had in consideration a bill that i was the author of and so i had to be that or present it and so it's good to be here with you as we start this hearing this hearing is going to be the fourth in the series on access to pediatric dental services in medicaid the subcommittee has focused on this issue since the death of the monte driver in february two thousand and seven and that's your monte driver's picture and his death highlighted the inadequacy of dental services for medicaid enroll children in maryland without objection the chair and ranking minority member will have five minutes to make opening statements followed by opening statements not to exceed three minutes by any other member who seeks recognition and without objection members and witnesses may have five legislative days to submit a written statement or extraneous materials for the record on february twenty fifth two thousand and seven human to driver a twelve year old boy from prince george's county maryland died from a brain infection caused by untreated tooth decay de'monte tragic death could have been easily prevented by access to dental care dental care he was entitled to and should have received through united healthcare maryland's medicaid dental provider unfortunately that company failed to meet its obligation to provide beneficiaries with access to dental providers so onerous were the administrative barriers united health care had created quote it took one mother one lawyer one on line health supervisor and three management professionals to make a dental appointment for one medicaid child adequacy adequacy of efforts on a state level to ensure access to pediatric dental services under medicaid as well as the actions for that the center for medicaid and state operations c m s to conduct oversight of state systems at our first hearing in may two thousand and seven we learned that the monte driver was not the only maryland youth who wasn't receiving dental care to which he was entitled by medicaid in fact our investigation of united health care found that approximately eleven thousand maryland children in united healthcare medicaid operation had not seen a dentist in at least four years we found that united healthcare provided information to medicaid beneficiaries that was so inaccurate and outdated it would have been virtually virtually impossible to find a dental care provider we also learned that c m s did virtually nothing to address the problems in poorly performing state systems dennis smith director of c m s at the time argued that financial sanctions are the only tool c m s has to enforce compliance and he was unwilling to hand down financial sanctions because he said the cost was ultimately borne by the patients simply put this is not the case and in a letter to mr smith the subcommittee outline nine actions that c m s could take that would serve to enforce the statutory responsibilities that states have to ensure that medicaid eligible children have access to dental services  second hearing focused on c m s is response to this letter and actions taken by them in the years since to monte driver's death to address the deficiencies in its oversight responsibilities well they did take some action their efforts unfortunately fell short of affecting any real change in fact their ng revealed that most of the progress of the state of maryland was made despite c m s that the agency was not actively involved in the state's efforts and provided almost no guidance additionally c m s continued to neglect the issue of provider reimbursement rates despite hearing testimony about the importance of them to affecting system wide reform astoundingly mr smith even acknowledged as such during our first airing but stubbornly stubbornly continued to avoid the issue mr smith resigned from his post not long after our second hearing after that things began to change a g a o report the report the first of its kind since two thousand revealed that millions of medicaid and roll children suffer from tooth decay almost one third of the total medicaid population medicaid children are roughly twice as likely as privately insured children to suffer from two more over this pattern has persisted for years very little been done to improve access to and utilization of dental services in a sense the promise to take a is getting worse because the rate of decay in the teeth of children age two through five has increased in recent years now our third hearing on the issue demonstrated that improvement is possible under new leadership and continued congressional scrutiny c m s began to turn a corner the interim director of the center of center for medicaid and state operations outlined a number of actions that they had taken to engage states actively in reform as well as to improve their own oversight functions they conducted seventeen reviews of state systems with you is a sion rates below thirty percent and provided each state with its own report and recommendations worked w develop oral health schedules have met federal guidelines and formed an oral health technical advisory group with state medicaid directors we also so learned that the state of maryland where this whole journey began continued making considerable progress the dental action committee that they formed developed seven recommendations to improve access to dental care for maryland's children two ended up in the budget submitted by martin o'malley the governor of maryland and another was passed by the state legislature today  some ice or dental oversight or hard work commission at the request of myself and mr cummings on the adequacy of pediatric dental oversight at the state and federal level and i'm thankful to g a o for their hard work and dedication studying this problem while so here for the first time from the new director of center and medicaid state operations i'm looking forward to their report on the progress they've made and how they plan to use that momentum to address the gaps that remain as identified in the g a o report additionally we're going to hear from state medicaid officials  researchers who have studied and implemented successful initiatives to increase access to and utilization of dental services as well as to improve improve provider participation i believe and hope that c m s has turned a corner in our oversight of pediatric dental services since the death of the mounted driver but the magnitude of the underlying problem is great and even today there are millions of children just like them and to entitled to dental care for not receiving it the urgent job of everyone here today is to move quickly to prevent another one of them from dying from preventable happen i remember growing up in the inner city and i was the oldest of seven my parents never owned a home within twenty one different places by the time i was seventeen including a couple cars and one of the things we didn't have was  dental and i can remember chewing on gumballs and eminem just break off and my teeth breaking off into gumballs and i can remember having dental problems and didn't get treated for a long long time and i'm not i don't want to get too graphic about it but for those who have experienced being a child without access to dental care you know what a nightmare it can be and so  he's really asking us what we're going to do about this how are we going to take the stand to make sure that the children of america get the dental services that they're entitled to that's really the challenge we have and i will not rest to be a driver of a new day in delivering dental services to the children of this country and particularly those who are served by medicaid so i want to thank you for your indulgence mr jordan for continuing to highlight the important issue of access to dental care for our children and afford to hearing from our witnesses about what has been done to enhance pediatric dental services and improve access since these issues were first looked at by the subcommittee following the tragic death of  monte driver in two thousand and seven barriers to care including low reimbursement rates for dentist lack of understanding of the importance of our oral health and excessive administrative burdens for patients and providers all contribute to the problem according the report released today state medicaid programs have taken steps toward improving access the gaps remain that must be addressed like why c m s has worked to improve its oversight of pediatric dental issues in medicaid more progress certainly necessary in two thousand and eight that one in three children on medicaid had untreated hope our witnesses today will tell us what is being done to fill these gaps and treat these children unfortunate the issue of access to care is not unique to pediatric dentistry for medicaid enrollees but a problem across the healthcare spectrum the problems of access to care problem in our existing government run programs including medicaid medicare as chip low reimbursement rates set at the state level for medicaid and the national level medicare lead to a low participation of providers in these programs in this respect the terrible story of mr recognizes mr cummings from maryland who has been working on this issue from the time that it was first known and i want to thank him for his dedication thank you very much mr chairman i really do thank you for your interest in this issue and i thank you as i listen to you just a moment ago i minded that what you have done is that you've taken some of your experiences in life as a child and turned them around and used them as a passport to help others and that says a lot so often people want to bury what happened in their past however you take it and you raise it up to remind us that this could happen to anybody and so i do and but not only do you do that you then lay out a mission to correct it and so i i really do appreciate you doing this  you know de'monte died on february twenty fifth two thousand and seven and i know the chairman's already talked about it but i think about it every day just about when i think about an untreated to you recall we first held a hearing on this topic at my request back on may second two thousand and seven in an effort to identify the critical breakdowns in our medicaid system and provision of dental care to children as our dental health professionals here today know oral health is an often overlooked but vital component of health care preventive dental care especially for children is a fundamental need for their healthy development into adulthood in fact two three k is the most common challenges ease it is five times as common as asthma and seven times as common as a fever this has the most detrimental impact on low income communities eighty percent of cavities and care in only twenty five percent of children but dimly low income children and low income children suffer twice as much from to decay as do more affluent children millions of school hours are lost each year to dental related illness poor children suffer nearly twelve times more restricted activity days than children from more fluent families d to dental related illness a previous hearings on this matter revealed woeful failures of the centers for medicare caid and medicare services and its state partners to  comply with section one hundred five our three of the social security act which ensures that every child every medicaid eligible child will have access to medically necessary dental care under the early periodic significant gains to improve children's access to dental care in just two years mr chairman forty one thousand more children in maryland receive a medicaid funded dental service than those who receive such a service in two thousand and seven  two thousand and nine alone mellon is making an overall eighty one point five million dollar investment in medicaid dental services statewide gov martin o'malley to his credit also convened a dental action committee which is valid seven recommendations to better serve our children including raising reimbursement rates for dental services and initiating a single statewide vendor for dental services spending two million dollars per year to enhance a dental health infrastructure providing dental screenings with children creating