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MEDICAID’S EFFORTS TO REFORM SINCE THE PREVENTABLE DEATH OF DEAMONTE DRIVER: A

PROGRESS REPORT

HEARING

BEFORE THE

SUBCOMMITTEE ON DOMESTIC POLICY

OF THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED ELEVENTH CONGRESS

FIRST SESSION

OCTOBER 7, 2009

Serial No. 111–129

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

(

Available via the World Wide Web: http://www.fdsys.gov

http://www.oversight.house.gov

(II)

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

EDOLPHUS TOWNS, New York, Chairman

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

JIM COOPER, Tennessee

GERALD E. CONNOLLY, Virginia

MIKE QUIGLEY, Illinois

MARCY KAPTUR, Ohio

ELEANOR HOLMES NORTON, District of

Columbia

PATRICK J. KENNEDY, Rhode Island

DANNY K. DAVIS, Illinois

CHRIS VAN HOLLEN, Maryland

HENRY CUELLAR, Texas

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

PETER WELCH, Vermont

BILL FOSTER, Illinois

JACKIE SPEIER, California

STEVE DRIEHAUS, Ohio

JUDY CHU, California

DARRELL E. ISSA, California

DAN BURTON, Indiana

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

BRIAN P. BILBRAY, California

JIM JORDAN, Ohio

JEFF FLAKE, Arizona

JEFF FORTENBERRY, Nebraska

JASON CHAFFETZ, Utah

AARON SCHOCK, Illinois

BLAINE LUETKEMEYER, Missouri

ANH ‘‘JOSEPH’’ CAO, Louisiana

RON STROMAN, Staff Director

MICHAEL MCCARTHY, Deputy Staff Director

CARLA HULTBERG, Chief Clerk

LARRY BRADY, Minority Staff Director

SUBCOMMITTEE ON DOMESTIC POLICY

DENNIS J. KUCINICH, Ohio, Chairman

ELIJAH E. CUMMINGS, Maryland

JOHN F. TIERNEY, Massachusetts

DIANE E. WATSON, California

JIM COOPER, Tennessee

PATRICK J. KENNEDY, Rhode Island

PETER WELCH, Vermont

BILL FOSTER, Illinois

MARCY KAPTUR, Ohio

JIM JORDAN, Ohio

MARK E. SOUDER, Indiana

DAN BURTON, Indiana

MICHAEL R. TURNER, Ohio

JEFF FORTENBERRY, Nebraska

AARON SCHOCK, Illinois

JARON R. BOURKE, Staff Director

(III)

C O N T E N T S

Page

Hearing held on October 7, 2009 ............................................................................ 1

Statement of:

Edelstein, Burton, D.D.S., M.P.H., Chair, Children’s Dental Health

Project; Mary McIntyre, M.D., M.P.H., medical director, Office of Clinical Standards and Quality, Alabama Medicaid Agency; Joel Berg,

D.D.S., M.S., Chair, Department of Pediatric Dentistry, University of

Washington; and Frank Catalanotto, D.M.D., professor and Chair, Department of Community Dentistry and Behavioral Sciences, University

of Florida, College of Dentistry, representing American Dental Education Association ......................................................................................... 58

Berg, Joel ................................................................................................... 83

Catalanotto, Frank .................................................................................... 88

Edelstein, Burton ...................................................................................... 58

McIntyre, Mary .......................................................................................... 68

Iritani, Katherine, Assistant Director, Health Issues, U.S. Government

Accountability Office; and Cindy Mann, Director, Center for Medicaid

and State Operations .................................................................................... 10

Iritani, Katherine ...................................................................................... 10

Mann, Cindy .............................................................................................. 23

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

Berg, Joel, D.D.S., M.S., Chair, Department of Pediatric Dentistry, University of Washington, prepared statement of ........................................... 85

Catalanotto, Frank, D.M.D., professor and Chair, Department of Community Dentistry and Behavioral Sciences, University of Florida, College

of Dentistry, representing American Dental Education Association, prepared statement of ........................................................................................ 90

Edelstein, Burton, D.D.S., M.P.H., Chair, Children’s Dental Health

Project, prepared statement of ..................................................................... 61

Iritani, Katherine, Assistant Director, Health Issues, U.S. Government

Accountability Office, prepared statement of ............................................. 12

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

of Ohio:

Letter dated December 15, 2008 .............................................................. 52

Letter dated October 7, 2009 .................................................................... 50

Prepared statement of ............................................................................... 5

Mann, Cindy, Director, Center for Medicaid and State Operations, prepared statement of ........................................................................................ 26

McIntyre, Mary, M.D., M.P.H., medical director, Office of Clinical Standards and Quality, Alabama Medicaid Agency, prepared statement of ..... 70

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MEDICAID’S EFFORTS TO REFORM SINCE THE

PREVENTABLE DEATH OF DEAMONTE DRIVER: A PROGRESS REPORT

WEDNESDAY, OCTOBER 7, 2009

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON DOMESTIC POLICY,

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 2:40 p.m., in room

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

(chairman of the subcommittee) presiding.

Present: Representatives Kucinich, Cummings, Watson, and Jordan.

Staff present: Jaron R. Bourke, staff director; Tom Mulloy, Office

of Representative Kucinich; Jean Gosa, clerk; Charisma Williams,

staff assistant; Carla Hultberg, chief clerk, full committee; Leneal

Scott, IT specialist, full committee; Adam Hodge, deputy press secretary, full committee; Ashley Callen, minority counsel; Molly Boyl,

minority professional staff member; and Adam Fromm, minority

parliamentarian/Member services coordinator.

Mr. KUCINICH. The Domestic Policy Subcommittee of Oversight

and Government Reform will now come to order.

I want to thank the witnesses and those in the audience and my

colleague, Ranking Member Jordan, for your patience. The House

had in consideration a bill that I was the author of, and so I had

to be there to present it. It’s good to be here with you as we start

this hearing.

This hearing is going to be the fourth in a series on access to pediatric dental services in Medicaid. The subcommittee has focused

on this issue since the death of Deamonte Driver in February 2007;

and that’s Deamonte Driver’s picture. His death highlighted the inadequacy of dental services for Medicaid and rural children in

Maryland.

Without objection, the Chair and the ranking minority member

will have 5 minutes to make opening statements, followed by opening statements not to exceed 3 minutes by any other Member who

seeks recognition.

Without objection, Members and witnesses may have 5 legislative days to submit a written statement or extraneous materials for

the record.

On February 25, 2007, Deamonte Driver, a 12-year-old boy from

Prince George’s County, Maryland, died from a brain infection

caused by untreated tooth decay. Deamonte’s tragic death could

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have been easily prevented by access to dental care, dental care he

was entitled to and should have received through United

HealthCare, Maryland’s Medicaid dental provider.

Unfortunately, that company failed to meet its obligation to provide beneficiaries with access to dental providers. So onerous were

the administrative barriers that United HealthCare had created,

‘‘it took one mother, one lawyer, one online help supervisor, and

three case management professionals to make a dental appointment for one Medicaid child,’’ according to testimony we received

from Laurie Norris, a legal advocate who worked with the Driver

family.

In the 21⁄2 years since Deamonte’s preventable death, this subcommittee has been conducting an inquiry into the adequacy of efforts on a State level to ensure access to pediatric dental services

under Medicaid, as well as the actions that the Center for Medicaid

and State Operations, CMS, to conduct oversight of State systems.

At our first hearing in May 2007, we learned that Deamonte

Driver was not the only Maryland youth who wasn’t receiving dental care to which he was entitled by Medicaid. In fact, our investigation of United HealthCare found that approximately 11,000

Maryland children in United HealthCare’s Medicaid operation had

not seen a dentist in at least 4 years. We found that United

HealthCare provided information to Medicaid beneficiaries that

was so inaccurate and outdated it would have been virtually impossible to find a dental care provider.

We also learned that CMS did virtually nothing to address the

problems in poorly performing State systems. Dennis Smith, director of CMS at the time, argued that financial sanctions are the only

tool CMS has to enforce compliance; and he was unwilling to hand

down financial sanctions because he said the cost was ultimately

borne by the patient.

Simply put, this is not the case; and in a letter to Mr. Smith the

subcommittee outlined nine actions that CMS could take that

would serve to enforce the statutory responsibilities that States

have to ensure that Medicaid-eligible children have access to dental

services.

Our second hearing focused on CMS’s response to this letter and

actions taken by them in the years since Deamonte Driver’s death

to address the deficiencies in its oversight responsibilities. While

they did take some action, their efforts, unfortunately, fell short of

effecting any real change. In fact, the hearing revealed that most

of the progress of the State of Maryland was made despite CMS,

that the agency was not actively involved in the State’s efforts and

provided almost no guidance.

Additionally, CMS continued to neglect the issue of provider reimbursement rates, despite hearing testimony about the importance of them to effecting system-wide reform. Astoundingly, Mr.

Smith even acknowledged as such during our first hearing, but

stubbornly, stubbornly continued to avoid the issue. Mr. Smith resigned from his post not long after our second hearing.

After that, things began to change. A GAO report, the first of its

kind since 2000, revealed that millions of Medicaid-enrolled children suffer from tooth decay, almost one-third of the total Medicaid

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population. Medicaid children are roughly twice as likely as privately insured children to suffer from tooth decay.

Moreover, this pattern has persisted for years. Very little has

been done to improve access to and utilization of dental services.

In a sense, the problem of tooth decay is getting worse, because the

rate of decay in the teeth of children aged 2 to 5 has increased in

recent years.

