State dealing with Medicaid dental woes
February 24, 2013
When she was 3, Torrie Smith tripped on an uneven sidewalk, fell face down onto some steps and broke four front teeth. An emergency room doctor stopped the bleeding and gave her something for the pain, but Torrie didn't get to a dentist for six months — her first time ever to a dentist — because her parents didn't have dental insurance and didn't have cash to pay for an examination.
Now 4, Torrie's dental problems are so severe she has to go to an operating room, not a dentist's chair, to have them fixed. While she is under anesthesia, an abscessed incisor will be pulled and nine other cavity-ravaged teeth will be pulled or treated.
Torrie's toothaches, along with the risk and high cost associated with curing them, probably could have been avoided. She is like many children in low-income families in Colorado who rarely, if ever, see a dentist even though they can go for free.
State Medicaid data reported to the federal government show that less than half of the 453,000 Coloradans younger than 21 who were eligible for benefits in federal fiscal year 2011 received some kind of dental service. Only a quarter of Colorado counties met a 2010 state goal of getting at least 44 percent of Medicaid-eligible residents younger than 19 to visit a dentist, according to an I-News analysis of state records.
"Dental disease is not self resolving," says Diane Brunson, director of public health for the University of Colorado's School of Dental Medicine. "It's not like catching a cold and you put up with it for a week or 10 days and you're fine. You have to get treatment. And it's so much more beneficial all the way around — to the child, to their family, to taxpayers — if dental problems can be prevented."
While the state appears to be making strides in improving its numbers, part of the problem is the paucity of dentists willing to see Medicaid children. Only 10 percent of Colorado's 3,500 or so dentists are considered "significant" Medicaid providers, meaning that they are reimbursed for at least 100 visits per year. Moreover, 20 of Colorado's 64 counties do not have a dentist who accepts Medicaid.
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In total, 21 percent of the dentists report having some Medicaid patients, and only 16 percent say they are willing to accept new Medicaid patients.
Income, dental health linked
Plenty of Colorado children covered by commercial dental insurance also fail to see a dentist regularly, about four in 10, according to a 2010 study by the Colorado Health Institute. But kids in low-income families are most at risk for tooth decay, which is the most common childhood disease.
A state health department survey released in October showed that 73 percent of third-graders in Colorado's poorest public schools (measured by eligibility for free- or reduced-price lunches) have had a cavity compared with 41 percent of third-graders in more affluent schools. Untreated cavities affected 19 percent of kindergartners in the poorest schools but only 7 percent in high-income schools.
Cavities are more common in some of Colorado's poorest counties, affecting more than two-thirds of all third-graders in Huerfano, Conejos, Costilla and other counties in the southern part of the state. More than a third of third-graders in some of those counties had untreated tooth decay during the 2006-2007 school year, the most recent county-level estimates publicly available. (The most recent county estimates on the use of dental services by Medicaid children are from fiscal year 2009-10. The state Department of Health Care Policy and Financing declined to make more up-to-date numbers available. )
Proper care of primary, or baby, teeth is just as important as adult dental care, dentists say. Baby teeth reserve space for the permanent teeth that eventually will replace them. They help in the development of speech and help give a child's face a normal appearance.
Decaying baby teeth can make it difficult for children to chew food and can damage the permanent teeth growing beneath them. Kids in Colorado miss nearly 8 million hours of school each year because of toothaches and infections, and many kids in pain end up using expensive emergency room services or undergoing multiple dental procedures while under anesthesia.
"People tend to believe that because they're just baby teeth and they're going to fall out, we don't need to worry about them," said Karen Cody Carlson, executive director of Oral Health Colorado, an umbrella group of oral health advocates. "They don't realize that kids can get severe infections, life-threatening infections, sometimes."
Dental care key for children
An untreated cavity can lead to an abscessed tooth, like Torrie Smith's, in which the root becomes infected. If an abscess goes untreated, bacteria can spread to bone tissue and other parts of the body.
Torrie is set to be put under anesthesia this month. In addition to the abscessed incisor, three other incisors and six molars have "severe" cavities, says Dr. Andre Gillespie, who examined Torrie in late November and referred her to a pediatric dentist with operating room privileges. The teeth that aren't pulled, he says, will need crowns and may need pulpotomies, or "baby root canals."
"She's got quite a bit going on,'' Gillespie says. "This could have been prevented" with proper dental hygiene, good nutrition and regular checkups.
Apples are Torrie's favorite food, but she also likes gummy fruit snacks, Sweet Tarts, chocolate and soda. In the living room of their home in Montbello, a northeast Denver neighborhood, Anthony and Wendie Smith say they thought they had been doing enough by brushing their daughter's teeth twice a day ever since her first incisors erupted. They never took Torrie to the dentist because they didn't have dental insurance at the time (Anthony recently became eligible through his job) and couldn't afford the cost. Anthony, 27, is a mechanic and Wendie, 26, is a stay-at-home mom.
It didn't occur to the Smiths, they say, that Medicaid would cover Torrie's dental care. Wendie had qualified while pregnant and Torrie was enrolled in Medicaid as an infant. "When she came along," Wendie says of Torrie, "they gave me a (Medicaid) card and said it was for her doctor visits. They didn't say dental or anything like that."
After Torrie fell on the sidewalk, the emergency room doctor told them she needed to see a dentist. Wendie says she called several around Castle Rock, where they were living then, but all wanted money up front that they couldn't pay. Meanwhile, Torrie's front teeth were turning black and Wendie had to cut her food into small pieces.
A friend eventually mentioned that Medicaid might help. The first dentist to see Torrie reshaped her two front teeth with porcelain, but her parents didn't take her back for further treatment because she "didn't feel comfortable there," her mother says.