a new dental hygiene and position improving education for double students and crafting a public education campaign on oral health the governor included the first three items in his two thousand budget and he is in currently working with a dental action committee to implement the other similar the united health group has stepped up to the plate to do its part invested one hundred seventy thousand dollars for a program at the university of maryland dental school to improve children's access to dental care in baltimore city including more than thirty thousand dollars to hire a pediatric dentistry case manager one sixty thousand dollars to hire pietro gentry fellow thirty thousand dollars a staff which many people we're going to be clinic in fifteen thousand dollars to provide continuing education  family practice residents as i close the company is now working to develop a similar partnership with howard university that will reach across the maryland border to the mits home county prince george's all of these act however they are being implemented solely on the state level in order for us to see my mental gains changes must be made nationwide we have been anticipating a review of c m s's efforts since our last hearing to to learn what has been accomplished at the federal level we were sorely disappointed regarding the lack of demonstrably all effort between our first and second hearings so g l's report has been eagerly awaited i'm programs that are already working on a state level mr chairman a child die because of our failure as adults of our failure as adults to discharge this mandate grow up it is their a term to be healthy children it is their to care and to deliver and develop the gifts that they have been given to deliver to us but if they are not healthy and if their teeth are writing and if we are not doing cummings for your commitment your statement your heart your passion and your willingness to take a stand we're now going to go to the witnesses or no additional opening statements subcommittee will receive testimony from the witnesses before us today i'd like to start by introducing our first panel ms katherine ireton is that right ms katherine ireton is acting director for health care issues at the u s government accountability office in her twenty seven year career which she has helped plan and execute a wide variety of program and evaluation assignments in recent years she has seen multi overseen multiple valued of studies on medicare financing and access issues including children's access to preventive and dental services ms ireton he currently works in j i s seattle field office and has a business administration degree from the university of washington next ms cynthia man this man was appointed director of the center for medicaid and state operations c m s june two thousand and nine where she is responsible for the development and implementation of national policies governing medicaid the state children's health insurance program survey and certification medicaid integrity program and the clinical laboratories improvement amendments c m s though the center for medicaid and state operations also serves as the focal point for all c m s interactions w states and local governments prior to her return to c m s in two thousand and nine ms mann served as a research professor at georgetown university health policy institute and executive director of the center for children and two thousand and one where she played a key role in implementing medicaid and the s chip program before joining the government in one thousand nine hundred ninety mismanage led the center on budget and policy priorities federal and state health policy where she also has extensive state level experience having worked on health care welfare and public finance issues in massachusetts rhode island and new york thank you both for appearing before the subcommittee today it's the policy of the committee on oversight and government reform to swear in all witnesses before they testify i would ask that you please rise and raise your right hand i would ask that each of the witnesses now give a brief summary of your testimony i ask that you keep this summary under five minutes in duration your complete written statements are going to be in the record and will that's and members of the subcommittee i'm pleased to be here to discuss children's access to medicaid dental services i was standing as you noted in your opening remarks an estimated one of every three children and medicaid has entreated tooth decay one and nine have it and three or more teeth this is about twice the rate experienced by privately insured children and translates to millions of medicaid children in need of dental care in too many cases this need is urgent my statement is based on g a o this report that you are releasing today this report summarizes at a national level efforts of states and  m s to improve medicaid dental services for children in summary we found that state medicaid programs and c m s have taken a number of actions to monitor and improve children's access to dental services but problems with access persist and gaps and c m s oversight remain first let me share highlights of state's actions from our web based survey of state medicaid programs all states  children's access to dental services and nearly all states have implemented one or more initiatives to improve access through actions to reach out to families such as establishing hotlines to help them find a dentist and initiatives such as raising reimbursement rates to encourage more debt to to serve medicaid children nonetheless states reported multiple barriers to improving access these barriers are well known and longstanding for example for families finding a dentist to treat their children for providers concerns remain about families missing their payments low reimbursement rates and administrative burdens these barriers persist despite state actions to address them as significant most states indicated their initiatives to improve access have not met their expectations and two thirds of the twenty one states that reported contracting with managed care organizations to provide dental services said those organizations were not meeting the state's access standards the bottom line children's access to medicaid dental services has been improving but remains low states report that only about thirty five percent of medicaid children nationally receive any dental service in two thousand and seven as compared to eighty eight just as goal as sixty six percent of low income children receiving a preventive dental service by two thousand and ten now let's turn to actions of c m s c m s of them proved its oversight of state programs in several ways but m can be done two observations first c m s is focused dental reviews of seventeen states with low dental access rates identified significant problems including concerns in eight states that managed care organizations had inadequate numbers of dentists in their network c m s did not though require corrective action plans of states or have plans to review other states have dental access rate second c m s has improved its guidance to and communications with state for example c m s posted descriptions of four states promising practices for improving access on its website but nearly every state forty nine and all reported us that they need more from c m asked states reported for example that they need specific guidance in areas such as the stablish inappropriate dental payment rates and improving billing policies notably when we asked states ho could help them most states answer that c m s to provide more information on what was working in other states twenty six states reported to us that they believe their state had one or more best practices for delivering d services that could be shared with others in conclusion c m s and states have taken note worthy a step to improve children's access to medicaid dental services concerted and continued efforts and in these challenging fiscal times innovative solutions will be needed to address the multiple and longstanding barriers to improving children's oral health for its part c m s can help the ongoing oversight and assessment guidance and support of states efforts building upon the steps the agency has recently undertaken we've made several recommendations to c m s towards this and have ongoing work to the congress for their examining these issues good afternoon chairman and its ranking member jordan and members of the subcommittee i too appreciate the opportunity to be with you today to talk about how children are fearing receiving needed dental services under the medicaid program and i want to begin by commending you mr chairman for your sustained interest in this area i have been the director for the centers for medicaid and state operation for a little less than four months and i've not been a witness to the prior hearings however in my position at georgetown university i closely followed the proceedings and now that i'm director of c m s and have taken stock of what we've done in the past period of time it is clear to me that the activity that has happened was triggered in large part by the activity of this committee and by your interest in this area and that you have been able to plant the seeds for a renewed commitment on this very important matter while i'm new to c m s i'm not new to this issue has you noted in your introduction of me i worked on children's access use for many years and i would note that in my eighteen months at c m s in one thousand nine hundred nine in two thousand and one i helped author the letter that was issued in january two thousand and one which you referred to in your first hearing which called for every state to conduct a dental access review since that time many states have made progress narrowing dental access gap for children but as the g a o correctly points out significant gaps remain we know from the research that there is an extra couple link between oral health and overall health and that every child needs dental care preventive care and treatment when appropriate sadly our country's record in assuring our kids have the dental care they need both in private coverage as well as in public coverage is not good and the record is particularly poor for low income children i can assure you mr chairman and members of the committee that's secretary sebelius and i share a firm belief that we have a responsibility to do much more to ensure that every child and rolled in medicaid receives the dental care they need the data show that about thirty six percent of all medicaid eligible children use to dental services over a year period of time with that data there can be little doubt that improvements are necessary states administer the program they enroll the providers they set the provider rates but c m s plays a critical role and we are intent on using all of the tools available to us to sure that every child covered by medicaid is as healthy as he or she can be my written testimony listen number of actions that c m s has taken over the past period of time since the last hearing i'm just going to repeat review it a few of those activities in policymaking activity we are now actively involved in providing guidance in the area of children's health insurance coverage and the new chip are provisions that expanded dental benefits for children in a number of different ways in fact today we released our guidance to states on the new chip dental benefit and the supplemental insurance option that's now available to states to provide dental coverage to children who have other sources of here  chip are also included several other provisions that we're working on one was a provision that required the secretary to publish the names of the dentists serving children in the medicaid program in every state around the country medicaid and the chip program we launched that website on august fourth and have those dental providers listed at this point that website i will say is a is a work in progress we think there's a number of improvements that we want to continue to make we have had a number of a lot of activity on that website about forty three thousand hits to the page but there are