Now our third hearing on the issue demonstrated that improvement is possible. Under new leadership and continued congressional scrutiny, CMS began to turn a corner. The interim director

of the Center for Medicaid and State Operations outlined a number

of actions that they had taken to engages States actively in reform

as well as to improve their own oversight functions. They conducted 17 reviews of State systems with utilization rates below 30

percent and provided each State with its own report and recommendations, worked with States to develop oral health schedules

that met Federal guidelines, and formed an Oral Health Technical

Advisory Group with State Medicaid directors.

We also learned that the State of Maryland, where this whole

journey began, continued making considerable progress. The dental

action committee that they formed developed seven recommendations to improve access to dental care for Maryland’s children. Two

ended up in a budget submitted by Martin O’Malley, the Governor

of Maryland, and another was passed by the State legislature.

Today, the GAO will share the findings of their most recent report, commissioned at the request of myself and Mr. Cummings, on

the adequacy of pediatric dental oversight at the State and Federal

level. I am thankful to GAO for their hard work and dedication in

studying this problem.

We will also hear, for the first time, from the new director of the

Center of Medicaid and State Operations. I am looking forward to

their report on the progress they have made and how they plan to

use that momentum to address the gaps that remain as identified

in the GAO report.

Additionally, we are going to hear from State Medicaid officials

and researchers who have studied and implemented successful initiatives to increase access to and utilization of dental services, as

well as to improve provider participation.

I believe and hope that CMS has turned a corner in their oversight of pediatric dental services since the death of Deamonte Driver. But the magnitude of the underlying problem is great, and even

today there are millions of children just like Deamonte entitled to

dental care but not receiving it. The urgent job of everyone here

today is to move quickly to prevent another one of them from dying

from preventable dental disease.

Finally, I just want to share with my colleagues, you know, people ask me when Deamonte’s death was first announced, why are

you so interested? It’s just 1 person out of 300 million. You know,

these things happen.

I remember growing up in the inner city. I was the oldest of

seven. My parents never owned a home and lived in 21 different

places by the time I was 17, including a couple of cars. And one

of the things we didn’t have was dental care. I mean, I can remember chewing on gum balls and having them just breaking off—my

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teeth breaking off into the gum balls. And I can remember having

dental problems that didn’t get treated for a long, long time.

And I don’t want to get too graphic about it, but for those who

have experienced being a child without access to dental care, you

know what a nightmare it can be.

Deamonte Driver, that’s me. That’s me as a young boy. His life

was sacrificed to an uncaring system. We can’t have any more

Deamonte Drivers out there.

Look at his face. I mean, he is just—he is really asking us, what

we are going to do about this? Are we going to take a stand to

make sure that the children of America get the dental services that

they are entitled to?

That’s the challenge we have, and I will not rest. I know there

are colleagues like Mr. Cummings and Mr. Jordan, we have very

powerful feelings about this as well.

But I will not rest until we have caused the death of Deamonte

Driver to be a driver of a new day in delivering dental services to

the children of this country and particularly those who are served

by Medicaid.

I want to thank you for your indulgence, Mr. Jordan.

With that, I yield to the ranking member of this committee, Mr.

Jordan, for his opening statement.

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

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Mr. JORDAN. I thank the chairman for his work and for calling

this hearing as well and for continuing to highlight the importance

of access to dental care for children. I look forward to hearing from

our witnesses about what has been done to enhance pediatric dental services and improve access, since these issues were first looked

at by the subcommittee following the tragic death of Deamonte

Driver in 2007.

Barriers to care, including low reimbursement rates for dentists,

lack of understanding of the importance of our oral health, and excessive administrative burdens for patients and providers all contribute to the problem. According to the report the GAO released

today, State Medicaid programs have taken steps toward improving

access, but gaps remain that must be addressed.

Likewise, CMS has worked to improve its oversight of pediatric

dental issues in Medicaid. More progress certainly is necessary. In

2008, GAO estimated that one in three children on Medicaid had

untreated tooth decay. I hope our witnesses today will tell us what

is being done to fill these gaps and treat these children.

Unfortunately, the issue of access to care is not unique to pediatric dentistry for Medicaid enrollees but a problem across the

health care spectrum. The problems of access to care are prevalent

in our existing government-run programs, including Medicaid,

Medicare, and SCHIP. Low reimbursement rates set at the State

level for Medicaid and the national level for Medicare lead to a low

participation of providers in these programs. In this respect, the

terrible story of Mr. Driver can prove to be a lesson as we move

through health care reform and evaluate the different options for

ensuring a healthy America.

With that, Mr. Chairman, I yield back the balance of my time.

Mr. KUCINICH. I thank my colleague from Ohio; and the Chair

recognizes Mr. Cummings from Maryland, who has been working

on this issue from the time that it was first known. I want to thank

him for his dedication.

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

I really do thank you for your interest in this issue, and I thank

you—as I listened to you just a moment ago, I am reminded that

what you have done is you have taken some of your experiences in

life as a child and turned them around and used them as a passport to help others, and that says a lot. So often people want to

bury what happened in their past. However, you take it and you

raise it up to remind us that this could happen to anybody. So I

do—but not only do you do that, you then lay out a mission to correct it. So I really do appreciate you doing this.

You know, Deamonte died on February 25, 2007, and I know that

the chairman has already talked about it, but I think about it

every day, just about. And when I think about an untreated tooth

and an infection spreading to a child’s brain, $80 worth of dental

care might have saved his life, but Deamonte was born, he never

made it to the dental chair.

Mr. Chairman, you recall we first held a hearing on this topic at

my request back on May 2, 2007, in an effort to identify the critical

breakdowns in our Medicaid system’s provision of dental care to

children. As our dental health professionals here today know, oral

health is an often overlooked but vital component of health care.

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Preventive dental care, especially for our children, is a fundamental need for their healthy development into adulthood.

In fact, tooth decay 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. Eighty percent of cavities occur in only 25 percent of

children, predominantly low-income children. Low-income children

suffer twice as much from tooth decay as do more affluent children.

Millions of school hours are lost each year to dental-related illness.

Poor children suffer nearly 12 times more restricted activity days

than children from more affluent families due to dental-related illness.

Our previous hearings on this matter revealed woeful failures of

the Centers for Medicaid & Medicare Services and its State partners to comply with section 1905(r)(3) of the Social Security Act,

which ensures that every child—every Medicaid-eligible child will

have access to medically necessary dental care under the Early Periodical Screening, Diagnostic, and Treatment [EPSDT], provision.

We found that Medicaid fell glaringly short of meeting this mandate and was given directives to address these disparities. I am

eager to hear today about efforts that they have partaken in to address the disparities.

Since Deamonte’s death, my home State of Maryland has resolved to do everything possible to prevent such an avoidable tragic

loss; and we have made significant gains to improve children’s access to dental care. In just 2 years, Mr. Chairman, 41,000 more

children in Maryland received Medicaid-funded dental service than

those who received such service in 2007. In 2009 alone, Maryland

is making an overall $811⁄2 million investment in Medicaid dental

care services Statewide.

Governor Martin O’Malley, to his credit, also convened a dental

action committee which developed seven recommendations to better

serve our children, including raising reimbursement rates for dental services, initiating a single State-wide vendor for dental services, spending $2 million per year to enhance the dental health infrastructure, providing dental screenings for children, creating a

new dental hygienist position, improving education for dental students, and crafting a public education campaign on oral health. The

Governor included the first three items in his 2000 budget, and he

is currently working with a dental action committee to implement

the others.

Similarly, the UnitedHealth Group has stepped up to the plate

to do its part. It invested $170,000 for a program at the University

of Maryland Dental School to improve children’s access to dental

care in Baltimore City, including more than $30,000 to hire a pediatric dentistry case manager, more than $60,000 to hire a pediatric

dentistry fellow, $30,000 to establish a mini pediatric dentistry

clinic, and $15,000 to provide continuing access to education to pediatric and family practice residents.

As I close, the company is now working to develop a similar partnership with Howard University that will reach across the Maryland border to Deamonte’s home county, Prince George’s.

All of these actions are commendable. However, they are being

implemented solely on a State level. In order for us to see monuVerDate 11-MAY-2000 13:04 May 23, 2011 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 C:\KATIES\DOCS\64919.TXT KATIE PsN: KATIE
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mental gains, changes must be made Nationwide. We have been

anticipating a review of CMS’s since our last hearing to learn what

has been accomplished at the Federal level. We were sorely disappointed regarding the lack of demonstrable effort between our

first and second hearings, so GAO’s report has been eagerly awaited. I am hopeful that we are turning the page to a new day.

With the leadership of Ms. Cindy Mann, CMS will work to create

innovative reforms to address the concerns raised in GAO’s report,

and these reforms will incorporate the effective and efficient programs that are already working on a State level.

Mr. Chairman, a child died because of our failure as adults, of

our failure as adults to discharge this mandate. For Deamonte

Driver and for every child and adult like him, we must proceed

with a sense of great urgency and with an unfailing determination

to see our efforts to completion. It is their turn. It is their turn to

grow up. It is their turn to be healthy children. It is their turn to

deliver and develop the gifts that they have been given to deliver

to us. But if they are not healthy and if their teeth are rotting and

if we are not doing anything about it, shame on us.

Thank you very much, Mr. Chairman. With that, I yield back.

Mr. KUCINICH. Thank you, Mr. Cummings, for your commitment,

your statement, your heart, your passion, and your willingness to

take a stand.

We are now going to go to the witnesses. There are no additional

opening statements. The subcommittee will receive testimony from

the witnesses before us today.

