral Health:

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Harriet Owens
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1 Improving Oral Health: New Tools for State Policy Makers Cassie Yarbrough, MPP Lead Public Policy Analyst Health Policy Institute Lansing, MI June 1, 2017

4 Just the Facts

5 23.0% 22.2% 27.9% 57.8% 52.0% 50.3% 61.0% 59.1% 58.1% 9.1% 10.6% 10.1% 20.5% 30.9% 6.5% 7.9% 38.7% 67.9% 67.2% 62.0% 32.5% 33.0% 21.7% 29.4% 17.1% 11.0% Dental Benefits Coverage 100% 90% 80% 70% 5.8% 60% 6.7% 50% 40% 30% 20% 10% 0% Children Ages 2-18 Adults Ages Adults Ages 65+ Private Public Public (with dental benefits) Public (without dental benefits) Uninsured Source: Health Policy Institute analysis of the Medical Expenditure Panel Survey, AHRQ. Notes: All changes were significant at the 1% level ( ). The change in uninsured from 2013 to 2014 was statistically significant at the 10% level American Dental Association. All Rights Reserved. 5

6 Dental Care Use: Children & Adults Ages % Percentage with a Denta Visit in the Past 12 Months 90% 80% 70% 60% 67.2% 73.1% 66.6% 62.8% 68.4% 69.7% 60.7% 60.1% 50% 40% 40.8% 35.8% 49.7% 46.4% 30% 20% 10% 0% MI US MI US MI US Children with Medicaid Coverage Children with Private Dental Benefits Coverage Adults with Private Dental Benefits Coverage 2017 American Dental Association. All Rights Reserved. 6

Barriers to Dental Care Michigan Adults 2017

10 NH CA WA RI MS MO IL KS NJ AZ GA DC MD FL KY TN NC ME VA WI OH MA NY HI US AK NV OR ID LA IN OK SC DE TX CT NM CO UT NE AR MN PA SD MI WV AL MT ND VT WY IA 37.9% 70.6% Dentists Participation in Medicaid for Child Services (2015) 100% 90% 80% 70% 60% 70.6% of Michigan dentists participate in the Medicaid or CHIP programs for Child Services 50% 40% 30% 20% 10% 0% 2017 American Dental Association. All Rights Reserved. 10

11 Medicaid FFS Reimbursement as a Percentage of Fees Charged by Dentists, Child Dental Services, % under Michigan Fee-For- Service as a Percentage of Fees Charged by Dentists DE ND AR AK SD WY CT MA LA MT MD IN* UT NH AL VT NE VA ID OK SC ME NC HI WA IA WI* CA WV KY DC NV TN KS AZ TX NM GA NJ CO NY PA MO IL OH OR FL MS RI MN MI 82.3% 65.6% 63.0% 62.4% 61.1% 60.7% 59.7% 59.4% 58.4% 57.3% 56.2% 54.5% 53.8% 51.7% 51.0% 49.9% 46.5% 46.4% 46.2% 45.8% 45.3% 44.6% 43.6% 32.5% 40.8% 41.6% 32.1% 30.8% 67.4% 77.9% 65.3% 60.7% 55.8% 55.6% 54.1% 48.8% 48.5% 47.4% 46.6% 45.3% 44.4% 43.2% 42.1% 39.3% 36.8% 35.6% 34.6% 31.4% 31.3% 31.1% 30.7% 0% 20% 40% 60% 80% 100% 80.0% Private Dental Insurance Reimbursement as a Percentage of Fees Charged by Dentists 2017 American Dental Association. All Rights Reserved. 11

Medicaid FFS Reimbursement as a Percentage of Private Dental Insurance Reimbursement, Child Dental Services, 2016 38.