improvements that can be done and we think we can ultimately use that website not only to share information to families like the monte drivers family about where to get dental care but also for us to use  e monitoring tool to be able to see what the numbers of dentists are in each medicaid program how many are taking new patients and what that access looks like over time we also are intent on changing our data reporting system  we want to change the so called c m s for sixteen which is our b s t reporting form to include information about other providers that are providing oral health care as well as to improve it to make other improvements to the four sixteen and we're planning to do that by the spring of this year there are a number of requirements to changes in the four sixteen that were part of chip so we want to consolidate those changes and put those out in the spring we're also partnering right now with the agency for health health quality and research to come up with dental dental health quality standards as part of the overall initiative to come up with children's health standards we believe that those health standards those dental quality standards themselves which will be reported by states hopefully it's a voluntary reporting by states will again give us another window to assure that children are getting the care that they need and get states to pay continued attention to the need to pay attention to oral health services were also helped as you noted in your introductory remarks chairman oral health technical advisory group that's going to help us move forward in our policy making but a second area of work and other two other to make including ok let me conclude by saying our two other areas that we're focusing on besides policy making is identifying best practices alibi eligible children who do receive dental services by next year so we've got sixty six percent not receiving and the goal on their head now mr man you've inherited an agency that for the better part of a decade has been held back from making progress towards the skull for instance when we asked the official who preceded you what was it was going to take to take and to encrease access to dental services i didn't believe there was much he could do he didn't believe that he could require corrective actions of the state progress has been made i do think that c m s can do corrective action plan we plan on doing it in a number of different areas where it's necessary i'd like to work with states and share best practices these are approximately how many children are going without dental services and that's a difficult question to answer because unfortunately data delivery is not reliable  children that are receiving dental services through managed care very well ok we're going to answer that question and we're going to work with you to help get the breakdown so we know where the targets are in terms of the goals that we have to reach we have to know where we're start driver as you know c m s recently conducted a significant review of dental services in seventeen states and you identified eight states where medicare managed care organization provider networks were not assured of being adequate to provide access to dental services and this man do you believe that in adequate dental provider networks and medicaid managed care organizations are a significant barrier for children to receive dental care chairman i think there's an access problem inside managed care an outside manager here and it's talk about inside managed care what do you believe i think it depends on each state and in some states there are managed care organizations are not providing it sufficient now k let's so what are you saying it depends on each  that's not and it's something more specific you're giving the answers that are interesting with a very general in a way that this committee works as we learn by getting specific answers can you be specific each state is different chairman so i can't thank you and i'm focusing on medicaid managed care organizations because they behave like a traditional h m o in the medicaid context retaining the risk in exchange for cavita under medicaid they make money when their enrollees don't get medical and dental care this subcommittee held a hearing last month on the health insurance industry and the industry spending on members healthcare is known as medical losses and insurance company executives try hard to keep those losses to a minimum obviously one of the ways a for profit medicaid managed care organization can please wall street and can keep their medical losses to a minimum is by making it difficult for people who are covered to find a dentist who accept medicaid in your opinion if you seen any evidence that dental utilization rates differ according to whether a state that you and your staff consider correspondence received by my staff from dr burton which he finds evidence for a correlation between medicare managed care organizations and lower utilization r did you collect data from the state which would allow you to determine if this is a fact or if there is a correlation between medicaid for profit managed care organizations i have not looked at data looking at for profit managed care organizations we can look at that more closely chairman and be glad to look at that thank you i will say that we have a real problem in the fee for service area as well and so i think that that's what th i thought the hearing is about medicaid access for children ok ms man do you believe that inadequate dental provider networks where they connected to the for profit motive are one of the reasons why so many of these children are not getting health care is because of the way the system is structured i think that medicaid managed care organization can make it worse or can make it better depending upon what the financing looks like what the incentives are and what the oversight is i wan states not in compliance with federal regulations however you told that you only follow up which states but had no plans to require action from them as you wrote in a cover letter quote these are programs a as formal corrective action plans unquote were not required and i'm wondering if c m s has backed down from its earlier commitment to this subcommittee to require corrective actions from the state has i stated a moment ago we believe the corrective action plans are part of our our tools in terms of moving forward on the medicaid program were done as you noted before and they were set up as technical if i could finish so i'm just going to answer that question if when we complete review back from the regional office if we still see problems then we will move forward in a separate action for corrective action  only one in three children are getting treatment for two k and other dental problems so i just want to i guess cut to the chase you seen an improvement in the past year is it better now  what's the status now i understand it just last year study but here we are late two thousand and nine what kind of improvement have we seen in helping helping these kids not going to miss mann first the data from tawny and you talked about one of the things that states have reported is this rather heavy administrative burden in fact i remember my days at the working at the state house and he talked to local officials as it's always the you know dealing with the federal government deal over the county government deal with the state government and the federal government so is it true do you feel like there's a big burden you placed on that's been placed on  by the federal government on stage and you know what ways can can states better navigate this better deal with this with this situation  there's it's in place and they don't you would you be in favor of some kind of some kind of penalty for for families who don't who don't bring their child to the for that appointment we asked states about model practices and i think there are states that are actually dealing with the broken appointment issue without a penalty situation in virginia for example rape we parted on a broke does not in this instance require any paperwork that the states use to enroll their providers so there i have been as as i was reported twenty eight states identify and providers often identify that paperwork as a problem so it's a state initiated problem and it's one of the things that i think is routinely on state's list to try and address and i think some of the states here to testify today will talk about what they've done to  university one of the programs we had placed was the dental school would we knew about it because as you know employed at ohio state but you know we had four children so we were looking to get the cheapest care possible for our kids we took him to the to the to the   you're look and to save dollars wherever you can seem to work seems to me that's that's a concept where you know here's a here's a state institution receiving all kinds of taxpayer support already many times in large metropolitan areas that that's something that we should be encouraging and again i was looking ahead in my in my briefing book here that they were going to hear from one of our witnesses about this issue but about this type of program that makes all the sense in the world to me  maybe a little more difficult in in rural areas where there may not be a dental schools close but i gotta believe that's a way to help meet this need and not cost the taxpayers more money which is obviously something that i know i'm concerned about my soon and i think the rest of the committee as well so if you could talk about that and what's going on already and how we can encourage more there are a number of dental schools that are providing direct services also there are some new programs being involved and we are trying to think partner with them in order to provide some payment for training and also some loan repayment program so that the dental students that get trained to go out into low income communities  there's also a county health departments that are providing dental health services and a lot of federally qualified health centers so i think looking at all of those avenues to build our workforce in terms of oral health providers is right  talking to a state legislator yesterday from kansas they don't have a dental school in kansas so that's why you need to think about the different landscape and what can work but i think the dental schools have been can be very critical to do either of you know how many many states have dental schools certainly something we should be doing and again not reinventing the wheel well i was talking about the reimbursement rate what for but this is dental students they need they need patients to learn their  mismanagement feeling a feeling of deja vu in that under the previous administration c m s so often this committee felt like we were getting the rope a and i want to be specific because i'm talking about the lives of children you said that there were things that you were willing to do and mr chairman i i hope you'll understand what i'm about to say  i want to make sure that mr man is held accountable and i want specific commitments for these children we've been through a process mr chairman as you will recall when we were told things and nothing happened now you know we're going to get some specifics as to what is going to happen and address these children needs as the urgency of now about president obama's words because it is the urgency of now when only one third of our children are getting what they need so they can grow up and be able to sit at a table like that to be able to go to school without pain to be able to live a healthy life well we need to do something different we need to be says if it mr china you said here that c m s agreed to three of the four recommendations is that right and partly the fault is that right that's correct and which ones of the day partly program matic review i mismanaged you said that there were things that you are going to do you go down each one of the things that you said you're going to do are doing and give us time tables now because the way we like to operate is we like to bring you back on a date within a week or two after you say it's