Legislative Process: OHCD

September 10, 2003

Federal/ State Programs

Government accepts the paradigm of health care as a right- 1960’s and 1970’s

The War on Poverty

The War on Poverty “ends” in 1980

Cost containment

The 1990’s Health Care as a Right re-examined within the context of cost

The War on Poverty

Explosion of health legislation during the Nixon and Johnson years; broadened the federal role of aid to communities and individuals

OEO

Medicaid

Health Planning Acts

Migrant Health

Appalachian Regional Development

Model Cities

The War on Poverty and Dentistry

Many of these programs required dental services, or at least preventive dental services, to be provided by grant-supported delivery systems.

Federal guidelines and requirements acted to standardize services and methods across the nation, diminishing State opportunities to experiment in delivering services. As a result a network of health centers and programs grew up to encompass thousands of urban and rural communities

History of State and Federal Programs

Before 1935 most federal grants in aid to states were awarded for specific purposes such as VD, TB

Health services for the needy were provided through philanthropic and occasionally state and local clinics

Few Federal Funds

1930 State Health Departments expended only $37,000

History of State and Federal Programs

Social Security Act of 1935, established federal matching grants in aid to state to provide assistance to the

Aged

Blind

Families with dependent children

First time that federal funds were channeled through the states to provide income supplements for needy persons.

History of State and Federal Programs

States were not required to spend dollars on dentistry

State dental departments competed for funding with other state health interests, and their dental programs grew quite slowly.

1955- 1.5 billion were expended for dental services in U.S.

2.1 million by State dental programs; 42% of this came from federal grant in aid programs

1956- more favorable formulas for medical and dental payments

States started to look more favorably at dentistry

History of State and Federal Programs

1956-1966 slow growth

Mid-1960’s federal involvement in the financing of health services expanded dramatically

SSA of 1965; amendments to the SSA act of 1935

Medicare Title 18

Medicaid Title 19

Medicaid

Title XIX provides dental benefits for indigent Americans

Individual States determine benefit eligibility, generally as a function of the federal poverty index and age of the recipient

EPSDT- Early Periodic, Screening, Diagnosis and Testing(EPSDT) program

Dental benefits for Medicaid eligibles vary form State to State

Medicaid

Title 19: 50 Different State Programs

Medicaid spends less than 1% of its payments on dental care

Sliding scale of payments to states or medical services to persons who qualified for public assistance programs for

Blind, aged,disabled

Families with dependent children

The act authorized matching funds for persons whose incomes while sufficient for normal purposes but were inadequate to cover medical services, a category of beneficiary known as the medically needy

Medicaid

Fourteen services authorized

Five were mandatory

inpatient hospital services

laboratory and x-ray

skilled nursing home services for adults

physicians services

Dental care and dentures were listed as optional along with drugs, eyeglasses, and physical therapy

Medicaid: EPSDT

In 1967 Medicaid was amended to expand disease prevention activities for children by requiring states to screen diagnose and treat health problems of children eligible for medical assistance. This program was known as

Early Periodic Screening, Diagnosis and Treatment(EPSDT)

Applied to everyone under age 21 and eligible for medical assistance.

Dental Services were mandatory.

All States were required to have an operating program by 1972.

EPSDT

The implementation of EPSDT proceeded so slowly that in 1972 Congress passed additional amendments penalizing states without functioning programs.

In 1981 the Omnibus budget Act repealed the penalty for States without EPSDT programs.

As of 1984 all States provide Medicaid, 30-32 provide dental care to all adults, under EPSDT all children are covered.

EPSDT and Dentistry

Inspector General’s report 1995: one in four children in the U.S. Is currently covered under the program

Fewer than 20% of eligible children receive an dental service at all

Multiple barriers to care

Rejection of low payments by dentists

Poor health behaviors by beneficiaries

Medicaid: Problems

Why Doesn’t Medicaid Work?

Conflicting and confusing policies

New York State Thresholds- 1989

Increased Fees- 1990; fees increased 50- 120 per cent, with emphasis on diagnosis and preventive services.

