Dental workforce capacity and california s expanding pediatric medicaid population
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Dental Workforce Capacity and California’s Expanding Pediatric Medicaid Population. DPH 175 Seminar, March 26 th , 2013. Carrie Tsai, DMD, MPH* Elizabeth Mertz, PhD, MA Cynthia Wides , MA. Background. California’s public insurance programs have served > 6 million children in 2010

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Dental Workforce Capacity and California’s Expanding Pediatric Medicaid Population

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Dental Workforce Capacity and California’s ExpandingPediatric Medicaid Population

DPH 175 Seminar, March 26th, 2013

Carrie Tsai, DMD, MPH*

Elizabeth Mertz, PhD, MA

Cynthia Wides, MA


Background

  • California’s public insurance programs have served

    > 6 million children in 2010

    • Medicaid (4.5 million);

    • State Children’s Health Insurance Program (S-CHIP) (1.7 million)

      • Called “Healthy Families” in California


Former HFP & Medicaid Income Eligibility Levels

S-CHIP

Medicaid (Denti-Cal)

Medicaid


Healthy Families Transition

  • Currently in the process of being eliminated  shifting of almost 900,000 low-income children from S-CHIP to Medicaid

S-CHIP

Medicaid (Denti-Cal)

Medicaid


Healthy Families Transition

  • Currently in the process of being eliminated  shifting of almost 900,000 low-income children from S-CHIP to Medicaid

All Covered by Medicaid


Patient Protection and Affordable Care Act (ACA)

  • Access to affordable, stable health insurance

  • Key provision: universal coverage of pediatric dental care

    • Requires inclusion of dental benefits as integral to the required pediatric benefit package*

    • Maintains Medicaid eligibility and enrollment standards

    • Expands minimum coverage for children of all age groups to 138% federal poverty level (FPL)

    • Maintains S-CHIP program until 2019, ensured funding through 2015

* Unclear at this point if purchasing of dental plan will be required in the state exchanges


Study Goal

The largest contributing factor


Methods

  • The following data was obtained for years 2006, 2008, 2011

    • Census data on total eligible Medicaid and S-CHIP populations based on income eligibility brackets

    • Numbers/locations of California Medicaid dental providers

    • Numbers/locations of California Pediatric dental providers

    • Pediatric dental enrollment and utilization within Medicaid and S-CHIP (Healthy Families)

  • These data were analyzed using descriptive statistics to examine trends

  • Using a ratio of 1:1000 provider to population ratio (with a sensitivity analysis from 1:800 to 1:1200), shortages in each county were computed and these trends were analyzed according to county type


Methods

DEFINITIONS

  • Throughout the study, counties are differentiated by…

    • Rural (N=35) vs urban (N=23):

      • “Rural Counties” defined as > 75% MSSAs designated rural or frontier

      • “Urban Counties” defined as > 75% MSSAs designated urban by CA Office of State Health Planning and Development (OSHPD)

    • Relative wealth of county

      • As designated by Median Household Income of county

      • Differentiated by top and bottom half, and by quartiles


Findings Outline

  • Population

  • Providers

  • Capacity


California's Low-income Pediatric Population


Low-Income Pediatric Population

Alongside population increases, there are increases in enrollment in Medicaid and Healthy Families from 2006-2011


Low-income Pediatric Population

  • AND, of those enrolled in Medicaid, numbers of procedures and rates of using dental services are increasing

  • Note that in 2009,most adult Medicaid dental benefits were cut


Expanding Pediatric Medicaid Population from 2011 to end of 2013

2.6 Million  3.5 Million Children

  • Considering only those currently ENROLLED …

  • Now considering those that will be ELIGIBLE…

2.8 Million  5.2 Million Children


Medicaid Providers


* Inclusive of pediatric dentists

Where are Medicaid-accepting dentists located?

  • 94% Medicaid dentists in urban counties, 6% in rural counties

  • 86% in the wealthiest half of counties

  • 49% in the wealthiest quartile of counties

Quartiles by Median Household Income


Loss of Medicaid Providers

  • From 2006 to 2011, there was a decline in total dentists accepting Medicaid from 12,101 to 11,392

  • There was a disproportionate loss of Medicaid dentists when counties were differentiated by rural/urban status and by wealth (median household income) from 2006 to 2011


888 Total, 41% accept Medicaid

California Pediatric Dentists

  • Urban: 833 pediatric dentists (36% accept Medicaid)

  • Rural: 52 pediatric dentists (46% accept Medicaid)

  • 95% in the wealthiest half of counties, 40% in the wealthiest quartile

Quartiles by Median Household Income


So… we have a hugely expanding pediatric Medicaid population AND a shrinking Medicaid Network.What, then, is the capacity of Medicaid dentists to serve the current and newly expanded pediatric Medicaid population?


Medicaid Dentist Shortages (Assumes no crossover from former HFP-only providers to Medicaid)

  • Currently, shortages that exist now are disproportionately seen in the rural counties

  • The shortages become more severe in all counties after ACA policy change and the HFP transition AND the shortage is worse in rural counties

    • Would need a 20% increase in dentists in urban counties

    • Would need a 50% increase in dentists in rural counties


Some Notable Counties

  • When calculating dentists available for the current Medicaid-eligible population using the 1:1000 provider to patient ratio, there were only a few counties with an actual surplus of dentists

  • These counties are all considered urban counties

  • 3 out of 5 are in the wealthiest quartile

  • Orange County

  • Los Angeles County

  • San Bernardino County

  • Santa Clara County

  • Ventura County


Some Notable Counties

  • When calculating dentists available for the newly Medicaid-eligible population using the 1:1000 provider to patient ratio, the following counties will have the largest shortages:

  • * Two of these counties have managed care Medicaid

  • Sacramento*

  • Los Angeles*

  • San Diego

  • Riverside


Dentists Available for the Current and Newly Eligible Pediatric Medicaid Population

Urban Counties

Rural Counties

Outlier Los Angeles: -572 (range from -328 to -937)


Conclusions

  • The pediatric Medicaid population and enrollment into Medicaid increasing in size

    • Possibly due to general population increase, policy changes

  • In addition, those children that are enrolled are utilizing dental services at increasing rates

  • Two very important policy changes happening NOW

    • ACA mandated enrollment of low-income children in dental programs

    • Transition of ~880,000 children from Healthy Families (S-CHIP) to Medicaid….


Conclusions

  • A misdistribution of dentists already exists (even more exaggerated with specialists)

    • 94% of all Medicaid dentists and 94% pediatric dentists in urban areas

    • 90% of all Medicaid dentists and 95% pediatric dentists in the wealthiest half of counties

  • The Medicaid network has been shrinking… rural and poor areas are experiencing a disproportionately higher loss of Medicaid dentists

    • Dentists are either physically leaving or choosing to not accept Medicaid anymore; new dentists are choosing not to accept Medicaid

  • There will be large shortages of Medicaid providers with the expanded population in all counties that continue to disproportionately affect rural and poor counties in California


Recommendations

  • In order to keep up with the expanding pediatric Medicaid population…

    • more providers need to accept Medicaid OR

    • existing Medicaid providers must accept and treat more Medicaid patients

  • Recruit more and maintain dental providers into the Medicaid program

    • Streamline and expedite the enrollment process

    • Increase the reimbursement rates

    • Simplify the administration process for submitting claims

  • Improve data collection and monitoring capabilities

    • Improve State data capacity

    • Make Medicaid (Denti-Cal) provider and claims info more easily accessible, timely and in more usable formats

    • Collect ESPDT dental data from federally funded clinics

    • Support programs like CHIS

  • Funding for the State Dental Director position


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