going to be done so that we can make sure is done so we have a limited amount of time to be in these jobs we may not win the next election and so we have to be we want to make sure that we are at fact of any fish and while we are here i mean that we might as well go and play golf so the question becomes what are you willing to do whether you  do it and mr chairman you said the schedule but i like for that so that we can come back and check with mr man as to what if he makes a commitment that we be able to ever come us and let us know that the commitment has been been completed with a german you yes this is our fourth hearing and you've been instrumental in creating every one of these hearings and as i indicated in  opening remarks we're going to stay on this so we're gonna get to know each other real well and we're gonna have a chance to be able to compare notes and stablished metrics timetables items because look where we are sixty six percent are getting the dental services to which they are entitled and the goal is for sixty six percent of children to get it so with your persistence and working with mr jordan our subcommittee i think i think we got a long way to go but this man is now on that road with us so we'll look forward to working with you now mr i'll yield back to mr cummings i just want to go through the things that you did the actions that you are going to take and when you expect to have it done that's all i mean you can be briefly you've talked a little bit already but i just want to know exactly what you going to do to correct this situation to get to that goal or do you agree with the goal first of all absolutely ok now just to tell us what you plan to do and mr richman don't take this personally the university mellon dental school because of the mit driver and part where i see apparently a brain because i want to miss gone to there i see apparently i don't know that much about dentistry apparently go see i before it goes to your brain and i'm talking up for those little kids because i want to grow up so that's why i'm kind of pushing hard on this because i don't want to be making the same arguments a year from now two years from now and then some kid will only has by the way a limited amount of time to be a child i don't want to i don't want to be in a situation where that child is either harmed because we did not do what we could have done i want every how i think was massive up to says we must be what we can be and i want every child to be what he or she can be so you can you can go ahead and tell us when you're going to do what you want to do what you're going to do and then i'm sure the chairman all deal with scheduling hearings appropriately so that we can measure our progress there are a number of actions already underway as as i noted on august twenty second the twenty seventh i wrote to each of the states in the sixty's that had sixteen the sixteen states that had reviews the regional offices are currently engaged with those states i can commit to you that in thirty days we can tell your response from those from those follow up reviews from the regional offices and let you know where we stand on each of those reviews we have a listening session on a p s t n where we should go any p s if you which is as you know the the children's benefit package and medicaid scheduled for october sixteenth that's the first we plan to have a few in that series to help guide us on one of the most important actions we can take going forward i'm happy to commit to you that week after that october sixteenth listening session to let you know exactly what the recommendations were going forward  plan to do dental review views in each of the states that that are at the top of the list to identify if the g a o has recommended what those best practices are and i can commit to you to provide you that information in the next  i have to figure out exactly when we can do those reviews but i can follow up and give you an exact date as to when we can do those and when we can bring give me outside date i mean i'm sure i would say by december we have committed to do the change in the four sixteen report by the spring of this year we have a number of changes that we've already developed and then there's new legislation in chipper that we want to incorporate in those changes and we want to do some consultation with experts so we're having that consultation that's part of the listening session that's going we're doing that consultation that fall we're going to be doing those changes this spring for sixteen which is to improve some of the data collection issues so that we can give you the numbers that you're looking that we are not going to stand by and watch anymore little kids dying i just don't take this personally but it's your job now it's your responsibility and joe ever was sitting in that you're going to hear the same thing from members of this committee about your obligation to these children this was a child that was full of promise like every child in the system let this happen to this child and i see from your background that you have concerns about people are in these lower economic situations that's where i come in and i den a five so that's why i will not give anyone who comes from the administration any way ballroom on this question you won't have it just know that i'm you know with all due respect because you know what the child died now i want to one of the significant reforms reimbursement for providing those services are discouraging doctors from doing it my staff has received this correspondence from the maryland chapter of the american academy of pediatrics on this topic and i ask unanimous consent to put this in the record reimburse pediatricians for providing and if there's any question that states have about their ability to claim medicaid reimbursement for that we can certainly clear that immediately if you study that letter it be very helpful maybe you can respond to it in  create uniform system of oversight assessment benefit eligibility for children that is the program and it is the guarantee that every child get that uniform eligibility which is simply stated all the medical care that they need that's necessary so we have a lot of variations for adults and medicaid but not for children the question is do we get it enforced and do we have providers taking the children and the families know about the availability and that's why we're setting up this listening session and doing this work group we have a problem beyond oral health we have a larger problem making sure that benefit is observed for every child in the medicaid program thank you very much i think mr chairman just a couple basics i was curious about what's that what's the average time a child is so i mean it is a lot of churning in and out and one of the one of the important advances i think that we can do to help children get access to care is to keep that coverage continuous but my point is so some of these kids who aren't getting coverage does your numbers account for this one third we've we've determined that or getting the dental care is it because could they be in fact moving out of medicaid and getting care from a private private source they could be moving out of care and getting care from private sources they could be moving out of coverage and medicaid and simply being uninsured but not have a card to then go to the dentist and for medicaid patients it's probably more the latter but it could be either what's the percentage of eligible uninsured children are eligible for either medicaid or chip but not enrolled some have been enrolled in the past but they have been churned through the program but in any given time about seven out of ten of eligible children of uninsured children could be enrolled for either more t v you know this and you know you know the stats how much funding was lacking and what was the cause of an availability do you know in other yes in the medicaid program under federal law coverage of dental services for adults is optional with the state and as you look through what's going on in the states now and during a recession is one of the first set of benefits  that states will cut out of they're looking to reduce their medicaid budget so it is not a requirement north of the standard even once they covered an adult in medicaid nearly as robust as the standard is for children mature china you were talking about in what the state said were the barriers and you said that one of the things that was talked about the most is failure to make appointments is that right correct did you all have any recommendations as to how to deal with problems including inadequate provider networks and we also advised c m s that they should take action to ensure that any state found with an adequate provider network take corrective action missed this man did you hear you know i was as when she when mr johnny was talking about this earlier i was thinking about how important it is that parents understand the relationship between teeth in a rest of the body i think a parent any parent one new kid to be healthy but i don't think a lot of parents have a clue of the relationship between the teeth and the body and i'm just wondering did you have any thoughts on that with regard to making sure that we get that information out there we well i was out of an amendment s chip where we were able to do some things in every guy but i'm just wondering is an on your list because you know that's one of the things that it was it might cost some money getting the information out but the benefits would be phenomenal compared to the money that we put out because then you a could lead to something far worse than a fever and so i'm just wondering what your what your feeling is on that i think you're absolutely right prevention is a is a key to moving forward there is a provision and perhaps this is the one you're referring to and in the chip legislation that requires education for pregnant women and parents of newborns and we are working on developing an education campaign we're partnering we plan on partnering with  the centers for disease control we've been reaching out to some of the philanthropic organizations around the country and to look at other mechanisms to get information out to pregnant women and to newborns about what they can do we also find that the dental part utilization rate is much lower for adolescents and i think that's also a lack of information about how important and care is for teenagers so i think coming up with a campaign that helps to provide some information  parents as well as to teenagers themselves will be really important to you it shouldn't give us a deadline on that give us some time a timetable on that sense is such a sense that such an important and potentially beneficial and cost saving thing we want to we want to really follow up on that and i have a tremendous personal interest in that and i would be glad to provide you with a with a plan and a timetable attached to it very well  putting its work there this is the domestic policy subcommittee of oversight and government reform today wednesday october seventh two thousand and nine title of today's hearing is medicaid jeffords to reform since the preventable death now professor of clinical dentistry and clinical health policy and management at columbia university's college of dental medicine and a mailman school of public health he's found director and board chair of the children's dental health project a nonprofit policy and strategic consulting organization that advances policies to improve children's oral health mary law and chair for oral health care of the department of pediatric dentistry at the university of washington and dental director at seattle children's hospital he's author of a multitude of manuscripts abstracts and book chapters regarding a variety of subjects including the sort of materials for children and other work related to violent and is coeditor of a textbook on early childhood oral health and behavioral sciences university of florida college of dentistry he shared a number of committees in the american academy of pediatric dentistry served on the editorial board of the academy's journal pediatric dentistry in addition he was a