Testimony of Laurie Norris, Public Justice Center, to House Government Reform Subcommittee

TESTIMONY OF THE PUBLIC JUSTICE CENTER TO THE SUBCOMMITTEE ON DOMESTIC POLICY COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM U.S. HOUSE OF REPRESENTATIVES ON THE STORY OF DEAMONTE DRIVER AND ENSURING ORAL HEALTH FOR CHILDREN ENROLLED IN MEDICAID

SUBMITTED BY

LAURIE J. NORRIS, ESQ.

MAY 2, 2007

I agreed to help Ms. Driver find a dentist for DaShawn. There my odyssey began. After confirming that DaShawn was enrolled in Maryland?s Medicaid HealthChoice program, and that his managed care plan was United Healthcare, I called the United Healthcare customer service number. From there I was transferred to the plan?s dental benefits administrator, a separate company called Dental Benefit Providers, or DBP. The very helpful customer service representative explained that DaShawn would first have to see a general dentist to get a referral to an oral surgeon in order to get the treatment he needed. She also explained that the Medicaid part of the United Healthcare company was called Americhoice, and that this was the company the dentists would be contracted with, not United Healthcare. She searched her database and forwarded to me a list of several dozen general dentists located near where DaShawn was staying at that time – with his grandparents. She cautioned me that while these dentists were supposed to be in the DBP network, and thus contracted with Americhoice (United Healthcare Medicaid), many of them had recently been dropping their contracts. She advised me to ask first whether the dentist contracted with ?Americhoice through the State.? Only a dentist that confirmed this would be a participating dentist in DaShawn?s Medicaid plan.

My administrative assistant started calling dentists on the list, asking if they accepted ?Americhoice though the State.? The first 26 dentists on the list said, ?No.? At this point I decided that another approach was needed. I called the Department of Health and Mental Hygiene?s (DHMH) Medicaid enrollee helpline. I explained the problem I was having and asked for help. The first person I spoke to argued with me for 5 minutes about what the problem was, insisting that she couldn?t find DaShawn in the computer and that he must be enrolled in a Medicaid managed care plan called Amerigroup, not United Healthcare. I asked to speak to a supervisor. The supervisor understood the problem right away, was able to find DaShawn in the computer, and agreed that I needed help. She transferred me to the supervising nurse in the case management unit at DHMH.

Over the next 5 days, the DHMH case management nurse, a case manager at the Prince George?s County Health Department?s ombudsman unit, and an employee at United Healthcare/Americhoice worked together to find a contracted dentist for DaShawn. Finally, he saw a general dentist on October 5, 2006.

It took the combined efforts of one mother, one lawyer, one helpline supervisor, and three health care case management professionals to make a dental appointment for a single Medicaid-insured child!

And yet, DaShawn?s path to adequate dental care was not yet over. DaShawn?s new dentist determined that DaShawn needed to have six teeth pulled by an oral surgeon. Again I contacted the DHMH case management nurse, who with the cooperation of the other case management professionals, located a contracted oral surgeon. Ms. Driver secured the earliest available appointment for DaShawn — November 16, 2006.

The oral surgeon agreed that six teeth needed to be extracted, and scheduled the first extraction for late December 2006. That appointment was subsequently cancelled by the oral surgeon (reportedly because of an emergency in his office), and rescheduled for early January. But by the time the January appointment rolled around, that oral surgeon had cancelled his contract with United Healthcare/Americhoice. So DaShawn had to find a yet another oral surgeon — his third. He finally had his first tooth pulled in February 2007. The third oral surgeon suggested pulling one tooth each month for six months.

In the meantime, two other relevant events occurred. First, 12-year-old Deamonte, who had not complained of any dental problems, began experiencing severe headaches. Over the period of a week or so in mid-January 2007, he was first diagnosed with a sinus infection, and then with a brain infection. He had two brain surgeries, had one tooth extracted, and spent six weeks in the hospital, where he seemed to be recovering well, but where he died unexpectedly on February 25, 2007.