New York State and Medicaid

Indecisive

Letter from Deputy Commissioner 10/1/89

Thresholds on visits

Limits on selected medical equipment and supplies

Check medical assistance program to see whether a patient has gone over the limit for care or services

New York State and Medicaid

5/14/90 letter from Deputy Commissioner

To dentists, raising Medicaid reimbursement for children

Fee increase of 50-120 percent with emphasis on diagnostic and preventive services

Medicaid: New York State- 1991

Examples

FMS     15.00     31.50

Child Prophylaxis            7.00     14.50

Pulpotomy     13.00         25.00

Orthodontics    1600.00 2500.00

Sealant, PCR              25.00

Diagnosis and Prevention

Oral Exam     10.00

Radiographs     31.50

Dental prophylaxis     15.40

Fluoride treatment     12.00

Medicaid: New York State

Treatment Visits

Amalgam Restoration 1 Surface 19.00

Dental Sealants, per tooth 12.00

Extraction, single tooth 25.00

Root Canal Therapy, one canal 140.00

Space Maintainer, Fixed Unilateral 97.50

Therapeutic Pulpotomy 25.00

Occlusal Sealant, PCR 25.00

Medicaid: California

MediCal Study

Physicians primarily influenced by financial considerations and factors that interfere with their professional judgment

Low reimbursement rates and denial of payment, 1st and second reasons why dentists don't participate in Medicaid.

Broken appointments are the third reason

Inability to treat Medicaid patients in a manner the dentists considered comprehensive

Medicaid: Problems

Reasons for Not Participating in Medicaid

Low fees

Not enough services covered

Denial of payment

Broken appointment

Slow payment

Need for prior approval

Complicated paperwork

Medicaid

Why participate?

altruism

income

Medicaid Mills

High volume, low quality Medicaid practices

ADA: “Health Care that works” Dentists provide over $20,000 to patients in free or reduced fee services to their private practice patients. Do you agree?

Medicaid: Problems

Poor Children missing basic dental care- Medicaid Study-American Medical News 1991

Medicaid programs fail to provide basic dental services to poor children as required by “EPSDT”

-inadequate services

-fail to meet fed guidelines

Evaluated NY, Texas, Michigan, Ohio, Mississippi, and Nevada, half of the children on Medicaid

Medicaid patients received fewer services than those provided to other patients; reason cited low Medicaid reimbursement

Section 1115 Waivers

State changes to the Medicaid Program

Eligibility requirements

The scope of services provided

Statewide uniformity of the program

The freedom to choose a provider

A provider's choice to participate in a plan

The method of reimbursing providers

Alternative delivery systems

Section 1115 Waivers

Operationally feasible

Budget neutral

Leave the States Medicaid population at least as well off s it was before the plan was implemented

Managed care 1115’s(the majority)

Medicaid and the ADA

“The federal government should assure comprehensive dental benefits for all no- and low-income individuals, regardless of age, by expanding Medicaid”

“Medicaid should be administered in the private sector, rather than through a government agency. This private/ public sector cooperative effort would yield better administrative efficiency”

Medicaid and S-CHIP

Dental caries remains the single most common chronic disease of childhood and is most severe amongst the low income children targeted y Medicaid and S-CHIP. National data confirm that pediatric oral health in the U.S. is worsening

BBA of 1997 that created S-CHIP the largest child health insurance program since Medicaid.

S-CHIP provides states with a higher federal match rate than Medicaid and leaves program design to the states

Medicaid and S-CHIP

States may use these new funds for Medicaid expansions or new children health insurance programs.

Most State financed plans and private plans, do not provide dental coverage

Federal legislation does not mandate States to include dental coverage

Publicly funded health insurance programs have strong potential to provide and assure necessary dental care of these children but have substantially failed to do so

Medicaid Managed Care

Carve out dentistry

Contract with dental managed care organizations directly

Dental Medicaid managed care may further reduce the dismal EPSDT dental access figures

Medicaid Law Suits

California, New Hampshire and New York

Charged with failing to fund Medicaid programs adequately to ensure sufficient provider participation

Does increasing fees increase provider participation?

California post law suit

New York State
Medicaid Suit

In February 1999, the Dental Society of the State of New York and individual dentists and patients brought an action in the United States District Court against the Governor of New York State, the Acting Commissioner of Health and the Director of the Budget.

The complaint alleged that, “…(the) inadequate Medicaid fee schedule discourages dentists from participating in the program and frustrates the mandate of the Medicaid law (particularly for children).”