member of the national affairs committee the american association for dental research from eighty nine to ninety five this committee works with the federal congressional delegation to increase funding for dental research particularly for the national dental research he's currently a member of the legislative affairs committee of the american dental education association which advises and lobbies and federal policies in appropriations related to dental  as with panel one i would ask each witness to give an oral summary of his or her testimony please keep this summary under five minutes in duration and your complete statement will be including the hearing record again thanks to each and every one of the about federal government's role and responsibilities in ensuring that children in medicaid have access to the dental care that is entitled to them by federal law i am dr burton edelstein columbia university professor and chair of the children's dental health project here in d the founding of the child as dental health project in one thousand nine hundred seven was a direct response to congressional enactment of the state child health insurance program because i as a pediatric dentist who treated children on a daily basis was shocked by the lack of attention hundred seven was given to children's oral health it was not until the death of damage the driver that so much attention has been brought to this issue and the subsequent work by the subcommittee and others has ensured that policy making simply as you've demonstrated today will not leave this issue to fester any longer the result of the attention that you have brought to this issue led to significant improvements in provisions in chip through chip i commend the chairman and the committee on this issue and i cannot think of a better example of how far we have come than to have seen the man as the c m s so director with her personal commitment to children and to children's oral health clearly mr cummings i agree with the same he made earlier that we may need to do something different and i think we need to explore the limits of what c m s can and cannot do as well as what it can do in partnership with other agencies across the federal government clearly all of the progress that has been made has still left a number of challenges so two and a half years after the subcommittee launched its investigation we still have damage the drivers out there and we need to consider some of the more structural the fundamental issues that limit the access to health care at the time that c h p was founded subsequent to s chip the vast majority of advocacy on behalf of oral health for children was made by organizations of dentists this makes sense of course because it's dentists who are on the front line of providing care to children however dentists parents and the program all both contribute to and can help solve the woeful inadequacy that you've highlighted today when asked about how to improve the program dental dentist organizations typically respond with the very items that we heard featured today low payments complex paperwork and non compliant patients unfortunately we have seen in states across the nation that addressing these three issues alone and many states have taken significant action on these three issues have not led to the kinds of increases that we would hope for research has shown that increasing reimbursement absolutely is a necessary but not a sufficient condition for improving dental access for example an analysis done by the california health care foundation in four states show that raising reimbursements did significantly kick up the percentage of kids receiving care but only from a quarter of children to a third which is that level that we're stagnating at today studies currently underway by my research group at columbia university indicate that during the period one thousand nine hundred ninety two thousand and six forty one states did increase fees twenty five showed no increase in utilization primarily because those increases didn't bring them into the market however amongst the twenty five that did have increased in both fees and utilization about half thirteen still only reached a level of thirty three percent or more overall in two thousand and six twenty of our states still provided care to fewer than one third and no state has broken the fifty percent level yet a variety of factors contribute to this problem which i've detailed further in my written testimony based on the complexity of this issue cd h p s advocated for a holistic approach to improving children's oral health an approach that combines both public health and patient focused interventions in my written testimony i lay out solutions that can be pursued by a variety of agencies by c d c and i wish i had star as well as c m s c m s of course plays a particularly pivotal role because it's both the funder and the regulator of so much of this care and the suggestions that we've made fall under the three categories that have been featured already today leadership technical assistance and oversight which i believe c m s is now fully committed to it to pursue my colleagues and i at the children's dental health project look forward to continuing to work with this committee with c m s and with all who are concerned about dental care for medicaid beneficiaries when c h p was founded we called it a project we specifically called it a project with the realization that the problem we're addressing is solvable tooth decay and children is preventable the irony is that we are putting so much effort into chasing after disease that can be prevented in the first place i look forward to continuing to work with you and with all who care about children or i'll help to solve this problem that concludes my testimony i look forward to your question thank you very much dr  medical director am not a dentist but a physician board certified in public health and general preventive medicine i appreciate the opportunity to testify before you today on the progress that we have made this has been a team plus your medicaid agency recognized that significant growth in the number of children eligible for medicaid dental services and decrease in demo provided participation in the medicaid dental program to come back to create a dental because of the was belief that preventive care for children especially very young children was an important pro batters complain of low and reimbursement rates uncooperative patien and families and cumbersome claims balun prompted a decade later alabama medicaid dental utilization is more than sixty two percent and there has been a two hundred sixteen percent increase in the number of dentist who see more than one hundred patients per year there is greater public awareness that good oral health is essential to overall here what made this possible is the collective determination of many people in both the public and the private sectors to find a solution and the willingness of dental providers state leaders and others to implement necessary to bring formation of a dental to increases in the demo reimbursement rate major claims process and change outreach for formation of a public private alliance creation of an orgy of strategic plan and policy reimbursed mean increased claims process and simplification patient outreach in education and provider out in conclusion in order to improve access to and the utilization of or health care short fall we all care only experiencing increased enrollment due to the present state of the economy which shrinking budgets while trying to increase utilization these factors will limit our ability to put up i'm a practicing pediatric dentist and i care for a large number of medicaid eligible children and i'm honored to appear before you today to represent ensure the success of washington state's access to baby and child dentistry or a b c d program the goal of a b c d is to expand access to all health services by medicaid eligible children from birth through their sixth birthday more than a dozen nationally publicized articles and published articles have clearly demonstrated that early prevention reduces future dental costs and that a b c d is an effective cost saving method of improving the world health status of children or old image kade the first a b c program was established in one thousand nine hundred five in spokane washington as a collaborative effort between public and private sectors the community agreed that something needed to be done to address the dental champion who is a leading pediatric dentist or general dentist who was selected and trained by the university of washington to identify recruit train and mentor other local general dentists a b c d encourages general dental offices not just pediatric dental offices to provide a positive dental experience and dental home by age one a b c program is embedded in many local head start and early head start programs now both under the american academy of pediatrics industry leadership in washington state a collaborative effort of washington dental service foundation the university of washington school of dentistry the department of social and health services the washington state dental association the department of health local dental societies and local health jurisdictions d certified dentist receive enhanced medicaid reimbursement for selected procedures and enroll children dental office staff receive training and communication and culturally appropriate follow up with families and the building staff learns how to work with the medicaid program with the c program an increasing number of washington physicians are now addressing oral health during well child checks because a b c trained dentist service referral sites medicaid reimburses train certified primary care providers for delivering oral screenings health education and advantaged applications during well child checks and they make the necessary referrals to dentists today thirty one of washington thirty nine counties more than one thousand dentist participate in a b c d and several other states expressed interest in adopting this successful program a b c has more than doubled the number of young medicaid children washington receiving dental care than forty thousand two hundred seven thousand utilization increase from twenty one to thirty nine percent a b c the program is reducing overall dental costs education prevention is most cost effective during the first two years of life and a b c d is making progress toward increasing the number of children who receive care before their second birthday in two thousand and eight nearly twenty two thousand children are aged to one hundred percent of eligible children receive dental services when the program began in ninety seven only three percent close to what is probably the national average day of eligible infants and toddlers receive dental care while target enhanced reimbursements for increased frequency of preventive interventions for young medicaid children are extremely important other elements must be present to ensure the success of a b c d the washington service foundation coordinates the program at the state level and provides three year startup grants to launch the program locally so that outreach to families case management support services for the dentists and other critical activities are included in the years ahead the a b c program will be expanding the use of risk assessment tools as exciting technologies are emerging this combined with increasing incentives for earlier intervention and for higher risk children and expanding partnership to refer the highest risk children the highest risk in low income children to a dentist is early in life is possible will further improve the oral health of the program's children we must come back to the growing crisis in childhood dental disease and increase access to care some of our country's most vulnerable patients a b c d is a proven best practice that is working in washington state i thank you for the opportunity to share this success chair of the department of community again astri and behavioral science at the university florida college of dentistry i'm here today on behalf of the american dental education association otherwise