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35–772 PDF 2007

EVALUATING PEDIATRIC DENTAL CARE UNDER

MEDICAID

HEARING

BEFORE THE

SUBCOMMITTEE ON DOMESTIC POLICY

OF THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MAY 2, 2007

Serial No. 110–8

Printed for the use of the Committee on Oversight and Government Reform

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.oversight.house.gov

(II)

COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

TOM LANTOS, California

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

——— ———

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

DAVID MARIN, Minority Staff Director

SUBCOMMITTEE ON DOMESTIC POLICY

DENNIS J. KUCINICH, Ohio, Chairman

TOM LANTOS, California

ELIJAH E. CUMMINGS, Maryland

DIANE E. WATSON, California

CHRISTOPHER S. MURPHY, Connecticut

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

BRIAN HIGGINS, New York

BRUCE L. BRALEY, Iowa

DARRELL E. ISSA, California

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

CHRIS CANNON, Utah

BRIAN P. BILBRAY, California

JARON R. BOURKE, Staff Director

(III)

C O N T E N T S

Page

Hearing held on May 2, 2007 ................................................................................. 1

Statement of:

Cosgrove, James, Ph.D., Director, Health Care, Government Accountability Office; and Dennis Smith, Director, Center for Medicaid and State

Operations, Health and Human Services ................................................... 54

Cosgrove, James ........................................................................................ 54

Smith, Dennis ............................................................................................ 77

Finklestein, Allen, chief dental officer, United Health Care; Susan Tucker, MBA, executive director, Office of Health Services, Maryland Department of Health and Mental Hygiene; and Jane Perkins, legal director, National Health Law Program ............................................................. 109

Finklestein, Allen ...................................................................................... 109

Perkins, Jane ............................................................................................. 129

Tucker, Susan ............................................................................................ 121

Norris, Laurie, staff attorney, Public Justice Center; Frederick Clark,

D.D.S, dentist, Prince George’s County, National Dental Association,

member; and Norman Tinanoff, D.D.S, Chair, Department of Pediatric

Dentistry Dental School, University of Maryland ...................................... 13

Clark, Frederick ........................................................................................ 24

Norris, Laurie ............................................................................................ 13

Tinanoff, Norman ...................................................................................... 31

Letters, statements, etc., submitted for the record by:

Clark, Frederick, D.D.S, dentist, Prince George’s County, National Dental

Association, member, prepared statement of .............................................. 26

Cosgrove, James, Ph.D., Director, Health Care, Government Accountability Office, prepared statement of ................................................................. 57

Davis, Hon. Danny K., a Representative in Congress from the State

of Illinois, prepared statement of ................................................................ 44

Finklestein, Allen, chief dental officer, United Health Care, prepared

statement of ................................................................................................... 111

Kucinich, Hon. Dennis J., a Representative in Congress from the State

of Ohio, prepared statement of .................................................................... 5

Norris, Laurie, staff attorney, Public Justice Center, prepared statement

of ..................................................................................................................... 15

Perkins, Jane, legal director, National Health Law Program, prepared

statement of ................................................................................................... 131

Smith, Dennis, Director, Center for Medicaid and State Operations,

Health and Human Services, prepared statement of ................................. 79

Tinanoff, Norman, D.D.S, Chair, Department of Pediatric Dentistry Dental School, University of Maryland, prepared statement of ...................... 33

Towns, Hon. Edolphus, a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 160

Tucker, Susan, MBA, executive director, Office of Health Services, Maryland Department of Health and Mental Hygiene, prepared statement

of ..................................................................................................................... 124

(1)

EVALUATING PEDIATRIC DENTAL CARE

UNDER MEDICAID

WEDNESDAY, MAY 2, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON DOMESTIC POLICY, COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 1:05 p.m. in room

2154, Rayburn House Office Building, Hon. Dennis J. Kucinich

(chairman of the subcommittee) presiding.

Present: Representatives Kucinich, Waxman, Cummings, Watson, Davis of Illinois, Issa, and Shays.

Also present: Representatives Towns, Sarbanes, and Wynn.

Staff present: Jaron R. Bourke, staff director; Noura Erakat,

counsel; Jean Gosa, clerk; Auke Mahar-Piersma, legislative director; Natalie Laber, press secretary, Office of Congressman Dennis

J. Kucinich; Karen Lightfoot, communications director/senior policy

advisor; Leneal Scott, information systems manager; Jacy Dardine,

intern; Tim Westmoreland, health consultant; Andy Schneider,

chief health counsel; Art Kellermann, health science fellow; Susie

Schulte, minority senior professional staff member; and Alex Cooper, minority professional staff member.

Mr. KUCINICH. The subcommittee will come to order.

We are expecting a series of votes, but I think what we will try

to do is at least get the opening statements in, and so I want to

welcome our witnesses and welcome everyone in the audience to

this hearing of the Domestic Policy Subcommittee of the Oversight

and Government Reform Committee, to today’s hearing, ‘‘Evaluating Pediatric Dental Care under Medicaid.’’

I want to thank our ranking member, Mr. Issa, for being here,

and thank Mr. Cummings, who was instrumental in creating the

circumstances which caused this committee to come forward and

have a hearing.

Mr. Cummings, thank you once again for your help.

Good afternoon. This subcommittee has come to order, and today

we are taking a closer look at the circumstances that led to the

death of Deamonte Driver, a 12 year old Medicaid eligible boy who

died of a brain infection caused by untreated tooth decay.

This hearing will focus on the adequacy of oversight of pediatric

dental care and Medicaid.

In its 2000 report, Oral Health in America, U.S. Surgeon General

David Satcher demonstrated that oral health is essential to general

health. The mouth and its surrounding tissues provide protection

against microbial infections and environmental germs, and they are

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associated with detecting nutritional deficiencies and systemic diseases.

We have a series of slides here, and I will just proceed and will

ask staff to just try to synchronize the slides with the text.

All oral diseases are progressive, cumulative, and consequential.

Tooth decay often occurs in early childhood and is the most common childhood disease. It is five times as common as asthma and

seven times as common as hay fever. This has the most detrimental impact on low-income communities. As the slide indicates, 80

percent of cavities occur in only 25 percent of children, predominantly low-income children. Low-income children suffer twice as

much from tooth decay than do the more affluent children.

Medicaid is the largest source of health insurance for low-income

children, providing care for one out of every four children. Despite

the coverage provided by Medicaid, it has been unable to fill the

gap of providing dental care to poor children.

In 1999, 26.12 percent of eligible children received any dental

services, and by 2000 that number had risen to only about 34 percent, not many percentage points more than dental service utilization by uninsured children.

On Monday, the Center for Disease Control issued a new national study that found that tooth decay in baby teeth had increased among U.S. toddlers and pre-schoolers age 2 to 5. The CDC

study also found that 74 percent of young children with cavities

were in need of dental repair.

In late February we witnessed the most tragic consequences of

untreated oral disease. On February 25th, 12 year old Deamonte

Driver died of a brain infection caused by untreated tooth decay.

By the time Deamonte received any care for his tooth, the abscess

had spread to his brain, and after 6 weeks and two operations

Deamonte died. Filling a cavity, performing a root canal, or extracting the tooth might have saved Deamonte’s life, and yet the challenges in finding a dentist and ensuring care precluded that opportunity.

Deamonte’s death demonstrates both the importance of oral

health to children’s welfare, as well as the sometimes fatal and

often costly consequences of its inadequate success.

We will take a closer look at Medicaid in Deamonte’s home State,

Maryland. Using the Health Plan Employer Data and Information

Set measures, they estimate that 45.8 percent of Medicaid eligible

children age 4 to 20 and enrolled for 320 days received dental care

in 2005. Using the CMS form 416 measure, which is slightly different, the Maryland utilization rate for 2005 is 30.7 percent.

Oversight by Government agencies is critical to ensuring that

Medicaid serves the population as intended. But what is the quality of the data used in this oversight function? Consider this: one

of the factors State regulators look at is the number of health care

providers in the provider network. The managed care organizations

providing the dental health services report this number to the

Maryland Department of Health and Mental Hygiene. Now, according to Maryland, between 2005 and 2006 the number of dentists

serving the Medicaid population in Prince George’s County increased from 162 to 360 providers. In Deamonte Driver’s case,

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there were 24 dentists in all of Prince George’s County, according

to the directory published on the Web site of United Health Care.

In preparing for this hearing, I directed my staff to do a spot

check of dentists listed in United Health Care’s provider network.

Of the 24 dentists that they called, 23 of the numbers were either

disconnected, incorrect, or belonged to a dentist who does not take

Medicaid patients. The 24th dentist did accept Medicaid patients,

but only for oral surgery and not for general dentistry. Effectively,

none of the 24 numbers listed would have been of any use to

Deamonte Driver.

The regulators who use MCO-provided data would have believed

that the number of dentists that could have served Deamonte was

24, because that is what United Health Care would have told them,

but the real number is zero.

The case of Deamonte Driver raises a question we are considering in today’s hearing: do the figures used by Government and for

government oversight accurately reflect the accessibility and utilization of dental care?

We will also consider the role played by the Centers for Medicaid

and State Operations [CMS]. The Federal Government provides

half or more of Medicaid funding to every State. It is the function

and responsibility of CMS to ensure that money is being spent effectively to provide dental care to Medicaid eligible children.

CMS uses the form 416 to ensure that children receive dental

care as mandated by the Social Security Act. Although the form

416 is the only oversight mechanism used by CMS to ensure compliance with the act, not all States submit their form 416s annually. One of the witnesses today will testify even when the form

416s are submitted, the data may not be reliable or informative.

Form 416s do not tell us why utilization rates are low, how many

children received adequate and appropriate care, how many of the

children that received the screening received preventative or restorative care for that screening, how many dentists are providing

the care for children, and they don’t tell us whether or not a handful of benevolent dentists are providing the care that should be

spread across a broad network of providers. All the form 416s tell

us is how many children are enrolled in Medicaid, how many of

them receive a screening, how many receive preventative care, and

how many receive restorative care.

Our hearing will afford us the opportunity to ask how can we

confirm that dental care and Medicaid is adequate if the only information available to us is either incomplete, unreliable, or both.

We know even less about Medicaid managed care organizations.

Managed care organizations don’t complete the form 416s. They

only report to the States. All of the data the MCOs report is created by the MCOs, themselves. This is concerning, since 47 States

and the District of Columbia enroll some or all of their Medicaid

populations in managed care.

In 2004, managed care provided benefits for approximately 60

percent of Medicaid beneficiaries nationwide. How do numbers reported by Medicaid managed care organizations and overseen by

Federal agencies reflect the reality of access to and availability of

dental care? What do these statistics really mean? What do they

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tell us about children’s dental care? Do we know enough to prevent

another tragedy like Deamonte’s?

Medicaid’s inability to provide adequate dental care to children

has been known since at least 2000, when the U.S. Surgeon General published his report. At the time of the report’s publication,

Deamonte was only 5 years old.

A year later, on January 18, 2001, when Deamonte was 6 years

old, the former Director of the Center for Medicaid and State Operations issued a Dear State Medicaid Director letter. These letters

are often used by CMS to provide information, guidance, and direction regarding Medicaid policy. In that letter, the Director requested information on State efforts to ensure children’s access to

dental services under Medicaid.

The January 18, 2001, letter indicated that HCFA, presently

known as CMS, would undertake intensive oversight of States

whose dental utilization rates, as indicated on the HCFA 416 annual reports, were below 30 percent, including the site visits by the

regional office staff. States between 30 and 50 percent would be

subject to somewhat less stringent review.

This letter was written 6 years before Deamonte’s tragic death,

at a time when something could have been done to save him. Significantly, Maryland was among the 15 worst performers. In 2005,

the date of the most recent documentation, Maryland had just

climbed out of the lowest category.

That raises the question: would Deamonte’s fate have been any

different if CMS had subjected Maryland to a stringent review in

2001, as indicated by the January 18th letter? Was a critical opportunity lost to save a boy’s life?

This is not a case of an unfortunate boy fallen through the

cracks, since the majority of Medicaid eligible children do not receive dental care. Rather, it is a tragic consequence of a system

that creates a captive population for managed care organizations

and allows managed care organizations to report on themselves to

Government regulators. This is a system that puts profit above

people.

A little boy died for lack of a dentist. A dental screening would

have only cost the managed care organization in which he was enrolled about $15. Taxpayers paid the managed care company about

$4,800 over the course of the last 5 years of Deamonte’s young life

to provide him with a dentist and routine screenings that he obviously never received. The managed care company’s parent retained

about $12.5 billion in net profits during the same period.

[The prepared statement of Hon. Dennis J. Kucinich follows:]

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Mr. KUCINICH. Mr. Issa, you are recognized for a statement.

Mr. ISSA. Thank you, Mr. Chairman.

I would ask unanimous consent that all members of the committee be allowed to include their statements and extraneous material

into the record.

Mr. KUCINICH. So ordered.

Mr. ISSA. Thank you, Mr. Chairman.

Now I will be brief, because there is a vote on, but I think it is

important to, first of all, thank you for holding this hearing today.

It is very clear that we do have a crisis within an existing system.

Little Deamonte’s death is not anecdotal. It may be one of the few

deaths, but it is just the tip of the iceberg of people who have losses

in the quality of life and probably in many cases in the length of

their life.

The absence to have good dental care and preventive maintenance early on in life reduces both quality and longevity. It leads

to early loss of teeth. Obviously, the abscesses, the other diseases

can often be devastating, sometimes fatal. The loss of the bone due

to tooth loss can lead to a number of other problems later in life.

It is clear that, although we were well meaning in the establishment of a Medicare system that relies on private health care, that

over the years, as public health institutions and public health doctors have been replaced by for-profit private systems, that we have

not held them accountable to the highest level.

The death of young Deamonte Driver is one of those tragedies

that had no bad actors. We cannot look at malice or any wrongdoing of any of the individuals involved. What we can look to is a

system that did not hold all of those involved to a standard that

would have prevented this.

I, for one, recognize through my own life experience and those of

my employees over the years, that, unlike health care, in general,

which you may or may not need, you need preventive dental care

from the time your first tooth comes in until the time you breathe

your last breath, and if you do not have it, both the quality and

length of life will be diminished.

So, unlike other areas of health care that you may or may not

go for a period of time and feel that I don’t know what is happening but I am probably OK, every absence of a tooth cleaning, every

absence of a timely inspection leads to the kinds of problems that

we saw here with young Deamonte Driver.

Maryland, with only 16 percent of its 5,500 dentists participating, certainly is a poster child for this problem, but, Mr. Chairman,

I commend you for bringing this to national attention. This is a national tragedy. It is one that can only be solved by fundamental

oversight and reforms in the system.

I commend you for bringing this beginning of the process here

today. I look forward not only to this hearing but to real reform

and real legislation to make sure that preventive dentistry becomes

part of overall health for all of us in America, but particularly for

those who cannot afford it on their own.

With that, I yield back.

Mr. KUCINICH. I want to thank the gentleman for his spirit of cooperation. I appreciate the spirit of your statement.

10

Without objection, the Chair and ranking minority member will

have time to include extraneous materials in the record. Without

objection, Members and witnesses may have 5 legislative days to

submit a written statement or extraneous materials. And without

objection we will be joined on the dais by Members not on our committee for the purpose of participating in this hearing, making

opening statements, and asking questions of our witnesses.

I think at this point what we will do is take a brief recess of

about 20 minutes. We will take a recess of 20 minutes. We are

going to vote. We will be right back.

Thank you very much.

[Recess.]

Mr. KUCINICH. The committee will come to order.

This is a meeting of the Domestic Policy Subcommittee of the

Oversight and Government Reform Committee. The topic for today’s hearing is Evaluating Pediatric Dental Care under Medicaid.

I am Dennis Kucinich, chairman of the committee.

At this time I will ask if any other Member seeks recognition to

make an opening statement.

Mr. CUMMINGS. Mr. Chairman.

Mr. KUCINICH. Mr. Cummings of Maryland.

Mr. CUMMINGS. Thank you very much, Chairman Kucinich. I

take this moment to express my sincere gratitude to you for taking

an interest in this important issue and agreeing to host this hearing today before the Domestic Policy Subcommittee.

Your staff had the tremendous task of organizing this hearing,

and I thank them for their efforts.

I requested this hearing to investigate critical breakdowns in the

Federal Medicaid program which have left so many children unable

to access the dental care services that they are entitled to by law.

I emphasize that—entitled to by law.

Many of you in this room will be familiar with the name of

Deamonte Driver. It is for him and other children who find themselves similarly situated that I requested this hearing.

For those of you who are not familiar, allow me to explain.

Deamonte Driver was a 12 year old boy from my home State of

Maryland who died on February 25th when a tooth infection spread

to his brain. A routine dental checkup might have saved his young

life, but Deamonte’s family was poor and they did not have access

to a dentist.

When I read Deamonte’s story in the Washington Post, I was

shaken and shocked. I asked myself, how could this happen in the

United States of America, a country that sends folks to the moon.

How could this happen? How in the 21st century, with all the resources available to us, did we thoroughly fail this little boy?

I often say that as adults we have a responsibility to provide for

and protect our children. Here, ladies and gentlemen, we simply

failed to meet those responsibilities for this young man.

I think we all should be ashamed by that fact. I know I am. But

shame will not correct the situations that allowed this young man

to die an early death. That is why I have made it a commitment

to attack the issue of insufficient access to dental care from every

single angle.

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In the weeks leading up to this hearing, my staff and I have met

with patient advocates, dentists, dental organizations, health care

providers, and Government officials to fully comprehend the scope

of this problem. I have joined my colleagues in reintroducing the

Children’s Dental Health Improvement Act of 2007, H.R. 1781, and

in working to ensure that dental coverage is included in the forthcoming State’s Children’s Health Insurance Program [SCHIP], reauthorization.

I have also worked with my colleagues on the House Armed

Services Committee, Personnel Subcommittee, to request a Government Accountability Office study to examine the quality of dental

care provided to our troops and the effects of that care on readiness.

Poor dental health is a leading cause of delayed deployment, and

for many of these troops dental problems, that is right, began when

they were children.

Through our work I have become acutely aware of the barriers

facing Medicaid patients who seek dental care. More and more,

dentists are not accepting Medicaid insurance because it pays only

$0.20 to $0.35 on the dollar. Further, Medicaid patients are more

likely to cancel appointments, and the paperwork burden is large.

Finally, I know also that there is a shortage of dentists capable

of doing this work. Many dentists are uncomfortable treating the

sort of complicated cases presented by Deamonte and others who

have not had regular access to care.

The University of Maryland Dental School, the only dental school

in the State of Maryland, graduates just three pediatric dentists

per year. But our purpose today is not to address the issue of access to dental care. That is a role better played by the authorizing

committees. Today we will investigate the systematic failures of the

Centers for Medicaid and Medicare Services and its State partners

to comply with the section 1905(R)(3) of the Social Security Act,

which ensures that every Medicaid eligible child will have access

to medically necessary dental care under the early periodic screening, diagnostic, and treatment, or SDSDT, provision.

We know that this service was not extended to Deamonte Driver.

Evidence suggests that he is certainly not alone. I think it is worthwhile to take another look at the chart the chairman just put up.

As this chart indicates, of the 24 dental offices listed as Medicaid

providers in the State of Maryland that the committee staff called,

23 were disconnected, incorrect, or belonged to a dentist who does

not take Medicaid patients. The 24th was an oral surgeon, not a

dentist.

At my request the majority staff of the committee has prepared

an analysis of the alterations of the guide created by a leading pediatric dentistry organization to Children’s Dental Care and Medicaid.

I ask unanimous consent, Mr. Chairman, that this analysis be included in the record of today’s proceedings.

We must do everything in our power to identify what went wrong

and to fix the broken system not yesterday but now. I simply cannot and we cannot allow another child to suffer Deamonte’s fate.

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I look forward to the testimonies of today’s witnesses and again,

Mr. Chairman, I thank you so very much for acting on this so expeditiously and so thoroughly.

With that, I yield back.

Mr. KUCINICH. I thank the gentleman. Without objection, the information that you requested be included in the record will be included. So ordered.

The Chair welcomes and wishes to recognize for purposes of an

introduction Mr. Sarbanes.

Mr. SARBANES. Thank you, Mr. Chairman. Thank you for holding

the hearing.

Thank you to you, Congressman Cummings, for requesting a

hearing, and thank you for your continued incredible leadership on

behalf of the State of Maryland.

I wanted to join you very briefly this morning to join you in welcoming one of the witnesses today, Laurie Norris. I had the opportunity to work with Ms. Norris for 7 years when I was on the board

at the Public Justice Center in Baltimore. I know of her good work.

I know of her incredible skills as an advocate and a lawyer, particularly on behalf of under-served families and communities and

children. I know that her testimony today will be compelling, and

I expect wrenching at times, but it is incredibly important.

I thank you again for the opportunity to join in welcoming her

today.

Thank you.

Mr. KUCINICH. I thank the gentleman.

The subcommittee will now receive testimony from the witnesses

before us today.

I want to start by introducing our first panel.

Ms. Laurie Norris, I want to thank you very much for your presence here.

Dr. Frederick Clark has practiced dentistry in Prince George’s

County for the past 17 years. Dr. Clark has served on the State of

Maryland Oral Health Advisory Committee. He has also served as

a member of the HeadStart Advisory Committee.

Welcome.

Dr. Norman Tinanoff is a practicing pediatric dentist in Baltimore and is a professor and chairman of the Department of Health

Promotion and Policy at the University of Maryland Dental School.

Dr. Tinanoff has authored over 50 articles concerning preventing

dental care carries and oral health access in under-served child

populations. Before joining the University of Maryland, Dr.

Tinanoff was the director of the Pediatric Dentistry Graduate Program at the University of Connecticut’s Health Center for 16 years.

Dr. Tinanoff has also served at the Army Institute of Dental Research at the Walter Reed Army Medical Center.

Welcome, Doctor.

It is the policy of the Committee on Oversight and Government

Reform to swear in all witnesses before they testify, and I would

ask the witnesses to please rise and raise your right hands.

[Witnesses sworn.]

Mr. KUCINICH. Let the record reflect that the witnesses answered

in the affirmative.

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I ask that each witness now give a brief summary of their testimony, and to keep the summary under 5 minutes in duration. I

want you to bear in mind that your complete statement will be included in the hearing record.

Ms. Norris, you will be our first witness. At this point we welcome your testimony. Thank you.

STATEMENTS OF LAURIE NORRIS, STAFF ATTORNEY, PUBLIC

JUSTICE CENTER; FREDERICK CLARK, D.D.S, DENTIST,

PRINCE GEORGE’S COUNTY, NATIONAL DENTAL ASSOCIATION, MEMBER; AND NORMAN TINANOFF, D.D.S, CHAIR, DEPARTMENT OF PEDIATRIC DENTISTRY DENTAL SCHOOL,

UNIVERSITY OF MARYLAND

STATEMENT OF LAURIE NORRIS

Ms. NORRIS. Thank you, Chairman Kucinich and members of the

committee. I have the pleasure to be here today, but the sad duty

of telling you the story of Deamonte Driver and his family.

I assisted Deamonte’s mother in trying to get dental care for her

children. Let me just briefly summarize what happened when I

tried to do that.

Deamonte was the third of five children in his family, all boys.

They were born and raised in rural Prince George’s County, MD.

They were at high risk for dental disease because they were a lowincome family, and Deamonte especially because he was a laterborn child. He was the third child in the family.

All children in the family had a medical home. They all had a

pediatrician that they could go to for regular childhood illnesses

and immunizations, but none of the children in the Driver family

had a dental home. They did not have a primary care dentist to

look after their preventive dental care needs, their regular checkups, or dental education.

As we have heard, Deamonte was 12 years old. During the

course of this story, Deamonte had a younger brother, DeShawn,

who was 10 in the summer of 2006, and I really want to start with

him.

All the boys were enrolled in United Health Care Medicaid managed care. In the summer of 2006, DeShawn started to experience

dental pain and swelling, and his mother worked to find a dentist

to treat him. And she was successful. She did find a contracted

dentist through United and took DeShawn to the dentist, but the

dentist refused to treat DeShawn because he wiggled too much in

the chair. She sent him away and she didn’t help the mother find

another dentist to treat DeShawn. The mother tried, but was unsuccessful in finding another dentist, and so she called me in September 2006.