I would like to start by introducing our first panel:

Ms. Katherine Iritani is Acting Director for Health Issues at the

U.S. Government Accountability Office. In her 27-year career with

GAO, she has helped plan and execute a wide variety of program

and evaluation assignments. In recent years, she has overseen multiple evaluative studies on Medicare financing and access issues,

including children’s access to preventive and dental services. Ms.

Iritani currently works in GAO’s Seattle field office and has a business administration degree from the University of Washington.

Next, Ms. Cynthia Mann. Ms. Mann was appointed director of

the Center for Medicaid and State Operations [CMSO], in June

2009, where she is responsible for the development and implementation of national policies governing Medicaid, the State Children’s

Health Insurance Program, survey and certification, Medicaid Integrity Program, and the Clinical Laboratories Improvement

Amendments. CMSO, the Center for Medicaid and State Operations, also serves as the focal point for all CMS interactions with

States and local governments.

Prior to her return to CMS in 2009, Ms. Mann served as a research professor at Georgetown University Health Policy Institute

and executive director of the Center for Children and Families at

the Institute. Her work at Georgetown focused on health coverage,

financing, and access issues affecting low-income populations. Previously, she served as director of the Family and Children’s Health

Programs at CMSO from 1999 to 2001, where she played a key role

in implementing Medicaid and the SCHIP program.

Before joining the government in 1999, Ms. Mann led the Center

on Budget and Policy Priorities, Federal and State health policy

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work. She also has extensive State-level experience, having worked

on health care welfare and public finance issues in Massachusetts,

Rhode Island, and New York.

Thank you both for appearing before this subcommittee today.

It’s the policy of the Committee on Oversight and Government

Reform to swear in our witnesses before they testify. I would ask

that you rise.

[Witnesses sworn.]

Mr. KUCINICH. Let the record reflect that each witness answered

in the affirmative.

I would ask that each of the witnesses now give a brief summary

of your testimony. I ask that you keep this summary under 5 minutes in duration. Your complete written statements are going to be

in the record; and that’s what we are here to do, to have you amplify on that in your time that you will be presenting.

So I would like you, Ms. Iritani, to be our first witness. You may

begin.

STATEMENTS OF KATHERINE IRITANI, ASSISTANT DIRECTOR,

HEALTH ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; AND CINDY MANN, DIRECTOR, CENTER FOR MEDICAID

AND STATE OPERATIONS

STATEMENT OF KATHERINE IRITANI

Ms. IRITANI. Mr. Chairman, Ranking Member Jordan, and members of the subcommittee, I am pleased to be here to discuss children’s access to Medicaid dental services, a longstanding concern.

As you noted in your opening remarks, an estimated one of every

three children in Medicaid has untreated tooth decay. One in nine

have it in three or more teeth. This is about twice the rate experienced by privately insured children and translates to millions of

Medicaid children in need of dental care. In too many cases, this

need is urgent.

My statement is based on GAO’s report that you are releasing

today. This report summarizes at a national level efforts of States

and CMS to improve Medicaid dental services for children. In summary, we found that State Medicaid programs and CMS have

taken a number of actions to monitor and improve children’s access

to dental services, but problems with access persist and gaps in

CMS oversight remain.

First, let me share highlights of States’ actions from our Webbased survey of State Medicaid programs. All States reported monitoring children’s access to dental services, and nearly all States

had implemented one or more initiatives to improve access through

actions to reach out to families such as establishing hotlines to help

them find a dentist and initiatives such as raising reimbursement

rates to encourage more dentists to serve Medicaid children.

Nonetheless, States reported multiple barriers to improving access. These barriers are well-known and longstanding, for example,

for families finding a dentist to treat their children; for providers,

concerns remain about families missing their appointments, low reimbursement rates and administrative burdens. These barriers persist, despite States actions to address them.

11

Of significance, most States indicated their initiatives to improve

access had not met their expectations; and two-thirds of the 21

States that reported contracting with managed care organizations

to provide dental services said those organizations were not meeting the States’ access standards.

The bottom line, children’s access to Medicaid dental services has

been improving but remains low. States report that only about 35

percent of Medicaid children nationally received any dental service

in 2007, as compared to HHS’s goal of 66 percent of low-income

children receiving a preventive dental service by 2010.

Now let’s turn to actions of CMS. CMS has improved its oversight of State programs in several ways, but more can be done.

Two observations: First, CMS has focused dental reviews of 17

States with low dental access rates, identified significant problems,

including concerns in eight States that managed care organizations

had inadequate numbers of dentists in their networks. CMS did

not, though, require corrective action plans of States or have plans

to review other States with low dental access rates.

Second, CMS has improved its guidance to and communications

with States. For example, CMS posted descriptions of four States

promising practices for improving access on its Web site, but nearly

every State, 49 in all, reported to us that they need more from

CMS. States reported, for example, that they need specific guidance

in areas such as establishing appropriate dental payment rates and

improving billing policies.

Notably, when we ask States how CMS could help them, most

States answered that CMS should provide more information on

what was working in other States. Twenty-six States reported to us

that they believe their State had one or more best practices for delivering dental services that could be shared with others.

In conclusion, CMS and States have taken noteworthy steps to

improve children’s access to Medicaid dental services. Concerted

and continued efforts and, in these challenging fiscal times, innovative solutions will be needed to address the multiple and longstanding barriers to improving children’s oral health. For its part, CMS

can help through ongoing assessment, guidance, and support of

States’ efforts, building upon the steps the agency has recently undertaken. We have made several recommendations to CMS toward

this end and have ongoing work for the Congress further examining these issues.

Mr. Chairman, this concludes my statement. I would be happy

to answer any questions.

Mr. KUCINICH. I thank the gentlewoman.

[The prepared statement of Ms. Iritani follows:]

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Mr. KUCINICH. The Chair recognizes Ms. Mann. You may proceed.

STATEMENT OF CYNTHIA MANN

Ms. MANN. Good afternoon, Chairman Kucinich, Ranking Member Jordan, and members of the subcommittee. I, too, appreciate

the opportunity to be with you today to talk about how children are

faring receiving needed dental services under the Medicaid program; and I want to begin by commending you, Mr. Chairman, for

your sustained interest in this area.

I have been the director for the Center for Medicaid and State

Operations for a little less than 4 months, and I have not been a

witness to the prior hearings. However, in my position at Georgetown University, I closely followed the proceedings. And now that

I am director of CMSO and have taken stock of what we have done

in the past period of time, it is clear to me that the activity that

has happened was triggered in large part by the activity of this

committee and by your interest in this area and that you have been

able to plant the seeds for a renewed commitment on this very important matter.

While I am new to CMS, I am not new to this issue. As you

noted in your introduction of me, I have worked on children’s access issues for many years; and I would note that in my 18 months

at CMS in 1999 and 2001 I helped author the letter that was

issued in January 2007, which you referred to in your first hearing,

which called for every State to conduct a dental access review.

Since that time, many States have made progress narrowing dental access gap for children. But, as the GAO correctly points out,

significant gaps remain. We know from the research that there’s an

inextricable link between oral health and overall health and that

every child needs dental care, preventive care, and treatment when

appropriate.

Sadly, our country’s record in assuring our kids have the dental

care they need, both in private coverage as well as in public coverage, is not good; and the record is particularly poor for low-income children. I can assure you, Mr. Chairman and members of the

committee, that Secretary Sebelius and I share a firm belief that

we have a responsibility to do much more to assure that every child

enrolled in Medicaid receives the dental care they need.

The data show that about 36 percent of all Medicaid-eligible children used dental services over a year’s period of time. With that

data, there can be little doubt that improvements are necessary.

States administer the program, they enroll the providers, they

set the provider rates, but CMS plays a critical role, and we are

intent on using all of the tools available to us to assure that every

child covered by Medicaid is as healthy as he or she can be.

My written testimony lists a number of actions that CMS has

taken over the past period of time since the last hearing. I am just

going to review a few of those activities.

In policymaking activity, we are now actively involved in providing guidance in the area of children’s health insurance coverage

and the new CHIPRA provisions that expanded dental benefits for

children in a number of different ways. In fact, today we released

our guidance to States on the new CHIP dental health benefit and

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the supplemental insurance option that’s now available to States to

provide dental coverage to children who have other sources of care.

CHIPRA also included several other provisions that we are working on. One was a provision that required the Secretary to publish

the names of the dentists serving children in the Medicaid program

in every State around the country, Medicaid and the CHIP program. We launched that Web site on August 4th and have those

dental providers listed at this point. That Web site, I will say, is

a work in progress.

We think that there’s a number of improvements that we want

to continue to make. We have had a number of—a lot of activity

on that Web site, about 43,000 hits to the page, but there are improvements that can be done; and we think we can use that Web

site not only to ultimately share information with families like

Deamonte Driver’s family about where to get dental care but also

for us to use as a monitoring tool to be able to see what the numbers of dentists are in each Medicaid program, how many are taking new patients, and what that access looks like over time.

We also are intent on changing our data reporting system. We

want to change the so-called CMS–416, which is our EPSDT reporting form, to include information about other providers that are

providing oral health care, as well as to improve, to make other improvements to the 416; and we are planning to do that by the

spring of this year. There were a number of requirements to

changes in the 416 that were part of CHIPRA, so we want to consolidate those changes and put those out in the spring.