known as a dia ideas membership consists of intuitions who serve as dental homes for a broad array of racially and ethnically diverse patients many of whom are uninsured under insured or reliant on public programs such as medicaid and the children then ill health program is grateful for the opportunity to share our perspectives and recommendations for improving children's dental programs medicaid first a couple of comments about academic dental institutions a safety net providers in this answer of some of your questions mr jordan adductor academic dental institutions include dental schools and dental hygiene schools that provide dental care reduce fees and provide millions of dollars of uncompensated care in our clinics each year all fifty nine u s dental schools and over two hundred schools of dental hygiene operate clinics that teach students how to treat a broader worry of patients and coned and conditions as part of our educational mission on average over fifty three thousand patient visits were conducted annually at each u s dental school totaling more than three million patient visits and over fifty percent of those patients were on public assistance programs at the university of florida college and i'm sure we had over a hundred in one thousand patient visits in two thousand and eight and seventy six percent of those patients were at two hundred percent of the poverty level or below a couple comments about medicaid dental benefits and an academic down to sions safety net dental programs and community health centers local health departments and academic dental clinics operating at full capacity are only able to meet about eighty percent of all the lelo on average they equal the lowest ten percent of market rate in many states in florida for example our medicaid reimbursement fees rank forty ninth of the states therefore the seventy four percent of the eighteen thousand children we soar in university for a college that he's going to work at or below poverty level in other words they were on medicaid and the low reimbursement rates we receive put considerable strain on our ability to continue providing these services i'd like to give you two examples of how academic dental incisions can help improve access to care in the united states the university of florida college of dentistry has a statewide network for community oral health that operates five dental clinics and is affiliated with nine other clinics throughout the state of florida from miami to the border of west the western part of the state and these partners include federally qualified community health centers scanning health departments and a mobile dental van the network serves florida's most vulnerable populations and provides comprehensive dental care in the areas of greatest need around the state the second example in two thousand and two the robert wood johnson foundation and the california endowment funded a program mount community based dental education in twenty three dental schools with grants totaling approximately thirty eight million dollars one of the dental schools funded was the ohio state university college of dentistry the college's goal with the rob johnson money was to reach populations in need of dental care across the state starting in two hundred two thousand and three when they first received the grants dental school had ten community based sites by two thousand and seven they had expanded to forty six sites where their dental students and residents provide they don't care to under served and low income minority patients so one of the recommendations we have my written testimony provides eight specific recommendations that i did would suggest but i'd like to focus on just story of them first fund the expansion of community based dental education learning programs with academic dental institutions and the robert wood johnson pipeline project is an example of the kind of funding that maybe could be provided at both the federal and at the state level second develop standards and protocols on models of the care that allow other primary care professionals to help  detect clinically pathological conditions they don't conditions triology and refer patients to appropriate dental professionals here one of the questions i asked earlier was about the role of physicians in providing oral health services  you may have noticed in my background that i have a grant from her son to actually train physicians to provide such care to i or health preventive services that are funded funded by medicaid and involving other members of the health care team is a critical step in this process of addressing access to care number three provide federal funds to states for school based oral health promotion education and prevention programs school based sealant programs and other are an example in other words bringing care to the k through twelve school system where the children are in conclusion american down legislation is ocean believes it is critical for congress to preserve basic medical services for medicaid beneficiaries and safeguard essential medical medicaid dental benefits and any reform of the u s health care system a day and its member institutions are repaired to work with congress and other health care advocates to a dentist by programs and policies that will increase access to just want to make sure that you feel that you communicated your major points the other six are provided in detail in the written testimony ok i just want to make sure that you had a chance to note that you addressed a situation that occurred in georgia where vendors providers from their networks to ward off utilization increases imposed by the state this is clearly an unintended consequence of reform that was intended to increase access to care in your opinion what does the evidence suggest about the consequences of relying upon medicaid managed care organizations to provide dental coverage to children what i'm referencing there is specifically placing managed care companies at financial risk and as was mentioned earlier depending on the quality the contracts and the degree of oversight it is possible to have a variety of relationships between a state and a managed care company and still have a satisfactory outcome however in the case of dentistry per se there's very little that managed care companies can currently do to manage the care in order to effect and so the primary technique that they have to rely upon in order to protect their profit line because these are for profit at rest companies is to control utilization and that means that there's a perverse incentive built into the concept with regard to dentistry because there's very little else that the managed care company can do programs both of your programs have a cage management component and what are some of the specific intervention of case management before you answer that question on this man i just want to note something first of all you may be one of the but we riginal only wanted to address the issues that the providers themselves talked about which was the missed appointments and what the character or the native provide it was a means of actually contacting patients to assist them with getting in to the issues transportation to the dental office and sometimes there were issues they didn't have anything to do with the transportation what you choose concerning well i don't know how i'm going to pay rent tomorrow so i'm not really worried about keeping a demo appointment makes week so that the care coordinator paid to get into not just the issues of the dental appointment them sales but also the other issues that were surrounding the reason why these patients when keep up one minute and then want to do things we had to deal with was also to address the put down the providers problem about behavior in the office and we did that all so it's part of this program which trying to educate you know taking one child and making sure that you  easier to get access to care through the a b c program because easier in the smaller communities to coordinate efforts we found actually that we had low or no show rates and some of the a b c d programs most jurisdictions then with a non medicaid population we have evidence to show that so these orders rapidly critical in the scheme of things to make things work and we have evidence that in different counties thank you dr berger the g a o study reveals that stage overwhelmingly would like additional guidance well as was stated i think that we had a relatively a very good relationship with our regional office when it came down to getting assistance we don't have any problems with college but specifically when it comes down to  recommendations the main thing this to communicate specifically what we can and cannot do from a state standpoint and i think a lot of times states are under just misinformation as far is with mis understand is about what policies will allow them to do or not do but we didn't have that that particular issue because we get clear communication about well you know when it came down the smell of bama no one told us that we couldn't go after out that funding so we did we did it and it was ok so we went after funding in order to do the program but i think that's something the other states need i know that you don't have to deal with just the money that you have you know within the state coffers that you can look beyond that and the state of montana just adopted and a b c like program modeled after washington state's program and they actually did what we would like to have done this year but it wasn't fundable in the current legislature and that is to incentivize earlier intervention where where we can separate the highest risk children we know that as as was stated earlier eighty percent or something of the cost is spent in twenty five percent of the children that starts at about twenty feet age two and a half or three and if it age one we can identify who they were and segregate them and have more aggressive intervention with higher risk children we can save money we've actually done an economic modeling of this through our health economist michel that it can work so i would absolutely look right now at earlier intervention incentivizing earlier intervention incentivizing higher as possible so save on costs in the long term and obviously hopefully avoid any type of tragedies like with the mounting and i appreciate the work that universities are doing it was that was great to hear that and i think you got the numbers three million you said and three three million dental visits across the fifty million dental schools that does not include any of the visits that might have occurred at dental hygiene programs wow and you said your university your school you know you had a hundred thousand last year one hundred thousand visits were seventy six percent of which were patients at two hundred percent of the poverty level or below one hundred thousand children no i'm sorry hundred thousand dollars is it there were twenty six thousand children's visits of that hundred and one thousand so we  in your comment you said three things paperwork low reimbursement rates and non compliant patients make it tough for certain providers to do this care which of the three is the is the one that if you had to rank order those those three which one is the one that is the most difficult for dentist to deal with the one that is perceived and reported to be the most difficult is the low reimbursement and the point i had hoped to make clear is that sufficient funding is a necessary but not sufficient condition would it help let me ask you this question i'm at some fundamental question what it would help if dennis would would be able to for those families who can pay something what it help if they could say ok medicaid covers this much and what would you as a family be willing to pay x amount of dollars to cover the cost of the care but that help i have no idea except to suggest that it would create a significant as small business people i would create significant billing households and problems trying to deal with the co payments as a practitioner who actively participated in both medicaid and chip in connecticut where co pays were allowed for some schip patients in