• low-income children have about 80% of the dental disease in this country;
• more than 50% of low-income preschool aged children in Maryland have dental decay;
• and 98% of that dental decay is untreated, each child having an average of 3 untreated cavities;
• only 31%-45% of Maryland?s continuously enrolled Medicaid children ages 4-20 (representing perhaps half of Maryland?s Medicaid children in that age group) saw a dentist in 2005;2
• and only 13%-16% of those children got any restorative treatment (e.g. filling for a cavity).3

We have a particularly troubled history in Maryland concerning access to dental care in Medicaid. In 1997, our State ranked dead last in access to oral health care services for poor children. We have progressed somewhat since then, but some of that progress is due to some data ?slight of hand.? For example, Maryland uses HEDIS data in its annual report to the State legislature about dental utilization.4

The HEDIS measure was specifically designed and intended to be used to permit comparison between insurance plans or HMOs. Thus, understandably, the measure suggests that only persons enrolled continuously in a particular plan (with not more than a single break in enrollment of 45 days or less) be counted in the analysis for that plan. Even though in its reporting Maryland purports to measure the overall performance of the entire HealthChoice program, not the individual performance of each of the seven participating managed care organizations, Maryland insists on excluding from the analysis all children who failed to maintain continuous enrollment of at least 320 days in a single managed care organization. This results in the elimination from the analysis of many children, perhaps half of all enrolled children, especially children from lowerincome families, because these children tend to experience a greater rate of disruption in their Medicaid coverage. Tellingly, while Deamonte and DaShawn were both insured by Medicaid for many years, they both probably will be excluded from the analysis for 2006 because of a 63-day break in enrollment with the United Healthcare MCO.

Historically, dental access in Medicaid has been measured by looking at the percentage of children who have had at least one dental encounter during a given year. It has become abundantly clear that these measures are wholly inadequate to describe the state of oral health of our country?s low-income children. Nor are these measures serving to lead us toward the reforms needed to address the severe deficit in care that exists.

As long ago as 1998, an expert panel commissioned by CMS determined that the current measures should be replaced by new measures: Use of Dental Services by Children profiling the range of different types of services provided, as well as measures to begin to address the domains of effectiveness of care, satisfaction with the experience of care, involvement in decision making and the cost and value of care.

• Require every State to comply with OBRA89 by developing and publishing a distinct dental EPSDT periodicity schedule, with dental care beginning no later than age 1 as recommended by the American Academy of Pediatric Dentistry and the Medicaid/SCHIP Dental Association.
• Require every State to actively monitor, and report to CMS concerning, participating dentists? compliance with the State?s dental EPSDT periodicity schedule.
• Begin immediately to require States to report to CMS on dental access for, and the oral health status of, the age cohort 1 to 20.
• Require every State to provide a ?dental home? for each child enrolled in a State plan.
• Effectively enforce current oral access standards as described in the January 18, 2001 Dear State Medicaid Director Letter, SMDL #01-010.
• Effectively enforce existing Terms and Conditions in states with Medicaid managed care under an 1115(b) waiver.
• Implement performance measures, and require States to report to CMS using them, to address the domain of effectiveness of care, looking at dental outcomes for these children, consistent with the recommendations of the CMS/NCQA Pediatric Oral Health Performance Measures Project.
• Develop and implement a high visibility long-term nationwide public education campaign about the importance of oral health in children and how to achieve it, similar to the ?back to sleep? campaign which has so successfully reduced the occurrence of sudden infant death syndrome (SIDS) in the United States.
• Enforce meaningful sanctions (withholding of federal financial participation) against States that fail to meet specified performance measures for achieving oral health for children enrolled in a State plan (see What Congress Can Do, below).
• Develop a portfolio of model State dental delivery systems based on State programs that meet specified performance measures and achieve oral health for enrolled children, and coach failing States to adopt or adapt these models.