We are also partnering right now with the Agency for Health

Quality and Research to come up with dental health quality standards as part of the overall initiative to come up with children’s

health standards. We believe that those health standards, those

dental quality standards themselves, which will be reported by

States, hopefully—it’s a voluntary reporting by States—will again

give us another window to assure that children are getting the care

that they need and get States to pay continued attention to the

need for oral health services.

We are also helped, as you noted, in your introductory remarks,

Chairman Kucinich, by a new oral health and technical advisory

group that’s going to help us move forward in our policymaking.

But a second area of——

Mr. KUCINICH. The gentlewoman’s time has expired, but I will let

you make a concluding statement.

Ms. MANN. Let me conclude by saying our two other areas that

we are focusing on, besides policymaking, is identifying best practices, sharing those widely with States, meeting with States on best

practices and then the issue of oversight.

On those 16 State reviews, on August 27th, I issued a letter to

all of those States, saying that we wanted to know the results of

those recommendations and those reviews. Our regional offices are

now working with each of those States, and we will look at those

reviews and also assess whether additional reviews are needed.

Thank you. I wanted to just close by saying that we are committed to continuing to make this a focus of our work as we go forward

and always welcome your insights and your suggestions in terms

of moving forward.

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Mr. KUCINICH. I thank the gentlewoman.

[The prepared statement of Ms. Mann follows:]

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Mr. KUCINICH. We are going to go to questions of the witnesses.

The Chair and the ranking member will have 10 minutes for questions and followed by 5 minutes from other Members’ questions.

We will see how we go in the rounds, whether we go one rounds

or two rounds.

I will begin by asking Ms. Iritani, does GAO have an estimate

of the number of Medicaid-eligible children who did not receive a

single dental service?

Ms. IRITANI. Yes, we do.

Mr. KUCINICH. How many?

Ms. IRITANI. That would be 12.6 million on the basis of nationally

representative surveys.

Mr. KUCINICH. Thank you.

What percent of children does that work out to be?

Ms. IRITANI. That’s 66 percent of Medicaid children.

Mr. KUCINICH. So the reality is that—you say 66 percent of the

eligible children do not receive dental services. Meanwhile, the Department of Health and Human Services has established a national

goal of achieving 66 percent of eligible children who do receive dental services by next year. So we’ve got 66 percent not receiving, and

the goal is 66 percent who will receive the preventative dental

services. That is, to achieve the national goal, we’re essentially

going to have to turn the current statistics on their head.

Now, Ms. Mann, you’ve inherited an agency that, for the better

part of a decade, has been held back from making progress toward

this goal.

For instance, when we asked the official who preceded you what

it was going to take to increase access to dental services, he indicated there wasn’t much he could do. He didn’t believe that he

could require corrective actions of the States. What do you believe?

Ms. MANN. I think there’s a great deal that we can do, Chairman. I believe it’s a multi-pronged problem, and we have an obligation to have a multi-pronged solution. I think it’s both——

Mr. KUCINICH. Excuse me. Those are words.

Ms. MANN. I think we have to give some guidance to States. If

they’re looking for guidance on how to set dental rates, we will provide that guidance on how to set dental rates. I believe we need

to do oversight. As I mentioned, we are following up with each of

the 16 States that we did the initial reviews. There had not been

followup till I got back—until I came on at CMSO, and we will assess whether additional State reviews are necessary. What I want

to do is focus on these 16 States, see where we are, see what

progress has been made.

I do think that CMS can do corrective action plans. We plan on

doing it in a number of different areas where it’s necessary. I’d like

to work with States and share best practices. These are complicated areas. These are troubling.

Mr. KUCINICH. OK. We’re going to get into the corrective action

in a little bit. I want to go back to Ms. Iritani—excuse me—and

thank you. We’re, you know, trying to create a dialog here.

Ms. Iritani, in your testimony, you mentioned that more than

half of the 21 States that provide dental services through managed

care organizations have reported that MCOs in their State do not

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meet any—or only meet some of the State’s dental access standards.

Approximately how many children are going without dental services in those States?

Ms. IRITANI. That’s a difficult question to answer, because, unfortunately, the data by delivery system is not reliable. So the 416

that captures the data on access by delivery system, we have

found, does not break out managed care versus fee for service for

access, and those States do not have managed care throughout the

State.

Mr. KUCINICH. OK. If we’re looking at achieving a goal then, we

need to really have some quantitative assessment of where we

start. Do you have any guess at all? Do you have a best guess of

what that number would be as to how many children are going

without dental services in the States?

Ms. IRITANI. In the States that have managed care?

There are 21 States that reported that they have managed

care——

Mr. KUCINICH. We know that.

Ms. IRITANI [continuing]. But in some of those States, the managed care penetration rate—that is the number of children that

were receiving dental services through managed care—was very

low.

Mr. KUCINICH. OK.

Ms. IRITANI. So we can’t answer that question, unfortunately.

Mr. KUCINICH. We’re going to work with you to help get the

breakdown so we know where the targets are in terms of the goals

that we have to reach. We have to know where we’re starting and

since it is on a State-by-State basis, so we’re going to need your

help on that.

Now, Ms. Mann, this subcommittee found that UnitedHealthcare,

as an inadequate dental provider network, was a contributing factor to the preventable death of Deamonte Driver. As you know,

CMS recently conducted a significant review of dental services in

17 States, and you identified eight States where Medicare managed

care organization provider networks were not assured of being adequate to provide access to dental services.

Ms. Mann, do you believe that inadequate dental provider networks in Medicaid managed care organizations are a significant

barrier for children to receive dental care?

Ms. MANN. Chairman, I think there’s an access problem inside

managed care and outside managed care, and actually——

Mr. KUCINICH. Well, let’s talk about inside managed care. What

do you believe?

Ms. MANN. I think it depends on each State, and in some States,

their managed care organizations are not providing a sufficient network.

Mr. KUCINICH. OK. So what are you saying? It depends on each

State. That’s not—I need something more specific here. You’re giving me answers that are interesting, but they’re very general, and

the way that this committee works is we learn by getting specific

answers.

Can you be specific?

43

Ms. MANN. Each State is different, Chairman, so I can’t tell you

that there is—it’s not that inherently managed care is a problem.

It is that every State has an obligation to make sure that network

is sufficient. In those eight States, we’re following up specifically to

look at what steps those States have taken to ensure——

Mr. KUCINICH. OK. Now, each State is different. Thank you. Now

I’m focusing on Medicaid managed care organizations because they

behave like a traditional HMO in the Medicaid context, retaining

the risk in exchange for capitation fees. Under Medicaid, they

make money when their enrollees don’t get medical and dental

care.

This subcommittee held a hearing last month on the health insurance industry and the industry spending—on numbers, health

care is known as medical losses, and insurance company executives

try hard to keep those losses to a minimum. Obviously, one of the

ways a for-profit Medicaid managed care organization can please

Wall Street and can keep their medical losses to a minimum is by

making it difficult for people who are covered to find a dentist who

will accept Medicaid.

In your opinion, have you seen any evidence that dental utilization rates differ according to whether a State relies upon for-profit

Medicaid managed care organizations to provide coverage?

Ms. MANN. The study that I have seen is the study that actually

you asked for, Chairman, in the CRS report, and it certainly

showed dental access problems. I have not seen a more broad

across-the-board study of it. I think that the evidence is that, in

risk-based contracts, there can be a greater propensity for denial

of care, and therefore there is a greater obligation, if the State

chooses to set up its system that way, to oversee and make sure

that care is sufficient. Medicaid obligations——

Mr. KUCINICH. OK. Now we’re making some progress here. I

would like to ask that you and your staff consider correspondence

received by my staff from Dr. Burton Edelstein in which he finds

evidence for a correlation between Medicare managed care organizations and lower dental utilization rates. Did you collect data from

the States which would allow you to determine if this is a factor,

if there is a correlation between Medicaid——

Ms. MANN. You asked about for-profit managed care organizations. I have not looked at data looking at for-profit managed care

organizations. We can look at that more closely, Chairman, and I’d

be glad to look at that more closely.

Mr. KUCINICH. Good. Thank you.

Ms. MANN. I will say that we have a real problem in the fee-forservice area as well, and so I think that——

Mr. KUCINICH. Well, that’s not what this hearing is about,

though, is it?

Ms. MANN. I thought the hearing is about Medicaid access for

children.

Mr. KUCINICH. OK. Ms. Mann, do you believe that inadequate

dental provider networks, where they’re connected to this for-profit

motive, are one of the reasons why so many of these children are

not getting health care? Is it because of the way the system is

structured?

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Ms. MANN. I think that Medicaid managed care organizations

can make it worse or can make it better depending upon what the

financing looks like, what the incentives are and what the oversight is.

Mr. KUCINICH. I want to ask you about one of GAO’s findings

that troubles me.

In testimony before this subcommittee in September 2008, interim director Herb Kuhn testified: CMS will require corrective actions for those States not in compliance with Federal regulations.

However, you told GAO that you will only followup with States

but had no plans to require action from them. As you wrote in a

cover letter, ‘‘These were programmatic reviews, and as such, formal, corrective action plans,’’ were not required.

I’m wondering if CMS has backed down from its earlier commitment to this subcommittee to require corrective actions from the

States?

Ms. MANN. As I stated a moment ago, we believe the corrective

action plans are part of our toolkit in terms of moving forward on

the Medicaid program. These reviews were done, as you noted, before I came, and they were set up as technical assistance reviews.

Mr. KUCINICH. So you plan to require corrective action plans?

Ms. MANN. Can—if I could finish?

Mr. KUCINICH. Well, just can you answer that question, though?