connecticut we did confront significant problems with trying to manage that cost sharing portion into so again you started i think you were starting to say that what you hear typically is low reimbursement that's the single biggest reason given for not accepting these patients but it sounds to me like that's not what you believe but what do you believe about the but was that our study nearing completion now tried to assess the impact of different levels of  increase utilization and what we discovered were a couple of things first off that with the increases generally you have the same providers who are already seeing medicaid patients seeing many more medicaid patients rather than bringing a lot of new providers into the actual provision of care now that's when these are the primary intervention as dr mcintyre mentioned in alabama there was additionally case management and reductions in  paperwork with prior authorization so a multi pronged approach did help on the other hand even in alabama with all of its tremendous effort we see that that relative increase was tremendous but we still hit the same sort of barrier  hitting the top levels that any state has hit in the forty to forty five percent range and it's tempting to think that that barrier really represents parents failure to pursue care but in fact parents are able to obtain significantly higher levels of medical care raising the question about whether the doors to the dental offices are truly open what you mention non compliant patients want to hear do you think that's a that's a real problem or not i mean just  noncompliance has to do with appointment keeping and i think dr mcintyre well explained how complex some of these individuals lives are but there's an excellent example that i cite in my written testimony from new york state tompkins county where a county level care coordinator like what the american dental association has suggested as the community dental health coordinator acted as a case manager and let me just ask this question of audience who is on it and i brought this i think up in the very first round of our first panel you know there are all kinds of taxpayer assistance that medic that the typical medicaid eligible family receives i kind of come from the school of thought that says if you want responsible behavior you should reward it and if you you know you're responsible have your should be be some kind of penalty for it do you think it would make some sense if in fact parents are complying with the appointments that they have aren't aren't doing what needs to be done for their kids or else it's dental care if there was some kind of sanctioning or some kind of  in typical families get and nine or ten different types they're getting tan if they get housing they're getting food stamps or get online go to some kind of sanctioning process do you think that would would be helpful along with what dr mcintyre i think and dr byrd refer to in a previous answer the kid the care coordinator in the case case manager approach as well as go down the line i personally am more of a carrot than a stick person thinking that as soon as there's a clear understanding of what the child's needs are that there be an effort to engage the family in a positive way my concern is the child and recognizing the complexity of some of these lives to get to that whatever benefits the children yeah it seems to me you mean look  know we did welfare reform the state of ohio i was the guy who did the language on the time limits component and we said we're going to make sure kids get health care we're going to make sure kids get get you know the food they need but at some point if if an individual's not willing to work and they're an able bodied adult they're no longer going to going to receive cash from the taxpayers and it was a long period of time and we didn't job training and everything else but at some point if you don't have that deadline if you don't have i always say deadlines influence behavior and if you don't have that out there as as some kind of thing that everyone has to think about we all have to function that everyone in the world has to function under those kind of responsible things in those kind of deadlines seems to me there might be an approach in there that that that can work and still make sure these kids get what they need perhaps when dental access is readily available when those office doors really are open and parents can have success in pursuing their desire to find treatment for their kids th perhaps it would be time to think about the stakes let's you know if i could ok i would agree the last part of dr adelstein statement as well that when the access problem is solved and there is much more readily available access then we could look at some pilot projects perhaps to study that i think we don't have enough information to know if it's effective or not i do want to study it on a small scale and see what kind of psychos we have and just to emphasize that in florida for example only ten percent of florida n s c medicaid patients are numbers are worse than the rest of the states we only have twenty five percent of our children achieving any kind of dental visits so until you solve the access problem it's not i don't think it's appropriate to talk about punishment for the parents which ultimately punishes the child we need to fix the access problem lot of community people in other words because you didn't give him the kind of sensitive the you're talking about i think we first have to understand it really reminds me of how healthy start  will drop out of the system but so you must must must look at a certain type of worker wears a certain level of sensitivity we didn't hear anyone let me get this straight when i talked about public private partnerships we actually work with the health department to get care coordinate is in the community i see so that many of these people were folks knew people already that people were comfortable with they were at the community level they were only county level so they when you're calling to get a challenge in bed a lot of times these people really know who the children are and so i think in that standpoint we don't go out and share a bunch of people we work with they have department t get care coordinator at the county level in order to work to put this program into place and that the whole thing about working together with all of the different entities within the state is not just a medicaid issue is an issue that involves the idea of a campaign to educate parents with regard to the significance of dental care for their children tell us i mean how do you feel about that significant you know the parents the parents clearly have a critical role particularly as dr bird mentioned that the disease onset is very early in life and so we need to get to parents very early in life as required now by chipper but one of the roles for the parents is the day to day moment to moment decisions that they make that either predispose they're kids to have this problem or predispose their kids to avoid this problem and so the education needs to be about more than dental care but it has to be about managing the risk factors for developing the disease in the first place you know i visited a u krieger in my district which and they they have this planet with severe dental problems to get and they showed me some kids who had had a nominal damage as little kids i mean little i mean who literally had to go through major surgery as a little kid like i'm going on three years old because of things like the bottle with sugar juice bottles and that and the sugar gets to the two and a of people don't realize how significant those little things are and i just think that that that education is so significant the other thing that we're going to ask you about is these federally qualified health centers one of the things that i've pushed hard for is making sure that they could contract with dentists because a lot of time that's a missing piece and those health centers are located smack dab in the middle of places where people would not normally be able to get health and you might want to comment on that to if i might reflect on the the value of that contracting it has so many values the first is that it allows dental practitioners who are not medicaid providers to contract with out to agencies to see medicaid patients and thereby become familiar with the patien as people as patients who they can become more comfortable with and discover really face the same kinds of dental issues that others do and can be were readily accommodated in their practices the second is that it expands the capacity t qualified health center so many of the health centers are limited either by not having dental facilities themselves or having facilities and no dentist because there is a shortage in the system so that allows them to contract with dentists to expand their capacity so both sides benefits the patients it benefits the dentist it benefits the health centers and we anticipate that that experience the dentist will have will lead the more available and some of the things that we deal with also identify not just the medicaid dennis per se but also an issue or because a lot about uninsured go in and off you know they're all medicaid then they have no insurance at all to make sure that those resources available for them but there is a shortage when we talk about addressing this issues one of the things i wanted to bring out was this over all in our state estimate we had a shortage of two hundred eighty eight dennis now this is not medicaid in this is a shortage in dentist in the county so in addressing the issue we have to address the workforce in order to like he was talking about a lot of doors really open well the doors are open but who gets in it this is something that you have to consider when you're looking at that because the work with itself is part of this problem i think the generated to recognize i think the gentleman and thank you chairman for holding this hearing because i do believe that it is important that we as the committee that looks at waste fraud and abuse also look at government efficiency and and that's i think a great deal of what we want to work on here today before i do my comments i'd like to yield to the gentleman from ohio for his that the number was one in three kids thirty two percent were getting the treatment accorded the study done in two thousand and eight and since that time this man's answer was it's been improved always up to thirty six percent now so obviously what we're doing isn't working maybe it makes sense to try you know the same old same old giving us the big increase of three percent maybe it makes sense to try something different and go the route that i suggested that that's my only point i know it's worked in other parts of welfare reform work in the state of ohio that probably gives me all the possible of opinions when i was growing up in cleveland ohio right next to but down the street from the chairman we still had a great deal of the if you will the public health care system and a lot of the services at that time were delivered through non private means if they were going to be delivered i got my shots through the public system and so on and and that that delivery system for the working poor and even up tiptoeing toward the middle class and certainly for what we would call the most indigent among us today was it accepted part of society it appears to me as though as we've divest ourselves of that in the medicaid system has been about money being delivered often often not at the same rate haven't we moved away from at least your main to today if preventive medicine recognizing that dentistry is a is expensive fill the amount of money you have that if if you have enough money and we here on the day is don't have a dental plan so it's not standard in our program if you have enough money you don't get him out if you have enough money you don't get you get implants if you have enough money you go through a series of much more expensive levels of care and i think you're you're all aware of just how how phenomenal dentistry can be if you have the dollars for it but are we here today talking fundamentally