Maryland Oral Health Reforms: Progress in the Face of Tragedy

Maryland Oral Health SummitOctober 20, 2011

Dr. Harry GoodmanDirector, Maryland Office of Oral Health

Importance of Oral Health

58.6

11.1 84.2

0

10

20

30

40

50

60

DentalCaries

Asthma Hayfever ChronicBronchitis

Percent of 5 to 17 year-olds with Various Disorders

U.S. Third National Health and Nutrition Examination Survey 1988-1994

Importance of Oral Health

They are “just baby teeth”, but this damage can be permanent…..

Cause permanent damage to their adult successors

Inhibit nutrition and physical development

Keep a child up at night Affect the child’s ability to

concentrate and learn in school

Importance of Oral Health Pictures Tell a Thousand StoriesBut if this doesn’t grab you…

…Will This? The Death of Deamonte Driver

12-year Maryland boy from PG County

Never complained/no one was looking

Untreated dental infection resulted in 2 brain surgeries, seizures, 1 tooth extracted, and spent 6 weeks in a hospital at a cost of $250,000 Medicaid cost of simple extraction -

<$100 and preventive services - <$60 - $80/year

Died unexpectedly-February 25, 2007

Lacked access to treatment and education and prevention services

“We can't solve problems by using the same kind of thinking we used when we created them.”

Albert Einstein

“So when a good idea comes, you know, part of my job is to move it around, just see what different people think, get people talking about it, argue with people about it, get ideas moving among that group of 100 people, get different people together to explore different aspects of it quietly, and, you know – just explore things.”

Steve Jobs

MARYLAND HISTORY: IN SEARCH OF A DENTAL HOME

Proud history: Robust Medicaid dental program until the 1970’s Early implementation of water fluoridation

99.8% of Maryland residents on public water systems receive fluoridated water (4,839,490 people) – CDC

Ranked #1 in U.S.

MARYLAND HISTORY: IN SEARCH OF A DENTAL HOME

Not so proud history: Since the 1970’s, nominal emphasis on oral health Poorly supported Office of Oral Health – continually

cut Only half of Maryland jurisdictions with public health

(safety net) dental services 1997–Medicaid managed care arrived with policy to

withdraw State funding from county dental clinics No partnerships/No oral health advocacy Late 1990’s, Maryland reported to have lowest

access to Medicaid oral health services in U.S.

MARYLAND’S EXPERIENCE: Planting the Seeds (1998 – 2007)

Oral Health Advisory Committee: Government agencies, organizations

from professional dentistry, academia, child advocacy, managed care, and public health

Advocacy efforts Mostly focused on access to care Networking

Legislation – State Senator Lawlah Surveillance

MCHB/Dental School Survey – Dr. Rossetti

HRSA SOCHS Grant Early 5-year Oral Health Plan

ADVOCACY and PARTNERSHIPS BEGIN: Legislation

Medicaid Reforms (SB 590 - 1998) Medicaid Utilization Targets Increased Medicaid Funding Oral Health Advisory Committee

Dental Loan Assistance Repayment Program (2000)

Pediatric Dental Fellowship Program (2001) Oral Cancer Prevention Program (2002) Increased HealthChoice MCO Dental Rates

(2003) Oral Health Safety Net (2007)

DENTAL ACTION COMMITTEE (DAC)Oral Health Access Reforms in the Face of Tragedy

February 2007 – Death of Deamonte Driver

June 2007 - Convened by DHMH Secretary Colmers after death of Deamonte Driver

September 2007 – DAC report 7 primary recommendations

October 2007 – All DAC recommendations supported by DHMH Secretary and Governor

April 2008 - Governor’s DAC budget initiatives and other DAC-related legislation passed and signed into law

DAC Recommendations and Progress

Focus Mainly on Access to Care

1. Statewide single Medicaid dental vendor – July 2009

Maryland Healthy Smiles Program (Medicaid dental program) – DentaQuest

Eased bureaucratic, paperwork, credentialing issues2. Over three years, increase dental rates to ADA

50th percentile - 1st year of increase started July 1, 2008

All preventive, most diagnostic, other procedures Additional increases delayed due to state budget deficit Approximately 400 new dentists have joined Maryland

Healthy Smiles Program since July 2009 More pediatric dentists now participate

DAC Recommendations and Progress

3. Begin to restore dental public health infrastructure New/expanded dental clinical and school-based/linked

public health programs – also dental van By April 1, 2011, residents in every Maryland jurisdiction

now have access to a dental public health program Deamonte Driver Dental Van Project

4. Create public health dental hygienist Legislation passed 2008 Being implemented in many public health programs

5. Institute school-based oral health screenings MDAC Kaiser Foundation grant for pilot project – Sept.

2011

DAC Recommendations and Progress

6. Train general dentists in pediatric dental care 550 trained

6a. Train pediatricians, family physicians, and nurse practitioners for oral health assessments and apply fluoride varnish