I agreed to take the case and to help her out, and I called United

Health Care directly to try to find a contracted dentist, and they

referred me to Dental Benefit Providers, which is their dental subcontracted administrator. The DBP folks sent me a list of contracted dentists in DeShawn’s geographic area, but they warned

me to check first to see if the dentist still accepted United Health

Care, because they said a lot of the dentists had recently dropped

the contract.

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I had my administrative assistant start at the top of the list. She

called the first 26 names on the list and none of them agreed to

take DeShawn as a patient because they said they didn’t accept

that insurance.

So at that point I called the State Agency Department of Health

and Mental Hygiene. They have a help line. I called there and

eventually, through their case management unit and the Prince

George’s County local Health Department, and assistance from

United Health Care, we did find a dentist for DeShawn in October.

It took one mother, one lawyer, one help line supervisor, and three

case management professionals to make a dental appointment for

one Medicaid child.

But finding the dentist was just the beginning. DeShawn saw

this dentist on October 5, 2006 and learned that he needed to have

six teeth pulled. DHMH assisted with finding an oral surgeon, but

the first available appointment was November 16th, 6 weeks later.

DeShawn went to that appointment. It was a consultation. No

treatment was given.

A December appointment was set. The dentist canceled that appointment. A January appointment was set. The dentist canceled

that appointment, too, because he said by then he had dropped the

plan.

So DeShawn still has six rotten teeth in his mouth, no dental

treatment. It is now 6 months later.

DHMH located a third oral surgeon and a first appointment was

set for February 7, 2007, and DeShawn did have his first tooth

pulled. That dentist recommended that DeShawn have one tooth

pulled each month for the next 5 months.

So let’s go back to Deamonte for a minute now. Deamonte had

not complained of any dental problems. Nobody in his family knew

that he had dental issues. He did begin experiencing severe headaches and he was diagnosed with a sinus infection in early January

2007. On January 12th, he was rushed to the hospital, had emergency brain surgery, and 6 weeks later, as we have heard, he

passed away.

Now, DeShawn eventually did get all six of his teeth pulled, but

that was only because he transferred his care to the University of

Maryland Dental Clinic, Dr. Tinanoff’s clinic, and was expeditiously taken care of, and so we still have DeShawn with us today.

I hope it is obvious that if we substitute the name Deamonte for

DeShawn in DeShawn’s story, the result is the same. Deamonte

would still have had his brain infection. It took 7 months for Ms.

Driver to get treatment for DeShawn, even though she was actively

seeking it and doing everything she could think of to access that

care.

As we have heard, Deamonte and DeShawn are not exceptions.

I will just close by saying that at the Federal level it seems to

me that there has been a toleration for gross under-performance by

the States in providing oral health to our children, and that just

needs to stop.

Thank you, Chairman.

[The prepared statement of Ms. Norris follows:]

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Mr. KUCINICH. Dr. Clark, thank you. You may proceed.

STATEMENT OF FREDERICK CLARK

Dr. CLARK. Thank you very much, Chairman Kucinich, members

of the committee. Thank you for inviting me to testify today.

Mr. KUCINICH. Dr. Clark, before you begin, I want to note that

we have been joined by the distinguished Congresswoman from

California, Congresswoman Watson.

Dr. CLARK. My name is Dr. Frederick Clark. I have been a practitioner in Temple Hills, MD, Prince George’s County, for some 17

years. I am a dental health care advocate.

I am here today because a child in my county and in my city in

Temple Hills, MD, lost his life because he couldn’t receive dental

care in a timely manner. I am here to provide my personal perspective on problems related to access to care for children in the Medicaid program, and those who are uninsured and barriers that may

exist in Prince George’s County.

I feel that one of the primary barriers to access is lack of adequate participation by private dental offices in the Medicaid program. Prince George’s County has approximately 43,000 to 50,000

child Medicaid participants. Some 200 dental offices are listed as

providers, according to the Prince George’s County Health Department, but when those offices were contacted to check on their participation, only 25 percent of those offices would see a child Medicaid patient.

With this disproportionate ratio of patients to providers, it is virtually impossible for a parent to find a dentist to treat a child’s

dental concerns. Why does this disparity exist? There are many

reasons, but some cited were, of course, low reimbursement rates

for dental services, inability to receive timely payments for services

rendered, inadequate network of specialists in which to refer difficult cases, poor communication between dental providers and the

managed care organizations, interference with the doctor/patient

relationship, difficulty in the credentialing process, and high broken appointment rates amongst Medicaid patients.

For years dentists have had difficulty participating in Medicaid

programs, even before the plans were taken over by managed care

organizations. Some of the same complaints existed for years, resulting in refusal by many offices to participate in Medicaid. HMOs

and MCOs have created a new landscape in which the medical field

has had to adapt, but the changes have not been favorable to doctors.

The way managed care plans are structured inherently create an

antagonistic relationship within the medical and dental communities due to fee setting, low co-payment by patients, non-negotiation with the providers of care to provide payments, and low capitation rates.

The combination of managed care plans and Medicaid makes an

unpalatable mix that most doctors refuse to have any part of.

At the treatment level, there is a silent scream which we in the

treatment community hear on a daily basis. At Ground Zero there

is a constant inundation of phone calls of patients attempting to acquire appointments. Parents report of calls to numerous offices and

inability to receive appointments. There are reports of children in

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pain, children with abscesses. When children can be seen, there

may be three, four, five children in a single family, all of whom

have a number of cavities and dental disease.

Sometimes they can be treated if a child is manageable, but if

they are not the search begins for a pediatric dentist, which is almost impossible to find. A search through our local Yellow Pages

revealed that there were only four listings for pediatric dentists in

a county which has 800,000 residents and 50,000 child Medicaid recipients.

I have served this Medicaid population, in spite of problems of

low compensation, and in some instances refusal to be paid. I grew

up in south central Los Angeles as a poor child, and I feel a commitment to treat these children who know that if I were not there,

there would be no one to serve them, there may be no one to serve

them.

The patients who pay for services allow me to treat some of the

patients who have little or nothing. Pro bono care is a part of the

norm in our community. This also occurs in treatment of adults

who are indigent.

Dental Medicaid dollars ultimately are allocated to ensure that

poor children are able to receive desperately needed health services. The managed care role in this process is to create the network

of providers and set up a compensation structure that ensures that

the process works.

My primary concern is that Medicaid dollars should go the Medicaid treatment and as little as possible to administrative costs.

This program was not set up for someone to profit off the backs of

children. I do not begrudge a for-profit business making Native

American profit, but this program was designed to help children

and should be run as a nonprofit organization with open books, so

that the bottom line of the business is not the primary concern.

I am not in a position to say if the managed care organizations

have anything to hide, but obviously the fees are still too low to

encourage private dental office participation in Medicaid.

Thank you very much.

[The prepared statement of Dr. Clark follows:]

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Mr. KUCINICH. We thank the gentleman.

Dr. Tinanoff.

STATEMENT OF NORMAN TINANOFF

Dr. TINANOFF. Chairman Kucinich and members of the Subcommittee on Domestic Policy, thank you for inviting me here

today to discuss the issues of oral health care for poor children, especially the situation in Maryland.

I would like to give you my perspective on how, in one of the

richest States in the country, Medicaid can fail our most vulnerable

children, as evidenced by the most recent tragic death of a child

due to a dental infection.

In 1997, access to oral health care for Maryland’s poor children

was the worst in the country; however, there has been incremental

progress made, primarily through the enactment of Maryland State

legislation championed by key legislators and promoted by oral

health advocates. Nevertheless, much more progress is needed, as

many Maryland children still suffer from pain and infection from

oral conditions and parents continue to struggle to find dental providers to get the needed reparative services for their children.

I am going to give you an analysis of some of the oral health care

issues in Maryland and compare these to the several Maryland Department of Health and Mental Hygiene’s—that is DHMH—reports.

The DHMH October 2006, report lists 918 unduplicated Medicaid

providers. A more realistic calculation of the actual providers may

be generated from direct calling of those dentists who are on the

provider list who ask the question, will you take a new Medicaid

patient? Using this method, the following information was obtained

from 748 of the listed 918 providers. This table shows that there

is perhaps only one-fifth the actual number of listed Medicaid providers who will see a new patient.

DHMH’s 2006 report also lists a number of children receiving

dental services counting only those children ages 4 to 20 who have

been enrolled for at least 320 days. However, the April 2005, report

of the National Oral Health Policy Center mandates that States

use form 416, which requires counting total eligible children. This

table compares, for 2005, the number of children enrolled in Medicaid and the percent receiving any dental service, as reported by

Maryland’s DHMH and as reported by CMS’s form 416.

Additionally, the last columns show the ratio of dental providers

to enrollees for 2006, as reported by DHMH. This should be dentists, not children. With this, it shows that with DHMH they report

one dentist for 439 children. Yet, if one uses the total eligible number of children that is in form 416 per the number of providers,

those willing to accept a new patient, the ratio would be about one

dentist for every 2,500 children, exceeding the ratio of 1 to 2,000

as required by Maryland law.

In 2001 DHMH conducted town meetings to assess issues regarding the Medicaid system. Although these meetings concerned total

health care in the system, reports from those who attended these

meetings indicated that most of the discussions focused on lack of

access to oral health care. However, of the four quality reports of

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managed care published by DHMH in 2005 and 2006, only one of

118 pages of these reports addresses oral health care.

It is difficult to appreciate why these reports essentially do not

include oral health care issues, since access to oral health care has

been a continued concern in Maryland for so many years.

Although the reimbursement rates for 12 selected restorative

procedures were increased in 2003, most of the rates for procedures

still are far below what the dentist will accept. The American Dental Association survey of March 2004, ranks Maryland as 39th out

of 50 States regarding reimbursement rates for diagnostic and preventive procedures. Incredibly, this report lists Maryland as the

worst State in the country for reimbursement rates for restorative

procedures.

An illustration of this problem is the current reimbursement rate for dental sealings. Maryland Medicaid pays $9 per sealing, whereas the 50th percentile for dentist fees in Maryland for sealing is

$40. It is unreasonable to expect a high number of dentists to participate in Medicaid when their rates do not cover their overhead

costs and do not equal an acceptable discount rate for dentist participation.

Furthermore, paperwork, red tape issues, and no-show rates are

frequently cited by dentists as reasons for not participating in Medicaid.

Oral health care for children in Maryland Medicaid continues to

be inadequate. Part of this inadequacy may be the result of reporting efforts that may mask the severity of access issues. Inaccurate

reporting frustrates parents and health care workers seeking care

for their children and adversely affects decisions of policymakers.

In summary, oral health care in Maryland Medicaid needs improvement and closer scrutiny as children with untreated dental

problems continue to suffer from pain and infection and morbidity.

Thank you for your attention and for your interest in oral health

care for poor children.

[The prepared statement of Dr. Tinanoff follows:]

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Mr. KUCINICH. Thank you, Dr. Tinanoff, Dr. Clark, Ms. Norris.

We are now going to proceed with questions from Members of Congress.

I would like to begin with Ms. Norris. In your practice have you

heard from other patients of Medicaid eligible children who have

trouble finding dental care for their children?

Ms. NORRIS. Yes, Mr. Chairman, I have heard from quite a few

families that have had trouble finding dental care. They complain

that the provider lists are inaccurate. They complain that they

have to call many, many dentists before they find one who is either

contracted or will accept a new patient. They complain of having

to wait many months for an appointment. Sometimes they have to

drive very long distances to see a dentist, sometimes more than an

hour, sometimes across the Bay Bridge. We have strange geography in Maryland and we have part of our State that isn’t really

connected to the rest of the State. I even had one family tell me

that they had an appointment and they drove an hour-and-a-half

to get to the appointment and they were turned away at the door

with no explanation.

So I have heard many, many stories from many parents, and this

is really an endemic problem.

Mr. KUCINICH. The information I presented at the beginning of

this hearing, where I pointed out that the staff of this committee

called 24 dentists, 23 numbers disconnected or incorrect, belonged

to a dentist who did not take Medicaid patients, 24th didn’t accept

Medicaid patients or did accept but only for oral surgery, not general dentistry, and that effectively none of the 24 numbers listed

would have been any use to Deamonte. Do you find this consistent

with your own experience?

Ms. NORRIS. Yes, very much so. The dental provider lists are absolutely unreliable.

Mr. KUCINICH. Now, given your understanding, Ms. Norris, of

why Medicaid eligible children have not been able to access adequate and appropriate dental care and Medicaid, what changes

would you recommend?

Ms. NORRIS. Well, the first thing is, as I mentioned before, the

tolerance of the gross under-performance of the State agencies. I

think that if CMS were to exercise its statutory right to sanction

States financially for failing to perform in this area, that would

light a fire under the States and encourage them to reform.

Mr. KUCINICH. So we are talking in terms of increased oversight

by CMS of dental access in State Medicaid programs?

Ms. NORRIS. Absolutely. Yes, Mr. Chairman, that is absolutely

critical to fixing this problem.

Mr. KUCINICH. Thank you very much.

Dr. Clark, you mentioned that in order to see Medicaid patients

a dentist must be willing to subsidize the patient’s treatment. Why

is that the case, and why do you think reimbursement rates for

dentists are so low?

Dr. CLARK. Well, I think that if you are going to be treating a

population of people as large as we have in Prince George’s County,

that you are invariably going to run across children who don’t have

access to care, and you are not going to be compensated at the rate

that you would with patients who have insurance or pay out of

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pocket. So basically what goes on is, as was mentioned, they are

paying between 20 and 25 cents on the dollar. So any time you

take any number of patients under Medicaid that you are treating,

you are going to be subsidizing their care, based on the fact that

there are other patients who pay for their services.

Mr. KUCINICH. So why do you think the reimbursement rates are

so low? I mean, your experience is probably similar to others, except that you make sure these kids receive help.

Dr. CLARK. Well, traditionally the Medicaid reimbursement rates

have been low, even before managed care got involved with the

process, so there has never been an effort on the parts of those who

fund dentistry for Medicaid or for under-served populations to actually pay the cost of what the service truly is. I think part of that

comes from the fact that there is not a participation by the dental

community to help aid in setting fees that is being listened to by

those who have control over that.

Mr. KUCINICH. Thank you.

Dr. Tinanoff, you explained that you obtained your data from

making individual calls to dentists in Maryland. Have you ever requested the same data from the State Medicaid agency to avoid the

trouble of making all those calls? And what type of response did

you get for your request for data?

Dr. TINANOFF. I specifically didn’t ask them to do that type of

analysis, but for some time I have been trying to work with them

to try to solve some of these issues by collecting data. Not until just

very recently, maybe in the last week, was I given new data that

will help us analyze and understand the situation much better in

Maryland.

I think that Maryland Medicaid would benefit greatly by working

with people outside their agency to analyze their data and help

them to analyze the problem. Part of the problem that we see here

is that the data that is being presented to policymakers and legislators is presented in a way that doesn’t excite legislators to put

any more money into the budget. Currently, the dental component

of the Maryland Medicaid budget is only 1 percent.

Mr. KUCINICH. Thank you, Doctor. I just was informed by staff

that you did receive data this week from Maryland; is that right?

Dr. TINANOFF. Yes.

Mr. KUCINICH. OK. The Chair will recognize Mr. Cummings.

Again, Mr. Cummings, this subcommittee owes you a debt of gratitude for not just calling this to our attention but for urging this

hearing today. I was more than happy to comply. Please proceed.

Mr. CUMMINGS. Thank you very much.

I want to just pick up where the chairman left off. The data that

you received, what did that data say?

Dr. TINANOFF. Excuse me?

Mr. CUMMINGS. He just asked you about some data that you just

received this week. What did the data say?

Dr. TINANOFF. I haven’t had a chance to analyze it because it is

an enormous amount of data. It breaks down all the procedures by

all the different types of dental procedures versus age, so it is

pages and pages of data. It will take me some time to understand

it.

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Mr. CUMMINGS. Would you provide us with your conclusions at

that point where you are able to come to some, please?

Dr. TINANOFF. I would be happy to.

Mr. CUMMINGS. I want to just thank you very much, chairman.

I want to go to you, Ms. Norris, and, as you know, Federal law

mandates that every Medicaid eligible child will have access to

medically necessary dental care under the early periodic screening

diagnostic and treatment or EPSDT provision. What is your assessment of that provision and how it is carried out?

Ms. NORRIS. Well, the provision——

Mr. CUMMINGS. So that means that every child should be able to

get treatment.

Ms. NORRIS. Well, each State sets its own dental periodicity

schedule, and what that means is each State is required to say how

frequently a child is supposed to get dental care and at what age

they are supposed to begin.

Maryland does have a periodicity schedule that starts at age 1

and provides for 6-month visits every year up until age 20.

Mr. CUMMINGS. So you are saying that a child in Maryland

should be getting some type of dental screening starting at age 1?

Ms. NORRIS. Yes.

Mr. CUMMINGS. All right.

Ms. NORRIS. It looks good on paper. The problem is that periodicity schedule exists in the pediatrician’s section of the manual, and

the pediatricians don’t do this work. There is no requirement for

dentists to actually do this work and there is no oversight of

whether dentists have actually done this work, so nobody is doing

it, and nobody is noticing that nobody is doing it.

Mr. CUMMINGS. That is deep. So, in other words, you have a provision and everybody is either assuming that they are not doing it

or that they are doing it and nobody is doing it?

Ms. NORRIS. Nobody is doing it. Part of the reason why nobody

is doing it is nobody is looking to see if anybody is doing it, and

another reason is because we don’t have the dentists. We don’t

have sufficient dentists willing to see these children.

Mr. CUMMINGS. So, going back to this EPSDT provision, the

breakdown then is not with the law and the way it is written, but

is, rather, with the implementation; is that correct?

Ms. NORRIS. Enforcement and implementation. Absolutely right.

Mr. CUMMINGS. And what is the best situation for oversight? I

mean, I am sure you have thought about this many times, and if

we could give you the magic wand and say how would you deal

with oversight of this, and I am assuming that oversight you think

would go a long way as long as there were sanctions connected

with the oversight, what would your wish be?

Ms. NORRIS. Well, I think we need to actually look at whether

care is provided to individual children according to the EPSD

schedule. We need to collect data about that, which we are not

doing right now. We are just collecting data about whether a child

saw a dentist this year. So it is not nearly detailed enough.

We are also not looking at the oral health status that children

are achieving through getting all this dental care that they are not

getting.

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I think that CMS needs to change its data collection and they

need to require dentists to participate in the EPSDT reporting, not

just pediatricians.

Mr. CUMMINGS. Do you think the Centers for Medicaid and Medicare Services are doing what they are supposed to do under the

law? And you might want to answer this too, Dr. Tinanoff. You can

go first.

Dr. TINANOFF. Part of the thing that is being reported to CMS

is total number of visits, total number of preventive visits and restorative visits. Not all the States are actually doing those reports

on a yearly basis. I think it is somewhere around 35 of the States

are reporting out of the 50 States. One thing that is being emphasized, both at the State level and at the Federal level, is whether

a child has seen a dentist in the past year. I don’t know if that is

the best indicator, because in Maryland, for instance, DHMH reports 45 percent of the children see a dentist, but the actual number of children that are getting care, restorative care, is probably

close to 13 percent, according to CMS’s form 416.

Mr. CUMMINGS. I am going to come back to you. I see my time

is running out. I do want to ask this question, though. Dr. Clark

and Dr. Tinanoff, I understand that less than one-half of 1 percent

of all Medicaid spending goes to provide dental coverage. Is that

your understanding? And if that is true, do you think that is sufficient.

Dr. TINANOFF. It is less than 1 percent.

Mr. CUMMINGS. It is less than 1 percent. Let’s go with 1 percent.

That is fine.

Ms. NORRIS. OK. Nationwide, dental Medicaid is about 5 percent.

In the public sector, with regard to health care, 25 percent of

health care for children is spent in dentistry. So you can see that

Medicaid is insufficient, and in Maryland dental care is very insufficient with regard to funding.

Mr. CUMMINGS. And these are probably the folks that need it the

most.

Dr. TINANOFF. That need it the most.

Mr. KUCINICH. Mr. Cummings brings up an important point, and

I would just respectfully suggest to the members of this subcommittee that a followup to this meeting would be a discussion, a meeting with Medicare or Medicaid to talk about the role of dental care

in overall health and how they may have to start dramatically appreciating the amount of money that is spent for dental care, because, as medical science understands, there is a closer relationship to dental health than to general health and maybe what previously thought when these guidelines were first adopted.

The Chair recognizes the gentlelady from California, Congresswoman Watson. Thank you.

We have been joined by the gentleman from Maryland, Mr.

Wynn. Thank you.

Ms. WATSON. Mr. Chairperson, I want to thank you for holding

this hearing. The timing is so right to look at the policy.

What is troubling to me is that we are setting up systems that

are so dysfunctional, and you can see it when we have a tragedy

like the one we have been talking about this afternoon. We build

a bureaucracy that attempts to thwart the consumer and the paVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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tient from getting services. And why is that? Because they feel in

these programs, the Medicaid program and others, that they do not

get reimbursed enough.

I could go on all afternoon, Mr. Chairman, with another issue

that has to do with dentistry, but I am going to stick on this one.

We are finding that the ratio of patients to providers is unacceptable. We are finding that students at the medical school are not

going into dentistry because they don’t want to get into a profession where they cannot get reimbursed properly.

And then I was just thinking, I think all of our universities that

have medical schools ought to have emergency dental care, and

then we would never have to have the kind of tragic situation that

happened with Deamonte.

So I guess my question goes to the panel. And there are two

other panels, Mr. Chairman?

Mr. KUCINICH. Yes, the gentlelady is correct.

Ms. WATSON. Because I want to get into the use of mercury. You

knew that was coming, dental amalgams. I have to get into that,

because that goes along with the lower socio-economic groups and

the inexpensive cost of that one.

But panelists, how would you like to see us improve on the provisions of services through CMA so we will never have these tragedies reported to us again? And is that Dr. Tinanoff? Yes, we will

start with you.

Dr. TINANOFF. There are many things that need to be improved,

and it is a complicated question. There are Congressmen and Senators that are working on legislation as we speak. But for sure dentistry in Medicaid in Maryland and across the country is underfunded. That is the first and most important step. There are many

other steps that need to be done, but that has to be addressed first.

Ms. WATSON. Sometimes you know the answers when you throw

these questions out.

Dr. Clark.

Dr. CLARK. Yes. I think that there is a breakdown in communication between the legislature of various States and funding for Medicaid programs. My understanding is that the State of Maryland’s

dental budget is about $63 million. Of that $63 million, we don’t

know how much actually gets to the treatment end, and that is

what needs to be established.

How much is required for administrative costs versus how much

is required for treatment? I think that if $63 million is not enough,

then that needs to be expressed to our legislators to let them know,

and I think the managed care organizations have a role to say if

it is not enough money, to encourage them and say well, our budget needs to be better than 1 percent of the overall Medicaid budget.

Ms. WATSON. All right. Ms. Norris, do you know if there is a cap?

Let’s just use Maryland, since we are starting there. Is there a cap

on the cost of the overhead to provide services?

Ms. NORRIS. Yes. In Maryland I believe it is 15 percent for overhead and 2 percent for profit.

Ms. WATSON. Would adjusting that cap downward help this, or

would we put all the dentists out of business?

Ms. NORRIS. Well, the dentists are not in the business of providing care to Medicaid children yet, but I don’t think by adjusting the

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15 percent administrative cost we would put the health plans out

of business. We certainly would not. I think that is one place to

start.

I also think in Maryland there are two layers. There is the

health plan and then there is the subcontracted dental plan, so

there are two sets of administrative costs in Maryland. I don’t

know if that is true in other States. I would make two other recommendations, in addition to more money. I think more money will

help us get dental homes for all these children. All these children

need to have assigned primary care dentists so that they don’t have

to go through this red tape of finding a contracted dentist.

The other thing I would recommend—and this I think might be

able to come from the Centers for Disease Control—we need to

have a nationwide high-profile public education campaign concerning the importance of getting children into early dental care so that

the preventive end can be taken care of. I think even parents don’t

understand the importance of dental care to their children. I think

that needs to be addressed at a national level.

Ms. WATSON. Thank you so much.

Thank you, Mr. Chairman.

Mr. KUCINICH. I think that is a very valuable suggestion and one

that this subcommittee is going to certainly be instrumental in promoting in followup to this hearing.

Ms. NORRIS. Thank you.

Mr. KUCINICH. The gentleman from Chicago, Mr. Davis, has long

been active in a range of issues relating to the children of the inner

city. Congressman Davis, you are recognized.

