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 expanding pediatric medicaid population

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

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

Former HFP & Medicaid Income Eligibility Levels

S-CHIP

Medicaid (Denti-Cal)

Medicaid


Healthy families transition

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 transition1

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

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

Study Goal

The largest contributing factor


Methods

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


Methods1

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

Findings Outline

  • Population

  • Providers

  • Capacity


California s low income pediatric population

California's Low-income Pediatric Population


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 population1

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

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

Medicaid Providers


Where are medicaid accepting dentists located

* 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

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


California pediatric dentists

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


Dental workforce capacity and california s expanding pediatric medicaid population

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

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

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 counties1

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

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

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….


Conclusions1

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

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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