Integrate oral health into routine primary care practice for 9mo – 3 yr olds as part of EPSDT well child visits

Receive Medicaid fluoride varnish reimbursement – 7/2009 Over 400 trained/Over 30,000 medical claims to date

7. Oral Health Literacy Campaign Federal grant thanks to Maryland Congressional

Delegation

Oral Health Literacy Campaign – Spring 2012

Leading the way in oral health literacy taking its cue from the Institute of Medicine (IOM) oral health report

Educate low income families about the importance of oral health and its effects on overall health and well-being Targets pregnant women and children ages 0-6 Encourage the public to request and keep dental

appointments and be better able to navigate the oral health delivery system

Empower the public to enhance oral health behaviors such as proper oral hygiene practices and nutritional choices at home

Need to evaluate campaign effectiveness Need to develop strategies and expand to other age

groups and health care providers

Maryland Oral Disease Prevention Program

5-Year Cooperative Agreement (2008-2013): Infrastructure Data and Surveillance State Oral Health Plan Partnerships and Coalitions Prevention Activities Policy Development Evaluation Collaborations

CDC State-Based Oral Disease Prevention Program

Maryland Healthy Smile Dental Providers

Region August 2009 J une 2010

Baltimore Metro

242 344 Montgomery/ Prince George's

208 296

Southern Maryland

29 39

Western Maryland

65 97

Eastern Shore

43 53 MD Bordering States 62 110

Total Dentists

649 939 (22.8% of active

dentists) Fluoride Varnish Providers (Medical) 225 319 Total Dental and Medical Providers 874 1258

Dentists Participating in Medicaid Maryland: 2009/2010

Percentage of Children Enrolled in HealthChoice who had at Least One Dental Encounter by Age Group, Enrolled for Any

PeriodAge Group

CY 2005 CY 2006 CY 2007 CY 2008 CY 2009

0-3 7.8% 7.9% 10.0% 12.3% 18.6%

4-5 37.7% 37.2% 42.4% 47.7% 56.0%

6-9 42.5% 42.3% 47.6% 53.1% 60.7%

10-14 39.4% 39.5% 44.2% 48.8% 56.4%

15-18 32.4% 32.3% 35.8% 39.5% 46.0%

19-20 19.0% 18.4% 20.1% 23.4% 30.1%

Total 29.6% 29.3% 32.9% 36.7% 43.8%

Number of Children Receiving Dental ServicesChildren ages 4-20, Enrolled for at least 320 days

(HEDIS)Year Total Number

of EnrolleesEnrolleesReceiving One or More DentalServices

PercentReceivin

gServices

HEDISNationalMedicaidAverage

FY 1997 88,638 17,637 19.9%

CY 1999 122,756 31,742 25.9% 36.41 %CY 2000 132,399 38,056 28.7% 40.34 %CY 2001 142,988 48,066 33.6% 37.4 %CY 2002 194,351 67,029 34.5% 39.0 %CY 2003 203,826 88,110 43.2% 39.4 %CY 2004 213,234 93,154 43.7% 42.7 %CY 2005 227,572 104,188 45.8% 41.0 %CY 2006 223,936 103,561 46.2% 42.5 %CY 2007 216,885 111,791 51.5% 43.5 %CY 2008 243,076 135,403 55.7% 44.2%CY 2009 254,811 150,275 59.0% N/A

Maryland Dental Action Coalition (MDAC)

Conversion from government charged Committee (DAC) to an independent Coalition (MDAC)

Funding from: Office of Oral Health

CDC State State-Based Oral Disease Prevention Cooperative Agreement

DentaQuest Foundation Many accomplishments A true partner in every sense of the word

Thanks and Acknowledgements

Making Good MusicTogether – the Value of

Partnerships “Being in a band is always a

compromise. Provided that the balance is good, what you lose in compromise, you gain by collaboration.”

Mike Rutherford (Genesis)

Congratulations!OOH Staffer

Ms. Chris Leo, RDH

Winner of the Maryland Rural

Health Association“2011 Outstanding

Rural Health Practitioner Award”

Progress and Recognition…

PEW Dental Health “Report Card”: Maryland received an "A" grade and was

determined to be the top performer in the country for dental health

…But We’re Not “There” by Any Stretch

Challenges Maintaining our current momentum Expanding statewide prevention

programs Providing a dental home for all

Marylanders: Adults and senior citizens Special needs children and adults

Integration of oral health with overall health system services

Expanding Oral Health Literacy Campaign to other age groups\healthcare workforce

Having a truly oral health literate populace

Countering anti-fluoridation efforts

But Together – We Can Continue Our

Progress!Still Awake?

(my always inspired boys)

hgoodman@dhmh.state.md.us(410) 767-5942