Mr. DAVIS OF ILLINOIS. Thank you very much, Mr. Chairman.

Let me apologize to the panelists because I didn’t hear all of their

testimony because I was engaged in some HeadStart activity. That

still deals with children.

Let me thank you, Mr. Chairman, for calling the hearing, and

also let me just ask if I might have unanimous consent to put into

the record an opening statement that I had prepared, as well as

a document, Access to Dental Care for Low Income Children in Illinois.

Mr. KUCINICH. Without objection, so ordered.

[The prepared statement of Hon. Danny K. Davis follows:]

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Mr. DAVIS OF ILLINOIS. Thank you very much.

It has been my contention for a long time that dental health was

actually the step-child of health care delivery. I think that is a fundamental premise, and I think that is where we really have to

begin and start from when we look at it.

I have always been fascinated because I couldn’t quite understand it whether or not people were saying that dental health was

not as important as physical health or mental health, although we

don’t do too well with mental health, either.

Would either of you venture an opinion as to why dentistry, dental health, has had such a low place in health care delivery?

Dr. TINANOFF. Maybe I could start, Congressman. Thank you for

your interest in oral health care and your interest in HeadStart.

I just want to give you a survey that we did at the University in

2001 regarding Maryland HeadStart children. We found that 45.6

percent of the 3-year olds in HeadStart had cavities, and many of

these kids were in pain.

It escapes me why dentistry for these children is a step-child.

Many of the kids that we see are in pain. We have a significant

number that have infections. When Medicaid budgets are cut, dentistry seems like it is the first one that goes.

Mr. DAVIS OF ILLINOIS. Of course, I have never felt that Medicaid

adequately funded anything, quite frankly, in terms of maybe some

services for some professionals, but certainly not hospital care. I

mean, it certainly does not do that.

Dr. Clark, would you care to comment?

Dr. CLARK. Yes. My perspective on why dentistry does not have

a high priority is that we haven’t adequately gotten the message

across to the general public that dentistry is very important. My

perception is that the biggest concern that people have is that they

don’t need to see a dentist because there is a continual lack of perceived need. In other words, if you don’t have pain, you don’t have

bleeding, if you don’t have presence of infection which is noticeable,

there is generally, amongst most people, not a need to seek the

treatment of a dentist.

I think that if we were to engage in public health initiatives that

involved public service announcements, commercials, and education

about dentistry, if we were to listen to what is coming from organized dentistry about how we need to approach educating people,

in general, about dentistry—I don’t mean just in Maryland, I mean

in the United States and in the whole world—the attitude would

change. But as it is right now, a lot of information concerning dentistry is never disseminated to the public unless you go to a dentist, because the information that we primarily get comes from the

toothpaste manufacturers and manufacturers of mouthwashes.

They will tell you to brush and floss and see your dentist and you

are going to be fine.

But I always say to people, I say if you brush and floss and you

see the dentist, people still manage to get toothaches, they still

manage to loose teeth, they still manage to get dentures and have

root canals. So obviously there is a disease process going on which

is silent, which most people are not aware of it and we are not educating them. I think that is where we need to go to start to begin

to educate people that not treating these disease conditions can

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cause much worse problems, it can cause what happened with

Deamonte Driver, it can cause problems related to heart disease

and stroke, it can cause all kinds of deleterious health effects, but

we are not communicating that to the general public.

Mr. DAVIS OF ILLINOIS. So education is the key.

Ms. Norris, could I ask you, I mean, I have always been intrigued also by the EPSDT that most of the emphasis seems to

have been on the EPSD and virtually none on the T. I am saying

many people seem to act as though the T is not there. I am saying

States seem to act as though the T is not there. People who do the

screening and detection seem to act as though the T is not there.

And oftentimes the recipients don’t really know that they can push

the T. How do we overcome that?

Ms. NORRIS. The T is the expensive part.

Mr. DAVIS OF ILLINOIS. Yes.

Ms. NORRIS. That is the treatment. Very often the people who do

the screening and the diagnosis are not the same people who have

to do the treatment, so that involves a referral. We also do a better

job, I think, of tracking whether the screenings are being done. We

don’t collect as much data as religiously concerning the T. We don’t

watch that. I think that could help a lot if we cared about whether

the T happened and we put enough money into this system to

guarantee that the treatment could take place.

Mr. DAVIS OF ILLINOIS. Well, thank you very much. Mr. Chairman, I assure you if this committee can just do something about

this one issue over the next 2 years, it will have been worth its

weight in gold. Thank you very much for calling this hearing. I

thank the witnesses.

Mr. KUCINICH. And I want to thank Congressman Davis for saying that, because I think we have the composition of this committee

and experience on this committee to be able to make a major impact on this issue, and certainly this testimony today provides us

with incentive.

When you look at the picture of that beautiful boy there, when

you look at his face and you can see that maybe there was a doctor

there, maybe there was a lawyer there, maybe there was a legislative leader, future Member of Congress, a life that was cut short,

you really realize how serious our responsibilities are to make sure

that the Deamontes of the world who are out there who you, Dr.

Clark, have been dedicated to treating, and you, Dr. Tinanoff, have

been dedicated, and you, Ms. Norris, make sure they have access.

I mean, we really go deeply into this, so this is a good subcommittee to do that.

The Chair wants to recognize the gentleman from Maryland, Mr.

Wynn, for purposes of a statement and questions as a followup.

Mr. WYNN. Well, thank you very much, Mr. Chairman. First, let

me commend you for holding this hearing and thank you for your

kindness and generosity in allowing me to participate.

I also want to thank the witnesses for coming in. I apologize that

prior commitments prevented me from hearing your testimony, although I have been briefed and I appreciate the contributions that

you are making here today.

This young man is my constituent. This was a tragedy that devastated our community because it seems so needless, and people all

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across the country were appalled to learn that a young man died

from a problem that basically started with tooth decay, a problem

that was preventable with access to adequate dental care, and a

problem that shed light on a tremendous gap in the U.S. health

care system.

Tooth decay is the most common disease among children, one of

the most common diseases amongst children. I was amazed to find

it is five times as common as asthma.

But what I was dismayed to find is that there are Medicaid hassles or administrative problems that seem to be a barrier to care.

As a matter of fact, I heard from some dentists that they would

rather give free care than have to work through the Medicaid system, which I think is a very telling statement.

I am working on a bill with the National Dental Association, the

American Dental Association, the American Dental Education Association, the American Academy of Pediatric Dentistry to work to

develop a bill that will remove some of these barriers. But I wanted

to ask a couple of questions about some of the testimony and some

of the views of the panelists here.

I believe, Ms. Norris, you said there was a cap on overhead of

15 percent. Do you consider that to be a fair cap or realistic or realistically calculated or realistically administered?

Ms. NORRIS. I think it is fairly typical. I don’t think it is out of

range of what most managed care organizations feel they need. I

would certainly like to see less money go to administrative care. As

I mentioned before, with the double layer of the health plan and

the dental plan, I don’t know how much of the money is sucked up

in additional administrative costs because of that double layer.

Mr. WYNN. Would a lower cap reduce the number of physicians

participating?

Ms. NORRIS. If the health plans had to spend more money on

dental care and less money on administration, it would certainly

help, because more money would be going to care for the

Deamonte’s of the world. Yes.

Mr. WYNN. Now, what about the 2 percent profit cap that you referred to? What is the impact of that? Should we increase it? How

would that work?

What we are trying to get at is actually more access. What

changes would help us with access?

Ms. NORRIS. Well, we need more money in the system, and 2 percent of $63 million is $1.2 million that is going directly to corporate

profit and not going to dental care, so if there is any way we could

reduce that amount, that would be terrific.

I also think we need to set our sights a little higher than just

getting children into care once a year. I think we need to set our

sights on achieving oral health for this population, and that would

require a different set of performance measures, but I think we

need to go there.

Mr. WYNN. Dr. Clark, you are a practitioner in the county that

I represent. What is your view in terms of the Medicaid program

and why so few—I believe the figure quoted was 46—why are so

few dentists willing to participate in the Medicaid program?

Dr. CLARK. When you look at the overall expense of providing

care, if you don’t at least meet the number percentage-wise to cover

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overhead, then you are operating at a deficit. At $0.25 on a dollar

when you need $0.65 or $0.70 on a dollar is just not going to get

it. You have to hire staff to treat people. You are doing a fee for

service Medicaid plan, which means that for every dollar that you

receive you are going to have to give treatment, which means you

have to hire some staff person to pay them. So by the time you hire

somebody, whatever money you receive, you are already operating

in the red. So it is just not feasible to incorporate this into a private practice business.

Mr. WYNN. What about the administrative hassles?

Dr. CLARK. It is not just with managed care organizations, it is

with any type of third party payer. When you submit a claim for

treatment, there is no guarantee of payment. When you submit the

claim, there are occasions when the claim is sent back to you. You

may call and check on claims, and therein lies a big problem because you are dealing with an automated system, you are dealing

with time consumed just to followup on getting paid, so a lot of people don’t want to deal with the red tape of trying to followup on

something for which there is very low compensation anyway, so it

has inherent barriers just in administering the plan.

Mr. WYNN. I would like to ask the entire panel, I guess, one last

question. Would you favor more school-based programs or schoollinked programs as a way to provide greater access to care?

Dr. TINANOFF. Maybe I will start with that. There are so many

kids in the system that are not getting care that school-based and

school-linked may not be sufficient. You may not have sufficient

providers. You really have to engage the private dental community

and the public health sector, as well. One of the ways to do that

is to increase the fees to a point where dentists will accept these

fees, and if that is the case then you have a sufficient number of

providers in the system. To get that, you probably have to have a

discount rate of 20 to 30 percent of normal fees rather than where

it is right now, where in this case Maryland is one of the lowest

in the country, and that is the reason why there are so few providers that will accept the Medicaid rates.

Mr. WYNN. Actually, Deamonte’s mother was relatively conscientious in some respects with regard to getting dental care. Would a

school-based program help the children of less-conscientious parents?

Dr. TINANOFF. With a school-based program the kids will be

there for sure, but there may be a great difficulty still to find dental providers, to find dentists that would work in the school systems, so it still may not relieve the problem.

Ms. NORRIS. If I may take a moment just to say that there are

some preventive measures such as fluoride varnishes and sealants

that may be able to be done in a school setting, maybe not cavity

pulling and filling teeth, but there may be a specific role for dental

care in the schools, but it would not cover the entire territory.

Mr. WYNN. What about screening in the schools? I know my time

must be out. What about screening in a school-based program so

that the school is at least able to identify potential problems and

see what resources are available. Could that help the situation?

Dr. CLARK. A school-based program might be good in identifying

the problem, but after you identify the problem you get right back

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to the same situation of, how do you followup with treatment, and

that is where the problem really lies.

Mr. WYNN. Thank you.

Thank you, Mr. Chairman.

Mr. KUCINICH. I thank the gentleman. Again, we are definitely

going to do some followup in this subcommittee, and one of the

things, as a result of your questioning, Mr. Wynn is, there has to

be a connection also with diet, and school is not a bad place to start

that discussion, as well.

So let’s now move to our distinguished colleague, Mr. Shays from

Connecticut. Thank you, Mr. Shays.

Mr. SHAYS. Thank you, Mr. Chairman. Mr. Chairman, sorry I

missed the beginning of this hearing.

Mr. KUCINICH. We are glad to have you here. Thank you.

Mr. SHAYS. We served together as a team on the subcommittee

on National Security, and I just think this is a great subcommittee

for you, as well.

This is a very important issue. I don’t have a question to ask, but

I just want to say to start that in my State we rank at the very

bottom, Connecticut, in reimbursement, so I have doctors that work

on $0.20 on the dollar of what they would charge, and we have

hardly anyone in the State that wants to help individuals receive

Medicaid assistance.

It is beyond disgraceful. My State, frankly, it can’t be a Republican or Democratic issue because it is a very strong legislative

body that is Democratic and a Republican Governor.

I want to be on record as saying that I think there needs to be

some type of percent. Is it 75 percent of whatever the market price

is, 85, whatever, but it shouldn’t be 20 percent.

I just would like to ask you, Dr. Clark, there was mentioned earlier in your testimony, in testimony, that appointments are broken.

Is that because we are saying that clients are reluctant to use this

service and they will make an appointment casually and not keep

it? What is the problem?

Dr. CLARK. I think when you are dealing with people in socio-economic areas that may not have transportation by car, rely on public transportation or someone else to bring them to the dentist, and

you also find this population that if you call to confirm appointments sometimes phone numbers have changed or they are using

a cell phone as primary form of communication, it is just difficult

to sometimes ascertain whether or not they are going to keep an

appointment, even when you schedule it.

Mr. SHAYS. Isn’t it the other issue, though, that if you let your

teeth deteriorate so badly that you almost feel that the medicine

kills the patient, I mean, talking about five teeth being pulled. I

wouldn’t want to make that appointment no matter what.

Dr. CLARK. There is a big problem with phobias and fear.

Mr. SHAYS. Well, that is a darn scary thing.

Dr. CLARK. Yes, that is true, and that is the way the general

public thinks about it. I mean, ideally we would like to think that

we could treat every patient in a setting where we could sedate

them. This is just not realistic.

Mr. SHAYS. Right. But the point is, though, that patients don’t

really know.

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Dr. CLARK. Right.

Mr. SHAYS. I have seen people that their teeth don’t look in good

condition and you want to say why don’t you just go to a dentist,

but if you have never really gone to a dentist your worst fears are

what you think.

Dr. CLARK. Right.

Mr. SHAYS. And, frankly, there are things that I wouldn’t want

to do. I wouldn’t want to get an MRI in a little tube. I don’t know

I’d say I would rather die first, but you are not getting me in that

thing.

Dr. CLARK. I find patients don’t want to get their teeth cleaned.

Mr. SHAYS. Yes.

Dr. CLARK. They just find dentistry obnoxious. So it is the nature

of the beast. I mean, we have to deal with people who are fearful.

We have to deal with children who are more fearful than adults

are. So it is something we have to deal with.

Mr. SHAYS. Let me ask you, Ms. Norris, you handled and were

an activist for the young man’s family who passed away helping

with another child.

Ms. NORRIS. Yes.

Dr. CLARK. I wasn’t associated with that.

Mr. SHAYS. Ms. Norris.

Dr. CLARK. Sorry.

Ms. NORRIS. Yes.

Mr. SHAYS. Would you make an assessment that, when we are

talking about health care, that you would rank up as one of the neglected areas dental care as one of the higher?

Ms. NORRIS. Most certainly. Most certainly. This system is close

to impenetrable for low income parents. It is complex and there

isn’t, even when they puncture the red tape, there aren’t any dentists at the other end. It is definitely a step-child of medical care

and something needs to be done about it.

Mr. SHAYS. What I was told by the dentists, as well, is that just, for instance, cleaning teeth, they may end up paying $60 to their

assistant, and in Connecticut they get $20.

Ms. NORRIS. Right.

Mr. SHAYS. So they literally are out of pocket. It is not their time

being used.

Ms. NORRIS. Right.

Mr. SHAYS. It is literally out of pocket.

Ms. NORRIS. They are not only donating their own time that they

do see the patient, but they are out of pocket. Absolutely. And we

only have about 200 dentists in the entire State of Maryland who

are willing to participate in that, and we have 500,000 children to

treat, so it is just not working.

Mr. SHAYS. What is the overall statistic of dentists and participation? I am told it is only about 10 percent participate.

Ms. NORRIS. In Medicaid?

Mr. SHAYS. Yes.

Ms. NORRIS. Well, the State’s numbers say 16 percent, but, as

Dr. Tinanoff’s survey shows, it is much less than that.

Mr. SHAYS. I’m sorry. That was covered before.

Ms. NORRIS. Yes.

Mr. SHAYS. Thank you all very much.

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Mr. Chairman, I am really grateful you have had this hearing.

A lot of work needs to be done. I know you will seek a solution on

both sides of the aisle on this.

Mr. KUCINICH. Certainly we can rely on the gentleman from Connecticut, Mr. Shays, to participate in any of our efforts to seek a

solution.

Before we discharge this panel and go on to the next, I want to

take my prerogative as Chair to recognize a young advocate of

health care for children who just happens to be right behind me.

This is Ari Bourke, and Ari is here today on Capitol Hill advocating on a very important child health care issue. We wanted to welcome you and thank you for sitting in on this hearing, which is

about children’s health and, in particular, making sure that children have access to dental health.

Mr. SHAYS. If you would like, you can sit on this side of the aisle.

We need as many recruits as possible.

Mr. KUCINICH. It is funny how they never fail to keep recruiting.

We are so happy that you are here, Ari, and just wanted to let you

know.

Did you want to say anything about health care for children?

Mr. BOURKE. No.

Mr. KUCINICH. OK. Well, we will be your voice today. Thank you

so much. Please join me in thanking Ari for being with us today.

[Applause.]

Mr. KUCINICH. Once again, thanks to the first panel. Our staff

will be in contact with you regarding followup on some of these

issues as we continue to do the work of this subcommittee in assuring that children are going to have more access to dental health

and that we look at the systemic issues that are brought forward

by this panel and the work of the subcommittee.

On behalf of the subcommittee, we thank each of you for your attendance here, and we will now move to the second panel.

While the second panel is getting ready to come forward, this

second panel will include the Director of Health Care for the Government Accountability Office and also the Director for the Director

for Medicaid and State Operations in Health and Human Services.

I would ask staff if they could provide the appropriate name

cards, and then we will begin.

I would seek unanimous consent to enter into the record documents that relate to managed care organization Health Choice, provider agreement, American Dental Education Association, an article on Protecting Children with Acute Care Dental Needs, and a

memorandum to the House Committee on Oversight and Government Reform from Specialists in Social Education, Domestic Social

Policy Division, CRS.

Without objection, so ordered.

Mr. WYNN. Mr. Chairman, could I also ask that my statement be

included in the record?

Mr. KUCINICH. So ordered, without objection. The statement of

Mr. Wynn is included. Thank you, sir.

Thank you very much. I would like to introduce panel two.

Dr. James Cosgrove is an Acting Director at the U.S. Government Accountability Office focused on health policy issues. During

his tenure at GAO, Mr. Cosgrove has directed several studies on

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Medicaid financing and policy topics, including States’ restructuring of their Medicaid programs using 1115 waivers, use of competitive bidding to set Medicaid managed care premiums, and the implication of block grant financing for Medicaid.

In related health policy work at GAO, Mr. Cosgrove has led numerous studies on Medicare financing and policy topics that cover,

among other things, managed care, physician services, and specialty hospitals.

Prior to joining GAO in 1989, Mr. Cosgrove was an assistant professor of economics at Marquette University.

Welcome, Dr. Cosgrove.

Next after Dr. Cosgrove we will hear from Dennis Smith. Mr.

Smith is the Director of the Center for Medicaid and State Operations. In this capacity, he oversees Medicaid, the State Children’s

Health Insurance Program survey and certification, and the Clinical Laboratories Improvement Act. The Center also serves as the

focal point for all CMS interactions with States and local governments.

Mr. Smith has been the director of CMSO since 2001, and prior

to his appointment Mr. Smith served on the Bush-Cheney Transition Team as Chief Liaison to the U.S. Department of Health and

Human Services and previously served as the director of the Department of Medical Assistance Services for the Commonwealth of

Virginia.

We are, indeed, fortunate to have these two outstanding witnesses on our second panel.

To the witnesses, it is the policy of our Committee on Oversight

and Government Reform to swear in all witnesses before they testify. I would ask that you would rise and raise your right hands.

[Witnesses sworn.]

Mr. KUCINICH. Let the record reflect that the witnesses answered

in the affirmative.

As with the first panel, I ask each witness to give an oral summary of his testimony and to keep his summary under 5 minutes

in duration, to bear in mind that your complete written statement

will be included in the hearing record.

Dr. Cosgrove, thank you for being here. We will begin with you.

STATEMENTS OF JAMES COSGROVE, PH.D., DIRECTOR,

HEALTH CARE, GOVERNMENT ACCOUNTABILITY OFFICE;

AND DENNIS SMITH, DIRECTOR, CENTER FOR MEDICAID

AND STATE OPERATIONS, HEALTH AND HUMAN SERVICES

STATEMENT OF JAMES COSGROVE

Mr. COSGROVE. Mr. Chairman, members of the subcommittee, I

am pleased to be here as you discuss Medicaid’s dental care for

children. By virtue of their Medicaid eligibility, more than 30 million children from low-income families are entitled to receive both

preventive dental care and treatment for dental disease. However,

untreated tooth decay is much more common among children from

low-income families than it is among children from higher-income

families. And, as you have heard today, lack of timely dental treatment may have serious and sometimes tragic consequences.

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Medicaid dental services are required under the early and periodic screening and diagnostic and treatment, or EPSDT, program.

As the agency responsible for overseeing administration of States’

Medicaid programs, CMS has an important role in ensuring that

States comply with Federal requirements, including reporting requirements. My remarks today will describe the data that CMS requires States to submit on provision of dental services and discuss

the extent to which these data are sufficient to inform CMS’s oversight of States’ programs.

My comments are based in part on relevant reports we published

between 2000 and 2003. To the extent that we could in the time

we had available before this hearing, we updated key findings by

reviewing selected reports from CMS and researchers, and also

interviewing officials from CMS, five State Medicaid programs, and

several national health associations.

In brief, CMS annually collects State data for purposes of overseeing the delivery of dental and other required EPSDT services.

States submit these data on a form known as the CMS 416, which

captures State-level summary data such as number of Medicaid eligible children within a State to receive any dental service, a preventive dental service or dental treatment.

States are required to report information on all EPSDT dental

services provided to children, regardless of whether those services

are provided under fee-for-service arrangement or managed care

arrangement.

We reported in 2001 and found again in 2007 that not all States

submit the required CMS 416s on time or at all. We further reported that many CMS 416s were not accepted because they were

incomplete or unreliable.

Currently, seven States have not submitted their 416s for fiscal

year 2005, which were due to CMS more than a year ago, and two

States have submitted reports considered to be deficient by CMS.

We estimate that these nine States account for 20 percent of all

children enrolled in Medicaid nationwide. This finding is, however,

an improvement over what we reported in 2001. In that year we

reported that CMS form 416s for fiscal year 1999 were missing or

deficient for 30 States.

The problem goes beyond missing data, however, in 2001 we also

reported that CMS 416 data were unreliable. According to the

State and National Health Association officials we recently interviewed, the data have improved over time; however, many of these

officials stated that data reliability problems remain. For example,

they cite inconsistencies in how States report data and urge caution in using the data to compare one State to another. One official

illustrated this point by saying that some States inappropriately include oral health assessments conducted by school nurses and

other health professionals as dental exams.

In addition to data completeness and reliability issues, the type

of data collected on the 416s limit their usefulness for program

oversight.

Let me mention three key limitations. First, rates of dental services delivered to children in managed care cannot be identified distinct from fee for service. Second, the extent to which children have

received the recommended number of visits cannot be determined.

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And, finally, the data do not reveal the specific factors such as the

availability of beneficiaries to find dentists to treat them, which

may be responsible for the low use of dental services in a State.

In conclusion, I want to underscore the importance of good data

for program oversight. Accountability starts with performance

measures that are comprehensive, accurate, and transparent. Currently, the CMS 416s, while improved from prior years, fall far

short of those standards. More work needs to be done so we can

quickly identify problems, recognize and promote best practices, engage the progress of individual States in our Nation in meeting the

oral health care needs of children from low-income families.

Mr. Chairman, this concludes my prepared statement. I would be

happy to respond to any questions you have, or members of the

subcommittee.

[The prepared statement of Mr. Cosgrove follows:]

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Mr. KUCINICH. I thank the gentleman.

We will now hear from Mr. Smith.

STATEMENT OF DENNIS SMITH

Mr. SMITH. Good afternoon, Mr. Chairman and members of the

committee. It is a pleasure to be with you this afternoon.

I hope that I am helpful to you in helping you to sort out the

Medicaid system, itself, how it works, that it is a partnership with

our States. The Federal Government funds approximately 57 percent of the Medicaid program. The States fund 43 percent of the

Medicaid program on a national basis. That varies by State, which

is calculated every year by what is called the FMAP, the Federal

Matching Assistance Percentage. That changes every year.

While there is a Federal framework for Medicaid program, itself,

States have flexibility within that framework. Above the Federal

mandated eligibility groups, for example, the States can go higher

up in the eligibility groups. There are certain mandatory services

spelled out in the Federal Medicaid program. There are certain optional services that are provided for under Federal law.