In an out-of-court settlement in May 2000, an agreement was reached that called for “…$573 million in increased funding over the next four years for Medicaid dental fees…”

New York State Medicaid

2000- $206.7 million was expended for Medicaid dental services to provide care for 770,191 New York State residents ($268 per recipient of care).

Approximately 70% ($144 million) was spent for 523,361 New York City residents (at the rate of $276 per recipient of care, compared to $253 per other-than-New York City residents).

2000- almost 3.4 million New York State residents, including 1.6 million children, were eligible for Medicaid dental services. But:

Approximately 770,000 individuals (22.7% of all eligible residents) received care.

Less than 340,000 children (21% of all eligible children) received care.

Approximately 69,500 elderly (15% of all eligible elderly) received care.

New York State Medicaid

1997, 3,534 New York State dentists participated in the Medicaid program (21.5% of the 16,458 individuals licensed and registered to practice dentistry in that year)

51% (1,810 dentists) of the participating dentists were in New York City.

Five or fewer dentists participated in 12 counties (Allegany, Chenango, Cortland, Greene, Hamilton [none], Lewis, Orleans, Schuyler, Seneca, Tioga, Washington and Yates).

New York State Medicaid

The Challenge (Dental Society Summary)

“The increases in the fees for services (if they are adequate) and improvements in processes and procedures are essential components of any effort to maximize the delivery of Medicaid dental services. But so, too, are the responsibilities of patients to keep appointments, carry out home-care directions and participate in their general oral health care.”

“The challenge is to overcome long-held attitudes and the reluctance of individual practitioners to participate in the Medicaid program. The challenge is to provide care to more than the current 22% of residents eligible for Medicaid dentistry who are receiving service.”

Medicare: Title 18

Part A is a basic hospital insurance plan financed by payroll taxes that pays for inpatient hospital and related care for most people aged 65 and over

Part B is a supplemental medical insurance plan available on a voluntary basis, that is financed by current premiums of enrollees and is matched by federal appropriations.

Dental services were not authorized under Part B, and only those surgical services related to the jaws and contiguous structure or to the reduction of any fracture of facial bone were authorized under Part A.

Routine dental services have never been authorized under Medicare.

Medicare: Dental Coverage

Inpatient hospital services, in connection with a dental procedure if the patient has severe impairments

Severity of the condition requires hospitalization

No coverage for treatment of teeth or structures directly supporting teeth

Medicare and the ADA

1960’s Dr. Lawrence I. Kerr testimony, don’t provide regardless of need, working people from the 1960’s retiring in the 1980’s and 90’s will have health care benefits! Stick to the private sector

1980’s “The Boat Passed” by “With Regard to Medicare, the Association notes that the elderly represent the fastest growing segment of the population. It is time to support an effective initiative to meet the total health care needs of elderly citizens.

1990’s If included, should be fee for service and traditional dentistry. “The basic association policy which generally opposed using public monies to fund health care for a population considered largely self-sufficient: the aged”.

Only 30 per cent of older Americans use dental

services; as opposed to 50% of the general population.

Medicare and the ADA

Catastrophic Health Insurance

Medicare Part C

Medicine and Medicare

A good deal for hospitals and physicians until cost containment

DRG’s, RBRVUs

Diagnosis Related Groups
(DRGs)

Represent an average charge for discharges in

specific diagnosis categories(rather than specific procedures) compared to the national average for all Medicare hospital discharges.

Medicare GME

Medicare’s share in funding teaching hospitals includes residency training support under Part A(hospital services) commonly referred to as Graduate Medical Education(GME)

Medicare GME has two components: Direct Graduate Medical Education(D-GME) and Indirect Medical Education(IME)

IME was created to compensate for factors that increase teaching hospitals costs such as treating a more severely ill patient population, offering a wider range of services and technology, providing more diagnosis and therapeutic services to certain types of patients, and allowing clinical inefficiencies as residents learn their profession(such as the ordering of more tests than the norm)

Medicare GME

As dental and medical residency programs have grown in number, interns and residents became increasingly important to the services delivered and a significant part of teaching hospitals budgets.

The basis of Medicare reimbursement for residency training was a direct or reasonable cost basis which is the forerunner of today's D-GME.

