Supporting Efforts to Advance Adult Dental Coverage and Access in Medicaid

February 26th, 2015

While comprehensive dental coverage is a required benefit for children served by Medicaid, the same is not true for adults. Dental benefits are optional for adults enrolled in Medicaid, and dental coverage is often among the first programs to be trimmed in tight fiscal times—most recently, Illinois Gov. Bruce Rauner (R) made such a proposal. Forty-six states and the District of Columbia currently offer some dental benefit to Medicaid-enrolled adults, but only thirty-two cover services beyond emergency care, and even fewer, fifteen, offer a comprehensive benefit.

As many states expand Medicaid coverage for adults through the Affordable Care Act (ACA), there are new opportunities to increase much‐needed dental coverage in Medicaid and avoid the dangerous and costly consequences of untreated dental disease.

A February 17 webinar hosted by the Center for Health Care Strategies (CHCS), “Dental Coverage and Access for Adults in Medicaid: Opportunities for States,” highlighted the experiences of two Medicaid-expansion states—Colorado and Kentucky—in implementing dental benefits for Medicaid-enrolled adults. The webinar was the first in a series funded by the DentaQuest Foundation and the Robert Wood Johnson Foundation as part of a CHCS initiative to improve oral health care access and quality for low-income adults. The webinar began by outlining the national dental coverage and access landscape for Medicaid-enrolled adults, as well as strategies undertaken to expand dental benefits.

Inadequate dental coverage is a significant barrier to oral health care access for low-income adults, who often cannot afford to pay out-of-pocket and have no other consistently available options for oral health care. Low-income people are 40 percent less likely than those with higher incomes to have visited the dentist in the past twelve months, and that frequent lack of care drives an epidemic of dental disease in this low-income population. Further, 42 percent of people with incomes below 100 percent of the federal poverty level (FPL) have untreated tooth decay, compared with 12 percent of Americans with incomes above 400 percent of the FPL. Oral health care access is even more challenging for vulnerable populations—such as people with chronic illness, racial/ethnic minorities, or people with disabilities—who have more tooth decay, dental infections, and tooth loss than the general adult population.

The nondental consequences of dental disease include elevated risks for diabetes, heart disease, and stroke, as well as potential lost workdays and reduced employability. Oral health care coverage and access challenges have also led to an increase in dental-related hospital visits over the past several years. Because up to 16 million newly eligible adults are expected to gain Medicaid coverage by 2024, many state Medicaid agencies are reconsidering how they can meet the oral health needs of this population. Read the rest of this entry »

Health System Lessons from Grantmakers In Health’s Trip to Cuba

February 24th, 2015

This post is adapted from an article originally published in the February 16 issue of GIH (Grantmakers In Health’s) Bulletin.

This January, some members of Grantmakers In Health’s (GIH’s) board and senior staff visited Havana, Cuba, with MEDICC (Medical Education Cooperation with Cuba), an organization licensed by the US Department of the Treasury to conduct people-to-people trips to Cuba. MEDICC promotes cooperation among the US, Cuban, and global health communities to improve health outcomes and equity.

GrantWatch-Group-Photo-1-web (2)

Photo credit: Archie J. Brown

One objective of our trip was to see in action the Cuban approach to health. Another was to see if there were lessons for US communities. MEDICC arranged meetings for us, over the course of a week, with schoolchildren, seniors, hospital patients, community groups, and families with mentally ill members. We talked to family doctors and nurses and to specialists. We walked down Havana’s scenic, low-crime streets, where a variety of living conditions could be observed. It was an exciting time to be in Cuba, knowing that we were on the cusp of changes in relations between our country and Cuba that will have major consequences for everyday people’s lives.

The effects of the fifty-six-year embargo are immediately evident: food is rationed, medical facilities lack certain supplies, and living quarters can be quite dilapidated. Famously, many cars on the road predate the 1959 embargo. Although eye-catching, they are also major air polluters—and almost everyone in our group felt the effects.

The other side of the story is that while material resources are limited, the social vision is rich and strong. We were particularly struck by the remarkable commitment to public health values, which was consistent across the settings we visited and among the health professionals we talked to. This commitment is the product of Cuba’s decision, in the early 1980s, that its country would become the first in the developing world to cover the health needs of every citizen by focusing on prevention and primary care. One of the most-noted results of this focus is that Cuba now compares favorably with the United States on outcomes like infant mortality and life expectancy, without the wide disparities by race and income that characterize the United States. Read the rest of this entry »

What Funders Can Do to Advance Payment Reform

February 17th, 2015

The movement to transform how we pay health care providers has taken a dramatic turn in the past several years as more and more purchasers, providers, and other stakeholders seek financial incentives to deliver high-quality, cost-effective care and enhance population health. While most purchasers and health care organizations are still paying providers on a fee-for-service chassis, use of alternative payment models is growing in many markets.

In recognition of important recent changes in the landscape of payment reform (including the major announcement from the US Department of Health and Human Services in January), it is appropriate and necessary to ask where more work needs to occur to ensure that alternative payment models succeed in achieving broad application and realize their full potential. Grant-making organizations have an opportunity to act on the answers to this question. We have identified six areas of opportunity for investment.

  1. Support the development and testing of payment models that integrate and align incentives to address public health, social services, and behavioral health. Currently, the Center for Medicare and Medicaid Innovation and other stakeholders have great interest in finding ways to (a) better integrate services that address social determinants of health and to (b) align public health programs with health care delivery. With respect to alignment of population-based public health approaches with health care delivery strategies, most of the work on the topic to date has been conceptual. More work has been done on primary care and behavioral health integrated payment models, but most of that work involves supplemental care management payments, rather than significantly modifying the basis of provider payments.
  2. Explore barriers and solutions to safety-net provider participation in payment reform and provide technical assistance to test solutions. To date, few safety-net providers have used alternative payment models. In part, this is because such providers often lack the capital reserves to invest in the staffing data and systems resources required to provide population-based health care and to assume downside risk. Foundations can provide support for researchers to assist in identifying what safety-net providers need to succeed under new payment models. (See, for example, this Commonwealth Fund-supported project.) More importantly, grantmakers can provide technical assistance to safety-net providers to test and evaluate the effectiveness of potential strategies. Today, the Robert Wood Johnson Foundation (RWJF) is releasing a Call for Proposals (CFP) designed, in part, to address this issue.
  3. Support research and testing of strategies to address the inflationary effects of provider market consolidation on payment. An unintended consequence of payment reform and risk shifting from payers to providers is the market consolidation of providers. In many markets, consolidation translates to reduced competition and provider control over prices. Foundations can use their influence to elevate this issue further in the public discourse by (a) funding studies of the impact that market consolidation is having on the cost and quality of care, (b) supporting strategies (such as true price transparency) to reduce the negative effect of consolidations, (c) highlighting examples of consolidated markets where purchasers and payers are more successful at implementing payment reform efforts and taming cost growth, and (d) elevating discussion and exchange of ideas to a national audience.

For example, as to our suggestions (a) and (b), a funder could commission a study of key markets that have significant consolidation, like Pittsburgh, Boston, and many other cities, and show how the cost of care and quality of care has been affected by provider consolidation. The study could assess what efforts are happening in the market to help mitigate the impact, including regulatory and market strategies. As for suggestion (c), foundations can also fund those working in highly consolidated markets to implement solutions that have been successful in other markets. Finally, as to our suggestion (d), foundations can convene leading national voices to participate in a multipart discourse on strategies to address inflationary effects of market consolidation that are worthy of testing and then disseminate the strategies.


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