States control the reimbursement rates. It is the States who set

how much they will pay their providers. In terms of dental, in particular, and services for children, all children are eligible for, as

has been mentioned earlier today, EPSDT, and therefore for all

dental preventative benefits and treatment that they may need. In

fact, Medicaid in many respects is a richer benefit package than

what you would find in your typical private insurance benefit package, as it does cover all those preventative care, as well as treatment.

In terms of Medicaid being a system, again the Federal law provides for certain rights and appeals that the beneficiary has. Those

appeals are generally heard at the State level, that they are appealed at that State level.

The managed care organizations that again have been referenced

earlier this afternoon, it is the States that contract with those

health plans. There are certain enforcement provisions that are

available to the States for health plans that do not live up to their

contractual obligations and to the requirements of the Medicaid

program, so there is an enforcement on the State side, as well.

On the Federal side, we did hear a little bit earlier today about

sanction and enforcement. Sanction and enforcement at the Federal

level against the States fundamentally means taking money away

from the States. That is the sanction that the Federal Government

has. And I think that is a responsibility that we do not take lightly.

It is a responsibility that is important to bear in mind that, in fact,

is what we are talking about. When the Federal Government is enforcing compliance, that is a financial penalty against the States.

In terms of dental, we have heard this morning—I think Dr.

Clark gave my testimony for me in terms of pinpointing the real

pressure points on the Medicaid system: low reimbursement rates,

patient education and awareness, and compliance as being the

issues, but he also fundamentally also said in his testimony the

real issue is about funding. Funding is determined by the State,

not by the State Medicaid Director but by those men and women

who get elected to make those decisions in the State capitals. They

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are the ones who set the reimbursement rates. They are the ones

who make those difficult decisions of balancing priorities. Where do

we put our dollars? Do we put them into expanding eligibility? Do

we put them into provider rates? Do we put them into more services?

The competing interests and the competing values that are

worked out at the State level really are fundamental to everything

else that you see. It all really reflects those decisions that get

made.

The EPSDT form 416, I think everyone acknowledges we have

struggled with the accuracy of what 416 tells you. Fundamentally,

it does tell you the percentages of children who had any dental

treatment whatsoever. It tells you whether they had preventative

treatment, as well, and it tells you the percentage of the children

who are in managed care organizations.

We all acknowledge, I think on everybody’s part, I think, the difficulty of moving from EPSDT reporting on 416, which really in effect reflected a fee for service environment, to where now we have

moved to the managed care environment. How do we sort that back

out?

But I would suggest that form 416 is not the only thing that has

informed us that there are issues in terms of access for Medicaid

recipients. In 1998, the State of Maryland knew it had a problem

with access. It had a Statewide effort to identify those issues. In

2000, the GAO told Congress that there is a problem with access

in the Medicaid program. States do go out. They do their own.

There are a number of reports and studies you can get, like researchers from the gentlemen on the previous panel that are going

out there and telling you, telling all of us that there is an access

problem for Medicaid recipients for dental care. They are also telling us why.

Mr. Chairman, I look forward to your questions.

[The prepared statement of Mr. Smith follows:]

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Mr. KUCINICH. Thank you very much, Mr. Smith.

Mr. CUMMINGS. Would the chairman yield?

Mr. KUCINICH. Yes, Mr. Cummings.

Mr. CUMMINGS. Mr. Chairman, I just would like to ask Mr.

Smith a few questions.

You mention in your prepared statement that your agency

partnered with experts to produce a guide to dental care, and that

this publication and community partnerships has helped get children the preventive and dental care that they need; did you not?

Did you say that in your written statement?

Mr. SMITH. In our testimony.

Mr. CUMMINGS. Yes, you did. I would like to ask you some questions about that guide.

It is my understanding that the original draft of that guide was

submitted to your agency in 2001, but that you did not publish it

until 2004; is that correct?

Mr. SMITH. I believe that is correct.

Mr. CUMMINGS. That is correct. It took you 3 years to publish a

52-page document. But, more important than the delay, the original draft of the guide and the published guide are very different.

Did you know that? Are you aware of that?

Mr. SMITH. Oftentimes reports and studies go through a number

of layers of review. Yes.

Mr. CUMMINGS. Well, someone made a lot of changes in this instance. Let me just point some of them out to you.

For instance, the original draft contained the statement ‘‘National surveys and Federal and State studies continue to demonstrate substantial disparities in both oral health and access to

services. Only a small percentage of children enrolled in Medicaid

receive safe and effective preventive measures.’’ These are the

statements that were in the original statement.

These statements make it clear that most children in Medicaid

are not getting good dental care. Someone took out these statements. Do you know why they did?

Mr. SMITH. Not offhand, sir. It is a statement I would agree with.

We know that we have access problems in the Medicaid program.

Mr. CUMMINGS. But yet still someone from your agency took out

the very statements that you now say were true. Do you understand that?

Mr. SMITH. I——

Mr. CUMMINGS. Do you know why?

Mr. SMITH. Not offhand, sir, no.

Mr. CUMMINGS. And so you do believe that most children in Medicaid are not getting good dental care; is that right?

Mr. SMITH. I think we all acknowledge that there are access

problems for children in the Medicaid program.

Mr. CUMMINGS. It gets worse. The original draft contained these

statements: ‘‘The Medicaid program is ultimately responsible for

ensuring that the child receives a complete diagnostic evaluation,

and for developing quality assurance procedures to assure comprehensive care.’’ And it goes on. This is the original statement:

‘‘State Medicaid programs are ultimately responsible for assuring

that direct referrals are made, that necessary followup and treatVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00094 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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ment services are made, and that children identified as needing

such services get to dentists’ offices.’’

These statements make it clear that the Federal and State governments are ultimately responsible for assuring that children get

dental care. But guess what—somebody took them out. Why? Why

is that, Mr. Smith?

Mr. SMITH. Again, sir, I don’t know.

Mr. CUMMINGS. You don’t know.

Mr. SMITH. I’m saying I do not remember as——

Mr. CUMMINGS. But do you agree with the original statements?

Mr. SMITH. I think this statement, again, is what I have stated

here this morning. We have a responsibility to make sure that children on Medicaid have access to those services, and access to those

services in Medicaid has been a longstanding problem.

Mr. CUMMINGS. Do you believe that the State government is not

responsible for assuring that children in Medicaid get dental care?

Mr. SMITH. I believe that the children on Medicaid have a right

to dental care and it is a responsibility that individuals who are

entitled to that care receive it.

Mr. CUMMINGS. By the way, a little bit earlier you talked about

sanctions. Has anybody been sanctioned? Any State been sanctioned?

Mr. SMITH. I have not sanctioned States for not increasing reimbursement rates. I would have to go back to see in the 40 year history whether that has been——

Mr. CUMMINGS. Sir, you——

Mr. SMITH [continuing]. A tool that the Federal Government——

Mr. CUMMINGS. But you don’t know of any sanctions; is that

right? Anybody being sanctioned?

Mr. SMITH. I have been Medicaid Director since July 2001. I can

assure you I have not sanctioned a State for the access issues in

dental care. In dental care what we have been seeing is that States

have improved their performance, and a greater percentage of children are receiving dental care than they did previously. So we do

see improvement in access. Access is still a problem.

Mr. CUMMINGS. Thank you very much.

I yield back.

Mr. KUCINICH. I thank the gentleman.

We are going to go to Mr. Shays.

Mr. SHAYS. Thank you.

Mr. Smith, I remember when I was chairing the contract that

oversees the Department of Health a number of years ago the then

Secretary of HHS actually testified before my subcommittee, and

for 2 years the Clinton administration did not move forward on a

Commission that was supposed to help ensure the safety of the

blood supply. I just remember we lost 25,000 hemophiliacs to AIDS

because of that.

Well, it was important to me, and the reason why she testified

was just trying to understand what she could do better. So I knew

her heart was in the right place. I didn’t want to rail on her for

2 years of inaction by the Department because I knew that she was

working on so many issues.

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So she came and testified and said what she is going to do, and

it was very impressive, and we licked the problem, but it existed

for a while.

I am less interested in where there is a failing right now in the

past. I am more interested to know—and I need to know where you

come down on this—how can I feel comfortable when a doctor is

only getting 20 or 30 percent of what they should get, and that we

have a fraction, anywhere from 10 to 16 percent, of the doctors participating, so there aren’t many choices of where they can go. Why

should I feel comfortable with that?

Mr. SMITH. Mr. Shays, I think that, again, I would say the decisions about what providers get paid how much money really is a

decision that gets made in the State capitals.

Mr. SHAYS. OK. That is not what I asked. That is not what I

asked at all.

Mr. SMITH. OK.

Mr. SHAYS. But why should I feel comfortable the State only

gives anywhere from 10 to 16 percent of what a doctor—first of all,

we only have one doctor basically participating, maybe two. He is

overworked. He has a waiting list of 6 months. He loses money. He

basically spends 2 days a week giving away money is what he does

because he believes in it, and he has one practice in the more affluent part of my town, in my District, and then he has another practice in Bridgeport. He would not be able to pass that practice on

in Bridgeport to anyone. No one would take it. He can’t even get

a young doctor coming out of dental school because they have large

dental costs.

So I am going to ask it again, whether or not you think you

should change it. Why should I feel comfortable with that process?

Mr. SMITH. I think the changes that you see in health care as

health care continues to evolve and Medicaid does, as well——

Mr. SHAYS. You know what the answer should be? It is a simple

one. If I was advising you before you were testifying before this

committee, it is not your fault, you could have just come and said

we shouldn’t be comfortable and we need a plan to deal with that.

I mean, I would think you would be advocating States fund this

system better and make sure doctors get—I mean, heck, they could

at least get $0.50 on the dollar. I mean, if it costs someone to pay

their employee $60 for a $20 reimbursement, they are actually taking money out of their pocket and giving it away. That is the system we have here.

The answer is I shouldn’t feel comfortable. The difference between you and the former Secretary of HHS is she would have

come here and said we shouldn’t be comfortable and we are going

to lick it.

Why I am not feeling very sympathetic toward you right at the

moment is that you don’t think there is a problem.

Mr. SMITH. I disagree that I didn’t say there is not a problem.

I think I said very clearly there is a problem with access to dental

services.

Mr. SHAYS. So?

Mr. SMITH. And the solutions, again, have been spelled out a

number of times by GAO, by——

Mr. SHAYS. But what I recommend——

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Mr. SMITH [continuing]. Many, many places about what the problem with access is.

Mr. SHAYS. The problem is that we are not paying our doctors

enough. To start with, we don’t have enough doctors in the system.

That is the problem. And the reason is they are basically being

asked to do it for less than their cost.

Mr. SMITH. Mr. Shays, if I may, in dental, in particular, Medicaid

rules allow the States to pay rates.

Mr. SHAYS. I am not arguing what they allow, but you can be an

advocate. I mean, you could be an advocate for a system that is

causing bad health care and hurting our kids and hurting our elderly, as well.

Mr. SMITH. And, if I may, I think we described some of the

things that we are doing in our testimony about trying to improve

quality of care in the Medicaid system, in terms of the different

States. There is a lot of talk about pay for performance. Medicaid

actually has been doing pay for performance in a number of States

and we are trying to help find the better models that work in

the——

Mr. SHAYS. The better model would be just to pay someone to

cover their costs. You are a government employee, aren’t you?

Mr. SMITH. Yes, sir.

Mr. SHAYS. You work, you get paid, as a government employee?

Mr. SMITH. My salary is about $165,000, sir.

Mr. SHAYS. OK. Why don’t we suggest that you work for $25,000.

Just come, and we will be fair, you get, say, 10 percent, we will

give you 20 percent, so you could make $32,000. Could you afford

to go to work?

Mr. SMITH. Mr. Shays, again, I am agreeing with your point

that——

Mr. SHAYS. You couldn’t afford to go to work at $32,000 and yet

we have doctors who are being asked to do the same thing.

Thank you, Mr. Chairman.

Mr. KUCINICH. I thank the gentleman, and his point is well

taken.

The Chair at this point is going to recognize the gentleman from

California who is the chairman of the full committee, Mr. Waxman.

Mr. Waxman, thank you.

Mr. WAXMAN. Thank you very much, Mr. Chairman.

Mr. Smith, I find it interesting that nowhere in your written

statement did you refer to Deamonte Driver or his death from untreated tooth decay. He was enrolled for many years in the program you administer. He was entitled to dental services to relieve

pain and infections and restore teeth, and he didn’t get the services

he needed, and died.

Has your agency conducted a review of this to determine what

went wrong, why, what changes are needed to be made to prevent

this from happening to anybody else who is also in Medicaid? If so,

what were your findings?

Mr. SMITH. Mr. Waxman, the tragic death of a young child, we

are certainly sorry for the loss and the family. I think there——

Mr. WAXMAN. I asked you if you did an analysis of what happened to him. Did you?

Mr. SMITH. I did not.

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Mr. WAXMAN. OK. And did anybody in your agency conduct a

critical incident review?

Mr. SMITH. I believe the regional office had discussions with the

States in terms of trying to understand what the situation was. In

terms of the individual, of course, those would be subject to any

privacy rules.

Mr. WAXMAN. You left it to the State then?

Mr. SMITH. Again, I think——

Mr. WAXMAN. Let me go into this issue of the Federal Medicaid

requirements. Federal Medicaid law requires that all children be

given both routine dental services and any necessary treatments on

a periodic basis. In 2004 the State of Maryland formally reported

to your office that only 28 percent of the Medicaid children got any

dental services at all. What action did you take when you received

that information?

Mr. SMITH. That information, as I had said earlier, is information

I think that has been known in the Medicaid program for quite

some time.

Mr. WAXMAN. But you are running the Medicaid program at the

Federal level. What action did you take?

Mr. SMITH. In terms of that particular—again, it is information

that is already known within the Medicaid program at the State

and the Federal level. There is an access problem.

Mr. WAXMAN. And you really did nothing. You received the information. For all 50 States, your own CMS data for 2004 show that

the average number of Medicaid children who got any dental services at all was 32 percent. When you heard that is what is happening in the country, even though the program promises these services, what action did you at the Federal level running this program

take?

Mr. SMITH. The enforcement tools, as I mentioned earlier, are to

sanction the State financially, and where reimbursement rates are

already low——

Mr. WAXMAN. Has CMS ever taken any action to enforce the Federal requirement that children get dental services?

Mr. SMITH. As I mentioned earlier, I have not. I don’t know if

my predecessors did.

Mr. WAXMAN. OK. While there is no minimum Federal payment

rate for State Medicaid program reimbursing for health services,

there is a statutory requirement that rates be ‘‘Sufficient to enlist

enough providers so that care and services are available at least to

the same extent they are to the general population.’’

GAO studies of Medicaid programs have repeatedly shown that

reimbursement rates for dental services are very low. Other reports

show that the overhead costs of a dental practice are about 60 to

70 percent of its billings. That means that reimbursement below

that level is actually a net loss to the dentist. You don’t expect the

dentist to take on a Medicaid patient if they are going to lose

money, do you?

Mr. SMITH. Mr. Waxman, as I have said, we believe that a variety of sources have been telling us and State legislatures and the

Congress that access is a problem in the Medicaid program because

of low reimbursement.

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Mr. WAXMAN. But if a State is reimbursing dentists at a rate

that is 50 percent of the average in the State, I assume you would

agree that the State is violating the statutory requirement about

sufficient rates?

Mr. SMITH. And, again, then it becomes an enforcement mechanism. Should I be taking money away——

Mr. WAXMAN. You agree it is a violation, then? then the question

is what you do about it? Is that what you are saying?

Mr. SMITH. That is where enforcement comes. What action do I

take against a State.

Mr. WAXMAN. OK. Well, has CMS ever taken any action to enforce that provision of the law regarding sufficient rates for dental

services?

Mr. SMITH. I have not during the time that I have been there,

Mr. Waxman.

Mr. WAXMAN. Has CMS ever taken any action to enforce that

provision of the law regarding sufficient rates for any Medicaid

service?

Mr. SMITH. Again, I can speak only while I have been there. I

do not know what my predecessors did on how they addressed

issues, whether they took sanctions against the State, financial

penalties against the State for those reasons. I do know that the

percentage of children on Medicaid receiving dental services is

higher while we have been here than previously. I do know that.

Mr. WAXMAN. What we have is a Federal program where we

spend an enormous amount of money. In fact, the Federal Government is going to pay $33 billion to help States purchase Medicaid

services for nearly 30 million lower-income children enrolled in

Medicaid, and there are a lot that should be enrolled but are not.

Given this kind of level of investment by the Federal Government,

don’t we have a strong interest in assuring performance by the

States and providers to receive the funds and to do the work and

to get the children to get the care that they need?

Mr. SMITH. Which, again, the strategy that we have tried to pursue is through quality initiatives, through best practices, through

things like pay for performance. In terms of managed care, I was

a Medicaid director in Virginia, and we went to managed care. I

don’t know by what factor, but we tremendously expanded access

not only to primary care physicians and dentists, but also specialists, as well.

Mr. WAXMAN. Wait a minute. Before you tell me all the good

things you are doing, the national average for Medicaid dental visits by children in 2005 was 33 percent.

Mr. SMITH. Which is a——

Mr. WAXMAN. Two out of every three children enrolled in Medicaid received no dental services of any kind, preventive or restorative, during that year. So, as we have heard, Deamonte was among

those children with no dental visits. Is 33 percent acceptable to

you? If not, what specific steps is your agency going to take to improve this performance?

Mr. SMITH. Again, Mr. Waxman, I would say it illustrates that

there is an access problem in the Medicaid program. I would also

say that those percentages, while they are still not the levels that

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any one of us like to see, they are higher than previously. States

are showing improvement.

Mr. WAXMAN. Have you ever asked a State to increase their reimbursement levels? Have you ever told them they are breaking

the law by not providing a sufficient reimbursement level to provide the care for those people who are eligible?

Mr. SMITH. Again, Mr. Waxman, enforcement is about taking financial penalties against the States, and——

Mr. WAXMAN. This is not even taking a penalty. This is simply

telling them they are not living up to the law. Have you ever done

that?

Mr. SMITH. Again, Mr. Waxman, I think everyone—Maryland did

their own review and said we have an access problem. This is information that they know.

Mr. WAXMAN. They know it, but you are in charge of the program. You are in charge of over $30 billion of Federal funds. We

want to be sure that when we are spending $30 billion of money

that we are getting the job done, and the law says the job is done

when every child has access to care, and we can’t get that if we

don’t reimburse at a sufficient rate for people to provide the care.

You notice that the State of Maryland and probably most other

States are not doing the job. Did you ever say to them you ought

to do more?

Mr. SMITH. I think we have done a number of things to help

States improve the quality of care for Medicaid children.

Mr. WAXMAN. Such as?

Mr. SMITH. Well, one thing we did in direct outreach to individuals—again, Dr. Clark talked about patient awareness in education. We have mailed out——

Mr. WAXMAN. If the patients are aware they are entitled to the

benefit and they can’t find anybody to give them the benefit, then

what is the patient supposed to do?

Mr. SMITH. Again, there are a number of steps if the patient does

not have access. There are——

Mr. WAXMAN. What steps?

Mr. SMITH. We spend——

Mr. WAXMAN. Tell me the steps.

Mr. SMITH. We spend——

Mr. WAXMAN. What would the young man’s family have been

able to do? What steps?

Mr. SMITH. Again, there are——

Mr. WAXMAN. Obviously, the guy running the Federal program

doesn’t seem to do anything about it. The people at the State level

don’t feel they have the ability to do anything about it. The law requires it. Should they call their Congressman and say pass a law

to require that we get these services? Congressman would say yes,

that is right, but we already have a law. What protection is the law

if it is not giving them the benefits?

Mr. SMITH. The law says——

Mr. WAXMAN. You are in charge of running this program.

Mr. SMITH. Under the Medicaid law, Federal dollars follow State

dollars. It is the State that must commit that dollar first.

Mr. WAXMAN. And if they don’t shouldn’t you tell the State they

have a obligation to do something more than what they are doing?

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Mr. SMITH. Again, Mr. Waxman, I think that as a system there

are rights for the individual, there are systems of people to help

give access. We spend $3 billion on what is called targeted case

management, which is supposed to be simply connecting individuals to the services that they need. I think there is a wide variety

of people who come into contact with individuals who need care,

and, again, I think——

Mr. WAXMAN. Well, what you are saying is that somebody ought

to provide the care for them for free?

Mr. SMITH. No, sir.

Mr. WAXMAN. You are saying it ought to be charitable?

Mr. SMITH. No, sir.

Mr. WAXMAN. Done charitably. But on the other hand we have

a law that says they are entitled to these benefits, that the States

are obligated to pay at reimbursement levels sufficient for people

to take these cases, dentists in particular when we are talking

about dental services, and if the State is not living up to the law

the Federal Government should tell them you have to live up to the

law, even if you don’t take enforcement actions. But if you are not

even telling them to live up to the law, they are not hearing from

the people running the program.

We have gone around in circles and I think you should—are you

proud of the job that Medicaid is doing when two out of three kids

aren’t getting dental services?

Mr. SMITH. I think Medicaid does a tremendous amount of good

for the 30 million children who are enrolled in the Medicaid program.

Mr. WAXMAN. And for the one out of three that do get the dental

care we are proud of it, but what about the two out of three that

don’t? Are we proud of that?

Mr. SMITH. I think, again——

Mr. WAXMAN. Are you satisfied with that?

Mr. SMITH. I think, again, Mr. Waxman, many different sources

have identified what the issue is for access. As I said, Federal dollars follow State dollars, and the decisions that get made by the

elected men and women who serve in State capitals are making decisions that are what is a priority, what gets funded——

Mr. WAXMAN. The chairman has been generous and we have

gone around in circles. You are passing the buck. You were appointed by elected people in the Government of the United States

to enforce the law with the States, but to tell the States they have

to live up to the law, and what you have decided is since they

aren’t living up to the law you are not going to do anything about

it because they already know about it.

I don’t find that a very satisfactory answer, and therefore I have

to hold the people responsible that appointed you to say to them

they are elected officials and they are not getting the job done at

the Federal level, and I have to hold you responsible, as well, because you are the one in charge of the program, and the least you

could do is sometimes write a State a letter saying you are not

doing a job if the reimbursement rates are so low. You ought to

come to the administration and say Congress has to do something

more because this program is not working for two out of three kids

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when it comes to dental services, and I’m sure for many others in

other services, as well.

I haven’t seen any proposals from the administration other than

to cut back on Medicaid, other than to give States more flexibility

to cut back even more. I just think that the buck is not going to

be passed on, as far as I am concerned. It is on your lap and I don’t

think you have done a very good job with it.

Mr. SMITH. Mr. Waxman, if I may, again, Medicaid as a system,

a construct within the Federal system that has been built with the

Medicaid program, but if you have built a car and you have designed it and you have engineered it, you still have to put gas in

the tank to make it run.

Mr. WAXMAN. Yes, and you need people running——

Mr. SMITH. The gas in the tank is what——

Mr. WAXMAN [continuing]. The program who will make sure that

the law is upheld. You are running the program. Federal law requires they get these services. Federal law requires that the States

must put in reimbursement levels sufficient for people to provide

the services. You can’t say well, it is a whole system that is just

not working. That is not an answer.

Mr. SMITH. But may I add——

Mr. WAXMAN. I don’t know that the Chair—there are others who

are waiting to ask questions. Maybe you can pass the buck during

their time, but you have said about all you can say.

Mr. KUCINICH. Mr. Chairman, Mr. Waxman has as much time as

you require.

Mr. WAXMAN. Do you have anything more to say?

Mr. SMITH. Again, I think that there are improvements that we

have found in the Medicaid program through a variety of different

strategies that we have been pursuing with the States as our partners. While you correctly cite the participation or the rates of

which the percentage of Medicaid children are receiving dental benefits, they are higher than they were under my predecessor. Again,

a number of sources, including the GAO, a number of sources have

been telling that access is a problem, and I agree that access is a

problem.

The key to improving access principally, from the provider perspective, is to increase reimbursement rates.

Mr. WAXMAN. Right, and Federal law requires that.

Mr. SMITH. And that is a State decision.

Mr. WAXMAN. And that is what?

Mr. SMITH. And that is a State decision.