Medicare GME

1995 total funds disbursed to teaching hospitals under Medicare GME was 5.8 billion dollars(2 billion dollars under D-GME) and 3.8 billion dollars under IME

Hospitals have been reimbursed for GME costs from the inception of Medicare in 1965

Medicare has shared in the cost of approved education activities that take place in teaching hospitals

Medicare GME Reimbursement

Increasingly important option for dental graduates to pursue careers in general dentistry, the dental specialties, hospital dentistry and geriatric dentistry

31% of dentists graduating within the last five years have received a hospital based training experience

Medicare GME

Medicare D-GME payments cover costs related to the training of residents, such as residents’ stipends and fringe benefits, salaries and fringe benefits for supervising faculty and allocated overhead for direct costs (malpractice) and institutional(maintenance and utilities)items.

Medicare GME

The Balanced Budget Act of 1997(BBA) placed a cap or freeze on the number of residency positions supported by D-GME. The number of residents for a cost reporting period beginning on or after October 1, 1997 could not exceed the number of full-time equivalent residents or the hospital's most recent cost reporting period ending on or before 12/31/96

This was enacted as a Medicare cost saving measure and in reaction to the perceived oversupply of physicians

Dental advocacy by AADS and supported by the ADA and AAHD convinced Congress to exempt dental positions from this residency cap

Medicare and Managed Care

Oxford

“You may think that Oxford is too good to be true, but believe me it’s for real”

“Cherry Picking”

Often include basic dental services to entice patients to join a plan

Summary

Federal support of health services delivery has been closely tied to social welfare and economic assistance legislation.

Underlying premise has been that health services should be provided by government only when individuals and families are unable to cope with health problems on their own.

Dental care has never drawn a major share of health and welfare resources.

Summary

Dentistry has been authorized in general terms by various statutes but seldom have funds been earmarked specifically for dental services.

Before 1965 states received little federal support for dental services, except for funds provide through maternal and child health or crippled children’s programs. Although Social Security authorized other public assistance funds that could be used for dental services, these were used principally to provide health services for the elderly.

Using the Legislative Process to Promote Public Health

State Government, federal Government, local Government

Industry, insurance companies

The role of the practitioner

The role of organized dentistry

The role of specialty organizations

Legislative Influence- The AMA

Medicaid- 1989 Health Policy Agenda for the American People

The program should be restructured so it is based on national standards for eligibility rules, benefits and rates of reimbursement

Medicaid eligibility should be set at the federal poverty level

Each state should provide a federally mandated standard benefits package

Reimbursement to MD’s and other health care providers should be increased to encourage more of them to treat Medicaid patients

Steps to improve cost-effectiveness should be incorporated into Medicaid

Insurance Industry and Health Care Reform

Opposed government providing coverage

Believed that government would invade the insurance field “competing” directly with private firms for business and possibly eventually widening the general scope of the types of federal insurance provided.

Industry and Health Care Reform

Most in industry opposed fearing increases in payroll taxes

Organized Labor- AFL- CIO strongly supported

Industry Support for Health Care Reform-1990’s

Mobil Ad- New York Times Op-Ed page

Influencing public opinion and federal and state legislators

The AMA and Medicare- 1964

Opposition based upon fears of Government interference in medical practice

A nationwide AMA publicity campaign, masterminded by the California public relations firm warned the nation that national health insurance would mean “socialized medicine”

The AMA spent 1 million dollars in the first 3 months of 1965 to oppose the bill, mainly for broadcasts and advertisements, it advertisements the third highest amount ever recorded for lobby spending exceeded by only by the AMA’s spending in 1949-50. Much of the AMA spending the first quarter of 1965 was for publicity for its own, alternative medical care bill “eldercare” plan

AMA and Medicare- 1960’s

In the second quarter of 1965, shortly before the senate vote on the Medicare bill, AMA ran advertisements in about 100 major daily newspapers opposing administration backed bill

The advertisements said passage of the bill would mean lower quality medical care and urged the public to let your senators, your congressman and the president know your views on this vital issue

The Medicare Debate- 1960’s

Pro

National Farmers Union

American Nurses Association

AFL-CIO

National council of Senior Citizens

National Medical Association

Con

Chamber of Commerce of U.S.

