Dental Workforce Capacity and California’s Expanding Pediatric Medicaid Population

1. Dental Workforce Capacity and California’s ExpandingPediatric Medicaid Population DPH 175 Seminar, March 26th, 2013 Carrie Tsai, DMD, MPH* Elizabeth Mertz, PhD, MA Cynthia Wides, MA

2. Background • California’s public insurance programs have served > 6 million children in 2010 • Medicaid (4.5 million); • State Children’s Health Insurance Program (S-CHIP) (1.7 million) • Called “Healthy Families” in California

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

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

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 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 2006-2011

13. Low-income Pediatric Population • 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

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

15. Medicaid Providers

16. * Inclusive of pediatric dentists Where are Medicaid-accepting dentists located? • 94% Medicaid dentists in urban counties, 6% in rural counties • 86% in the wealthiest half of counties • 49% in the wealthiest quartile of counties Quartiles by Median Household Income

17. Loss of Medicaid Providers • 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. 888 Total, 41% accept Medicaid California Pediatric Dentists • 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 Quartiles by Median Household Income

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