Mr. WAXMAN. But Federal law says for the States to be a participant in the Medicaid program they have to provide enough

reimbursement——

Mr. SMITH. That is correct, and to sanction them——

Mr. WAXMAN. Therefore, don’t you have any responsibility in all

of this?

Mr. SMITH. The sanction that I can apply against a State for failure for a State plan is to withdraw all of its Federal funding.

Mr. WAXMAN. Yes.

Mr. SMITH. That doesn’t seem to be the right solution.

Mr. WAXMAN. So do you have a suggestion for changing the law?

Mr. SMITH. Not today, Mr. Waxman.

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Mr. WAXMAN. OK. And do you have, other than the law is tough,

any other reason to tell us why you are not enforcing the law? Do

you feel you have an obligation to enforce the law? Couldn’t you

have written a letter to Maryland?

Mr. SMITH. Again, I believe, with the different reviews that have

been done, and my staff has corrected me where I wasn’t able to

come up with the figure on how many reviews have been done, we

have done 11 reviews from States based on their EPSDT reports.

So we do go back into the States. We do reviews at all different

types of or different parts of the program, and I think, again, while

access is clearly an issue, it is an issue that the program, itself, at

the State, the Federal level, and Congress, as well, has been aware

of it for some time.

Mr. WAXMAN. Mr. Chairman, let me just conclude my comments

by saying Federal law requires these services be made available to

the children for dental services for the children that are eligible for

the program. We now find for the most part two out of three kids

are not getting any of the services that they are entitled to. Federal

law requires that the States must pay a reimbursement level, and

that is not happening. Federal law should require that the Department or the Center for Medicare and Medicaid make sure that

when there is a case like this they do an investigation and tell the

State they are not doing what they should be doing in that case.

I don’t see any of those things having been done by CMS, and

I must say, Mr. Smith, you are just giving me a lot of bureaucracy,

a bureaucratic answer. It is a system. It is not working. It is just

too bad. The States are not doing their job. I don’t see any sense

of responsibility, and I don’t think that is the way the Federal Government ought to be operating.

Mr. SMITH. If that is your conclusion, sir, then I haven’t done a

very good job in trying to express the different ways that we have

been trying to improve the quality of care in the Medicaid program.

My statement reflects——

Mr. WAXMAN. I don’t say that you are doing everything wrong,

but I am saying you are not doing a good enough job. That is at

the minimum when two out of three kids don’t get pediatric dental

care and they are eligible for it.

Thank you, Mr. Chairman.

Mr. KUCINICH. The Chair thanks Mr. Waxman for his participation. I note the gentleman, Mr. Smith, talked about Congress’ responsibilities, and this subcommittee will endeavor to discharge

those responsibilities.

Mr. Smith, in January 2001, there was a Dear State Medicaid

Director letter about dental benefits under Medicaid. States received a letter from CMS noting that a number of States are not

meeting participation goals for pediatric dental services, and then

the letter goes on to say these States must take further action to

improve access to these services.

Staff may have a copy of that. If you want to put up that slide,

that would be appreciated.

The letter also——

Mr. SMITH. This is the January 18th letter? Is that what you are

referring to, Mr. Chairman?

Mr. KUCINICH. Mr. Smith, I haven’t finished my statement.

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Mr. SMITH. I just wanted to make sure I understood——

Mr. KUCINICH. Let me finish my statement.

Mr. SMITH. OK.

Mr. KUCINICH. That was January 2001. That letter also said that

the Federal Government was going to increase our oversight activities to assess State compliance with statutory requirements. It laid

out a plan to have Federal reviews and visits to States with special

attention to States in which fewer than 30 percent of the Medicaid

children have received dental services. Forty-nine States responded

to that letter, as shown in slide No. 2, 49 States responded. Among

those who responded, 15 States reported that less than 30 percent

of the Medicaid children had received dental services. Maryland

was one of those States.

Mr. Smith, did you carry out the plan to have Federal reviews

and visits to States?

Mr. SMITH. Mr. Chairman, those reviews were done. Every State

except one submitted a corrective action plan based on that information.

Mr. KUCINICH. Did Maryland have a Federal review then and

visit for oversight?

Mr. SMITH. I understand that Maryland did their own plan.

Mr. KUCINICH. So the answer is no? Did Maryland have a Federal review and a visit for oversight?

Mr. SMITH. Maryland did not have a review.

Mr. KUCINICH. Did every State do its own plan?

Mr. SMITH. Every State but one submitted a corrective action

plan. Yes, sir.

Mr. KUCINICH. Did you take any actions to require Maryland to

comply with the requirements?

Mr. SMITH. Again, I think the Maryland plan, itself, as I said

earlier, Maryland since 1998 had identified the problems of access

to dental in their own program. They set up Statewide advisory

committees. They had, I think, a pretty comprehensive plan on how

they intended to increase access.

Mr. KUCINICH. Did you take any actions to require Maryland to

comply with the requirements?

Mr. SMITH. Again, Mr. Chairman, I think the information was

the State was taking corrective action, had its own plan for what

steps it would take.

Mr. KUCINICH. Did you take any actions to require any State to

comply with the requirements? There is a difference between

States saying we are going to straighten this out and the Federal

Government reviewing it and saying look, you haven’t straightened

it out, here is what we want you to do. Did you take any action

on that?

Mr. SMITH. Again, we have taken a number of actions. We meet

regularly with the Medicaid directors on a State basis. There are

10 regional offices across the country. There are a number of different ways we have contacts with States at the national level, at

the policy level. We meet twice a year with the Medicaid directors.

We have technical assistance groups. Again, those are more on the

policy side of things that apply to all States.

Mr. KUCINICH. So how many States now meet their legal requirement to have adequate dental services?

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Mr. SMITH. Again, Mr. Chairman, I think the increase in access

to dental services is lower than, again, what we—it clearly continues to show us there is an access problem in Medicaid.

Mr. KUCINICH. Wait. Wait. There is an access problem. We can

all agree with that. But what about the oversight and enforcement

from your office? I mean, there are legal requirements here.

Mr. SMITH. And, again, they——

Mr. KUCINICH. If they don’t meet those requirements, aren’t you

supposed to take action under statute?

Mr. SMITH. It is a rather big step, which is saying they are not

in compliance with——

Mr. KUCINICH. How many aren’t compliant?

Mr. SMITH [continuing]. The State plan, which is to take all of

their Medicaid dollars away from them.

Mr. KUCINICH. But how many are compliant?

Mr. SMITH. In terms of access——

Mr. KUCINICH. No. How many are compliant in terms of the law

with respect to the legal requirement to have adequate dental services? How many are compliant? Isn’t the answer zero?

Mr. SMITH. Mr. Chairman, I think you are looking at——

Mr. KUCINICH. I am looking at your responsibility, sir. How

many are compliant? How many States are compliant?

Mr. SMITH. The use of dental services varies for a wide variety

of reasons, including the individuals seeking the dental services in

the first place.

Mr. KUCINICH. How many are compliant?

Mr. SMITH. I have not found any State to be out of compliance,

Mr. Chairman.

Mr. KUCINICH. Are you telling this committee that you are prepared to produce for this committee documentation that 50 States

are meeting the legal requirement to have adequate dental services? Are you telling us that under oath?

Mr. SMITH. I think you are——

Mr. KUCINICH. I don’t want to have any misunderstanding about

this. I am just going to give you another chance to answer the

question. Are you telling us that?

Mr. SMITH. I think to some extent we are looking at this two separate ways. In terms of the individual, their right to access dental

benefits, they are entitled to those benefits. The extent to which

that individual has rights of appeals, the extent to which health

plans are operating within the Medicaid law and within those requirements, I believe I can tell you that those things, in fact, are

present.

Using a measure of how many children sought and received dental care is a different measure. Those measures clearly say we have

an access problem. The reason we have an access problem, I think

as I said before, Dr. Clark pinpointed those reasons very well.

So in terms of compliance with the parameters of the Medicaid

program, and again States have responsibilities that they certify to

us that certain things are being met, that those rights and responsibilities are present for use by the beneficiaries, the constructs I

can say I do believe those are present in all of the States.

Using a measure, though, to say how many children are reported

to have received services is a different measure, and I cannot say,

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by using that measure, that the Medicaid program is in full compliance.

Mr. KUCINICH. So, to answer my question, when I asked how

many are compliant, is the answer zero?

Mr. SMITH. By using the measure that you are using, yes, Mr.

Chairman.

Mr. KUCINICH. Well, that is what I wanted to find out, and I am

going to ask staff to develop a series of questions to be quite specific State-by-State to followup on determining compliance and specifically reviewing with respect to utilization goals.

I want to pick up on a question that Mr. Waxman had about

changes, about reimbursement for dental services to children under

Medicaid and the Guide to Children’s Dental Care and Medicaid.

The original draft contained seven full pages about reimbursing

dentists adequately under Medicaid for taking care of children. The

draft contained statements such as ‘‘a substantial gap in funding

levels exists in most States between current Medicaid dental program allocations and market-based requirements,’’ and average

Medicaid reimbursements ‘‘may not cover the cost of providing

services and are not likely to be viewed as positive incentives for

dentists’ participation.’’

Now, someone took these statements, and, as Mr. Cummings

pointed out, many more pages about the inadequacy of Medicaid

payment rates out. Why?

Mr. SMITH. Again, Mr. Chairman, as I was trying to draw on my

memory to address Mr. Cummings, we are not disagreeing. I am

not disagreeing today. I think that the access about dental rates is

a core issue as to why we have an access problem.

Mr. KUCINICH. You agree with that, but there was a document

produced. Those statements were taken out, which actually, if I am

right, Mr. Cummings, these undermine the concern that people

would have about whether or not dentists are being adequately

reimbursed——

Mr. SMITH. Again, I——

Mr. KUCINICH. Excuse me. I am having a colloquy—and therefore

would cause a lack of participation. Wouldn’t you agree, Mr.

Cummings?

Mr. CUMMINGS. I would agree 100 percent. I was just sitting here

thinking, Mr. Chairman, this is a very sad state of affairs when the

very people who are supposedly making sure that a system works

and works well then take out the very words that are the essence

of—it is like the Bible for making sure it works well. I mean, something is wrong with this picture.

I yield back.

Mr. KUCINICH. I would just say that I think this committee needs

to probe a little bit more deeply into why was this taken out. Do

you have any idea? Did you know this was taken out?

Mr. SMITH. I remember yes, I did review it.

Mr. KUCINICH. Were you the person who excised it?

Mr. SMITH. Again, I am trying to draw on my memory of the dental guide, itself, in terms of the purpose and the use of it, and I

do recall having discussions and making changes, myself, that the

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son, that reimbursement rates didn’t—they were not a part of the

purpose of the guide, itself, is my recollection.

Mr. Chairman, yes, I did review the guide. Yes, I did make edits

to the guide. And I do remember that and I will be happy to go

back, but my recollection is the guide was for one thing and the

financing pieces seemed to me that they weren’t appropriate to

what the guide, itself, is being used for.

Mr. CUMMINGS. Would the gentleman yield, please?

Mr. KUCINICH. Yes, I will yield.

Mr. CUMMINGS. Mr. Chairman, you just talked about or asked

Mr. Smith some questions about things that have been taken out,

and, Mr. Smith, you said just now that some of the things were

taken out because I guess you felt that, although you agreed with

them, you thought that they were inappropriate for this guide; is

that correct?

Mr. SMITH. For the purpose of what the guide was to be for.

Mr. CUMMINGS. And what was the purpose of the guide? I guess

that is the better question.

Mr. SMITH. Again, I am——

Mr. CUMMINGS. Wasn’t it to lay out the States’ responsibilities

for meeting Federal regulations? Wasn’t that the reason?

Mr. SMITH. That is not my recollection of what the guide was for.

Mr. CUMMINGS. Well, what is your recollection?

Mr. SMITH. And I——

Mr. CUMMINGS. Don’t tell me you don’t remember, please. And

let me tell you why I am saying that. I have never said that to a

witness ever in a courtroom or since I have been here in the Congress 11 years, but you just sat there and you just told us that you

made changes, you participated in the changes because you felt like

certain things were not appropriate for this. And now please don’t

tell me you now forgot. Did you?

Mr. SMITH. Mr. Cummings, the guide, itself, for the purpose of

the guide, if I recall—and I might—the purpose of the guide was

not about explaining financing and reimbursement about Medicaid.

It was about, if my recollection is, it was about quality and measures and of that nature.

Mr. CUMMINGS. I understand that, but let me ask you this question: the original draft had these words: ‘‘Improvements in Medicaid will cost more—’’ listen to this—‘‘because more children will be

served and have more of their treatment needs met, but that as

children receive care—’’ listen to what they are saying—‘‘unmet

need should decline and ongoing costs should be less.’’ That was in

the original.

But it went on. It said, ‘‘Dental program improvements can be

expected to yield significant savings in treatment costs on an individual level and reduce the overall need for investments in safety

net clinic capacity.’’

Those words were also taken out. Do you remember that? Did

you participate in that, too?

Mr. SMITH. I don’t remember the specific words, Mr. Cummings.

I did participate in editing the guide, and the guide was about clinical information. Financing, I am trying to recall my rationale that

discussing the reimbursement side wasn’t regarding clinical standards.

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Mr. CUMMINGS. Yes, but this piece—and I will yield back, Mr.

Chairman, in a second—but this piece here sort of goes to it is talking about cost and reimbursement, but it is also talking about

being helpful to children, to children that we, as adults, are supposed to help and provide for, the children that you are supposed

to be helping through your agency.

What I am saying to you is that it seems like this goes to the

essence of making sure that they are treated, because what it is

basically saying is that we do these things and there is less—you

can pay me now or you can pay me later scenario. But the one big

factor is at least the children are healthy, as opposed to—because

when we pay later we have situations like this young man, Mr.

Driver.

Mr. SMITH. Mr. Cummings, I agree with you. Health care is driven in many respects by under-utilization of services that are preventative, that will make that investment today will save you

money down the road as well as improving the quality of care.

Mr. CUMMINGS. Ms. Norris, I think it was, said something in her

testimony. This is my last question. She said that we need to have

a campaign, your organization needs to have a campaign about

folks making sure that kids get dental care early.

Mr. SMITH. Yes.

Mr. CUMMINGS. Do you do any of that kind of thing now?

Mr. SMITH. Mr. Cummings, we have mailed out, we have provided more than 50 million copies. This is direct to Medicaid families.

Mr. CUMMINGS. OK.

Mr. SMITH. This is the first year of life. There is one for every

month. This is for the parents for what they need to do for their

child. At month six we talk about the need for——

Mr. KUCINICH. Excuse me. I am going to ask if staff could obtain

what the gentleman is saying and we could just take a look at it.

Mr. SMITH. Sure.

Mr. CUMMINGS. I yield back, Mr. Chairman.

Mr. KUCINICH. No, continue, Mr. Cummings.

Mr. CUMMINGS. I mean, Ms. Norris is a person who, as you heard

her say, I mean, that is what she does. She helps folks get care.

And she sat at that table, and when we asked what should your

organization be doing she said apparently she believes that you

should be doing more of getting the word out and encouraging people.

Mr. SMITH. To my knowledge, Mr. Cummings, this is the first

time the Federal Government has ever produced something like

this for beneficiaries to help them to understand the health care for

their children. As I said, we have distributed more than 50 million

copies of this. This is the series, the first year of life, so there is

one for every month. In month six it starts talking about the importance of oral health care.

Again, we are in passionate agreement about the need for greater patient awareness of the importance of oral health.

Mr. CUMMINGS. I yield back.

Mr. KUCINICH. The Congresswoman from California has been

very patient. I wish to yield to her such time as she may consume,

a minimum of 10 minutes. You may proceed, Congresswoman.

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I want to say that at the conclusion of your questioning I have

a followup question relative to testimony based on a document just

handed to me, so if you could just go ahead.

Ms. WATSON. All right, because I am taking my discussion in a

little different direction, you might want to go ahead now, since it

is relevant to this discourse. I want to talk about another aspect.

Mr. KUCINICH. OK. That is fine, and I appreciate the indulgence

of the gentlelady.

In response to my question, Mr. Smith, relative to how many

States were, in fact, in compliance, you bifurcated your answer.

You gave, on the one hand, if you are talking about financing of

dental services, and on the other hand if you are talking about the

organization of dental services.

Now, isn’t it true that CMS issued a contract to the American

Academy of Pediatric Dentistry for the purpose of reviewing the

original guide?

Mr. SMITH. Yes, sir. I believe that is correct.

Mr. KUCINICH. And didn’t they issue a contract for developing a

revision for use by stakeholders concerned about children’s oral

health and Medicaid?

Mr. SMITH. I don’t remember the timing and when, but I believe

that was concluded in 2004.

Mr. KUCINICH. And isn’t it true that the contractor was requested to incorporate information on not only the organization but

on the financing of dental services, dental work force and capacity

and accountability?

Mr. SMITH. I don’t know what the original contract called for, Mr.

Chairman. I am sorry I don’t.

Mr. KUCINICH. I want to submit into the record a preface page

from a Guide to Children’s Dental Health and Medicaid and to help

you to recall that the operative language here is that the contractor

was requested to incorporate information on the organization and

financing of dental services, dental work force and capacity and accountability, along with other administrative issues which might be

of assistance to State Medicaid agencies and stakeholders in their

efforts to improve access to oral health services for children. I want

to state, I mean, there is an obvious significance to this.

If, in fact, CMS issued a contract to the American Academy of

Pediatric Dentistry to incorporate information on the financing of

dental services in the report and if, in fact, we see issues relating

to finance and the ability for reimbursement, for example, for dentists taken out of the final report, we have reached one of these

teachable moments, Mr. Smith.

I want you to square for this committee how in the world you requested a contractor to provide information on the financing of dental services and then you simultaneously took out of the contractor’s report information that was absolutely critical for States to be

able to make an assessment about the delivery of pediatric dental

care to the children of the United States.

Mr. SMITH. Mr. Chairman, I didn’t write the original contract. I

didn’t review the contract.

Mr. KUCINICH. I am going to withdraw the question. I have to

say, in going along with Mr. Cummings, this is really an extraordinary hearing because the response that we are getting is so obVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00109 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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tuse that it is non-responsive, and, rather than waste the time of

this committee with non-responsiveness, I am going to go to Ms.

Watson.

Thank you.

Ms. WATSON. Mr. Chairman, I am sorry that Mr. Waxman left

because I wanted to commend you and Mr. Waxman for the oversight. I have been here going on my 6th year, and we never had

these kinds of hearings. We were not fulfilling our responsibility to

oversee the agencies that we fund.

The reason I can be patient is because I was listening to the responses, and it comes to me that in this country we set priorities,

and we talk about homeland security. It is not about the land, it

is about the people on the land. And when we sit up here at a Federal agency and allow a young man to die because he didn’t get the

kind of dental care, it is our responsibility. So I am pleased that

we are trying to get down to where the flaw is in this system. We

just have not set a priority on the health of Americans.

There is another issue that I wanted to bring up. I have been

championing this issue for decades. When I was the Chair in California of the Health and Human Services Committee, we learned

that mercury is a neurotoxin. What does that mean? That means

that it poisons the body, and particularly the brain.

I don’t know if you out there listening—and maybe Dr. Clark in

the back knows this—the amalgam fillings that most people, and

people who you serve, Dr. Clark, that silver filling is 50 percent

mercury, and mercury is the most toxic substance in the environment. Guess what? We put it into your mouths. Regardless of how

tightly encased the mercury is, it still can escape. We had a spill

last year in Virginia and we had to close three high schools down

because kids were playing with mercury. It balls up and it bounces

down and it is fun, but it is poisoning.

With mercury in your amalgam, it goes up in your T-zone. Hello?

It is always emitting. It goes up into your T-zone. It is like lead.

It starts to destroy the meninges. That is the thin skin over the

brain. And we allow it.

And so for 15 years in California my legislation instructed the

Dental Board to come up with a pamphlet that could be given out

to the patients. It took 15 years to get it done, and we didn’t get

it done until I came here, put some pressure, held some hearings

in Los Angeles. We held hearings and I joined in a nonpartisan

way with my colleague, Dan Burton, and we finally got them to do

that.

So I am a sponsor, and you need to know this is coming down

the line, Mr. Smith. I am a sponsor of legislation that would ban

the use of mercury dental amalgams immediately in children and

pregnant women and phase it out for the rest of the population

over a period of 2 years.

The number of mercury-free dentists—and they are becoming

aware—is slowly rising in this Nation. In fact, Clinical Research

Associates of Utah State in a recent survey said roughly one-third

of dentists licensed in the United States now have mercury-free

practices.

In 2005 and 2006 in a survey conducted by the Consumers of

Dental Choice, it found that all of the 31 States that responded do

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allow their Medicaid patients a choice of either dental amalgam or

non-mercury fillings. But none of the States, zero, had a program

to publicize to patients that they have a choice.

I should also note that dentists with mercury-free practices have

refused to participate in their State’s Medicare programs because

they may still believe that State Medicare rules would only allow

them to use dental amalgams.

Mercury is a neurotoxin and we still allow it to be used, so my

bill would require the banning of mercury amalgams in children

under 18 and in pregnant women and in lactating mothers because

of the toxicity of mercury amalgam.

So my question to you: are you doing anything to educate the

dentists across the 50 States to the dangers of using mercury amalgams, Mr. Smith?

Mr. SMITH. Congresswoman, you are bringing up a subject that

is entirely new to me.

Ms. WATSON. OK. Fair enough. But you see that is my thing. I

am passionate about it. We fought for it in the State of California.

Our Medicaid program is MediCal, and during my tenure there, 17

years as the Chair, I was there 20 years, but 17 years as the Chair,

we added 32 to 34 benefits that were not required under Medicaid.

I am sure since I have been gone these 6 years or so they have

added others, because our people demanded it.

I think the people in the State of Maryland and across this country ought to demand more from their Federal Government in terms

of these programs we have created.

That is my statement. I wanted to get that out to you. It is a

heads-up. Watch for my bill. I intend to have it signed into law,

because I have the other side working with me on this in the best

interest of health in America.

Thank you, Mr. Chairman. I am going to go to the floor. We have

a vote.

Mr. KUCINICH. I thank the gentlelady.

Before I dismiss the second panel, I would just like to thank Mr.

Cosgrove for his attendance and appreciate your being here. We appreciate Mr. Smith, as well.

I would like to just let Mr. Smith know that this committee will

be giving you a detailed request to produce all documents relating

to the editing of that particular guide and any type of communication that was in-house or that you received in e-mails or such. We

would ask the committee staff to communicate with Mr. Smith’s office to make sure that you could get this to this committee expeditiously.

We want to thank you for your participation here today. The second panel is dismissed.

We will proceed with the third panel for their opening statements, and then we are going to recess for votes. Thank you very

much.

This is the third panel of the Domestic Policy Subcommittee

hearing on evaluating pediatric dental care under Medicaid.

This panel includes: Dr. Allen Finklestein, who is a former U.S.

Army Captain who is assigned to the Post-Preventive Dental Office

at Fort Bragg, NC. Dr. Finklestein has been a practicing dentist for

more than 35 years, with a specialization in periodontal prosthesis.

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His professional memberships include the Rhode Island Dental Association and the New Jersey Dental Association, the Essex County

Dental Association, and Alpha Omega Dental Association. Currently, Dr. Finklestein serves as chief dental officer of

AmeriChoice. This business segment within United Health Group

is exclusively focused on serving beneficiaries of Medicaid and the

State Children’s Health Insurance Programs [S-CHIP].

AmeriChoice serves over 1.4 million Medicaid members, including

children in 13 States.

We will be hearing from Ms. Susan Tucker, who recently rejoined

the staff of the Department of Health and Mental Hygiene. She is

executive director of the Office of Health Services for the Maryland

Medicaid Program. The Office of Health Services is responsible for

developing and implementing policy relating to Medicaid covered

services. Ms. Tucker has 19 years of experience with State Medicaid programs. She has special expertise in maternal and child care

programs within Medicaid.

Finally, we will hear from Ms. Jane Perkins, who is the legal director at the National Health Law Program, a public interest law

firm working on behalf of low-income people, children, people of

color, and individuals with disabilities. Ms. Perkins focuses on public insurance and civil rights issues. She engages advocacy on these

topics, manages the National Health Law Program’s litigation

docket, and has written numerous articles on Medicaid and children’s health coverage.

I would ask the witnesses to please rise. It is the policy of this

committee to swear in all witnesses before they testify.

[Witnesses sworn.]