AMA

American Farm Bureau Federation

ADA

AMA and Health Care Reform-1990’s

Congress lobbied for:

Universal coverage

Insurance reform

Standard benefits package

Include

Reduced bureaucracy, clinical autonomy, patient choice, liability reform, antitrust relief, quality assurance, and medical education

Political Action Committees

Receives voluntary contributions which are used to support candidates in congressional races of persons favorable to the action committee


	Government accepts the paradigm of health care as a right- 1960’s and 1970’s
		The War on Poverty
	The War on Poverty “ends” in 1980
		Cost containment
	The 1990’s Health Care as a Right re-examined within the context of cost


	Explosion of health legislation during the Nixon and Johnson years; broadened the federal role of aid to communities and individuals
		OEO
		Medicaid
		Health Planning Acts
		Migrant Health
		Appalachian Regional Development
		Model Cities


	Many of these programs required dental services, or at least preventive dental services, to be provided by grant-supported delivery systems.
	Federal guidelines and requirements acted to standardize services and methods across the nation, diminishing State opportunities to experiment in delivering services. As a result a network of health centers and programs grew up to encompass thousands of urban and rural communities


	Before 1935 most federal grants in aid to states were awarded for specific purposes such as VD, TB
	Health services for the needy were provided through philanthropic and occasionally state and local clinics
	Few Federal Funds
	1930 State Health Departments expended only $37,000


	Social Security Act of 1935, established federal matching grants in aid to state to provide assistance to the
		Aged
		Blind
		Families with dependent children
	First time that federal funds were channeled through the states to provide income supplements for needy persons.


	States were not required to spend dollars on dentistry
		State dental departments competed for funding with other state health interests, and their dental programs grew quite slowly.
	1955- 1.5 billion were expended for dental services in U.S.
		2.1 million by State dental programs; 42% of this came from federal grant in aid programs
	1956- more favorable formulas for medical and dental payments
		States started to look more favorably at dentistry


	1956-1966 slow growth
	Mid-1960’s federal involvement in the financing of health services expanded dramatically
	SSA of 1965; amendments to the SSA act of 1935
		Medicare Title 18
		Medicaid Title 19


	Title XIX provides dental benefits for indigent Americans
	Individual States determine benefit eligibility, generally as a function of the federal poverty index and age of the recipient
	EPSDT- Early Periodic, Screening, Diagnosis and Testing(EPSDT) program
	Dental benefits for Medicaid eligibles vary form State to State


	Title 19: 50 Different State Programs
	Medicaid spends less than 1% of its payments on dental care
	Sliding scale of payments to states or medical services to persons who qualified for public assistance programs for
		Blind, aged,disabled
		Families with dependent children
	The act authorized matching funds for persons whose incomes while sufficient for normal purposes but were inadequate to cover medical services, a category of beneficiary known as the medically needy


Fourteen services authorized
	Five were mandatory
		inpatient hospital services
		laboratory and x-ray
		skilled nursing home services for adults
		physicians services
Dental care and dentures were listed as optional along with drugs, eyeglasses, and physical therapy


	In 1967 Medicaid was amended to expand disease prevention activities for children by requiring states to screen diagnose and treat health problems of children eligible for medical assistance. This program was known as
	Early Periodic Screening, Diagnosis and Treatment(EPSDT)
		Applied to everyone under age 21 and eligible for medical assistance.
		Dental Services were mandatory.
	All States were required to have an operating program by 1972.


	The implementation of EPSDT proceeded so slowly that in 1972 Congress passed additional amendments penalizing states without functioning programs.
	In 1981 the Omnibus budget Act repealed the penalty for States without EPSDT programs.
	As of 1984 all States provide Medicaid, 30-32 provide dental care to all adults, under EPSDT all children are covered.


Inspector General’s report 1995: one in four children in the U.S. Is currently covered under the program
	Fewer than 20% of eligible children receive an dental service at all
		Multiple barriers to care
			Rejection of low payments by dentists
			Poor health behaviors by beneficiaries


	Why Doesn’t Medicaid Work?
		Conflicting and confusing policies

	New York State Thresholds- 1989

	Increased Fees- 1990; fees increased 50- 120 per cent, with emphasis on diagnosis and preventive services.