Ms. MANN. If there—when we complete these reviews back from

the regional offices, if we still see problems, then we will move forward in a separate action for corrective action plans, yes.

Mr. KUCINICH. So you’re not adverse to corrective action plans?

Ms. MANN. Absolutely not.

Mr. KUCINICH. And you’ll be letting this committee know about

timeframes for the component of that requirement?

Ms. MANN. Sure.

Mr. KUCINICH. OK. Thank you very much.

The Chair recognizes Mr. Jordan.

Mr. JORDAN. Thank you, Mr. Chairman.

Let me pick up where the chairman was.

The first question or the first point he made was only a third of

children—this, I guess—I think—I assume he got his information

from the same place I did—from a GAO study last year. Only one

in three children are getting treatment for tooth decay and other

dental problems. So I just want to, I guess, cut to the chase.

Have you seen an improvement in the past year? Is it better

now? What is the status? And I understand that this is last year’s

study, but here we are late in 2009. What kind of improvement

have we seen in helping these kids?

I’ll go to Ms. Mann first.

Ms. MANN. The data from the last 2 years shows a slight improvement from 33 percent to 36 percent of kids having a dental

visit in the past year. So we’re—nationwide, we’re moving, albeit

very slowly, in the right direction.

Mr. JORDAN. I would say most people would say that’s really

slowly in the right direction. OK.

Ms. Iritani, do you want to comment?

Ms. IRITANI. Yes, and we’ve seen the same data.

Mr. JORDAN. OK. Let me just bring up something to Ms. Iritani.

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You talked about one of the things that States have reported is

this rather heavy administrative burden. In fact, I remember my

days working at the Statehouse, and you talk to local officials. It’s

always, you know, dealing with the Federal Government—dealing

with county government, dealing with the State government and

the Federal Government.

So, A, is it true? Do you feel like there’s a big burden you’ve

placed—that has been placed by the Federal Government on

States, and you know, what ways can States better navigate this

and better deal with this situation?

We’ll let both of you go at it.

Ms. IRITANI. We asked States about the barriers in their States

to providers serving more children. Most States actually reported

broken appointments—patients missing appointments as a major

barrier. Administrative requirements was reported as a major barrier to providers serving more children by about 28 States, so not

as much of an issue.

Mr. JORDAN. Would you be supportive of—and it’s one of the

things I worked on in my days at the Statehouse because of the

whole welfare reform thing. Would you be supportive of some kind

of penalty for—I’m just curious—for parents who—the appointment

has been made. You know, it’s in place. Would you be in favor of

some kind of penalty for families who don’t bring their child for

that appointment?

Ms. IRITANI. We asked States about model practices, and I think

there are States that are actually dealing with the broken appointment issue without a penalty situation. Virginia, for example, reported on a broken appointment initiative whereby they tracked

broken appointments and tried to help patients get to their appointments.

Mr. JORDAN. OK. Go ahead. I interrupted you. Go ahead. What

other actions are being taken to help States deal with the administrative burden?

Ms. IRITANI. Our report didn’t look at those issues.

Mr. JORDAN. Ms. Mann.

Ms. MANN. Representative, just to be clear, the Federal Government does not in this instance require any paperwork that the

States use to enroll their providers. So there—I have been—as

GAO has reported, 28 States identify and providers often have

identified that paperwork is a problem. If so, it’s a State-initiated

problem, and it’s one of the things that, I think, is routinely on

States’ lists to try and address, and I think some of the States here

to testify today will talk about what they’ve done to——

Mr. JORDAN. It’s an internal issue?

Ms. MANN. It’s a State—it’s a State issue.

Mr. JORDAN. OK. OK.

Ms. MANN. It’s—to the extent that it’s causing barriers, we regard it as a CMS issue—an oversight issue, but it’s not requirements that we put on States.

Mr. JORDAN. OK. OK.

Let me ask you—one of the things I remember—and this is, oh,

probably 15, 20 years ago—I guess 15, 18 years ago—and maybe

it would be better for the second panel, but in Ohio—this was way

back when I was just—when I was assistant wrestling coach at

46

Ohio State University. One of the programs they had in place was

the dental school would—we knew about it because I was, you

know, employed at Ohio State, but you know, we had four children,

so we were looking to get the cheapest care possible for our kids.

We took them to the dental college—the dental school, and we

were very pleased, and it was very—you know, very inexpensive.

I don’t know what it cost, but I just know, when you’re, you know,

a young couple and you’ve got four kids—or maybe at the time we

only had three—you’re looking to save dollars wherever you can. It

seemed to work. It seems to me that’s a concept where, you know,

here is a State institution receiving all kinds of taxpayer support

already, many times in large metropolitan areas. That’s something

that we should be encouraging, and again, I was looking ahead in

my briefing book here. I think we’re going to hear from one of our

witnesses about this issue, but—about this type of program. That

makes all the sense in the world to me. It may be a little more difficult in rural areas where there may not be a dental school as

close, but you’ve got to believe that’s a way to help meet this need

and not cost the taxpayers more money, which is obviously something that I know I’m concerned about, and I assume—and I think

the rest of the committee is as well.

So, if you could, talk about that concept and what’s going on already and how we can encourage more——

Ms. MANN. I think there are a number of dental schools that are

providing direct services. Also, there are some new programs being

involved, and we are trying to think of partnering with them in

order to provide some payment for training, so—and also some loan

repayment programs so that the dental students that get trained

go out into low-income communities. There’s also county health departments that are providing dental health services and a lot of

federally qualified health centers.

So, I think, looking at all of those avenues to build our work

force in terms of oral health providers is right.

I was just talking to a State legislator yesterday from Kansas.

They don’t have a dental school in Kansas, so that’s why each—

you know, each State you need to think about the different—the

landscape and what can work, but I think the dental schools have

been—can be very critical.

Mr. JORDAN. Do either of you know how many States are implementing such an approach right now with one of their dental

schools or, maybe, with their single dental school?

Ms. MANN. I don’t know, but we can find that out and get that

information to you.

Mr. JORDAN. It seems to me if it’s like—look, if that’s working

and, you know, many States have dental schools——

Ms. MANN. Sure.

Mr. JORDAN [continuing]. It’s certainly something we should be

doing; and again, not reinventing the wheel, we’re always talking

about the reimbursement rates and what providers—these are dental students. They need patients to learn their craft on, so it makes

sense to me.

Ms. Iritani, did you want to comment? Do you have any idea——

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Ms. IRITANI. I think that there are many States that have innovative practices such as that, and we recommended to CMS that

they develop more ways for sure.

Mr. JORDAN. You don’t know the number, though? OK. OK.

Mr. Chairman, I’ll yield back the balance of my time.

Mr. KUCINICH. I thank the gentleman.

The Chair recognizes Mr. Cummings. He may proceed.

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

I want to thank you both for your testimony.

I must admit that, Ms. Mann, I’m feeling a feeling of deja vu in

that, under the previous administration with CMS, so often this

committee felt like we were getting the rope-a-dope, and I want to

be specific because I’m talking about the lives of children. You said

that there were things that you were willing to do.

Mr. Chairman, I hope you will understand what I’m about to say.

I want to make sure that Ms. Mann is held accountable, and I

want specific commitments for these children. We’ve been through

a process, Mr. Chairman, as you will recall, where we were told

things, and nothing happened. Now, either we’re going to get some

specifics as to what is going to happen and address these children’s

needs as the urgency of now, to borrow President Obama’s words—

because it is the urgency of now when only one-third of our children are getting what they need so that they can grow up and be

able to sit at a table like that, to be able to go to school without

pain, to be able to live a healthy life or we need to do something

different. We need to be specific.

Ms. Iritani, you said here that CMS agreed to three of the four

recommendations—is that right?—and partly the fourth; is that

correct?

Ms. IRITANI. That’s correct.

Mr. CUMMINGS. And which ones did they partly agree to?

Ms. IRITANI. They agreed, in part, with our recommendation to

conduct reviews in all States with low dental access rates. They indicated that they would consider conducting additional reviews in

the context of other programmatic reviews.

Mr. CUMMINGS. All right.

Ms. Mann, you said that there were things that you all were

going to do. Can you go down each one of the things that you said

you’re going to do or are doing and give us timetables now? Because the way we like to operate is we like to bring you back on

the date within a week or two after you say it’s going to be done

so that we can make sure it’s done. See, we have a limited amount

of time to be in these jobs. We may not win the next election, and

so we have to be—we want to make sure that we are effective and

efficient while we are here. Other than that, we might as well go

and play golf. So the question becomes:

What are you willing to do? When are you going to do it?

Mr. Chairman, you set the schedule, but I would like for that—

so that we can come back and check with Ms. Mann as to what—

if she makes a commitment that we be able to have her come before us and let us know that the commitment has been completed.

Mr. KUCINICH. Will the gentleman yield?

Mr. CUMMINGS. Yes, of course.

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Mr. KUCINICH. This is our fourth hearing, and you’ve been instrumental in creating every one of these hearings; and as I indicated in my opening remarks, we are going to stay on this. So we’re

going to get to know each other real well, and we’re going to have

a chance to be able to compare notes and establish metrics, timetables, completion of items because look where we are—66 percent

are not getting the dental services to which they are entitled; and

the goal is for 66 percent of children to get it.

So, with your persistence and in working with Mr. Jordan and

our subcommittee, I think we’ve got a long way to go, but Ms.

Mann is now on that road with us, so we’ll look forward to working

with you.

Now I yield back to Mr. Cummings.