Mr. KUCINICH. Let the record reflect that all of the witnesses answered in the affirmative.

In order to provide the witnesses with the full opportunity for

uninterrupted testimony, we are going to take a recess right now.

Unfortunately, I have been informed that Congress has at least 1

hour and 15 minutes of votes, so if there is any difficulty in any

of the panelists staying you should let our staff know, but I would

ask you to stay. I am going to make sure that Members of Congress

know that you are still present so we can give them the opportunity to participate.

I am grateful for your being here. I thank you for your patience.

This committee will stand in recess for 1 hour and 15 minutes,

which means that we will be back here at approximately 20 to 7.

Thank you.

[Recess.]

Mr. KUCINICH. The committee will come to order.

This is the Domestic Policy Subcommittee. Our hearing today is

on evaluating pediatric dental care under Medicaid.

We are now beginning our third panel. I have been informed that

due to the extenuating circumstances of the congressional schedule

with so many roll call votes that we have now encroached into

someone’s travel time. What I want to do for the witnesses, Ms.

Perkins, if you have a flight to catch I would be happy to have you

read your testimony. Did you have a flight to catch? Is that correct?

Ms. PERKINS. I now do tomorrow morning.

Mr. KUCINICH. OK. Tomorrow morning? Tonight?

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Ms. PERKINS. Not any more. I am good.

Mr. KUCINICH. Oh, it is tomorrow? OK. Great. We are not going

to be here until tomorrow morning. I promise. I will promise you

that. This is a long hearing, but we are not going to go that long.

Well, then, let us begin, if we may, with Dr. Finklestein. Thank

you, Doctor. Please proceed.

STATEMENTS OF ALLEN FINKLESTEIN, CHIEF DENTAL OFFICER, UNITED HEALTH CARE; SUSAN TUCKER, MBA, EXECUTIVE DIRECTOR, OFFICE OF HEALTH SERVICES, MARYLAND

DEPARTMENT OF HEALTH AND MENTAL HYGIENE; AND

JANE PERKINS, LEGAL DIRECTOR, NATIONAL HEALTH LAW

PROGRAM

STATEMENT OF ALLEN FINKLESTEIN

Dr. FINKLESTEIN. Good evening, Mr. Chairman. Thank you for

the opportunity to testify here today.

I am Dr. Allen Finklestein. I am the chief dental officer for

AmeriChoice, which is part of United Health Group. We serve the

Medicaid population. I have also been a practicing dentist for 37

years. As a health care professional, I take care and pride in treating people. That is why I am deeply moved by the death of

Deamonte Driver.

I want to add my personal condolences to the family. I hope with

all my heart that we can keep this from ever happening again.

I have worked with governments for many years. As a young

Army Captain, I helped design a preventive program to avoid dental emergencies in Vietnam. More recently I was on the forensic

team that helped identify victims of September 11th. But, first and

foremost, I am a dentist, and a dentist always has been trained to

fix problems.

Now we need to take a broader approach, a move to a preventive

model. We have heard today about access to dental care, but access

is not the only problem. We have to get past all barriers and deliver dental care.

Clearly, one barrier is poverty, itself. For family S with Medicaid,

dental care is a lower priority than food, shelter, and safety. You

have heard today that some dentists don’t want to take new Medicaid patients. The reimbursements may be one of the reasons. But

even more of a factor that I find when I build networks is missed

or broken appointments. Lots of dentists are willing to treat my

children, but if the child doesn’t show up the dentist has lost a slot

and missed an opportunity to treat another patient.

I want to help every child, but I can’t help them unless they sit

in my chair or my colleague’s chair.

The AmeriChoice approach is to help Medicaid patients get their

appointments. Our multi-lingual call center is staffed around the

clock, and the phone number is clearly written on every member’s

card. It is an 800 number. The call center can help make appointments, even arrange for transportation to the office and back home.

We also reach out by mail and by phone, but that doesn’t help if

the member doesn’t have a phone or a fixed home.

So AmeriChoice is developing innovative ways to connect with

our members. We are collaborating with everyone who touches the

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lives of these children, including government agencies, schools,

community organizations, parents, and health care providers. This

collaboration is not some hypothetical concept. It leads to real benefits in the lives of real people.

Rhode Island is a great example. We worked with the State to

create a program called Right Smiles, which now serves all of the

Medicaid population 6 and under, all 32,000 of them. By stressing

preventive care, we hope to start them on a path of a lifetime of

oral health. Now the State wants to expand this program to reach

older children.

In Maryland and other States, we partner with local dentists to

run screenings in schools. Each child gets a toothbrush, dental education, and, above all, a dental baseline examination.

Elementary schools are incredibly important. I may look young,

but nearly 60 years ago I had to have a dental checkup before I

could enter kindergarten or return to any grade subsequent to that.

We are working with schools in Patterson, NJ, which now require

an annual dental checkup before a child can return to school. We

partner with retailers adjacent in Maryland and elsewhere. We

give parents a $10 gift certificate for taking a child to the dentist.

A family with Medicaid is much more likely to see their physician than to go to a dentist, so we are working with Brown University and Hasborough Hospital in Providence to teach early signs of

dental disease to physicians.

What we are doing in Rhode Island can be replicated in any

State. We are eager to help. These partnerships are good for patients, they are good for the community, and they are good for

AmeriChoice. If I can treat a young child in my dental chair, that

child is so unlikely to have a dental emergency later.

Surgeon General Satcher called it the silent epidemic. As you can

see from today’s testimony, it is not so silent. We have to partnership. We have to collaborate together. This disease is totally preventable and only when we can do preventive measures.

Thank you for your time. I appreciate all that the committee has

done.

[The prepared statement of Dr. Finklestein follows:]

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Mr. KUCINICH. I thank the gentleman.

Ms. Tucker.

STATEMENT OF SUSAN TUCKER

Ms. TUCKER. Chairman Kucinich, my name is Susan Tucker. In

March 2007, I rejoined the Maryland Department of Health and

Mental Hygiene as executive director of the Office of Health Services within the Medicaid program. I am accompanied today by the

new Secretary of the Department, John Colmer, who is behind me.

The death of Deamonte Driver is a tragedy. We have been asked

to address the oversight mechanisms the Department uses to ensure access to oral health services for Maryland Medicaid’s eligible

children and to address any measures that we have taken to avoid

another tragic loss like that of Deamonte Driver.

Maryland, like all States, has a problem with access to dental

services for low-income children. We have been working on increasing access to dental care for years, and, while we have made

progress, we recognize that much more needs to be done.

All stakeholders need to help with this issue in Maryland: dental

providers, public health programs, parents and caregivers, Medicaid agencies, pediatricians, managed care organizations, and Federal policymakers. This is a national problem.

Only about half of all children in the United States have a regular annual dental checkup. White, non-Hispanic children are almost twice as likely to have usual routine dental checkups as Hispanic or Black children. Children in households where neither parent attended college are much less likely to have an annual dental

checkup. Children with Medicaid fall into many of these risk categories. They are more likely to be minority. They are more likely

to be poor and to have parents with lower educational levels. This

is not an excuse.

This situation is intolerable from a human and public health perspective, but it is a fact. That means that public health agencies

providing services for Medicaid populations start from a difficult

position.

One of the first priorities of the O’Malley administration in

Maryland has been to address dental access issues. We are hiring

a State Dental Director and forming a Dental Action Committee,

which will include a full array of stakeholders. The stakeholders

will be examining the system and social issues which may have

contributed to Deamonte’s untimely death, and to make recommendations regarding appropriate reimbursement rates for dentists, education to encourage families to improve oral hygiene in

the home and to seek preventive dental services in order to assure

that children don’t get to the point where they are seeking dental

care in the emergency rooms, strategies to allow other dental

health professionals to provide more preventive services in underserved areas, strategies to increase the training of pediatric dentists—only three pediatric dentists graduate a year from the University of Maryland—and strategies to improve access at federally

qualified health centers and school-based health centers.

The Secretary of the Department has requested recommendations by September 2007 and is committed to thoroughly reviewing

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these recommendations and implementing changes to improve access to dental services.

In regard to oversight, the Maryland Medicaid program implemented a mandatory managed care program called HealthChoice in

1997. Our main goal at the time was to improve medical and dental care for children. Prior to implementing the program, only

about 20 percent of continuously enrolled children received a dental

service. Today, 46 percent receive a service.

When we monitor the MCOs we review the dental data on a regular basis to see how many children receive services. We have

made improvements. Are we satisfied that we have completed the

job? Absolutely not. Are we convinced that we need new efforts and

strategies to address the problem? Yes.

We also require MCOs to develop and implement an annual outreach plan. This plan describes outreach activities and includes

written materials that MCOs send to encourage families to seek

regular care. We review these plans and we do look at the materials that the MCOs do send out to families.

We have addressed rates in this session. DHMH does have low

payment rates, but we did increase dental fees substantially in

2001, partly in response to Federal studies, and in 2004 we increased rates again for the restorative procedures. Despite these increases, we recognize that our payment rates are below what dentists receive from private-paying patients. Although fees are not

the only answer to increasing dental participation, we know we

need to do better.

DHMH also requires MCOs to contract with dentists. In Maryland, as elsewhere, dentists will not contract to take a limitless

number of Medicaid patients. If MCOs required contracting dentists to take all Medicaid patients presenting for treatment, most

would decline to participate in the program altogether.

We acknowledge that the current approach makes it difficult for

patients to find dentists and nearly impossible for the State to

monitor ever-changing dental networks. This is unacceptable to us,

and we are working with the MCOs to reach out to contracted providers. However, we must also jointly find a way to engage the dental community in Maryland. Dentists in the program need to accept

more patients, and dentists not participating need to step up to the

plate.

We have met with the Maryland Chapter of the American Dental

Association and the Maryland Dental Society, and they have committed to assisting us in this effort.

We also require MCOs to have an infrastructure to assist enrollees with locating and accessing services. They need to be more

proactive in assisting patients in receiving dental services.

The Department also has a complaint resolution line, and each

member has this information on their card and in their member

handbooks. We do receive a lot of calls on this line, but, interestingly enough, we don’t receive a lot of dental calls, so families don’t

call us very often with assistance in this area. We receive about 20

a month. That is not a lot, considering there are 400,000 children

on the Maryland Medicaid program.

Finally, Maryland provides modest financial incentives and disincentives to encourage managed care organizations to improve acVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00126 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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cess to services. One of the areas that we look at in terms of our

pay for performance is dental utilization.

In conclusion, we take our oversight of MCO performance seriously and are committed to implementing additional strategies to

increase access to dental services. We ask the committee’s assistance in recommending additional Federal dollars for education of

pediatric dentists, dental clinics and schools, and federally qualified

health centers, and in funding a national dental education campaign to highlight the importance of dental hygiene in the home

and regular early preventive dental care.

Thank you.

[The prepared statement of Ms. Tucker follows:]

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Mr. KUCINICH. Thank you very much, Ms. Tucker.

Ms. Perkins, you may proceed. Thank you.

STATEMENT OF JANE PERKINS

Ms. PERKINS. Thank you. Thank you for having me here this

evening.

I wanted to, in my few moments, just go through again some

issues that are present in the States and talk about a few more

issues with respect to this Centers for Medicare and Medicaid Services.

To flip the statistics that have been used today, in 2004 70 percent of kids who were eligible didn’t get any dental care, 80 percent

of kids who were eligible didn’t get any preventive care, and over

85 percent of kids who are eligible didn’t get corrective treatment.

It is true that the Driver’s stories are not unique to Maryland.

In the District of Columbia, children enroll in one of four managed

care organizations. The Medicaid Act requires States or MCOs,

managed care organizations, to assure CMS and the States that

they maintain a sufficient number, mix, and distribution of providers; however, the participation list in the District had been repeatedly inaccurate, listing dentists as participating when they no

longer do, when they have closed offices. Some have moved overseas.

According to the D.C. Action for Children, 5 percent of licensed

dentists in the District participate in Medicaid, and by saying participate there, that means taking even one claim. That doesn’t talk

about active participation.

The court monitor, in an ongoing case in the District, found ‘‘substantial evidence that the majority of children eligible are not receiving adequate dental care.’’

According to the District’s 416 report, which we just received for

2006, 22 percent received a preventive dental service, and that was

less than had received preventive dental care in 2005.

Mr. KUCINICH. Excuse me? What was that percentage?

Ms. PERKINS. It was 22 percent in 2006 versus 25 percent in

2005. Only one of the four participating managed care organizations increased their percentages. The others, Health Right, Charter, and AmeriGroup, showed decreases.

In Miami-Dade County, a pilot project that was proposed by Governor Jeb Bush and approved by CMS in record time requires children to enroll in a capitated managed care plan. A report from the

State’s contractor found that the number of children who received

dental care through the program dropped 40 percent in the first

year. The number of participating dentists declined from 669 to

251. An analysis by Columbia University found that the State lost

value under the program by paying the same amount for less care

and less quality. To give an example, a dental group which was paid $4.25 a

month for each of 790 children provided services to 45 of them.

That is 5.7 percent during the first 6 months of 2005. Thus, the

group was paid $20,145 for treating 45 children.

A handful of Medicaid programs in States such as Alabama, Indiana, South Carolina, Vermont, and Virginia have targeted children’s oral health services. These efforts share some common feaVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00133 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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tures: first, increases in payment levels tied to usual and customary fees; second, streamlined administration; third, appointment of a high-level position to focus on problem solving; fourth,

effective outreach to beneficiaries; and, fifth, case management to

address appointment no-shows.

South Carolina’s effort to tie patient navigators with beneficiaries has resulted in 85 percent of beneficiaries keeping their

appointments. I would point out that case management is a covered

Medicaid service. Athens County, OH, and Oakland, CA, are a couple of other examples of areas that have used case management to

make sure kids get to their appointments.

To use an example from Virginia, until recently, as Mr. Smith

pointed out, Virginia has delivered services using a capitated managed care mode; however, the State recently transitioned out of

that model and back to fee for service. This move, coupled with additional changes, a 30 percent increase in rates and a number of

recruitment and retention strategies for dentists resulted in 76 additional dentists enrolling in the program between July and November 2006, and there was a 43 percent increase in preventive

services and a 75 percent increase in restorative services delivered

to Medicaid eligible children between 2005 and 2006.

Many of the points that I wanted to make or was going to make

about CMS have been covered here already. I will just add three

points.

First, the Medicaid Act requires that the Secretary of Health and

Human Services shall annually develop and set participation goals

for EPSDT for each State. Given the increased use of managed care

and the stated rule of managed care to provide children a medical

and dental home, it could be expected that the Secretary would increase these participation goals over time. However, the last time

the Secretary developed and set participation goals was 1990.

Second, CMS appears committed to privatizing monitoring by allowing States and MCOs to use performance measures that are

tied to those or offered by private accreditation standards. However, the private standards lack the degree of specificity needed to

assure that States are complying with the Medicaid Act. For example, 2007 HEDIS includes only one dental measure, annual dental

visit. By contrast, 416 requires States to report on the number of

eligible children receiving services, the number receiving preventive services, and the number receiving corrective treatment.

Moreover, the HEDIS is not measuring what Congress has required in the statute for the States to do, and that is to ensure dental visits according to schedules arrived at by the State after consultation with dental providers. Our review found that, as of May

2005, all but three States called for children to receive a dental

exam every 6 months, not annually.

Third, CMS has not enforced the Medicaid Act, so it is important

that beneficiaries’ rights to enforce the provisions of the act be reaffirmed by Congress.

Thank you for having me here today.

[The prepared statement of Mr. Perkins follows:]

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Mr. KUCINICH. I want to thank all the witnesses for their testimony.

At this point we will go to questions.

I want to thank Congressman Cummings for rejoining us.

I would like to begin the questions with Dr. Finklestein.

Doctor, in 2006 how many children eligible for Medicaid in Maryland enrolled in your plan?

Dr. FINKLESTEIN. Out of total membership of 110,000, approximately 80 percent of those are children.

Mr. KUCINICH. That was 110,000 that were what, please?

Dr. FINKLESTEIN. It is 110,000 total membership, of which 80

percent are children.

Mr. KUCINICH. OK. The Department paid, according to the information we had, the Department paid United Health Care $339.3

million in 2006. How much in total revenue did you receive from

the State of Maryland Medicaid program for enrolling these children during 2006?

Dr. FINKLESTEIN. Sir, I don’t have those numbers. I would be

happy to share them with the committee to make sure they are accurate.

Mr. KUCINICH. Thank you, sir.

And in 2006 do you know how many of the Maryland Medicaid

children enrolled in your plan received at least one preventive dental service?

Dr. FINKLESTEIN. Yes, sir. Over 45 percent.

Mr. KUCINICH. So 45 percent. OK.

Dr. FINKLESTEIN. And if I can followup?

Mr. KUCINICH. Of course.

Dr. FINKLESTEIN. Again, I am a dentist. That is 55 percent of my

children that didn’t receive. That is unacceptable, totally unacceptable. Until we get 100 percent, then we are talking about the numbers that I can do the proper health care for my children.

Mr. KUCINICH. Thank you, Doctor. And how many received at

least one dental treatment service during the year?

Dr. FINKLESTEIN. At least one?

Mr. KUCINICH. You said 45 percent received at least one preventive dental service, but how many have received at least one dental

treatment service during the year?

Dr. FINKLESTEIN. I could make that available to the committee.

Mr. KUCINICH. Could you do that, please?

Dr. FINKLESTEIN. Sure.

Mr. KUCINICH. Now, Doctor, did Deamonte Driver see a dentist

in the year before he was hospitalized?

Dr. FINKLESTEIN. Sir, in all my years of treating patients, there

has always been a certain trust. Discussing this individual case

would be a total violation of that.

Mr. KUCINICH. Have you been advised by counsel not to discuss

it?

Dr. FINKLESTEIN. This is the person sitting in front of you.

Mr. KUCINICH. This committee, you should be informed, Doctor,

has oversight jurisdiction specifically and actually a specific exemption from HIPAA with respect to gathering information and data,

so we are going to ask you, if you cannot do it now, to provide for

the committee the following information.

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Staff has just given me something, and I would like to read this

to you. This is section 45, and it is 35th chapter, No. 164.512(d)(1)

states that ‘‘A covered entity may disclose protected health information to a health oversight agency for oversight activities authorized by law, including—’’ subparagraph 2—‘‘Government benefit

programs for which health information is relevant to beneficiary

eligibility.’’

The Committee on Oversight and Government Reform is the

principal oversight committee in the House of Representatives with

broad investigative jurisdiction as set forth in House Rule 10, so information—and I just want to make sure that you, as a witness,

have that information. So what I am going to say, if you are not

prepared to answer that question at this moment—and I will respect that you aren’t available to answer that question at this moment—we are going to ask you to submit to this committee the following information: Whether or not Deamonte Driver saw a dentist

in the year before he was hospitalized; whether he saw a dentist

in the year before that or the year before that, the previous year.

We could actually go back 5 years, at least.

And I would ask you to provide the following information, as

well: if United Health Care received a capitation fee for Deamonte

Driver in the year before he was hospitalized and in the 5-years

preceding that.

Would you be able to answer that now? If you can answer some

of these questions now, that would be helpful, but if you want time

to do it and you want to prepare a response——

Dr. FINKLESTEIN. I would appreciate that.

Mr. KUCINICH. You would like to have time to do it?

Dr. FINKLESTEIN. Yes, sir.

Mr. KUCINICH. I respect that, Doctor.

I would like to ask you, Doctor, what statistic does United Health

Care generate about its own performance that would capture

Deamonte’s last 5 years of life? For example, do you report a statistic to the State about the number of enrollees who do not receive

dental services in the preceding year?

Dr. FINKLESTEIN. Sir, if I can talk globally?

Mr. KUCINICH. Of course.

Dr. FINKLESTEIN. If that is OK with you, we have a tracking system throughout the country. It is called universal tracking. This is

a report card on all of our children that are EPSDT. The T is the

key. I totally agree with that.

In that report card, it is sent on to the primary care physician.

Primary care physicians get a report on the child for not only baseline examination, physical examination—this is the pediatrician—

they get lead screening, well child, immunization, and dental.

Those are sent to the physicians so that they know exactly which

children fall in or fall out.

In addition to that, as a company we do total outreach to our

members that have not seen their dentist. That includes phone

calls, it includes mailings, it includes educational material on a

quarterly basis that is sent, and there is a 24-hour call center that

is available to all of our members. Not only that, they are trained

to educate members. They also help to navigate them through the

system. Again, transportation to and from, and even scheduling

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them so that they can be rewarded with a gift certificate when they

do go to the dentist.

Mr. KUCINICH. OK. What I would like you to do, Doctor, I am

going to ask you this information and I would urge you to consult

with your attorneys so that you could make sure that you feel comfortable reporting this, and I can assure you that if any information

is necessarily privileged for some legal reason, such as a pending

lawsuit or anything like that, our staff attorneys will be glad to acquaint you with the way in which this committee handles such information.

So we are going to want you to provide us with a report whether

or not you keep statistics about the number of enrollees who do not

receive dental services, if you report those statistics to the State,

what the report. We would like you to have that available for at

least the last 5 years, assuming, of course, that it is possible to

generate such statistics. I mean, if you have them, the committee

would like to take a look at them.

I assume that you do keep statistics?

Dr. FINKLESTEIN. Yes, we do, sir.

Mr. KUCINICH. So it is possible——

Dr. FINKLESTEIN. Absolutely.

Mr. KUCINICH [continuing]. To determine utilization?

Dr. FINKLESTEIN. Absolutely.

Mr. KUCINICH. OK. So we want to be able to determine, of

course, whether or not you are informing the State about the existence of individuals who are chronically not receiving dental care.

I think you would have to agree that would be relevant for the

State to know.

I would now like to ask you, Doctor, United Health Care uses

HEDIS measures to estimate how many children are eligible for

Medicaid, correct?

Dr. FINKLESTEIN. HEDIS? Yes.

Mr. KUCINICH. Yes. Now, according to HEDIS, eligible children

are 4 to 20 years old and enrolled in Medicaid for 320 consecutive

days. In 2006, according to information that this committee has

been given, Deamonte was not enrolled for 63 days. Is that correct

according to your information?

Dr. FINKLESTEIN. I would have to confirm that.

Mr. KUCINICH. OK. If anyone is not enrolled for that length of

time, would that person be ineligible according to HEDIS standards?

Dr. FINKLESTEIN. Would they be for reporting purposes?

Mr. KUCINICH. Yes. I will go over it again.

Dr. FINKLESTEIN. No, I understand the question.

Mr. KUCINICH. If they weren’t enrolled for, let’s say, 60-some

days, would that person then be ineligible according to HEDIS

standards?

Dr. FINKLESTEIN. No. They wouldn’t be a required reporting statistic.

Mr. KUCINICH. Excuse me?

Dr. FINKLESTEIN. They would fall out of reporting only. Again,

we are treating children, if they are enrolled with our plan for 1

month or for an entire year. HEDIS says our denominator consists

of only children that are continuously enrolled for 320 days. That

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is only a reporting statistic. This does not interfere with their dental coverage. Whoever the patient is would have dental coverage for

as long as they are enrolled in our plan.

Mr. KUCINICH. We are trying to establish whether or not

Deamonte, based on the circumstances, would have been part of

the eligible children that you list. Would he have been considered

eligible?

Dr. FINKLESTEIN. Any child in our health plan is eligible for care.

What we are doing——

Mr. KUCINICH. You are eligible for care, but are they reported as

such?

Dr. FINKLESTEIN. They are not required to be reported under the

definition of HEDIS.

Mr. KUCINICH. So someone could be eligible but they could fall

out of reporting?

Dr. FINKLESTEIN. That is correct, sir.

Mr. KUCINICH. Now, what kind of a bearing does that have on

United Health Care’s responsibility for making sure that a patient

gets access to health care, which includes dental?

Dr. FINKLESTEIN. None, whatsoever.

Mr. KUCINICH. In other words, whether someone is reported or

not, it has no bearing on the service, but it does have a bearing

on whether or not the State can determine utilization, right?

Dr. FINKLESTEIN. If I may expound, HEDIS is a pure measure of

one time dental treatment, I can tell this committee. Do I find

quality in that? There is no quality component to it. It is

strictly——

Mr. KUCINICH. No quality component?

Dr. FINKLESTEIN. There is no quality component at all.

Mr. KUCINICH. To what?

Dr. FINKLESTEIN. To the HEDIS measure. OK? I am talking

now——

Mr. KUCINICH. It is strictly eligibility?

