By Miriam Straus
One year after a 12-year-old Medicaid beneficiary could not obtain dental care and died after tooth decay spread to his brain, witnesses told a House panel that the Centers for Medicare and Medicaid Services (CMS) has done little to improve beneficiaries' access to dental services.
"Medicaid still hasn't learned the most important lessons from the preventable death of Deamonte Driver," said Rep. Dennis J. Kucinich, D-Ohio, referring to the Maryland youth whose death highlighted the difficulties Medicaid beneficiaries face in obtaining dental services.
While many experts say that increasing Medicaid reimbursements for dental services is critical to improving beneficiary access, that has not happened, Kucinich said at a February 14 hearing. Kucinich is chairman of the House Government Oversight and Government Reform Domestic Policy Subcommittee, which held the hearing to review Medicaid's coverage of dental services a year after Driver's death.
Jim Crall, the director of the National Oral Health Policy Center at the University of California, Los Angeles, told the panel that Medicaid dental reimbursement rates are far lower than the "Usual, Customary and Reasonable" (UCR) fees that private providers charge for dental services. In addition, he said, most states have no provisions for updating Medicaid reimbursement rates regularly to account for inflation and other increases in the cost of services. The center studies access to dental care, particularly among low-income children and families.
Crall told the panel that the rates are calculated by analyzing how much dentists charged patients in the past year for given procedures. However, instead of submitting their charges for all patients, dentists in many cases submit their charges for Medicaid patients only. "This custom relates to the dentists' recognition that they are bound by law to accept the Medicaid fee as payment in full for any covered procedure, and that billing Medicaid at the Medicaid fee instead of their usual charge eliminates the need to reconcile or write-off the difference for each procedure provided," Crall said in prepared testimony. "There is no incentive for dentists to make this accounting adjustment because they cannot 'balance bill' Medicaid clients for the difference between Medicaid and their private-sector fees, as they would for their private sector clients." The result is much lower reimbursement rates in Medicaid, he said.
For example, Connecticut's Medicaid payment rate for a periodic oral exam was $18.08 in 2004, Crall testified, while the median charge for such a procedure in the state was $37.00. In states that have increased their Medicaid reimbursement rates, the increase in provider participation is substantial, he said. Georgia raised its Medicaid rate to the 75th percentile of dentist fees in the state, and dentist participation has increased 825 percent in the 48 months since the change, according to materials Crall submitted to the subcommittee.
Oral diseases, such as tooth decay and gingivitis, or inflammation of the gums, are among the most common chronic diseases of U.S. children. These problems can have severe consequences for general health. Tooth decay infections can spread to the bloodstream, lymph systems, and other parts of the body, for example, which is what happened in Driver's case. Although Driver had been enrolled in United HealthCare through his Medicaid coverage until close to the time of his death, he had not seen a dentist in several years.
Dennis Smith, director of the Center for Medicaid and State Operations at the Centers for Medicare and Medicaid Services, emphasized that Medicaid spends approximately $2,900 per child each year. According to Smith's written testimony, in 2006, one in three children enrolled in Medicaid or the State Children's Health Insurance Program (SCHIP) had received a dental service during the past year, a 10 percent increase from 2003.
Smith noted that CMS had submitted to the subcommittee a review of children's dental coverage in Maryland and has begun reviews of several other states in the last week. But when Kucinich asked Smith about the number of Maryland children enrolled in Medicaid who have not received dental care in the last three years, Smith responded that the agency did not have data on specific individuals. "States have that information," Smith testified.
Kucinich was not pleased with that answer. "Did you ever pick up the phone and ask?" he pressed, noting that his own staff had contacted Maryland officials. The number of Medicaid-enrolled children in the state who had not received dental care in the last three years is 22,555, Kucinich said. "As a federal administrator, it might be helpful if you could find a way for your own staff to access the kind of information that a small congressional office was able to get," he told Smith.
Rep. Elijah E. Cummings, D-Md., also directed sharp remarks towards the CMS director, recalling that the subcommittee had sent a seven-page outline of steps that CMS could take to improve dental care for Medicaid beneficiaries. "I have been significantly underwhelmed by your lack of urgency," Cummings said. He added that all the deadlines CMS had given to states were imposed after the agency had received notice of the hearing.
Emphasizing that CMS "ought to be doing everything in its power" to improve the situation, Cummings asked if Smith had encouraged states to raise reimbursement rates.
Smith replied that he recognized Medicaid reimbursement rates for dental services were low and that the rates were "major barriers of access" for Medicaid beneficiaries trying to obtain dental care.
Rep. Diane Watson, D-Calif., asked Smith to investigate why only two states have developed guidelines for the frequency of dental visits. "Forty-eight states are in violation of federal law," she said. Watson was referring to the Omnibus Budget and Reconciliation Act of 1989 (PL 101-239), which amended the Social Security Act to mandate that each state develop its own periodicity schedule for dental services and examinations.
Witnesses also questioned why under Smith's leadership, CMS in 2004 removed a policy section from the agency's Guide to Children's Dental Care in Medicaid. According to the subcommittee's Web site, the section dealt with reimbursement rates, legal obligations to ensure dental care for low-income children, data on the lack of children's access to dental care, and how states should oversee dental services provided by Medicaid managed care organizations.
Smith explained that he had not thought that the policy section belonged in what he described as a "clinical guide."