By Anne Blythe
As lawmakers ponder whether to expand Medicaid to add some 600,000 more people to the rolls, the North Carolina Oral Health Collaborative is looking at a different aspect of the federal- and state-sponsored insurance program.
Nearly a year ago, North Carolina transformed its Medicaid program from a fee-for-service-based plan to a system managed by private insurers.
The oral health portion of the program, however, was not part of the Medicaid transformation. It is still managed by the state.
Zachary Brian, director of the North Carolina Oral Health Collaborative and vice president of impact, strategy and programs at the Foundation for Health Leadership and Innovation, said recently in a telephone interview that his organization has partnered with the North Carolina Institute of Medicine and The Duke Endowment to launch the Oral Health Transformation Initiative. (Disclosure: The Duke Endowment is a NC Health News sponsor).
In July, a task force with members from diverse vantages in oral health care delivery will begin a year-long process in which members consider whether oral health care provided through Medicaid should remain a fee-for-service program or be overseen by private insurers.
“The traditional fee-for-service payment system incentivizes costly, more invasive procedures,” Brian contended while announcing the joint initiative.
“Nationally, we see a movement in remodeling our health care delivery system in many ways,” Michelle Ries, associate director of the North Carolina Institute of Medicine, added in the same video announcing the initiative. “As North Carolina has moved to managed care for primary health care and behavioral health services, we believe we owe it to the consumer and provider communities to thoroughly look at the current landscape for oral health and make recommendations based on an analysis of what other states are doing and lessons learned from the rollout of Medicaid managed care so far in North Carolina.”
Whole-body care
For too long, many public health advocates say, oral health care has been in a silo, of sorts, the mouth separated from the body. This is increasingly out of step with the systemic “whole-body” approach being advocated for more recently.
A look into someone’s mouth can reveal evidence of heart disease, cancer, autoimmune syndromes, viruses, diabetes and gastrointestinal problems.
Public health advocates say that integrating oral health care with primary care could not only make many communities and populations healthier but also reduce costs. People who do not have routine access to dental care often end up in emergency rooms with toothaches or infections in the oral cavity. Those visits can be far more costly for the patient, the provider and the insurer.
Many communities in North Carolina face challenges accessing “optimal oral health care,” according to the Oral Health Collaborative.
Four counties in North Carolina do not have a regularly practicing dentist, according to data collected from 2020 by the Cecil G. Sheps Center for Health Services Research. They’re in the northeastern tip of the state — Camden, Gates, Hyde and Tyrrell counties.
Will more dentists participate?
The collaborative says roughly 35 percent of the dentists in North Carolina participate in Medicaid or the Children’s Health Insurance Program, or CHIP as it’s often called.
Dave Richard, head of Medicaid at the state Department of Health and Human Services, said his office puts that number closer to 40 percent.
Nonetheless, that number can pose a challenge for children and adults in need of care, often in the state’s rural reaches, public health care advocates note. Only 18 percent of adult Medicaid recipients in North Carolina use the dental care option, according to the collaborative’s statistics.
Richard said that in 2021, the state’s fee-for-service Medicaid oral health program paid $24 million in claims for children in the CHIP program. The program paid $300 million for children ages 6 to 20 in the Medicaid program, and $104 million for adults 21 and older.
Richard took no stance on whether it would be better to shift the oral health program to managed care or keep it as a fee-for-service program.
Instead, he posed several questions.
“What value add would you bring if you move to managed care?” Richard asked. He also wondered whether the state would lose or gain more dentists through such a shift.
That’s what the task force plans to study over the next year with hopes of delivering a report and potential series of recommendations for a reimagined oral health care system. Their goal is to get something that policymakers and lawmakers can have to review in time to decide whether the state should make the shift before the next contracts are negotiated in 2024.
“So often we don’t have the opportunity to really slow down and take a year, 18 months and dig in and engage with other states and engage with experts and really bring people to the table,” Stacy Warren, program officer for The Duke Endowment, said when the initiative was announced.
“We can’t just fund a lot of programs,” she said, although she said that’s actually happening. “We fund school-based oral health programs. We fund medical-dental integration programs, but what we’ve learned and the North Carolina Oral Health Collaborative has certainly helped teach us this over the years, is that these programs can’t exist successfully in isolation of true systems change.”
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Dr. Brian notes that fee-for-service models of care incentivize providers to render more costly invasive care. What he did not mention is that there is evidence that capitated rates that managed care entities are paid incentivize these for profit dental benefit plans to curb utilization of dental services. It may be that managed care plan members are not receiving the services that they need to maintain optimal oral health. Please see this study in Health Economics for a more thorough discussion of the impact that managed care organizations have on dental services utilization: The effect on dental care utilization from transitioning pediatric Medicaid beneficiaries to managed care, 23 March, 2022
Most agree that the model for dental care is dysfunctional at best but we continue to return to FFS or MC both of which are payment mechanisms not care mechanisms. The FFS or MC system hasn’t worked because it does not incentives the patient. Why not use a cash back system? Have treatment, get a check. Works for credit cards (payer) and client (patient).