about the least find to find the least efficient least most efficient least expensive most universal for the poor delivery of evaluation cleaning and prevention and isn't our system somewhat broken in that if that's what you wanted to provide would you provided the way you do today and this is regardless of three percent more money six percent less money i'd like your comments on that because for this committee we do try to think in the sense of organization of government go right down the line thank you doctor interestingly this problem is not unique to united states and under served populations having lack of dental care is a global phenomenon so if we look at other countries like ours great britain new zealand australia the netherlands to see how they've approached this they do it primarily with the advent of different kinds of providers i wouldn't say that it's necessarily the public delivery system as opposed to a private delivery system but it's a more readily accessible more limited in scope provider who is more like the vulnerable population being treated and there are a number of ideas in american dental hygienists association the american dental association new legislation in minnesota experiments and new programs in alaska a variety of approaches that bring dental therapists to the increasing the capacity for the luxury of services so looking at other country that might be one direction a particular value as you go down the list the reason i said public is that i understand the dental practice and state regulations to predetermine certain things such as being able to work on their own or not an assistant work on their own or not use the term public because it's a preemption for the poor potentially that would allow us to work to find the most efficient way to provide preventive medicine that might not be universally available in some states are being a californian now i'm aware of that please dr well as a physician one of the things started using our primary care providers physicians more but called dental caries is a disease and like in a disease in order to get away from the disease later we have to prevent it so if we can start early when children first get there you know when they get those first two in the mouth even before they get their teeth we start educating mothers when they're pregnant about what they need to do they get brochures and information from the  carol manages about how to take care to teach in the babies and here they are more likely to listen before the babies are born than when they get here and doctors who see children to give them there is an adult opportunity to educate  and refer and that's what we're trying to do to utilize the system and if we narrow the answer just to the organisational one because i really am testing the chairman intervene the more preventable it is and the other non dental providers who are treated in the surgical aspects of dentistry can assist us in the risk assessment of the prevention for advantage is not the cure but the risk assessment determining who's at greatest risk in providing more aggressive and more frequent interventions that is the solution so i think we need to segregate the surgery and not think about dentistry as surgery we have dentists who can do surgery we need some assistance in the earlier intervention for those folks as mentioned we do see the children earlier but thank you the other point that i would mention about this is that there is a fundamental problem though in the dental public health infrastructure what i mentioned in my testimony is that seung had at full capacity the existing public health infrastructure the dental institutions county health departments federally qualified health centers they can only address about eighty percent of the dental me that's out there so part of your solution that you need to look at this is improving the dental public and dr berg and i think your two states have participated in some promising a practices that were posted by c m s and in a survey that was taken by g a o there were thirty seven states who indicated a need for more information and other states efforts and have you been share that information have you been part of it our website we've mailed out brochures to all fifty states you know basically in the pay is to actually give them the information about what we were doing so and we actually put the information where acceptable and we're willing to share it with anyone one of the things that concerns me is that many of the dentists kind of look at the medicaid beneficiaries and say i really don't want them what's with that attitude  part of what we did as part alper about out education and outreach was to educate providers that it was a two way street and a it in order to receive you know the behavior that they were expecting they also needed to be willing to treat people with respect so we came up with a demo rights and responsibilities sheet that adrift the provider what they could expect and what the patient could expect from the provider and for both of them to sign it in the reason for that is because and i'm saying this because as a child who grew up with no insurance and no access to health care ok and people on a lot of times looking down on people just because of their income level is something that we have to go beyond and that is one of the things that we address with the providers that you know you need if you expect people to behave a certain way you have to treat them so that they will behave that way if you expect behavioral you will get bad behavior so that part of the education that we do it without dental tests for burke i think part of the success of a b c d is training and cultural sensitivity and that's a big part with the staff it's effective you know that there are unique needs of this different population their circumstances are different and that's been critical to success so  t that statement well let me give you a pet peeve of mine i've had a bill for the last eight years to look at dental amalgam some outcomes are as you know silver fillings are fifty percent mercury mercury is number one toxic element and i've been getting to the dentists in fact the minority it in this came in and they're adamantly opposed to it because they say it's cheaper to put an amalgam filling in well the research shows that when you have mercury in your feelings it is constantly gasses are constantly it's kaitlin particularly with children and so i find a real problem with the dentist said says to me it's a matter of cost and you know we have now in your state's medicaid providing dental health care and then we don't have this kind of patient result however when you get the industry saying to you it's a matter of cost black people don't like to go to the dentist so this is the cheapest we can give i think that's a violation of ethics how do we continue to educate these dentists anybody want to take a swipe at that if you're talking about the amalgam question specifically well i think first of all that to remind them that only about six percent of their total cost is materials including album and other materials and the real cost is how efficiently are at running their practice and i think they're our best practices and a b c has an annual meeting where are our champions come together and talk about how do i run efficiently in my office and by changing those behaviors in their office they can do well by doing good and be much more efficient so i think that's the focus we give and by the way i think i think in our state i wouldn't say there's a differentiation in any population in terms of who gets what restorative procedure we don't happen to do many amalgam because there are alternatives today some do but i think we like to educate that is the efficiency of running the practice where they're going to save the money not difference the materials are really minuscule compared to the staff costs and other costs in the practice thank you thank you thank you very much we are going to conclude just hearing about i want to thank all of you for your testimony as a representative from the state where the driver died this hearing means a lot i've often said that the mit driver was a little boy who was suffering from and in fact it too and he died in one of the richest states and wonder richest counties in one of the richest countries in the world and there's something wrong with that picture and we can do but people feel so often that folks are talking down to them and they don't so they don't they feel that they're not respected when we look at health care disparities for example one of the things that is clear is that there is a there's a divide and some type of misunderstanding between sometimes those people who are trying to treat and those who need treatment and so i think it's very important that when we look at the mit drivers with it we look at the kinds of things that you all are talked about here today and how and i was glad that ms man stuck around to hear some of this she one of the things that ms man said was that not ms man but the our lady miss teen era tani said was that they wanted these other states want to know best practices da i mean i mean we i mean these this is not this is not rocket scientist stuff this is basic common sense and trying to work things out in treating human beings and human beings and so i just kind of think that i know we made a lot of headway but i just want to take time to thank all of you all for what you are doing every day because you have acting children i mean i mean they and i and i it over and over again children come on this earth with gifts they bear gifts every want to bear gifts they are born on the day that they are born to deliver gifts at certain points in their lives but what happens is that we don't treat them right and we don't know to them and nourish them and help them develop they'll never deliver those gifts and if they're sitting as i did as a little boy sitting in elementary school thinking that cavities was a part of life when the question of it was like a headache you supposed to have cavities and a lot of people are still thinking that today that's why this whole education thing is so significant letting people know and that whole idea of letting them know that there is a direct relationship between the body and teeth they don't think it so i think all of us i mean the testimony that you all have provided today is the basics and hopefully somebody is listening somebody will come to you all because you all seem to know where you're going and you're on the right path and allow you to help others to you to get it now the question becomes sometimes not whether people get it but whether they want to get it whether they have the will to do what's necessary and that's where we're going to come in come in we're going to try to do everything in our power to make sure that our children that the providers that the states and  others have the kind of information they need so they can set it they can touch our children in a positive way and look out for generations yet unborn finally let me say this this is about generate this is bigger than us this is bigger than us when you were talking and dr mcintyre i talked to all my and i said you know it's a great idea to educate mothers before they give birth because you know all that excitement that you have when you have found i'd never get you know i'm not a woman so i don't know but but folks get real excited about that first birth in particular and they get your name prepare the room and then all i kind of good stuff and then the question becomes you know shouldn't proper part of the preparation be making sure that you're prepared for the chief of that child and then the dental health and what i was telling my was that you know the wonderful thing about it is if you if you then educate the first the mother when they're delivering the first child then nest sets a pattern for the other children that may come but it does something else it then teaches the child as a child grows up how to take their teeth and then hopefully generations you have a generational cycles of good teeth to do with taking good care of your teeth your teeth that's what it's all about and so