The Smiths found Gillespie around Halloween when a flyer sent home from Torrie's preschool mentioned that his Li'l Teeth Dentistry practice in Aurora accepts Medicaid patients. Gillespie says he treats children on Medicaid, who make up about 60 percent of his practice, because he was on Medicaid as a child.
"For me, it's very personal to make sure these kids get all the treatment they need," he says. "Everyone deserves to be treated."
Increasing Medicaid access
Some dentists volunteer their services at free dental care events, such as the TeamSmile clinic that served 300 low-income kids at the Pepsi Center in November. But many avoid Medicaid because of lower reimbursement rates and extensive paperwork to get qualified.
Another explanation surfaced during a focus group of dentists held last year: "The concern was being able to provide care to very young children," says Karen Savoie, director of nonprofit Cavity Free at Three. "They don't like to say they're not trained or won't do it, but that was the barrier we identified. It wasn't so much the compensation, which surprised us."
Started by several Colorado foundations in 2006, Cavity Free at Three aims to ensure that all children have a "dental home," a dentist they see regularly like their pediatrician, by age 1. To that end, the organization has initiatives to educate parents, get more dentists to accept Medicaid and teach all health care providers who see children to screen them for dental problems. A network of dentists and hygienists around the state works to get general dentists, especially those in underserved rural areas, more comfortable treating babies and toddlers.
The CU dentistry school has begun focusing on this issue as well, Brunson says, by encouraging dental students to treat "all populations" after they graduate, teaching them a business model that includes Medicaid patients and exposing them to young patients "to increase their knowledge and comfort level."
Medicaid guidelines changed in 2009 so that licensed medical providers across disciplines can be reimbursed for doing dental screenings. Cavity Free at Three so far has trained 1,900 providers "to value oral health and help us get that message out to families," Savoie says. "Pediatricians in a well-child visit at three months or six months are now asking parents about a child's teeth."
Oral Health Colorado, meanwhile, is working to increase the number of dental hygienists who go into schools to screen students and apply fluoride varnish and sealants, if needed. These "direct-access" hygienists also can be reimbursed by Medicaid.
At the same time, the state has stepped up efforts to get parents of children on Medicaid to take their kids to the dentist. In 2010, the Health Care Policy and Financing department started sending letters to parents whose children hadn't seen a dentist in a year, reminding them of their dental benefits and the importance of dental care. The agency has conducted 30 parent training sessions on oral health, and a robo-call reminder system is in the works.
With several nonprofits and the state now working together on the dental-care needs of children, progress has been made recently:
■ About 48 percent of Colorado Medicaid clients under age 21 received a dental service in federal fiscal year 2011, up from 34.5 percent five years earlier and more than five percentage points above the national utilization rate. Use of dental services in Colorado is a bit higher when children are continuously enrolled in Medicaid — 52 percent for those eligible for benefits for at least 90 days in a row.
■ Although the prevalence of cavities among third-graders statewide hasn't changed much, dropping to 55 percent in the 2011-2012 school year from 57 percent in 2003-2004, the proportion of third-graders with untreated decay fell from 26 percent to 14 percent.
■ Among kindergartners statewide the prevalence of dental disease dropped to 40 percent in 2011-2012 from 46 percent in 2003-2004, and the proportion of untreated decay fell to 14 percent from 27 percent.
"We're moving in the right direction," Savoie says. "Reducing the decay rates of children in kindergarten is huge."
Striving for improvement
But the numbers can be much better, advocates acknowledge.
The umbrella group Oral Health Colorado has set several goals for 2017 that focus on Medicaid utilization: At least 65 percent of children on Medicaid would get an annual checkup; the Medicaid provider network would grow 20 percent; the proportion of 1-year-olds seeing a dentist for preventive care would grow from 3.4 percent to 6 percent; and 50 percent of Medicaid-eligible pregnant women would receive oral health care.
Getting more parents and expectant parents to have their own teeth checked is considered crucial to meeting these goals, with studies showing that parents who visit a dentist regularly are more likely to take their kids to a dentist. Also, bacteria that cause dental disease often is passed from adults to children.
However, motivating more parents to see a dentist also is problematic. Colorado is one of only a few states that does not cover dental services for adults on Medicaid, except for emergency services.
Forty percent of Coloradans, 2.1 million residents, lacked any dental insurance in 2011, according to a new study by The Colorado Trust. Those without dental insurance, the study found, were twice as likely to forgo needed dental care due to cost concerns than those with coverage.
The state Legislature last year killed a bill that would have provided limited dental benefits to pregnant women on Medicaid. The measure is expected to be revived this year.
Gov. John Hickenlooper's proposed budget for fiscal year 2013-14 allocates $33 million for dental care for adults on Medicaid. The money would come from a fund used for CoverCover, a high-risk health insurance pool that will be phased out when the federal Affordable Care Act is fully implemented.
The Affordable Care Act is not expected to increase the number of children in Colorado covered by Medicaid because the state's program already covers children up to 133 percent of the federal poverty limit.
Boosting the use of services may cost more in the short term, says Cody Carlson, of Oral Health Colorado, but should save tax dollars over time. "The amount you put into prevention and early treatment will more than make up for potential costs down the road if children are not treated," she says.
Anthony and Wendie Smith know this firsthand, and not just because of Torrie's dental problems. Anthony rarely went to the dentist and as a teenager had an abscess "so bad it looked like somebody had shoved a softball inside my face." Still in his 20s, he faces the loss of most of his teeth and hopes to get implants.
From now on, the Smiths promise, they will take Torrie and her 1-year-old sister, Skylee, to Gillespie for checkups. Torrie's toothaches are a lesson learned "smack in the face," Anthony says.
"I didn't want her to wind up like me or her grandpa or my mom. She had worse teeth than I did."