Dr. FINKLESTEIN. It is strictly a way to show utilization. It was

so pointed out by Mr. Davis when he spoke about treatment. When

I go into the OR with a child who has been devastated, totally devastated by milk bottle decay——

Mr. KUCINICH. By what?

Dr. FINKLESTEIN. Milk bottle decay, which means that the child

has been going to sleep at night, and the only way to bring this

child back to oral health is in the operating room. That is the same

HEDIS count as if the child came to my office and I did a quick

screening. It is a one-time hit. If that is quality, not in my dental

life.

Mr. KUCINICH. Now, I think we mentioned this earlier. The State

of Maryland paid United Health $339.3 million in 2006. Those are

the figures that we had. In Deamonte’s case, in particular, you

were paid about $80.96 a month. Does Deamonte appear in your

annual records?

Dr. FINKLESTEIN. Again, sir, I will talk globally about my members. Any member will appear in our records. OK? It has nothing

to do with HEDIS. From the day they are in, if they are brought

into a dental office—you have one of our top doctors was here before testifying. He has one of the highest utilizations at the UniverVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00144 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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sity of Maryland with quality outcomes. That was available. Care

was available. The only way I can treat a child—I said that in my

statement—is by having them in my dental chair. The same thing

with Dr. Tinanoff and Dr. Clark.

Mr. KUCINICH. I accept what you are saying, except that if you

could tell me how do the numbers account for failure to provide

care in Deamonte’s or in anybody’s case?

Dr. FINKLESTEIN. In anybody’s case?

Mr. KUCINICH. Yes.

Dr. FINKLESTEIN. It is absolutely. I don’t know if we can say the

word failure, but it is.

Mr. KUCINICH. What is a failure?

Dr. FINKLESTEIN. A failure is not having 100 percent of our children in this country seeing the dentist. A failure is not having the

ability to mandate that my children go to the dentist. A failure is

having school systems that won’t let me in to do screening because

they take away from chair time, education time.

Mr. KUCINICH. Doctor, would the failure also be if the numbers

weren’t kept to account?

Dr. FINKLESTEIN. No. No, sir. I pride myself and this company

prides itself on individual care, on outcomes. That is what it is

about. Numbers are wonderful——

Mr. KUCINICH. But the numbers have to be reported so there can

be some kind of assessment of utilization; am I correct?

Dr. FINKLESTEIN. That is so true.

Mr. KUCINICH. OK. And so would the numbers that are reported

to be able to assess utilization in any way reflect the failure? You

just said, 55 percent aren’t cared for. Is that one way of looking at

it?

Dr. FINKLESTEIN. That is exactly right. Not only that. The way

I assess it, we have a system called Metrix, and Metrix looks at

what each individual child is getting when they do access care, not

that it is a one-time exam. What we do is measure on their recall,

when they come back 6 months, do I have baseline health. That is

what it is all about. Getting the child in, getting them healthy,

maintaining health, not 5 years prior, but every day of their life,

that is my commitment to you.

Mr. KUCINICH. Doctor, what in your records or figures of United

Health Care reflects the death of Deamonte?

Dr. FINKLESTEIN. Again, sir, I have never violated this in my life.

If you want, I will present you with anything——

Mr. KUCINICH. I don’t want to ask you to do anything the you

are really uncomfortable with, but I do want to say that this committee needs the following information.

Dr. FINKLESTEIN. OK, sir.

Mr. KUCINICH. We want to know specifically where did Deamonte

appear in your annual records. We want to know the manner in

which your statistical evaluation and your numbers account for any

failure to provide him with care. We want to know what in your

records or figures reflects the death of Deamonte. And, again, this

is consistent with the right to information which this committee

has, and specifically under rule 8(a)(1) of the Rules of the Committee on Oversight and Government Reform.

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Doctor, again, thank you. We verbally requested documents reflecting United Health Care’s costs, their earnings, and revenues

from the Department of Health and Mental Hygiene. That Department refused. We made the verbal request a second time. We submitted a document request to the Department of Health and Mental Hygiene that included a request for United Health Care’s costs,

earnings, and revenues. We were told by the Department that

United Health Care refused to release that information because it

was described as proprietary.

Again, I know that you are a doctor, you are not an attorney, I

understand, but I want you to know that we insisted that our subcommittee had the right to that information under rule 8(a)(1) of

the Rules of the Committee on Oversight and Government Reform.

The Department responded that United Health Care did not grant

express consent to release that information and therefore refused

our request a second time.

We are entering a written request as well as refusals to produce

the requested documents in writing into the record. Without objection, Mr. Cummings, this goes in.

Now, Doctor, half of United Health Care’s funding is Federal,

and we have an obligation and responsibility to make sure that

funding is spent appropriately. This is exactly why this subcommittee has broad jurisdiction and investigative jurisdiction as set forth

in House Rule 10. Now, would you be at liberty at this moment to

tell us what United Health Care’s costs, earnings, and revenues

were in Maryland?

Dr. FINKLESTEIN. No, I do not have that information.

Mr. KUCINICH. OK. So our subcommittee is formally making that

request right now for you to provide the cost, earnings, and revenues in Maryland.

Now, my understanding is that the National Children’s Medical

Center incurred expenses in excess of $200,000 in providing emergency care and treatment to Deamonte in the last few weeks of his

life. He was uninsured at the time of admission into the hospital.

He leaves no estate. His family is unable to afford the charges. I

am assuming that the Maryland Medicaid program will not be paying the charges and that the United Health managed care plan

with which Maryland Medicaid contracted to manage Deamonte’s

care also will not pay. Do you have any advice for the National

Children’s Medical Center as to where they might turn to recoup

even some of the costs they incurred in attempting to save his life?

Dr. FINKLESTEIN. At this time, again, I can’t comment on the individual nature. I don’t even have this material in front of me, sir.

Mr. KUCINICH. OK. Doctor, one measures of how much value a

public program like Medicaid gets from purchasing care through a

managed care organization like United Health, as you understand,

is the medical care ratio. This is the amount that the MCO pays

out for medical cost divided by the amount of premium revenues

that the MCO takes in. Are you familiar with the medical care

ratio, Doctor?

Dr. FINKLESTEIN. I know exactly what you are talking about. I

just happen to call it benefit.

Mr. KUCINICH. You call it benefit?

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Dr. FINKLESTEIN. I call it benefit, not medical. There is more to

it than just——

Mr. KUCINICH. So the higher the ratio or the benefit, the better

the value for Medicaid. And for example, if an MCO’s medical cost

ratio on a Medicaid managed care contract is 60 percent, then only

$3 out of every $5 the State and Federal Government pay the MCO

goes to purchase hospital, physician, dental, and other health care

services. The remaining $2 goes to administration, marketing, and,

in the case of a for-profit company like United Health, profits.

So if the medical cost ratio is 90 percent, then $9 out of every

$10 the State and Federal Government pay the MCO goes to purchase health care services and only $1 goes for administration,

marketing, and profits.

Now, according to form 10K that United Health filed with the

Securities and Exchange Commission on March 6, 2007, their company’s overall medical care ratio in 2006 was 81.2 percent. In other

words, a little under $1 out of every $5 you get paid in premium

goes to marketing and administration and profits.

Now, would you be able to tell us what the medical care ratio

was on your risk contract with the Maryland Medicaid program in

2006? Would you be able to tell us that?

Dr. FINKLESTEIN. No, I don’t have that.

Mr. KUCINICH. If you could please——

Dr. FINKLESTEIN. May I just put in you still have a claims run.

It would be an approximation.

Mr. KUCINICH. If you could provide us with the information, understanding that there is a claims run, we would like to get that.

I think that is the only questions I have right now before we go

to Mr. Cummings.

I just want to say, Doctor, I admire the spirit in which you presented your concern for the children who you are dedicated to serving. You speak of them as your children, and I think it is heartening to see the concern that you expressed for the children. I think

you understand that our committee has the same motivation in

asking for the information which we feel we need to be able to effectively evaluate this case and to, from a public health policy

standpoint, to be able to use the information we gather not simply

as an analysis of United Health Care, but to look at it from the

more global experience of the industry, itself.

So I think it would be good if we were able to proceed on this

in a cooperative way, because I think that it can be a very favorable experience for everyone who is involved in committing themselves in the care of children.

Dr. FINKLESTEIN. Thank you. I appreciate those kind words. The

frustration that is inside of me, I can’t even tell you. This is not

the first case. I hope and pray it is the last case. Any skilled dentist could have brought health to any one of these children, whether it was Mississippi this month, New York 3 years ago, and this

unfortunate situation. Sir, we have the ability to heal these children. We could keep them healthy. We must get them in to see the

dentist. We need your help. I need it so desperately I am begging

for it right now.

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Mr. KUCINICH. I believe you. I think we are having a dialog here

that I think is going to be very productive. I certainly appreciate

your testimony.

Mr. Cummings, thank you.

Mr. CUMMINGS. Mr. Chairman.

Ms. Perkins, CMS Director Dennis Smith seemed to indicate that

his hands were tied with regard to the agency’s response to the

States that are not complying with EPSDT for dental care. Is that

your view?

Ms. PERKINS. The impression that I got from Mr. Smith’s testimony was that it was being portrayed as an all or nothing alternative, either we have to withdraw all Federal funding or we don’t

have much power. I don’t agree with that. The CMS has and States

know that CMS has the power of the purse string. The Federal

Government is funding from $0.50 to $0.73 out of every dollar that

is spent in States on Medicaid. When CMS is serious about something and wants something done, States listen.

I think that the January 18, 2001, letter that was sent from CMS

to States is just one example of that. The 49 States sent back plans

of action. I have been at the National Health Law Program 22

years, and there are numerous examples of that sort.

Now, it is also true that the Secretary at Health and Human

Services is, in the Medicaid Act, and has always in the Medicaid

Act been charged with the responsibility of taking enforcement action when the Secretary finds that the State’s plan is no longer in

compliance with the Medicaid Act. There are State plans that are

no longer in compliance with the Medicaid Act. The notice to the

State can tell the State that the action and the funding involved

is directed at the service that is out of compliance. That doesn’t

mean that the funding is stopped the next day. There is a process

for the State to go through to have a hearing and for an impartial

decision to be made ultimately about what to do about that funding.

We see in the Federal Register numerous, numerous occasions of

notices where the Federal Government is saying we are not going

to approve this. We don’t think it complies with the act. Many,

many of those cases settle, again, going back to my first point, because the Federal Government has such a powerful purse string

with the Federal funding.

Mr. CUMMINGS. Ms. Perkins, it is interesting that we have seen

over and over again—and I think it was Ms. Watson a little bit earlier who talked about it—the systems that are supposed to work

that don’t work. We see it. I see it as the chairman of the Coast

Guard Subcommittee on another committee. I have seen it in this

committee, Oversight and Government Reform. We have systems,

but because of individuals who either are incompetent, lack empathy, negligent, or just don’t care, the systems break down. I see it

over and over and over again.

If you look at the problems that we have had in this country—

Katrina was a good example—we are seeing it in a program called

Deepwater where we spent $24 billion for some boats that don’t

float, in this country.

I am just trying to figure out what are the kind of things you

would like to see in place so that, no matter what, when you have

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the kind of problem I just talked about, lack of empathy, negligence, people who just don’t care, you are going to have that, but

how do you minimize that in a situation like this? Are you following my question?

Ms. PERKINS. I do. I think that the solution is already on paper,

and it is what Congress has already passed in the Medicaid Act.

Congress has made it incredibly clear what it wants States to do

in providing early and periodic screening services to children. It

has made it clear to the Secretary what kind of reporting it wants

to have happen. And it has made it clear what kind of oversight

it wants to have States engage in where they are contracting with

capitated managed care plans that are getting paid ahead of time

to provide the care that kids are going to need.

So I think that the blueprint is on paper. It isn’t a matter of having the will to enforce the law and to take the law that Congress

has passed more seriously, than the desire, for example, to have

private accreditation companies and their HEDIS measures be

what is going to be equated with quality and a well-running program.

Mr. CUMMINGS. I am going to move on to you, Dr. Finklestein.

We kept hearing this term a dental home. What is the significance

of that?

Dr. FINKLESTEIN. The significance of a dental home is a place

that anyone—in this case, youngsters—can receive dental care 24

hours a day. Not to say the dentist is there 24 hours a day, but

our contracted doctors are required to provide emergency, urgent

care, and routine care.

What we have to do is seize the opportunity of the dental home.

It is almost like how do we get the water where we want it. We

have to go into schools. We have to start screening programs in

schools and then assign these children to dental homes that are

permanent. This is the model that will work. Every child should

know they have a dental home. A lot of them don’t. We often treat

a youngster 1, 2, or 3. This is a child that is in pain. That is a child

that cries himself or herself to sleep, a child with low self-esteem,

a child that misses school. This is a cycle that can be ended.

If we can’t get our members to come to us, we are going to have

to change the model. We are going to have to get into the school

systems, work with school systems, and then assign a dental home

to them. That is the only way.

Mr. CUMMINGS. So is the dental home the primary?

Dr. FINKLESTEIN. It would be my practice. If you came to me, I

am your dental home.

Mr. CUMMINGS. OK. Now, United deals with medical and dental;

is that right?

Dr. FINKLESTEIN. Yes, sir.

Mr. CUMMINGS. Now, do we assign folks medical homes?

Dr. FINKLESTEIN. Yes, we do. We do assign a primary care physician.

Mr. CUMMINGS. And do you assign them dental homes?

Dr. FINKLESTEIN. We do not. We have open access.

Mr. CUMMINGS. Let’s say Johnny Watts would be receiving medical treatment through you.

Dr. FINKLESTEIN. Yes, sir.

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Mr. CUMMINGS. And receiving dental treatment through you.

Dr. FINKLESTEIN. That is correct.

Mr. CUMMINGS. Why would he have a medical home and not a

dental home?

Mr. CUMMINGS. Our model throughout the country, we have

found that it is easier to have access, not restrictive access. If that

dentist is not there, they can call our 800 number, we can get them

another dentist.

Another way, when you sign panels, most of this panel and dental home assignment came off of something that was touched up

eloquently about capitation. Doctors receive remuneration to have

X amount of patients, let’s say 100 patients who are assigned to

them, to treat them. There is no incentive to treat when you prepay.

Our model is to do a fee for service and give you access, just as

you have with your—you have a plan, you have doctors, you have

700 dentists in the State of Maryland. You can choose any one of

them. And if you are in need of transportation, we will get you

there.

Mr. CUMMINGS. So having a dental home is your philosophy, and

I guess the philosophy of your company, that it is better to not

have a dental home than to have one; is that right?

Dr. FINKLESTEIN. No. We give you the dental home, but you select the doctor of your choice. You find that home. He is your dentist, or she is your dentist.

Mr. CUMMINGS. But if you can’t find a dental home——

Dr. FINKLESTEIN. That is our job. That is why if you call right

now there is someone answering the phone, how can we assist you,

in any language that you can make up, any language in the world.

We will respond and we will help them, as I said, navigate through

the system.

Mr. CUMMINGS. You had said a little earlier in answer to one of

the chairman’s questions, you said something about 45 percent that

you said that used the system had, I think, one dental screening

in 2006, at least one, is that right? Was that 45 percent?

Dr. FINKLESTEIN. Yes, 45 percent of unique dental visits. Correct.

Mr. CUMMINGS. And you put your head down and said it should

have been—you wished that you could have gotten the other 55

percent, or something to that effect; is that right?

Dr. FINKLESTEIN. That is my profession. My profession is to

treat. That means 55 percent of my youngsters never got to see a

dentist. That is unacceptable in this country. It is unacceptable.

Mr. CUMMINGS. And you believe they should have, the other 55

percent?

Dr. FINKLESTEIN. With all my heart.

Mr. CUMMINGS. Period?

Dr. FINKLESTEIN. Period.

Mr. CUMMINGS. So, in other words, everybody enrolled with

United, you want to see have at least what a year?

Dr. FINKLESTEIN. Get them to baseline health, whatever it takes.

You see, it is an investment. It is a good investment. The children

that come in that I can get healthy and keep them healthy, then

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tive end. Not treating catastrophic illness; treating preventable disease. There is nothing so preventable.

This disease, you heard, five times asthma, etc., Doctor Satcher

called it the silent epidemic. It is unbelievable that we can’t control. Sometimes with my colleagues I will sit and talk. We have basically two diseases to deal with, besides congenital defects, birth

defects, that we found in the mouth: periodontal disease, more in

adults, and decay. We can’t get it under control and we have to

make it mandatory that every child sees a dentist. Then we will

have results. Then we will have healthy children that won’t miss

school, that will have self esteem, that will sleep at night, and that

is it.

We also have our obstetricians. That is where we start. We have

our obstetricians talking to our future moms. You can’t give a bottle to this child to go to sleep. It is difficult. They have so many

problems. They do not know where they are living, etc. The child

is sleeping. It is so simple to give a bottle with lactic acid. That

is what it breaks down. And then I have no teeth to restore. I have

abscesses. I have potential disasters on my hand, all because someone—and here is the biggest problem. I am so happy you asked this

question. The physicians have to buy into this. I’m tired of being

the repair man. Sixty-three years of age, almost 38 years in this

profession, why can’t I do preventive dentistry. Why am I not rewarded for doing what is right instead of fixing what went wrong?

This is the basic premise. This is the problem in dentistry today.

Mr. CUMMINGS. You said that we don’t pre-pay dentists because

there would be no incentive for them to see patients; is that what

you said?

Dr. FINKLESTEIN. That is correct. That is correct. That is a

capitated program.

Mr. CUMMINGS. Couldn’t the same be said for the pre-paying of

United Health?

Dr. FINKLESTEIN. No, sir.

Mr. CUMMINGS. What is the difference?

Dr. FINKLESTEIN. The difference is when I get a child healthy in

dentistry I save money.

Mr. CUMMINGS. Yes.

Dr. FINKLESTEIN. That is a preventive model. When I have a disaster, it is financially a disincentive and it affects the family, transportation. You just look at the cost. There was one mentioned. The

cost of that for a simple extraction, for a simple extraction that a

sophomore dental student could do? Early diagnosis, early treatment, that is EPSDT. But I need these kids. I need them terribly.

I won’t let you down if I get the kids. If I don’t get them, I cannot

treat them, sir.

Mr. CUMMINGS. So if they never get there, then it doesn’t cost

you anything?

Dr. FINKLESTEIN. If they never get there it costs me much. It hits

on my medical end. It hits on the emergency room end. Oh, it costs

me. It costs me way more than doing preventive dentistry.

Mr. CUMMINGS. I see Ms. Perkins shaking her head. You in

agreement with him?

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Ms. PERKINS. That is one of the measures that we use as an indicator of a broken system, how many children are getting their dental services in the emergency room.

Mr. CUMMINGS. Yes. And did you look at Maryland in that regard?

Ms. PERKINS. We were looking actually at North Carolina.

Mr. CUMMINGS. I found it interesting what you said. I just want

to go back to Ms. Perkins for a moment, what you said about the

South Carolina system. You seem to be very impressed with that;

is that right?

Ms. PERKINS. Well, by making changes to its program, it is behind only the State of Vermont in terms of screening the most

number of kids. Their rates are at the 75th percentile of dentist

rates in the region. They have really focused on partnering with

dentists to get them to train general dentists to provide services to

pediatric cases to kids, special needs kids, so you can get services

in rural areas where there are general provider shortages. They

partnered with the AME churches where they have done over 110

screenings. And the screening levels have increased dramatically.

That is what the end game is here. It is not how much a doctor

or dentist is getting paid, but how many kids are seeing a dentist

for preventive care and getting the corrective treatment.

Mr. CUMMINGS. If I yield to the chairman, then he is going to

yield back to me, but let me just ask this real quick question. Who

drove that plan? Who made that happen? Was it the Governor? Did

it come through the State legislature? Do you know?

Ms. PERKINS. I don’t know.

Mr. CUMMINGS. Well, we can find out.

Ms. PERKINS. Yes.

Mr. CUMMINGS. I yield to the chairman.

Mr. KUCINICH. Thank you, Mr. Cummings.

In the course of your discussion with the doctor, something occurred to me to ask because, again, I see this great compassion expressed for the children, which is mandatory. Now, Doctor, I have

heard you say a couple of times that you can’t help your kids unless they are sitting in your dental chair. I have heard you say that

a few times, and I understand the spirit that motivates that statement.

Here is what I am wondering. Earlier today our staff provided

me with information that said that they did a spot check of dentists that were listed in United Health Care’s provider network.

They called 24 dentists. The score is up on the screen there. Twenty-three of the numbers were either disconnected, incorrect, or belonged to a dentist who did not take Medicaid patients. The 24th

did accept Medicaid patients, but only for oral surgery and not general dentistry. So effectively, according to the spot check by the

congressional subcommittee staff, none of the numbers listed would

have been of any use to Deamonte.

Help me with this. What is going on?

Dr. FINKLESTEIN. The locale? Was that Prince George’s County?

Mr. KUCINICH. Yes, sir.

Dr. FINKLESTEIN. OK. I can only give you my statistics. I am not

finding any——

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Mr. KUCINICH. I want you to explain that, though. I mean, help

me.

Dr. FINKLESTEIN. I will. I will explain it the way I can see it.

First of all, I would have to look at the access availability studies, because we do those also. We also have something called a silent shopper. We make appointments. This is done. We report this

to the State. We constantly do access and availability.

But the number that sticks in my mind—now, I am not finding

fault with the survey, because I really haven’t studied it—is that

in Prince George’s County last year, 2006, United Health Care paid

unique claims to 78 dentists that are in our network, 78 dentists,

and we can share this information with you, received payment from

us as par, meaning participating, dentists.

Mr. KUCINICH. Is it possible that any of the information that is

in that list on the provider network could be incorrect?

Dr. FINKLESTEIN. It is interesting. My windshield was broken on

the way down and I called to make an appointment to have my

windshield fixed. I called the Yellow Pages. It was a wrong phone

number, and it was the recent directory. I went to this place in

New York prior. Is it possible? Perhaps.

Mr. KUCINICH. Hopefully you would have a better batting average with repairing your windshield than our staff did with trying

to find a provider.

Dr. FINKLESTEIN. I would hope so.

Mr. KUCINICH. Now, this was on your Web site, I might add,

which hopefully has high reliability. I think it is important for us

to look at that, because, while I believe you when you say you want

to get those kids sitting in a dental chair, I think it is really important to try to square that with the apparent lack of availability. It

came from, admittedly, a single study, but, nevertheless, I would

guess that if we did a second study, it would probably be pretty

close, if we called the same numbers, probably pretty close response to what we had the first time. So I wanted to call that to

your attention——

Dr. FINKLESTEIN. Yes, sir.

Mr. KUCINICH [continuing]. Because I think that what I would

like to do to staff is to have staff review this with the doctor so that

you should know what we found.

Dr. FINKLESTEIN. Absolutely.

Mr. KUCINICH. And I would be happy to share it with you so that

maybe we could have a greater understanding as to how that could

occur.

Now, part of your job, Doctor, is to create a dental provider network.

Dr. FINKLESTEIN. Yes, sir.

Mr. KUCINICH. We talked about the dental house. What have you

done to broaden the dental provider network?

Dr. FINKLESTEIN. The basis, first of all, we are getting more pediatricians involved in early screening, early recognition of disease,

and then we also have a reimbursement for a wonderful program

for fluoride varnish. A lot of decay that is in a youngster’s mouth

can, believe it or not, be arrested and reversed. It is a whole new

concept. It is not as new as we think, but it took the American

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imburse on. That just happened January 1, 2007. But we are including pediatricians in this now.

Mr. KUCINICH. Yes.

Dr. FINKLESTEIN. So we are broadening the denominator of providers. We also have to get to the medical schools. They have to

learn what the disease entity in the mouth is. It is so simple to

look at the throat and beyond. They do not look that carefully at

teeth. I am not finding fault with my colleagues, but I am finding

fault with them. It is just the same thing with my colleagues on

the dental end. There are systemic linkages between periodontal

disease and systemic disease. We have to take this further.

If I can prevent one prenatal birth, one low birth weight, perhaps, I want healthy new moms giving birth.

But let me get back, because I will start talking dentistry and

we will be here until midnight. The piece that we do when I recruit—and I do a lot of recruiting hands-on. I like my providers to

have my telephone number. I like them to have my pager number.

