Making Sufficient Oral Healthcare for People with I/DD a Cost-Effective Reality: Examining the Medicaid Reimbursement Rate

Deliver electronic Word and PDF versions of business and technical proposals to: asoliman@ncd.gov

  

Project Summary

NCD seeks to explore whether NCD should recommend to Congress and the President that increasing the Medicaid oral healthcare reimbursement rate for people with intellectual and developmental disabilities (I/DD) is fiscally cost effective policy vis-à-vis the money ultimately spent on preventable operations and in emergency rooms due to untreated dental problems, aside from being good preventative services policy and policy consistent with the objectives of the Americans with Disabilities Act[1] and Rehabilitation Act[2]. Further, NCD seeks to discern the extent that respective states are using unique plans as a means of providing accessible oral healthcare, that is more cost effective than increasing the Medicaid reimbursement rate, and that could potentially be adopted by the federal government.

Background and Issues 

A significant oral health disparity exists for people with I/DD. Studies have shown that adults with developmental disabilities are at risk for multiple health problems including poor oral health.[3] Further, in 2002, the U.S. Surgeon General reported that, compared with other populations, “adults, adolescents, and children with [intellectual disability (sic)] experience poorer health and more difficulty in finding, getting to, and paying for appropriate health care.”[4] This disparity has made people with I/DD more likely to have poor oral hygiene, periodontal disease and untreated dental caries than members of the general population.[5] Equally noteworthy is the comprehensible frustration and sense of injustice this disparity creates, a disparity created in part by insufficient Medicaid oral healthcare reimbursement rates for people with I/DD.

Approximately 60 percent of people in the United States with I/DD rely on Medicaid for their health insurance coverage;[6] and Medicaid’s reimbursement doesn’t always suffice as a means of encouraging dentists to provide care. While comprehensive dental coverage is mandatory for children enrolled in Medicaid, dental benefits for adults vary depending on the state. Some states provide extensive coverage with more generous expenditure caps annually, while others provide limited coverage with shorter caps, and some states only provide coverage for emergency relief alone.[7] While increasing the reimbursement rate with respect to oral healthcare for adult patients with intellectual and developmental disabilities would greatly improve access to care for persons with I/DD, cost concerns certainly cannot be ignored.

There were about two million annual emergency department visits in the United States for nontraumatic dental problems, representing 1.5% of all emergency department visits as of 2015.[8] Studies have shown that adults with developmental disabilities are at risk for multiple health problems including poor oral health,[9] and people with I/DD tend to have higher rates of emergency department visits when compared with people that do not have I/DD. As of November 2017, only 34 states covered services beyond medically necessary care in emergency circumstances, and only 17 offered an extensive benefit.[10] As one state example, in 2009 California had eliminated its Medicaid dental benefits and emergency department visits per 100,000 people increased by 32.3%, and emergency department costs due to dental emergencies increased by 68%.[11] Access to relevant state data that evaluates the cost/benefit analysis of increased Medicaid reimbursement rates of preventive services vis-à-vis the actual savings to the overall healthcare costs by keeping persons with I/DD out of emergency and operating rooms is essential. To that end, NCD is initiating a project whereby NCD is soliciting outside proposals to research and pull together this information nationally.

This project is a means to explore whether NCD should recommend to Congress and the President that increasing the reimbursement rate for people with I/DD is fiscally cost effective policy, aside from being good preventative services policy and policy consistent with the objectives of the Americans with Disabilities Act[12] and Rehabilitation Act[13]. Further, NCD seeks to discern the extent that respective states are using unique plans as a means of providing accessible oral healthcare, that is more cost effective than increasing the Medicaid reimbursement rate, and that could potentially be adopted by the federal government.

NCD has focused much of its work on achieving improved access to oral healthcare for people with intellectual and developmental disabilities, beginning in 2017, with publication of its policy brief, Neglected for Too Long: Dental Care for People with Intellectual and Developmental Disabilities. In that brief, NCD outlined areas through which access to improved oral health can be achieved. Those areas included required training for dental students to manage treatment of patients with I/DD; changing the American Dental Association’s Code of Professional Conduct to stipulate that dentists may not deny treatment to a patient based on the patient’s disability status, and referring the patient to a provider able to provide treatment when necessary; and designating people with I/DD as a Medically Underserved Population under the Public Health Service Act, which would involve increasing the Medicaid reimbursement rate for people with I/DD (another policy recommendation presented by NCD in its brief).