Mr. CUMMINGS. I just want to go through the things that you—

the action that you are going to take and when you expect to have

it done. That’s all. I mean, you can be brief. You talked about it

a little bit already, but I just want to know exactly what you’re

going to do to correct this situation to get to that goal.

Do you agree with the goal, first of all?

Ms. MANN. Absolutely.

Mr. CUMMINGS. OK. Just tell us what you plan to do.

Ms. Mann, don’t take this personally.

Ms. MANN. I’m not.

Mr. CUMMINGS. I’m serious. I’m speaking about the kids. You

know, the chairman talked about himself. I was the same little kid

who got all kinds of dental treatment later in my life. I’ve got kids

right now in Baltimore who are going to the University of Maryland Dental School because of Deamonte Driver, in part, and

they’re discovering that the infection has gone to their eyes. See,

apparently—I don’t know that much about dentistry. Apparently, it

goes to your eye before it goes to your brain, and I’m talking out

for those little kids because I want them to grow up.

So that’s why I’m kind of pushing hard on this because I don’t

want us to be making these same arguments a year from now or

2 years from now, and then some kid who only has, by the way,

a limited amount of time to be a child—I don’t want to be in the

situation where that child is either harmed because we did not do

what we could have done. I want every child—I think it was

Masloff that says we must be what we can be, and I want every

child to be what he or she can be.

So you can go ahead and tell us when you’re going to do what

you’re going to do, what you’re going to do, and then I’m sure the

chairman will deal with scheduling hearings appropriately so that

we can measure our progress.

Ms. MANN. There are a number of actions already underway.

As I noted on August 27th, I wrote to each of the States that had

16—the 16 States that had reviews. The regional offices are currently engaged with those States. I can commit to you that, in 30

days, we can tell you a response from those followup reviews from

the regional offices and let you know where we stand on each of

those reviews.

We have a listening session on EPSDT and where we should go

on EPSDT, which is, as you know, the children’s benefit package

in Medicaid, scheduled for October 16th. That’s the first. We plan

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to have a few in that series to help guide us on one of the most

important actions we can take going forward. I’m happy to commit

to you the week after that October 16th listening session to let you

know exactly what the recommendations were going forward.

We plan to do dental reviews in each of the States that are at

the top of the list to identify, as the GAO has recommended, what

those best practices are, and I can commit to you to provide you

that information in the next—I have to figure out exactly when we

can do those reviews, but I can followup and give you an exact date

as to when we can do those and when we can provide that information.

Mr. CUMMINGS. Can you give me an outside date?

Ms. MANN. Sure. I would say by December.

Mr. CUMMINGS. OK.

Ms. MANN. We have committed to do the change in the 416 report by the spring of this year. We have a number of changes that

we’ve already developed; and then there’s new legislation in

CHIPRA that we want to incorporate in those changes, and we

want to do some consultation with experts. So we are having that

consultation. That’s part of the listening session that’s scheduled

for October 16th. We are doing that consultation this fall. We are

going to be doing those changes this spring in the 416, which is to

improve some of the data collection issues so that we can give you

the numbers that you’re looking for so that we can have a better

idea and a more accurate idea, whether it’s in managed care or fee

for service, how many kids are or aren’t getting the services that

they need.

Mr. CUMMINGS. I see my time has expired.

Thank you, Mr. Chairman.

Mr. KUCINICH. I think, Ms. Mann, you can tell by Mr. Cummings’

remarks that this committee needs your cooperation and that we

are not going to stand by and watch any more little kids dying.

Don’t take this personally, but it’s your job now; it’s your responsibility, and so whoever was sitting in that chair is going to hear

the same thing from members of this committee about your obligation to these children.

These aren’t statistics. This was a child who was full of promise

like every child, and the system let this happen to this child; and

I see from your background that you have concerns about people

in these lower economic situations. That’s where I come from, and

I identify with Deamonte, so that’s why I will not give you or any

witness who comes from the administration any wiggle room on

this question. You will not have it. Just know that.

You know, with all due respect—because you know what? A child

died. Now, I want—one of the significant reforms that could, in

theory, increase the number of children who receive some preventative dental services is allowing pediatricians to apply fluoride varnishes. However, this subcommittee has heard that the administrative barriers to reimbursement for providing those services are discouraging doctors from doing it. My staff has received this correspondence from the Maryland Chapter of the American Academy

of Pediatrics on this topic, and I ask unanimous consent to put this

in the record.

[The information referred to follows:]

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Mr. KUCINICH. Can you do anything about streamlining reimbursement for this procedure?

Ms. MANN. We do—thank you.

The Medicaid program does—will—does already in many States

reimburse many pediatricians for providing sealants, and if there’s

any question that States have about their ability to claim Medicaid

reimbursement for that procedure, we can certainly clarify that immediately.

Mr. KUCINICH. Great. If you’d study that letter, it would be very

helpful, and maybe you could respond to it and send us a copy.

Ms. MANN. I would be glad to do that.

Mr. KUCINICH. In a letter to the subcommittee, Dr. James Crall,

who has testified before us on two occasions, recommends, ‘‘A uniform program oversight and performance assessment regardless of

State of residence.’’

I ask unanimous consent to insert the entire text of Dr. Crall’s

correspondence into the record.

[The information referred to follows:]

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Mr. KUCINICH. Ms. Mann, what can CMS do to fix the patchwork

of oversight at the State level and to create a uniform system of

oversight and assessment.

Ms. MANN. I think we can do a uniform system of assessment,

Chairman. I think that the responses aren’t uniform because the

problems aren’t uniform, and that’s—if I could wave the wand and

get that 66 percent and make it all happen by doing reviews tomorrow, I would do that. We don’t have providers in many States and

in many parts of the country that are willing to take Medicaid

beneficiaries. We have a participation rate—a utilization rate in

private health insurance of about 59 percent right now. We’ve got

a multitude of problems in terms of getting oral health care to children both in and outside of the public systems. It is not an overnight problem.

We will commit, and we are committed to doing everything we

can to make the Medicaid program work for every child and to

make sure that dental care is there; but it is a multi-pronged problem, and I don’t say that to try and get around our responsibilities.

I say that to say that we’re rolling up our sleeves, and it is not a

simple solution. If I could do the oversight of 50 States tomorrow

and say that would solve it, I would do the oversight of 50 States

tomorrow. It won’t solve it, but it will get us farther along, and

we’re willing to do that, of course, and to be as aggressive as we

can.

Mr. KUCINICH. I think the watch words would be ‘‘corrective action’’ here, wherever there is action to be taken, that you don’t

stand by and figure they’ll solve their own problems.

Ms. MANN. I agree. I agree. But when we have States come to

us and say they don’t have a dental provider within, you know, five

counties of their State, corrective action plans won’t get the child

the dental care.

Mr. KUCINICH. But Deamonte Driver died. He had a provider, all

right.

Ms. MANN. You’re absolutely right, and that would have been a

very different story. That’s exactly right.

Mr. KUCINICH. So we understand that there are certain circumstances where you have to become involved in encouraging

States with respect to their—to provider networks, but there are

areas where they have providers, and we’re wondering about corrective action in those areas.

Now, Dr. Crall’s letter also recommends uniform eligibility and

benefits regardless of State of residency.

Could you tell us what challenges CMS faces to creating such a

system?

Ms. MANN. In the Medicaid program, actually, there is uniform

benefit eligibility for children. That is the EPSDT program, and it

is the guarantee that every child get that uniform eligibility, which

is, simply stated, all the medical care that they need, that’s deemed

necessary. So we have a lot of variations for adults in Medicaid but

not for children.

The question is do we get it enforced, and do we have providers

taking the children, and do families know about the availability;

and that’s why we’re setting up this listening session and doing

this EPSDT work group. We have a problem beyond oral health.

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We have a larger problem making sure that EPSDT benefit is observed for every child in the Medicaid program.

Mr. KUCINICH. Thank you very much.

Mr. Jordan.

Mr. JORDAN. Thank you, Mr. Chairman.

Just a couple of basics I was curious about.

What is the average time a child is enrolled in Medicaid?

Ms. MANN. Generally, in any given year, about 9 months.

Mr. JORDAN. So they’re in 9 months, out? I mean, is there a

back-and-forth a lot? Just tell me the typical scenario.

Ms. MANN. There’s a fair amount of back and forth. If you look

at——

Mr. JORDAN. Over their lifetime, what is the average? I mean,

the lifetime of the child from 0 to 18. What’s their lifetime?

Ms. MANN. I don’t know. Over the lifetime, if you look at a cohort

of uninsured children, about a third of them have actually been on

Medicaid in the last year or so. So there’s a lot of turning in and

out, and one of the important advances, I think, that we can do to

help children get access to care is to keep that coverage continuous.

Mr. JORDAN. But my point is—so some of these kids who aren’t

getting coverage—I mean do your numbers account for this onethird we’ve determined that are getting the dental care? Is it because—could they be, in fact, moving out of Medicaid and getting

care from a private—you know, a private source?

Ms. MANN. They could be moving out of care and getting care

from private sources. They could be moving out of coverage in Medicaid and simply being uninsured, but not have a card to then go

to the dentist; and for Medicaid patients, it’s probably more the latter, but it could be either.

Mr. JORDAN. What’s the percentage of eligible Medicaid children,

the percentage who are eligible who aren’t enrolled—or the number? Give me those numbers.

Ms. MANN. About 7 out of 10 of all uninsured children are eligible for either Medicaid or CHIP but not enrolled. Some have been

enrolled in the past, but they’ve been churned through the program; but at any given time, about 7 out of 10 of eligible children—

of uninsured children—could be enrolled through either Medicaid

or CHIP. They’re eligible.

