The Kaiser Commission on Medicaid and the Uninsured Alliance for Health Reform Briefing

1. The Death of Deamonte Driver: Out of Tragedy, A Light to Shine on the Mouths of Maryland Children The Kaiser Commission on Medicaid and the Uninsured Alliance for Health Reform Briefing Washington, DC July 25, 2008 Dr. Harry Goodman, Director Office of Oral Health Maryland Department of Health and Mental Hygiene

2. Deamonte Driver • Grew up in Prince George’s County, Maryland, the 3rd of 5 boys • From low-income family • Children had medical and dental insurance through the Maryland HealthChoice (Medicaid) program contracted thru managed care organizations (MCO) • Had long-standing tooth decay and abscess – but never complained • Always received primary medical care through a pediatrician – a medical home • But not a dental home – no primary care dentist • Mother could not find a dentist willing to accept Medicaid despite the Medicaid MCO listing 27 dentists on their provider panel for that area • All panel dentists could not see his brother • Needed the Public Justice Center along with the help of others to finally find a dentist to treat his brother

3. Deamonte Driver’s Maryland • 1990’s – Ranked last by the ADA for Medicaid dental access • No dental rate increases since the 1970’s • Many dentists stopped participating in Medicaid for various reasons • 1997 - HealthChoice – 7 MCOs with 3 dental subcontractors • 1998: • Office of Oral Health established in statute • A major state legislative bill targeting Medicaid dental access passed • 2000 - 52% Head Start children with untreated tooth decay • 2005 - 31% schoolchildren with untreated tooth decay • 2003 – Medicaid dental rates for 11 procedures increased • 2006 (most recent data): • 29% of Medicaid enrolled children had at least one dental visit • 16% of all provided dental services were for restorative (fillings) care • 19% of dentists participated in Medicaid • 7% billed $10,000 or more • Very few pediatric dentists

4. Deamonte Driver’s Maryland • By February 2007 (just prior to Deamonte’s death): • Most Medicaid fees paid at below the ADA 25th percentile and many below the 10th percentile • 12 of 24 local health departments with clinical dental services • 10 of 16 federally qualified health centers with clinical dental services - most located in Baltimore City • Dental hygienists unable to practice in public health settings without a dentist present and a dentist seeing a patient first • Physicians not routinely involved in oral health assessments • Dentist and dental hygienist workforce issues – maldistribution • More acute situation for specialists – pediatric dentists • Recruitment and retention problems – public dental programs

5. Deamonte Driver • Deamonte never complained and no one was looking • Mid-January 2007, had severe headaches • Pediatrician found tooth decay upon an oral exam • Diagnosed first as a sinus infection and then a brain infection • Underwent 2 brain surgeries, experienced seizures, had 1 tooth extracted, and spent 6 weeks in a hospital • Emergency treatment cost = $250,000 • Medicaid cost of simple extraction - <$100 • Medicaid cost of preventive services - <$60 - $80/year

6. Tragedy • Died unexpectedly on February 25, 2007 • Cause of death listed as meningoencephalitis and subdural empyema • He was failed on the front end (lack of timely diagnostic and preventive dental care) and on the back end (lack of access to dental treatment) • Laurie Norris, Esq. of the Public Justice Center called him the “canary in the coal mine”

7. The Legacy of Deamonte Driver:A Light Begins to Shine in Maryland • June 2007: • Dental Action Committee (DAC) convened by John Colmers, Secretary, Maryland Department of Health and Mental Hygiene • September 2007 • DAC Report issued • 7 main recommendations (60+ in all) • October 2007 - All recommendations supported by Secretary Colmers • January 2008 – all funding recommendations in Governor Martin O’Malley’s FY 09 budget whose support was critical • Medicaid dental rates increase ($14M/each for 3 years) • Enhancement of dental public health infrastructure ($2M/year) • April 2008 – Governor’s oral health budget initiatives and other related bills passed by the Maryland General Assembly and signed into law by the Governor • Tremendous support from our Maryland federal and state legislators

8. Dental Action Committee7 Main Recommendations • Increase dental reimbursement rates (indexed by inflation) to median fee charged by area dentists (ADA 50th percentile) – began July 1, 2008 • First of 3 annual increments – most diagnostic and all preventive rates increased • Single payer dental Medicaid program – carve out from Medicaid program • RFP issued June 2008/Target implementation date – July 2009 • Increase the dental public health infrastructure - $2M/yr. • Funding to Office of Oral Health beginning July 2008 • Expand the role of dental hygienists in public health practice • Legislation (HB 1280/SB 818) unanimously passed/Takes effect October 2008 • Pediatric dental training of physicians and general dentists • April 2008 – 150 trained at the University of Maryland Dental School • Fluoride varnish initiatives - Medicaid reimbursement to physicians in July 2009 • Oral health screenings required for school entrance • Projected demonstration project 2009 school year • Legislation in 2010 state legislative session • Develop a unified educational/social marketing program • Will need federal funding ($2-3M) • University of MD Dental School – CDC grant request: • Deamonte Driver Program of Oral Health Access - $1.1M

9. Federal Assistance to the States • Funding to increase public awareness of oral health, specifically disease prevention and management • Funding to develop specific social marketing campaigns to educate and recruit health care practitioners (dentists and physicians) regarding Medicaid dental coverage and services • Include education to treat very young children and related incentives • Support for: • SCHIP Reauthorization: • A guaranteed dental benefit for SCHIP eligible children • Informing new parents about cavity prevention • Expanding public/private partnerships by allowing community health centers to contract with private dentists to provide services • The CHAMP Act • Deamonte’s Law (H.R. 5549 – Maryland Congressman Cummings) • Elements of the Essential Oral Health Care Act (H.R. 2472 – former Maryland Congressman Wynn) • Increase the FMAP so that the federal government would pay 100% of the differential needed to move dental payment rates to between 70-80% of full commercial rates • S. 739 (Senator Bingaman – 2007) - A bill to provide disadvantaged children with access to dental services • Upcoming legislative bill – Oral Health care for All Americans Act (Senator Bingaman)

10. Final Thoughts • Reference – Dental Action Committee Report http://www.fha.state.md.us/pdf/oralhealth/DAC_Final_Report.pdf Thanks to Governor O’Malley and Secretary Colmers for their leadership and support Thanks to our effective advocacy partnership with many key supporters, such as our Maryland Congressional offices (such as Senator Cardin and Congressman Cummings and their staff), State legislative leaders (such as State Senator Mac Middleton and Delegate Peter Hammen) and many other entities representing the welfare of children and youth “We can easily forgive a child who is afraid of the dark, the real tragedy of life is when men are afraid of the light." Plato