I want to be involved in patient care. That is really my life. The

statistics you asked for, that will come. That is not my life. My life

is the kids.

What we are doing now is you have to see not every dental provider is the same. You have to have unique ways of contracting.

Reimbursement, and then measure their outcomes. Doctor, you

don’t know how they love when I say no more pre-authorizations,

no more you are getting this rate. We are going to make it so you

are a total partnership. We only do a retro review to make sure our

children are having the right outcomes. This is the uniqueness of

it.

Yes, you have to have a fee differential and, as was stated our

Medicaid rates in Maryland have gone up. They have gone up

throughout the country. We are recruiting. We have a more robust

network than we ever had before.

Mr. KUCINICH. So when you say outcomes, you mean on the care

to the patient?

Dr. FINKLESTEIN. See, that is a better measure than HEDIS.

Mr. KUCINICH. But do you also measure their outcomes with respect to whether someone’s care for a patient exceeds a certain

threshold that goes beyond the capitation?

Dr. FINKLESTEIN. We don’t do capitation.

Mr. KUCINICH. Beyond the fee for service.

Dr. FINKLESTEIN. Yes, obviously.

Mr. KUCINICH. Right.

Dr. FINKLESTEIN. Obviously.

Mr. KUCINICH. And that has never had a bearing on whether

someone is in the provider network?

Dr. FINKLESTEIN. It is medical and dental. You have to——

Mr. KUCINICH. But I mean has that ever had a bearing as to

whether or not someone is invited to be in or out of your network?

Dr. FINKLESTEIN. No, no. The barrier’s could be if they are fraudulent, obviously, if they are fraudulent, but that is certainly a barrier. But the best way is to discuss and try to find out. What I see

on a claim and radiographs, I am not the treating dentist, so I sit,

we talk. Let’s find out what is going on.

Mr. KUCINICH. Mr. Cummings.

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Mr. CUMMINGS. Did you hear Ms. Norris’ testimony?

Dr. FINKLESTEIN. Yes, sir.

Mr. CUMMINGS. Did you hear her talk about the hoops that she

had to go through to get a dentist in this case? I am not asking

you to talk about this; I am just asking did you hear her testimony.

Dr. FINKLESTEIN. I heard it, sir.

Mr. CUMMINGS. How did that make you feel?

Dr. FINKLESTEIN. I would just say could you take the member’s

card, could you dial the 800 number and see if I failed you. Let us

navigate it. Let us get the appointment. Let us be the health insurer. That is all I am asking for. If you want a test, check the 800

number, and that is how you check access to care.

Mr. CUMMINGS. I don’t have her testimony in front of me,

but——

Dr. FINKLESTEIN. I heard it.

Mr. CUMMINGS [continuing]. It seems like she did that. She did

all those things. She is back there shaking her head, by the way.

Dr. FINKLESTEIN. I don’t know, sir.

Mr. CUMMINGS. Let me tell you where I am. The chairman has

heard more of your testimony than I have. I was at another meeting, and so I didn’t hear all of your testimony. He has concluded

that you are a very caring person, and I believe that. What I find

difficult to synchronize is numbers like that and the caring person

that he has just described.

Dr. FINKLESTEIN. Yes, sir.

Mr. CUMMINGS. I understand that there are a lot of people that

work for your company. I understand that. Because this is the bottom line: if I make a commitment to do something and, for whatever reasons, don’t have the capability of delivering it, that is a

problem. And when you see numbers like that, I can be the most

loving, caring person in the world, but if I can’t deliver, that is a

problem.

So I guess what I am trying to say to you is, the chairman asked

you about what you do to try to improve numbers like that. I would

imagine that after this case you all did some things, but are things

better in Maryland? Is that a fair question?

Dr. FINKLESTEIN. Yes.

Mr. CUMMINGS. Are they better?

Dr. FINKLESTEIN. Yes, they are better in Maryland, but, on the

other hand, we have some models in other States that are time

that we make some changes in the Maryland model. You weren’t

here, sir, when I spoke about our Rhode Island model. It is a

change. What we did is we took EPSDT, which is kind of restrictive, and mixed it into a commercial model, and we came out with

a blend that dentists can live with. It is time. It is working there.

It only started September 1, 2006. We didn’t get full enrollment of

32,000 youngsters until November 1st. And now the State is so

pleased that they are trying to increase more membership to

United on this model.

Whatever I do has to be re-evaluated not only by you but by myself. My outcomes have to constantly be evaluated. When I have a

patient come back to me, as I had this past Saturday, of 40 years,

and I saw a restoration, a filling that I did 40 years ago, that is

pride. I have to put the pride back into this program, sir. If there

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is anything that I can do—and you used the word commitment.

That is what I am pledging to you today is my commitment to

make this program better throughout the country—that is, Medicaid—working with you and anybody else in collaboration, because

it is unacceptable to have a result as we had that you read in the

newspaper. That is unacceptable.

Mr. CUMMINGS. In fairness to Ms. Norris—and I just want us to

be clear—I just want to read a little bit of her written testimony.

Dr. FINKLESTEIN. Yes.

Mr. CUMMINGS. She’s talking about DeShawn, now, that

DeShawn was enrolled in Maryland’s Medicaid HealthChoice program, and his managed care plan was United Health Care. ‘‘I

called United Health Care’s customer service number.’’

Dr. FINKLESTEIN. OK.

Mr. CUMMINGS. The number I guess you talked about, 1–800.

‘‘From there, I was transferred to the plan’s dental benefits administrator, a separate company called the Dental Benefits Providers,

or DBP. A very helpful customer service representative explained

that DeShawn would first have to see a general dentist to get a referral to an oral surgeon in order to get the treatment he needed.

She also explained that the Medicaid part of United Health Care

Company was called AmeriChoice, and that this was the company

the dentist would be contracted with, not United Health Care.’’

Dr. FINKLESTEIN. You just hit it right on the head. It is convoluted.

Mr. CUMMINGS. Yes.

Dr. FINKLESTEIN. I have to look into it. I have to look at root

cause analysis on that.

Mr. CUMMINGS. Yes.

Dr. FINKLESTEIN. There is confusion and there shouldn’t be confusion.

Mr. CUMMINGS. And I am telling you that when people—Dr. Finklestein, I have lived in the inner city and refused to move from

the inner city for 56 years. I live where a lot of the people that we

are talking about live, by choice. A lot of these folks, just trying to

get from day to day is a struggle.

Dr. FINKLESTEIN. Admittedly.

Mr. CUMMINGS. It is a struggle. So then when they have to go

through these kind of hurdles, I am amazed that they got as far

as they got. I am just being very frank with you. We can say what

we want about them, but the fact is that is reality. So all I am saying is I think it is very clear that we have to find—first of all, nobody should have to go through what Ms. Norris did. Now, she is

a professional, and if she is frustrated, a professional now, imagine

somebody who is doing it on their own.

So then the question becomes, if I have this product—and this

is assuming I have a product to get them to—and if they have to

go through 50 million changes to get there, they may never get

there. And, as she said, once they get there, then there is no there.

That is a problem. That is why it is very difficult for me to sit here

and feel—I have to tell you, I am just being frank with you. It is

hard for me, when I try to synchronize the way the chairman has

talked about you so nicely, and then to see what ends up.

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I have just got a few more questions, Mr. Chairman. I can see

you are getting anxious over there, but I am almost finished.

I want to go to you, Ms. Tucker. I want to thank you for appearing before our committee here today, and I know it has not been

easy. I realize that. I do appreciate your willingness to speak candidly, and I do appreciate all the things that Governor O’Malley is

doing trying to straighten this situation out. I understand there

has been legislation that has been passed, and the question becomes funding for the legislation. I am just wondering where that

stands. I have been told by some of the people who have looked at

Maryland that we have legislation but there is no money to do it

with. Can you comment on that? Will you comment on that, please?

Ms. TUCKER. There was legislation this year to fund increased

public health dental outreach efforts, and there wasn’t funding attached to the legislation, and we are looking at alternative ways to

do some of those activities, even without the funding that was attached.

For example, there is a Maryland Health Resource Commission

that gives out grants. It has funding to give out grants to try to

improve health care access to different kinds of services. We are

going to be working with that Commission to see if they will do a

special solicitation for dental services and to try to fund some of

what was not funded in the legislation. It was originally $2 million,

to try to fund it through other mechanisms like that.

Mr. CUMMINGS. Well, we are going to hold you to it. I mean, that

is just very important. I realize we are dealing with the legislature,

and I used to be in the legislature, so I know how that goes, but

we have a situation here where we don’t want to see another one

of these situations come forward. In the meantime, I think, as I

said to some other folks, I do believe sadly these incidents like this

happen, and it is very, very unfortunate, but it also is supposed to

shine a bright light on places we need to go and things we need

to address.

Ms. TUCKER. I agree with you.

Mr. CUMMINGS. Speaking of bright lights, I know that you have

a list of strategies, which sounds very good, but one of the things

that I did not see was oversight of managed care organizations. Is

that a part of your——

Ms. TUCKER. That was actually the second part of my presentation. We do a lot of activity.

Mr. CUMMINGS. Did you make that presentation?

Ms. TUCKER. I did.

Mr. CUMMINGS. OK.

Ms. TUCKER. But we do monitor the utilization of encounter data.

We actually require managed care organizations in our State to

submit every medical encounter that occurs for all recipients, so we

do look at that to look at how many individuals receive care, all

different kinds of care, not just dental care.

We require annual outreach plans. We review them carefully.

They have to have a dental section. They have to have materials

that they send to recipients. We review those for literacy and for

how they are going to do that. The United dental outreach plan

also includes incentives, $10 incentives for families who take their

154

children in for a checkup, for example. There are all these different

strategies. So there is this outreach plan that we review.

Mr. CUMMINGS. Let me ask you this: how much control does the

Health Department, the State Health Department, have over the

validity of the MCO’s listed practitioners?

Ms. TUCKER. We monitor the MCO encounter data very carefully.

This is not data the MCOs make out; this is data that providers

submit. We run it through a rigorous review, just like we review

all our claims data that comes in to our system, to look to make

sure that the provider is on the file, that the procedure makes

sense, that there is not duplicate procedures going through the system, etc., so that we can then do the measures to look and see what

is happening with our recipients.

The thing that is not the best about it is that it is not like an

electronic medical record. It is not real time. So it is hard to use

it for tracking and for looking to see if children need services immediately, because what we are doing is the provider is billing United

or AmeriGroup or any of our MCOs, and then they are forwarding

the provider’s claims data to the State.

Mr. CUMMINGS. Let me tell you something, Ms. Tucker. There is

no one that I know of in the United States that is better at tracking than Governor O’Malley.

Ms. TUCKER. I understand that.

Mr. CUMMINGS. I am just saying I don’t know of anybody.

Ms. TUCKER. Right.

Mr. CUMMINGS. All I am saying is maybe you ought to talk to

the Governor, because there may be some things that he can bring

to this process that might help us.

Ms. TUCKER. It is the whole——

Mr. CUMMINGS. I know it is very complicated. I understand that.

Ms. TUCKER. Yes. Electronic medical records is a whole——

Mr. CUMMINGS. I understand. I understand. He is the master of

that.

Ms. TUCKER. Right.

Mr. CUMMINGS. Let me ask you this, and this is just one last

thing. First of all, let me go back to the chairman. I really do appreciate his can-do attitude. When Democrats took over the Congress, one of the things that we were very concerned about is accountability, but we are also very concerned about results. What

the chairman has said, as I heard him, is we are trying to figure

out results that come out of all of this. We just don’t want to be

meeting here until 9:30 or 9. So I don’t know how all this works,

but you have Dr. Finklestein saying that he wants to do everything

in his power to help the situation—am I right?

Dr. FINKLESTEIN. Yes, sir.

Mr. CUMMINGS. And you have experts like Ms. Perkins, who has

given wonderful testimony. I mean, is there things that you all can

do working together to come up with some solutions? Let me tell

you something. Let me tell you what is so frustrating about being

here in the Congress. I’m sure the chairman will agree with me.

Sometimes, as much as we like to make laws, it takes time.

In the meantime, when people can resolve matters, that is nice,

but it takes time. I am hoping that there are some things that you

all can do. That is not to say that Congress will not act and do

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some things, but there are some things that perhaps you all can

do working together with others in your situation, Dr. Finklestein,

to help remedy some of these problems.

I take it that you have taken some steps since this case came up

and you are doing some things. I was just wondering, do any of

those things involve companies like United and the others?

Ms. TUCKER. The action group that we are pulling together has

a full array of stakeholders, including MCOs, including dentists, including parents, public health professionals, so it is going to have

a full array of stakeholders, including individuals like Ms. Norris,

advocates. So we are pulling together this action committee.

Mr. CUMMINGS. And would you ask them to take a look at the

South Carolina model?

Ms. TUCKER. We can definitely look at any models. What we

want to do is get the group together to look at all the different

issues, and we want them to come up with an action plan quickly

so that they can get recommendations to the Secretary by September, which is still time for possible budget initiatives for next year.

That is why the timing is kind of a rapid turn-around. Definitely

we can look at South Carolina.

Mr. CUMMINGS. Like I said, I think that as a citizen of the State

of Maryland I can tell you I want a person like Ms. Perkins to come

before a committee and say, you know what? Everybody ought to

be like Maryland. Maryland is a leader in health care and everybody ought to be like Maryland. I think that is so important. As

I say many times, if we can send people to the moon, we ought to

be able to do these earthly things and pull folks together to make

things work.

So I want to thank you all for your testimony. I know the chairman is going to say a few other words, but I want to thank you

all. I don’t ask, because asking is simply too cheap; I beg you to

address these issues. We just can’t have this. We can’t. This is

America. It doesn’t work that way and we shouldn’t have this.

Thank you all.

Mr. KUCINICH. Thank you, Mr. Cummings. I want to thank you

for all the work that you have done today and in cooperating to put

this hearing together.

We can send someone to the moon, but the question of this hearing is can we send a child into a dental chair. According to the

Congressional Research Service, of the 502,000 Maryland children

eligible for Medicaid in 2005, 75 percent, or 375,000, did not receive

even one preventive dental service during the year.

What is the State’s plan for accelerating its rate of improvement?

Ms. TUCKER. As I outlined in my testimony, what we are doing

is we are pulling together this Dental Action Committee to look at

all sorts of strategies. Medicaid agencies can’t do this by ourselves.

We need the dental community to be involved, the provider community. We need parents to be involved. We need Federal policymakers like you all to help us with funding for some of the safety

net connects to make sure that federally qualified health centers

have dental suites, to consider screening in schools. We need your

help.

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Mr. KUCINICH. So would you agree that there is a connection between low dental payment rates for providers and the lack of access to the dental chair?

Ms. TUCKER. I definitely think there is a problem, but it is not

the whole problem. For example, Ms. Perkins just talked about the

District of Columbia. They have the highest rate in the area, and

yet their dental utilizations seem to be very, very poor.

We have tried to work on improving dental rates, but our rates

are still low in Maryland.

About 2 or 3 years ago the State of Maryland decided to finally

bring physician rates up to the Medicare rates. Our physician rates

had lagged for years and years and years, and some of them were

10 percent of Medicare rates they were so low. The legislature decided to tackle that and provide over a 5-year funding to try to

bring us up to 80 percent of Medicare.

Mr. KUCINICH. Now let’s——

Ms. TUCKER. We need to do the same kind of thing with dental.

We need——

Mr. KUCINICH. OK. So here is the question: has the Department

required managed care organizations to beef up their provider networks with dentists who will actually accept as patients the lowincome children for whom the managed care organization has responsibility for managing care?

Ms. TUCKER. I think that I have heard a lot of very distressing

testimony about the dental networks. We do know that there are

918 unduplicated dentists in the networks that the MCOs use. We

do know that those dentists do bill. What that means is that they

have accepted Medicaid patients, that they are seeing Medicaid patients, but what it doesn’t mean is that they are open to new patients necessarily, which is bad.

Mr. KUCINICH. We had Dr. Tinanoff looking at 19 of Maryland’s

23 counties, and he found that, of 743 listed dentists, only 170 are

willing to accept new Medicaid patients.

Ms. TUCKER. New patients. I agree. And we have to look at a different way to give information to patients. Rather than giving them

lists of providers who have contracts with MCOs, we are going to

have to look at, instead, not giving them lists of providers that

have contracts, but actually actively linking them with a dentist

that does accept new patients.

Mr. KUCINICH. The next question is how can the Department expect parents to find dentists for their children if the information

that is provided isn’t reliable?

Ms. TUCKER. I totally agree. One of the things that we are doing

is we are meeting tomorrow with the MCOs to talk about all of the

dental issues that have come up in the hearing today, and that we

have been talking about actually over the years and during the last

2 months. This is going to be one of the top items on the agenda.

Mr. KUCINICH. So has the Department required these managed

care organizations to demonstrate improved outcomes in the dental

health of low-income children for whom they have the responsibility for managing care, such as a reduction of untreated cavities?

Ms. TUCKER. That is a really hard measure to get at. What you

would have to do is you would have to do actual oral exams of Medicaid patients to then measure that. What we try to do is look for

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measures where we can get data. But this is something that we are

going to need to talk to, again, with our Action Committee to see

if there are some other measures that we might be able to use in

addition to the HEDIS measure.

The reason that we do use the HEDIS measure is because it is

the only way we can compare our performance with other States.

It is the only measure that the managed care system uses across

the board, and so that is the measure we have used, but it doesn’t

mean it is the ideal measure or it is an outcomes oriented measure,

so it is something that we should talk about in our action committee.

Mr. KUCINICH. So do you regularly check the number of providers

still? Do you run a constant canvass on the number of providers?

How often do you update your number of providers?

Ms. TUCKER. I actually am not sure how often we do that. I do

know that we look to see if the providers are billing, and we do

look to see if they have contracts with the MCOs. But I am not

sure that we do regular checks in terms of whether or not they are

open. I know that they open and close frequently. It is very frustrating in trying to monitor that situation.

Mr. KUCINICH. Well, do you think it would be helpful if you

found a way to be in contact or have some vehicle for contacting

providers so you would be able to really know how many providers

you have, and therefore you could guess how many people are

going to be able to have access to some of these?

Ms. TUCKER. We can try to set up a program. It is only going to

be as good as the day you do the calls, because they open and close

at will, based on their current case load.

Mr. KUCINICH. In your testimony you talked about you made 20

calls?

Ms. TUCKER. I did not. It must have been someone else’s testimony.

Mr. KUCINICH. OK. I would like to ask Ms. Perkins a question

about D.C. You talked about the accuracy of lists?

Ms. PERKINS. Yes.

Mr. KUCINICH. How accurate are those lists?

Ms. PERKINS. We have looked at them on a couple of different occasions in March 2005. Let me just say that it was very difficult

getting these lists in the first place from the District, who was having great difficulty getting them from the managed care organizations, but of the 135 unduplicated dental providers named, only 45

individual dentists and one clinic confirmed that they accepted

Medicaid eligible children, that is even to take one child. It doesn’t

say anything about the extent of participation.

And of those 45 dentists, 29 were general dentists, 6 were oral

surgeons, 3 were pediatric dentists, and there was one orthodontist.

When you check that one orthodontist, there were four plans.

There were two MCOs in the District who had no orthodontist on

their plan.

Mr. KUCINICH. And you did testify that only 16 percent of children received any dental treatment services at all with respect to

in States that were reporting to the CMS.

Ms. PERKINS. In 2004. We could not use 2005 data because, although it appears that the GAO was able to get access to addiVerDate 11-MAY-2000 13:37 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00161 Fmt 6633 Sfmt 6633 C:\DOCS\35772.TXT HGOVREF1 PsN: HGOVREF1
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tional data that is not publicly available, there are 15 States missing in the public data.

Mr. KUCINICH. What was the percentage of dentists you say that

participate in Medicaid? Did you say 5 percent overall?

Ms. PERKINS. In the District of Columbia, 5 percent of licensed

dentists. Again, that is just meaning that they take one person. It

doesn’t say how active that participation is, whether they have age

cutoffs for the number of kids they are going to serve, or whether

they limit the number of patients they are going to serve.

Mr. KUCINICH. And I want to ask a question to Ms. Tucker.

Thank you. In your contract with United Health Care there is a

managed care reimbursement clause that states that ‘‘The Department has the authority to recover any over-payments made to

MCOs.’’ The contract does not define over-payments. Do you consider the capitation payments made for children who do not receive

services that they need, such as Deamonte, do you consider that an

overpayment?

Ms. TUCKER. No, sir.

Mr. KUCINICH. And how many years would have to pass during

which children did not get the services they needed for it to be considered that an overpayment has been made?

Ms. TUCKER. There is no time limit. That isn’t the methodology

for developing it, a capitation rate. A capitation rate is based on

the general population in the program, and it is more of an average

rate for individuals in different groups.

Mr. KUCINICH. I understand, but what do you do with children

who chronically receive no services? I mean, does the State hold

these managed care organizations accountable by recovering payments made for children who chronically receive no services?

Ms. TUCKER. We don’t. It is not a fee for service program, so we

don’t do a cost settlement based on each individual child, just like

we don’t pay them more if they spend more on other individuals.

That is not the way capitation works. That is not the way insurance works. We are not just paying them for providing those services; we are providing them for taking risks for catastrophic services, as well. It is all built into the capitation rate.

Mr. KUCINICH. OK.

Ms. TUCKER. So, again, it is not a fee for service program, and

it is not a program with—no insurance is a program where, when

you are paying for insurance, other than a fee for service, no insurance program is one where you pay for the individual patient’s cost,

or capitation program.

Mr. KUCINICH. OK. I think we are at the point where we are

going to be soon concluding this hearing, and I want to thank all

of those who came here to testify and participate in what has been

a very long day on a very critical subject.

I think that, Mr. Cummings, you would agree that, with the individuals on this committee who have participated from this afternoon, that there is a high degree of interest in looking at some policy issues here where Congress can effectively participate to make

sure that the case of Deamonte is never going to be repeated.

Before I conclude, would you like to say something?

Mr. CUMMINGS. I would just like to thank our witnesses. I know

it has been a very long day. If there are things that you all want

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to submit—Ms. Tucker, you, in particular, I noticed some things in

your testimony—but if there are things that you want to submit as

to what we can do to help move this process along, we would ask

that you submit it as soon as possible. There may have been some

things that you heard today that caused you to say well maybe this

is something the Congress needs to look at. We just want to be effective and efficient and make a positive difference.

Thank you all very much.

Mr. KUCINICH. Thank you, Mr. Cummings.

I am going to just have a final word here.

In the United States of America we spend approximately $2.2

trillion a year on health care. That is about 16 percent of our gross

domestic product. About 31 cents on $1, according to a Harvard

University study, goes for the activities of the for-profit health care

sector for corporate profits, stock options, executive salaries, advertising, marketing, the cost of paperwork, 15 to 30 percent in the

private sector as compared to Medicare’s 2 to 3 percent.

If the United States had a health care program where it was not

for profit and we took the approximately $660 billion a year that

is spent in for-profit medicine and put it into a not-for-profit system, we would have enough not only to meet all medical needs but

to provide every child, and every American, for that matter, with

fully paid dental care, fully covered, vision care, mental health,

long-term care, prescription drugs that, in fact, Americans are already paying for this. They are not getting it. We are talking about

a system that would have no premiums, co-pays, deductibles. This

is the essence of the Conyers-Kucinich bill, H.R. 676.

I mention that because when I think of the doctor’s commitment

to children, I share that same commitment. I think of how we may

some day in this country create a system where everyone is covered, and then people aren’t chasing around trying to find someone

because every dentist would be required to provide care and they

would receive a fair reimbursement.

So it may be that down the road there is only going to be one

solution to this, but in the meantime we have a lot of work to do.

The witnesses here have all helped us provide some very detailed

definition to the work that is cut out for us.

I think it is worthy of our efforts to devote our continued work

to the memory of Deamonte, because this little boy whose life demonstrated a total breakdown of a system, maybe what we can do

is provide some deeper meaning that can help children everywhere

get the care they need.

Thank you.

I am Dennis Kucinich. This is the Subcommittee on Domestic

Policy. I am here with Congressman Cummings from Maryland.

We have held a day-long and into-the-evening hearing on evaluating pediatric dental care under Medicaid.

I want to thank all the witnesses.

This committee is adjourned.

[Whereupon, at 9:15 p.m., the subcommittee was adjourned.]

[The prepared statement of Hon. Edolphus Towns and additional

information submitted for the hearing record follow:]

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