Mr. JORDAN. OK.

Ms. MANN. That’s why enrollment and continuous enrollment is

a very important piece of the quality puzzle.

Mr. JORDAN. OK. OK.

Thank you, Mr. Chairman.

Mr. KUCINICH. I thank the gentleman.

The Chair recognizes Mr. Cummings.

Mr. CUMMINGS. Ms. Mann, the Government Accountability Office

reported in September 2008 that the extent of dental disease in

children had not decreased between 1994–2005, which means that

kids were estimated to have untreated tooth decay. Information

from that report showed that about one in three children ages 2

through 18 in Medicaid had untreated tooth decay, and one in nine

had untreated decay in three or more teeth.

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Compared to children with private insurance—and you know,

you know the stats—how much funding was lacking and what was

the cause of unavailability, do you know?

In other words, what is CMS doing about the urgency of the need

for the treatment of these children, some of whom may be adults

now, and how are we addressing that? How do you plan to address

that?

Ms. MANN. I’m sorry. The treatment of adults?

Mr. CUMMINGS. Yes.

Ms. MANN. In the Medicaid program under Federal law, coverage

of dental services for adults is optional with the States, and as you

look through what’s going on in the States now and during a recession, it’s one of the first set of benefits that States will cut out if

they’re looking to reduce their Medicaid budgets, so it is not a requirement nor is the standard, even once they cover an adult in

Medicaid, nearly as robust as the standard is for children.

Mr. CUMMINGS. Ms. Iritani, you were talking about barriers and

what the State folks said were the barriers, and you said that one

of the things that was talked about the most was the failure to

make appointments; is that right?

Ms. IRITANI. That’s correct.

Mr. CUMMINGS. Did you all have any recommendations as to how

to deal with that?

Ms. IRITANI. Our recommendations aimed at CMS were to conduct more reviews of the States with low access rates. They—CMS’

reviews looked at a number of different access-related problems, including inadequate provider networks, and we also advised CMS

that they should take action to ensure that any State found with

an inadequate provider network to corrective action.

Mr. CUMMINGS. Ms. Mann, you know, when Ms. Iritani was talking about this earlier, I was thinking about how important it is

that parents understand the relationship between teeth and the

rest of the body. I think a parent—any parent wants their kid to

be healthy, but I don’t think a lot of parents have a clue of the relationship between the teeth and the body; and I’m just wondering

did you have any thoughts on that with regard to making sure that

we get that information out there?

We—well, I was the author of an amendment to SCHIP where

we were able to do some things in that regard, but I’m just wondering: Is that on your list? Because, you know, that’s one of the

things that—it might cost some money getting the information out,

but the benefits would be phenomenal compared to the money that

we put out because then you’d have all these agents call parents,

who—you know, it’s just like I think of a parent who thought that

their kid had a fever. They would do everything in their power to

address that when, certainly, tooth decay could lead to something

far worse than a fever, and so I’m just wondering what your feeling

is on that.

Ms. MANN. I think you’re absolutely right. Prevention is a key

to moving forward. There is a provision—and perhaps this is the

one you’re referring to—in the CHIP legislation that requires education for pregnant women and parents of newborns, and we are

working on developing an education campaign. We’re partnering—

we plan on partnering with the Centers for Disease Control. We’ve

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been reaching out to some of the philanthropic organizations

around the country and to look at other mechanisms to get information out to pregnant women and to newborns about what they

can do.

We also find that the dental utilization rate is much lower for

adolescents, and I think that’s also a lack of information about how

important dental care is for teenagers, so I think coming up with

a campaign that helps to provide some information to parents as

well as to teenagers, themselves, will be really important.

Mr. CUMMINGS. Can you assume—give us a deadline on that,

give us some type of timetable on that since it’s such an important

and potentially beneficial and cost-saving thing? We want to really

followup on that, and I have a tremendous personal interest in

that, all right?

Ms. MANN. I would be glad to provide you with a plan and a

timetable attached to it.

Mr. CUMMINGS. Very well.

Thank you, Mr. Chairman.

Mr. KUCINICH. I thank the witness for her responsiveness and

the GAO for their report. This committee appreciates your attendance, and we will be in touch with you regarding our next meeting.

Thank you very much.

The first panel is dismissed. We will now go to the second panel.

While our staff is concluding its work, this is the Domestic Policy

Subcommittee of Oversight and Government Reform. Today is

Wednesday, October 7, 2009. The title of today’s hearing is ‘‘Medicaid’s Efforts to Reform since the Preventable Death of Deamonte

Driver.’’

We have heard from witnesses from the GAO and also from the

new director for the Center for Medicaid and State Operations. We

are fortunate to have an equally outstanding group of witnesses on

our second panel.

Burton L. Edelstein, who is a D.D.S. and an M.P.H., is a professor of Clinical Dentistry and Clinical Health Policy and Management at Columbia University’s College of Dental Medicine and

Mailman School of Public Health. He is founding director and

board Chair of the Children’s Dental Health Project—a D.C.-based

nonprofit policy and strategic consulting organization that advances policies to improve children’s oral health.

Mary G. McIntyre, M.D. and M.P.H., is medical director of the

Office of Clinical Standards and Quality for the Alabama Medicaid

Agency. She received an award from the Alabama Dental Association’s House of Delegates in 2004 for outstanding leadership and

championing the cause for improved oral health for Alabama’s children. Dr. McIntyre served as chairman of the Robert Wood Johnson

Foundation National Advisory Committee State Action for Oral

Health Access.

Joel Berg, D.D.S. and M.S., is professor and Lloyd and Kay

Chapman Chair of the Lloyd and Kay Chapman Chair for Oral

Health. He serves as the Chair of the Department of Pediatric Dentistry at the University of Washington and dental director at Seattle’s Children’s Hospital. He is author of a multitude of manuscripts, abstracts and book chapters regarding a variety of subjects,

including restorative materials for children and other work related

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to bio materials and is coeditor of a textbook on early childhood

oral health.

We have Doctor—or Frank Catalanotto; is that right?

Dr. CATALANOTTO. Yes.

Mr. KUCINICH. D.M.D. He is professor and Chair of the Department of Community Dentistry and Behavioral Sciences, University

of Florida College of Dentistry. He has chaired a number of committees in the American Academy of Pediatric Dentistry. He has

served on the editorial board of the Academy’s journal, ‘‘Pediatric

Dentistry.’’ In addition, he was a member of the National Affairs

Committee of the American Association for Dental Research from

1989 to 1995. This committee works with the Federal congressional

delegation to increase funding for dental research, particularly for

the National Institute of Dental Research. He is currently a member of the Legislative Affairs Committee of the American Dental

Education Association, which advises and lobbies on Federal policies and appropriations related to dental education and practice.

I want to thank all of you for appearing before our subcommittee.

It’s the policy of our Subcommittee on Domestic Policy of the Committee of Oversight and Government Reform to swear in all witnesses before they testify.

I would ask that you rise and raise your right hands.

[Witnesses sworn.]

Mr. KUCINICH. Thank you very much.

Let the record reflect that each of the witnesses answered in the

affirmative.

As with panel one, I would ask each witness to give an oral summary of his or her testimony. Please keep this summary under 5

minutes in duration, and your complete statement will be included

in the hearing record.

Again, thanks to each and every one of the witnesses for being

here. I would like Dr. Edelstein to begin as the first witness on this

panel.

You may proceed, sir.

STATEMENTS OF BURTON EDELSTEIN, D.D.S., M.P.H., CHAIR,

CHILDREN’S DENTAL HEALTH PROJECT; MARY McINTYRE,

M.D., M.P.H., MEDICAL DIRECTOR, OFFICE OF CLINICAL

STANDARDS AND QUALITY, ALABAMA MEDICAID AGENCY;

JOEL BERG, D.D.S., M.S., CHAIR, DEPARTMENT OF PEDIATRIC DENTISTRY, UNIVERSITY OF WASHINGTON; AND

FRANK CATALANOTTO, D.M.D., PROFESSOR AND CHAIR, DEPARTMENT OF COMMUNITY DENTISTRY AND BEHAVIORAL

SCIENCES, UNIVERSITY OF FLORIDA, COLLEGE OF DENTISTRY, REPRESENTING AMERICAN DENTAL EDUCATION ASSOCIATION

STATEMENT OF BURTON EDELSTEIN

Dr. EDELSTEIN. Thank you, Mr. Chairman, Ranking Member Jordan and members of the subcommittee. I appreciate the opportunity to come before you today to testify about the Federal Government’s role and responsibilities in ensuring that children in

Medicaid have access to the dental care that is entitled to them by

Federal law.

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I am Dr. Burton Edelstein, Columbia University professor and

Chair of Children’s Dental Health Project here in D.C.

The founding of the Children’s Dental Health Project in 1997 was

a direct response to congressional enactment of the State Child

Health Insurance Program because I, as a pediatric dentist who

treated children on a daily basis, was shocked by the lack of attention that in 1997 was given to children’s oral health. It was not

until the death of Deamonte Driver that so much attention has

been brought to this issue, and the subsequent work by this subcommittee and others has ensured that policymaking simply, as

you’ve demonstrated today, will not leave this issue to fester any

longer.

The result of the attention that you have brought to this issue

led to significant improvements in provisions in CHIP through

CHIPRA. I commend the chairman and the committee on this

issue, and I cannot think of a better example of how far we have

come than to have Cindy Mann as the CMSO director with her personal commitment to children and to children’s oral health.

