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Dental Workforce Capacity and Californias Expanding Pediatric Medicaid Population Carrie Tsai, DMD, MPH* Elizabeth Mertz, PhD, MA Cynthia Wides, MA DPH.

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Presentation on theme: "Dental Workforce Capacity and Californias Expanding Pediatric Medicaid Population Carrie Tsai, DMD, MPH* Elizabeth Mertz, PhD, MA Cynthia Wides, MA DPH."— Presentation transcript:

1 Dental Workforce Capacity and Californias Expanding Pediatric Medicaid Population Carrie Tsai, DMD, MPH* Elizabeth Mertz, PhD, MA Cynthia Wides, MA DPH 175 Seminar, March 26 th, 2013

2 Background Californias public insurance programs have served > 6 million children in 2010 Medicaid (4.5 million); State Childrens Health Insurance Program (S-CHIP) (1.7 million) Called Healthy Families in California IncomePoorLowMiddleHigh Type of Insurance Medicaid (ESPDT) CHIP Private Insurance through State Exchanges and Possible Coverage Through Employers

3 Medicaid (Denti-Cal) Medicaid S-CHIP Former HFP & Medicaid Income Eligibility Levels

4 Healthy Families Transition Currently in the process of being eliminated shifting of almost 900,000 low-income children from S-CHIP to Medicaid Medicaid (Denti-Cal) Medicaid S-CHIP

5 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

6 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

7 Study Goal Assess the dentist workforce capacity to serve the newly expanded Medicaid population ACA mandated enrollment Healthy Families Transition The largest contributing factor

8 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

9 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

10 Findings Outline Population Providers Capacity

11 California's Low-income Pediatric Population

12 Low-Income Pediatric Population Alongside population increases, there are increases in enrollment in Medicaid and Healthy Families from

13 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 Low-income Pediatric Population

14 Expanding Pediatric Medicaid Population from 2011 to end of 2013 Considering only those currently ENROLLED … Now considering those that will be ELIGIBLE… 2.6 Million 3.5 Million Children 2.8 Million 5.2 Million Children

15 Medicaid Providers

16 Where are Medicaid-accepting dentists located? * Inclusive of pediatric dentists Q UARTILES BY M EDIAN H OUSEHOLD I NCOME 94% Medicaid dentists in urban counties, 6% in rural counties 86% in the wealthiest half of counties 49% in the wealthiest quartile of counties

17 Loss of Medicaid Providers P ERCENT C HANGE AND (N) IN M EDICAID D ENTISTS FROM Urban CountiesRural Counties -5% (-533)-19% (-156) Wealthiest Quartile of Counties Poorest Quartile of Counties -8% (-269)-15% (-69) 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

18 California Pediatric Dentists 888 Total, 41% accept Medicaid 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 Q UARTILES BY M EDIAN H OUSEHOLD I NCOME

19 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?

20 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

21 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

22 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

23 Dentists Available for the Current and Newly Eligible Pediatric Medicaid Population R URAL C OUNTIES U RBAN C OUNTIES Outlier Los Angeles: -572 (range from -328 to -937)

24 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….

25 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

26 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 1.Recruit more and maintain dental providers into the Medicaid program 1.Streamline and expedite the enrollment process 2.Increase the reimbursement rates 3.Simplify the administration process for submitting claims 2.Improve data collection and monitoring capabilities 1.Improve State data capacity 2.Make Medicaid (Denti-Cal) provider and claims info more easily accessible, timely and in more usable formats 3.Collect ESPDT dental data from federally funded clinics 4.Support programs like CHIS 3.Funding for the State Dental Director position


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