Many of these policy recommendations have been implemented. The American Dental Association has revised its professional code to state that a provider may not deny care to a patient based on a patient's disability, the Commission on Dental Accreditation now requires all US dental schools to train students to manage treatment of patients with I/DD, and a bill designating people as a Medically Underserved Population under the Public Health Service Act has been referred to the Subcommittee on Health of the US of Representatives Energy and Commerce Committee.[14] Determining whether increasing the Medicaid reimbursement rate for patients with I/DD on a national level would ultimately save costs spent on emergency procedures is a useful component of achieving best approaches towards realizing the policy proposal of improving access to oral health preventive care for patients with I/DD.

Statement of Work

This report will collect and analyze relevant state data and evaluate the cost/benefit analysis of increased Medicaid reimbursement rates of preventive services vis-à-vis the actual savings to the overall oral healthcare costs by keeping persons with I/DD out of emergency and operating rooms. Additionally, the report will discern the extent that respective states are using unique plans as a means of providing accessible oral healthcare, that is more cost effective than increasing the Medicaid reimbursement rate, and that could potentially be adopted by the federal government.

The Report will address the following questions:

·        Which states provide more generous dental care coverage through Medicaid, and which states provide more generous coverage to patients with I/DD in specific, including through waivers?

·        Which states have seen an increase in dental-related hospital visits, and how does that response correlate to the respective states that provide little to no dental care coverage under Medicaid, and with respect to patients with I/DD in specific?

·        Have states that provide more generous oral healthcare coverage through Medicaid seen an overall cost-savings return on their investment with respect to patients with I/DD?

·        What additional costs have states paid through decreased oral healthcare coverage through Medicaid, and with respect to patients with I/DD in specific?

·        State by state, have patients with I/DD visited Emergency departments with respect to oral health concerns at a rate higher than patients without I/DD in the US? 

·        What successes or setbacks have been experienced in the states that have increased oral healthcare coverage for people with I/DD?

·        What can be learned, and potentially adopted as useful policy, from states that have unique plans regarding oral healthcare for people with IDD, including from New Mexico, South Dakota, Missouri, the District of Columbia, etc.?

·        Should the Center for Medicare and Medicaid Services require state Medicaid funding to include dental services for adults with I/DD with ample reimbursements and would that ultimately be a cost saving function in the long run?

The report will be no more than 75 pages long (not including endnotes) and must include: 

-        A review of the literature and evidence supporting the need for and recommendations made with respect to increasing the I/DD oral healthcare Medicaid reimbursement rates;

- A description of applicable federal laws and policies, and applicable state laws if any exist;

- Recommendations to Congress, federal policymakers, relevant federal agencies, and relevant State policymakers and agencies. 

 

[1] 42 U.S.C. § 12101.

[2] 29 U.S.C. § 794.

[3] National Council on Disability. 2009. “The Current State of Health Care for People with Disabilities.” 86.

[4] Slashcheva, Lyubov, Rick Rader, MD, and Stephen B. Sulkes, MD. 2016. “Would People with Intellectual Disabilities Benefit from Being Designated ‘Underserved’?” American Medical Association Journal of Ethics 18(4): 424.

[5] National Council on Disability. 2009. “The Current State of Health Care for People with Disabilities:” 86, 87, 89. See also Morgan, et al. 2012. “The Oral Health Status of 4,732 Adults with Intellectual and Developmental Disabilities.” Journal of the American Dental Association: 839.

[6] The Arc. “Still in the Shadows with Their Future Uncertain.” http://www.thearc.org/document.doc?id=3672. (Accessed October 16, 2017.)

[7] Center for Health Care Strategies, Inc. 2017. “Medicaid Adult Dental Benefits: An Overview.” 1.

[8] Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. 2012. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed March 17, 2020.

[9] National Council on Disability. 2009. “The Current State of Health Care for People with Disabilities.” 86.

[10] S. Chazin. “Medicaid Adult Dental Benefits: An Overview.” Center for Health Care Strategies, Updated May 2017. Available at: https://www.chcs.org/resource/medicaidadult-dental-benefits-overview/.

[11] Center for Policy and Evaluation, Administration for Community Living. “Oral Health’s Relationship to Disease and Options for Expanding Services for Older Adults and Adults who Have Disabilities,” Jne Tilly, DrPh (2016).

[12] 42 U.S.C. § 12101.

[13] 29 U.S.C. § 794.

[14] H.R.2417 – The Healthcare Extension and Accessibility for Developmentally Disabled and Underserved Population Act (“HEADs UP Act”), 116th Congress (2019-2020).