	Indecisive
	Letter from Deputy Commissioner 10/1/89
		Thresholds on visits
		Limits on selected medical equipment and supplies
		Check medical assistance program to see whether a patient has gone over the limit for care or services


5/14/90 letter from Deputy Commissioner
	To dentists, raising Medicaid reimbursement for children
		Fee increase of 50-120 percent with emphasis on diagnostic and preventive services


	Examples

	FMS 15.00 31.50
	Child Prophylaxis 7.00 14.50
	Pulpotomy 13.00 25.00
	Orthodontics 1600.00 2500.00
	Sealant, PCR 25.00

	Diagnosis and Prevention
	Oral Exam 10.00
	Radiographs 31.50
	Dental prophylaxis 15.40
	Fluoride treatment 12.00


	Treatment Visits

	Amalgam Restoration 1 Surface 19.00
	Dental Sealants, per tooth 12.00
	Extraction, single tooth 25.00
	Root Canal Therapy, one canal 140.00
	Space Maintainer, Fixed Unilateral 97.50
	Therapeutic Pulpotomy 25.00
	Occlusal Sealant, PCR 25.00


	MediCal Study
	Physicians primarily influenced by financial considerations and factors that interfere with their professional judgment
	Low reimbursement rates and denial of payment, 1st and second reasons why dentists don't participate in Medicaid.
	Broken appointments are the third reason
		Inability to treat Medicaid patients in a manner the dentists considered comprehensive


	Reasons for Not Participating in Medicaid
		Low fees
		Not enough services covered
		Denial of payment
		Broken appointment
		Slow payment
		Need for prior approval
		Complicated paperwork


	Why participate?
		altruism
		income
	Medicaid Mills
		High volume, low quality Medicaid practices
	ADA: “Health Care that works” Dentists provide over $20,000 to patients in free or reduced fee services to their private practice patients. Do you agree?


	Poor Children missing basic dental care- Medicaid Study-American Medical News 1991
	Medicaid programs fail to provide basic dental services to poor children as required by “EPSDT”
		-inadequate services
		-fail to meet fed guidelines
	Evaluated NY, Texas, Michigan, Ohio, Mississippi, and Nevada, half of the children on Medicaid
	Medicaid patients received fewer services than those provided to other patients; reason cited low Medicaid reimbursement


	State changes to the Medicaid Program
		Eligibility requirements
		The scope of services provided
		Statewide uniformity of the program
		The freedom to choose a provider
		A provider's choice to participate in a plan
		The method of reimbursing providers
		Alternative delivery systems


	Operationally feasible
	Budget neutral
	Leave the States Medicaid population at least as well off s it was before the plan was implemented
	Managed care 1115’s(the majority)


	“The federal government should assure comprehensive dental benefits for all no- and low-income individuals, regardless of age, by expanding Medicaid”
	“Medicaid should be administered in the private sector, rather than through a government agency. This private/ public sector cooperative effort would yield better administrative efficiency”


	Dental caries remains the single most common chronic disease of childhood and is most severe amongst the low income children targeted y Medicaid and S-CHIP. National data confirm that pediatric oral health in the U.S. is worsening
	BBA of 1997 that created S-CHIP the largest child health insurance program since Medicaid.
	S-CHIP provides states with a higher federal match rate than Medicaid and leaves program design to the states


	States may use these new funds for Medicaid expansions or new children health insurance programs.
	Most State financed plans and private plans, do not provide dental coverage
	Federal legislation does not mandate States to include dental coverage
	Publicly funded health insurance programs have strong potential to provide and assure necessary dental care of these children but have substantially failed to do so


	Carve out dentistry
	Contract with dental managed care organizations directly
	Dental Medicaid managed care may further reduce the dismal EPSDT dental access figures


California, New Hampshire and New York
	Charged with failing to fund Medicaid programs adequately to ensure sufficient provider participation
		Does increasing fees increase provider participation?
			California post law suit


	In February 1999, the Dental Society of the State of New York and individual dentists and patients brought an action in the United States District Court against the Governor of New York State, the Acting Commissioner of Health and the Director of the Budget.
		The complaint alleged that, “…(the) inadequate Medicaid fee schedule discourages dentists from participating in the program and frustrates the mandate of the Medicaid law (particularly for children).”

	In an out-of-court settlement in May 2000, an agreement was reached that called for “…$573 million in increased funding over the next four years for Medicaid dental fees…”