Low-income children still short on good dental care
Allyson Feinstein, pediatrics dental resident, examines 12-year-old patient Samantha Agostino of Cuddy at the Pitt dental clinic with Debra Evans, dental assistant, standing by.
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Nearly 104,000 children in Allegheny County are covered by Medicaid, yet even though they are required to enroll in a managed care organization, a new study suggests a significant percentage of them did not see a dentist in 2009.
The online report by the Pennsylvania Medicaid Policy Center at the University of Pittsburgh Graduate School of Public Health found that Medical Assistance covered about 1 million, or 35.5 percent, of all Pennsylvania children last year. Only 42.8 percent of children enrolled in managed care had an annual visit to a dentist.
"Oral health is an important component of overall physical health and well-being," the report says.
"...Tooth decay can produce illness and difficulty with daily activities such as eating, speaking and excessive missed school hours. Poor oral health among low-income children might also lead to serious medical problems and even death."
Managed care is required for recipients of Medical Assistance, Pennsylvania's name for Medicaid, in the 10-county Southwest and Central regions and the five-county Southeast region. Children in the remaining 28 counties can voluntarily enroll in managed care if a program is available; otherwise, reimbursements to dentists are fee-for-service.
The managed care organizations are required by the state to have a network of dental providers.
Therein lies a problem. According to the study, only 26 percent of practicing dentists treated at least one Medicaid patient between May 2009 and April 2010.
"There's not anything different than if they'd done [the study] five years ago or 10 years ago," said Robert J. Weyant, associate dean, the Office of Public Health and Outreach at the Pitt School of Dental Medicine. "It's an age-old problem with Medicaid. The participation rates are low -- not only the number of dentists who participate, but the number of procedures they do if they do participate."
"They can choose to accept [Medicaid] patients," said Monica R. Costlow, a senior policy analyst at the policy center and co-author of the study. "It's not a mandate or anything. It's a choice."
And the choice more often than not is against participating. The report suggests that is because reimbursement rates from Medical Assistance were only 53.2 percent of dentists' median retail fees in 2008. "Compared to other state Medicaid programs, Pennsylvania reimbursement rates are low," the study says. "On average, national Medicaid fees for dental services are 60.5 percent of retail fees."
Medical Assistance paid about $109 per enrolled child for dental services, spending a total of about $124.9 million, in 2008. That compares to a national average for all children of about $284, the report says.
Within Pennsylvania that expenditure ranged from $68 per enrolled child in Delaware County to $223 per child in Fayette County. Expenditure per enrolled child in Allegheny County was $118.
The Allegheny County figure would cover an examination, a cleaning, a topical fluoride treatment and two X-rays at the Pitt School of Dental Medicine clinic, whose clientele comprises 75-80 percent Medicaid patients, said Deborah Studen-Pavlovich, chair of the department of pediatric dentistry and a registered Medicaid provider. "That would be about $109 ... It might provide [those services] for less than at a private dental office."
The obvious solution to the shortage of participating dentists would seem to be increasing dental reimbursements, but that is unrealistic given the state's budget crunch.
"It's not as easily done as said," Dr. Weyant said.
And the situation has improved in recent years, Ms. Costlow said.
"We don't have exact [figures], but I can say the state is making great strides in improving the dental assistance portion of the [Medicaid] program. I know it has increased certain services by 76 percent. ...
"We suggest more dentists should enroll," she added, "but we don't want state budget pressures to erase what the state has done so far."
There have been other improvements, too. For example, in April the state began to reimburse enrolled physicians and certified nurse practitioners for the application of topical fluoride as a decay preventative for eligible children up to age 4. It also expanded the Access transportation system to help parents get their children to providers.
This year the General Assembly also passed legislation to create the position of expanded function dental assistants who can perform certain dental processes such as polishing or the taking of impressions for athletic mouthpieces. At present, Medical Assistance does not directly reimburse those dental assistants for services but instead reimburses supervising dentists.
Dr. Weyant and the study both noted that Minnesota passed legislation in 2009 to create the position of an oral health practitioner.
"The thinking is if you have someone without the time and expense of dental school then the costs of the service should come down," he said. "That might encourage dentists to see more Medicaid patients if they can oversee the supervision" of others.
Expanding the ages of children who can get the fluoride varnishes from doctors and nurse practitioners is another possible improvement.
"None of these things are new," Dr. Weyant. "These things have been going on around the country."
First Published June 16, 2010 12:00 am