12 Medicaid FFS Reimbursement as a Percentage of Private Dental Insurance Reimbursement, Child Dental Services, % percent under Michigan Fee-For- Service as a Percentage of Private Dental Insurance Reimbursement 2017 American Dental Association. All Rights Reserved. 12

13 Repeal and Replace?

16 Repeal and Replace? In Medicaid expansion states with an adult dental benefit, dental care use increased between 2 and 6 percentage points in the second half of American Dental Association. All Rights Reserved. 16

17 Repeal and Replace? State CHIP Enrollment (FY2015) United States 8,397,651 Michigan 119,699 (number is low due to reporting issue) Wisconsin 168,576 Illinois 330,571 Indiana 100,560 Ohio 181,100 Source: Kaiser Family Foundation. Total Number of Children Ever Enrolled in CHIP Annually. FY American Dental Association. All Rights Reserved. 17

18 Repeal and Replace? Block Grants/Per Capita Caps Would states be able to keep/add an adult benefit? Impact on EPSDT? No CHIP Reauthorization Kids go back to the market No essential health benefit could impact the number that obtain dental coverage CMS showed that Medicaid/CHIP had better coverage than marketplace plans 2017 American Dental Association. All Rights Reserved. 18

19 Tools for Policymakers

21 Measuring What Matters

22 Measuring What Matters Move away from clinical terms Talk about how oral health impacts other aspects of individual and societal life Make speaking about oral health more relatable to policymakers and dental care users 2017 American Dental Association. All Rights Reserved. 22

25 Measuring What Matters US and Michigan Among MI Adults: Among U.S. adults with Medicaid dental benefits, 86% plan to visit the dentist, and only 20% actually visit the dentist American Dental Association. All Rights Reserved. 25

26 Measuring What Matters Takeaways Some states tie benefits to work programs These data show that oral health impacts one s ability to interview for a job Need more relatable, tangible outcome measures These data are easy to understand HPI plans to replicate these surveys, but states can replicate them in the interim 2017 American Dental Association. All Rights Reserved. 26

27 Understanding Access

28 Understanding Access Many policymakers believe we need more providers in the system may not always be the case Need to understand current supply Map where Medicaid providers practice versus where Medicaid enrollees live If it is a Medicaid provider supply problem, how do you get more providers into the system? 2017 American Dental Association. All Rights Reserved. 28

29 Dental Care Use Understanding Access The Dentist Workforce 75% Is the Number of Medicaid Providers Really That Important? (2015 Data) 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% Supply of Medicaid Providers 2017 American Dental Association. All Rights Reserved. 29

31 Methods PROVIDERS Medicaid or CHIP participating dentists Includes FQHCs and dental school clinics Map every location participating in Medicaid or CHIP Based on Insure Kids Now and ADA office data base POPULATION % children with public health insurance Census tract level 5, 15, 30 minute travel times based on road networks 2SFCA method to measure density of providers per population 2017 American Dental Association. All Rights Reserved. 31

34 Geographic Access 2% of publicly insured children do not have a Medicaid or CHIP dentist within a 15 minute travel time 88% of publicly insured children live in areas with more than one Medicaid or CHIP dentist within a 15 minute travel time for every 500 publicly insured children 9% of publicly insured children live in areas with one Medicaid or CHIP dentist within a 15 minute travel time for every 500 to 2,000 publicly insured children 1% of publicly insured children live in areas with less than one Medicaid or CHIP dentist within a 15 minute travel time for every 2,000 publicly insured children 2017 American Dental Association. All Rights Reserved. 34

Geographic Access 1% of the population do not have a dentist within a 15 minute travel time 64% of the population live in areas with more than one dentist within a 15 minute travel time for every

35 Geographic Access 1% of the population do not have a dentist within a 15 minute travel time 64% of the population live in areas with more than one dentist within a 15 minute travel time for every 2,500 people 25% of the population live in areas with one dentist within a 15 minute travel time for every 2,500 to 5,000 people 10% of the population live in areas with less than one dentist within a 15 minute travel time for every 5,000 people 2017 American Dental Association. All Rights Reserved. 35

38 Next Steps Access Maps 2.0 Color the maps according to dental care utilization among Medicaid enrollees Color providers based on alternative definitions of participate in Medicaid or CHIP Rerun analysis for Medicaid adults Mystery shopper study to verify that dentists are accepting Medicaid patients Dentist workforce projections under alternative assumptions Policy simulations to predict impact of Medicaid reforms 2017 American Dental Association. All Rights Reserved. 38

Simulating Policy Impact Survey and Analysis Results pay one

Dental ER Visits: Evidence of a Failed System. Shelly Gehshan AACDP Conference April 29, 2012

Dental ER Visits: Evidence of a Failed System Shelly Gehshan AACDP Conference April 29, 2012 Overview of Pew s s findings Preventable dental conditions were the primary diagnosis in 830,590 visits to hospital