Clearly, Mr. Cummings, I agree with the statement you made

earlier that we may need to do something different, and I think we

need to explore the limits of what CMS can and cannot do as well

as what it can do in partnership with other agencies across the

Federal Government.

Clearly, all of the progress that has been made has still left a

number of challenges. So, 21⁄2 years after the subcommittee

launched its investigation, we still have Deamonte Drivers out

there, and we need to consider some of the more structural and

fundamental issues that limit the access to health care.

At the time that CDHP was founded, subsequent to SCHIP, the

vast majority of advocacy on behalf of oral health for children was

made by organizations of dentists. This makes sense, of course, because it’s dentists who are on the front line of providing care to

children. However, dentists, parents and the program all both contribute to and can help solve the woeful inadequacy that you’ve

highlighted today.

When asked about how to improve the program, dentist organizations typically respond with the very items that we heard featured

today: low payments, complex paperwork and noncompliant patients. Unfortunately, we have seen in States across the Nation

that addressing these three issues alone—and many States have

taken significant actions on these three issues—has not led to the

kinds of increases that we would hope for. Research has shown

that increasing reimbursement absolutely is a necessary but not a

sufficient condition for improving dental access.

For example, an analysis done by the California Health Care

Foundation in four States shows that raising reimbursements did

significantly kick up the percentage of kids receiving care but only

from a quarter of children to a third, which is that level that we’re

stagnating at today.

Studies currently underway by my research group at Columbia

University indicate that, during the period 1999 to 2006, 41 States

did increase fees; 25 showed no increase in utilization primarily because those increases didn’t bring them into the market. However,

amongst the 25 that did have an increase in both fees and utilizaVerDate 11-MAY-2000 13:04 May 23, 2011 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6633 C:\KATIES\DOCS\64919.TXT KATIE PsN: KATIE
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tion, about half—13—still only reached a level of 33 percent or

more. Overall, in 2006, 20 of our States still provided care to fewer

than one-third, and no State has broken the 50 percent level yet.

A variety of factors contribute to this problem, which I’ve detailed

further in my written testimony.

Based on the complexity of this issue, CDHP has advocated for

a holistic approach to improving children’s oral health—an approach that combines both public health and patient-focused interventions. In my written testimony, I lay out solutions that can be

pursued by a variety of agencies—by CDC, NIH, HRSA, WIC, Head

Start, AHRQ, as well as CMS.

CMS, of course, plays a particularly pivotal role because it is

both the funder and the regulator of so much of this care, and the

suggestions that we’ve made fall under the three categories that

have been featured already today—leadership, technical assistance

and oversight—which I believe CMS is now fully committed to pursue. My colleagues and I at the Children’s Dental Health Project

look forward to continuing to work with this committee, with CMS

and with all who are concerned about dental care for Medicaid

beneficiaries.

When CDHP was founded, we called it ‘‘a project.’’ We specifically called it ‘‘a project’’ with the realization that the problem

we’re addressing is solvable. Tooth decay in children is preventable.

The irony is that we’re putting so much effort into chasing after

disease that can be prevented in the first place.

I look forward to continuing to work with you and with all who

care about children’s oral health to solve this problem. That concludes my testimony. I look forward to your questions.

Mr. KUCINICH. Thank you very much, Dr. Edelstein.

[The prepared statement of Dr. Edelstein follows:]

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Mr. KUCINICH. Dr. McIntyre, you may proceed for 5 minutes.

STATEMENT OF MARY McINTYRE

Dr. MCINTYRE. Mr. Chairman, Ranking Member Jordan and

members of the subcommittee, thank you for the opportunity to

speak on behalf of the Alabama Medicaid Agency and the population that we serve.

My name is Dr. Mary McIntyre, and I serve as medical director,

and I’m not a dentist, but a physician, board certified in public

health and general preventative medicine. I appreciate the opportunity to testify before you today on the progress that we have

made. This has been a 10-plus-year journey, and it isn’t over yet.

The vision statement for our State Oral Health Coalition and for

our Smile Alabama! initiative is to ensure every child in Alabama

enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized, promoting the total well-being of the child.

I have been asked to address the programmatic aspects of the

Smile Alabama! initiative that have, No. 1, improved access to and

the utilization of pediatric dental services and, No. 2, increased

provider enrollment and participation.

More than 10 years ago, the Alabama Medicaid Agency recognized that significant growth in the number of children eligible for

Medicaid dental services and a decrease in dental provider participation in the Medicaid dental program had combined to create a

dental access crisis. The dental utilization rate in 1998 was approximately 25 percent, due largely to the low number of Medicaid

participating providers but also because of the widespread belief

that preventative dental care for children, especially very young

children, was unimportant. Providers complained of low reimbursement rates, uncooperative patients and families, and a cumbersome

claims filing process.

A decade later, Alabama Medicaid’s dental utilization is up by

more than 62 percent, and there has been a 216 percent increase

in the number of dentists who see more than 100 patients per year.

There is greater public awareness that good oral health is essential

to overall health.

What made this possible is the collective determination of many

people in both the public and the private sectors to find solutions

and the willingness of dental providers, State leaders and others to

implement steps necessary to bring about meaningful change.

While the initiative known as Smile Alabama! was the primary

catalyst to this important public health achievement, there were

several important milestones that laid the groundwork for its success. These include the formation of a dental task force, increases

in the dental reimbursement rate, major claims processing

changes, dental outreach efforts, formation of a public-private alliance, creation of an oral health strategic plan and policy leadership

team, convening of two State dental summits, and finally, the successful funding and implementation of the Smile Alabama! initiative.

In February 2001, the Alabama Medicaid Agency received a

grant of $250,000 to enhance dental outreach efforts through the

Smile Alabama! initiative. Funding for the grant was provided

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through the Robert Wood Johnson Foundation’s 21st Century Challenge Fund—a component of the Southern Rural Access Program—

and was matched by Federal, State and private funds to total more

than $1 million.

In summary, the Smile Alabama! initiative was composed of four

components—a dental reimbursement increase, claims processing

simplification, patient outreach in education and provider outreach.

In conclusion, in order to improve access to and the utilization

of oral health care services, a focus on prevention and early care

is important. A multi-pronged approach must be taken for a complex multifaceted issue. Efforts must be ongoing. None of us want

any child to suffer. I, personally, know what it is to be a child in

severe pain from a dental abscess because my parents lacked the

means to obtain care.

States are struggling to maintain services in the light of severe

budget shortfalls. We are currently experiencing increased enrollment due to the present state of the economy, with shrinking budgets, while trying to increase utilization. These factors will limit our

ability to push utilization up, and must be considered in any discussion surrounding finding the solution to the dental access issue.

It is important that everyone understand that improving the oral

health status of this most vulnerable population will require an understanding of all of the factors that result in underutilization.

Thank you for this opportunity to speak today on behalf of the

Alabama Medicaid Agency and the recipients that we serve.

Mr. KUCINICH. Thank you, Dr. McIntyre.

[The prepared statement of Dr. McIntyre follows:]

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Mr. KUCINICH. Dr. Berg, you may proceed.

STATEMENT OF JOEL BERG

Dr. BERG. Good afternoon, Mr. Chairman and members of the

subcommittee. I thank you for the invitation to testify today.

My name is Joel Berg, and I am the Chair of the Department of

Pediatric Dentistry at the University of Washington, dental director at Seattle Children’s Hospital, as well as the secretary-treasurer of the American Academy of Pediatric Dentistry. I am a practicing pediatric dentist, and I care for a large number of Medicaid

eligible children. I am honored to appear before you today to represent and to share the success of Washington State’s Access to

Baby and Child Dentistry [ABCD] program.

The goal of ABCD is to expand access to oral health services by

Medicaid eligible children from birth through their 6th birthday.

More than a dozen nationally publicized articles and published articles have clearly demonstrated that early prevention reduces future dental costs and that ABCD is an effective, cost-saving method

of improving the oral health status of children enrolled in Medicaid. The first ABCD program was established in 1995 in Spokane,

Washington as a collaborative effort between public and private

sectors. The community agreed that something needed to be done

to address the severe lack of dental access among high-risk, lowincome preschool children.

ABCD programs are locally administered by a health jurisdiction

or a community agency that contracts with the local health department. The administrator then works with an identified ABCD dental champion, who is a leading pediatric dentist or general dentist

who is selected and trained by the University of Washington to

identify, recruit, train, and mentor other local general dentists.

ABCD encourages general dental offices, not just pediatric general

offices, to provide a positive dental experience and a dental home

by age 1. The ABCD program is embedded in many local Head

Start and Early Head Start programs, now both under the American Academy of Pediatric Dentistry Leadership.

In Washington State, ABCD is a collaborative effort of Washington Dental Service Foundation, the University of Washington

School of Dentistry, the Department of Social and Health Services,

the Washington State Dental Association, the Department of

Health, local dental societies, and local health jurisdictions.

ABCD-certified dentists receive enhanced Medicaid reimbursement for selected procedures on enrolled children. Dental office

staff receive training and communication in culturally appropriate

followup with families, and the billing staff learns how to work

with the Medicaid program.

With the growth of the ABCD program, an increasing number of

Washington physicians is now addressing oral health during well

child checks because ABCD-trained dentists serve as referral sites.

Medicaid reimburses trained and certified primary care providers

for delivering oral screenings, health education, employed varnish

applications during well child checks, and they make the necessary

referrals to dentists.

Today, 31 of Washington’s 39 counties—more than 1,000 dentists—participate in ABCD, and several other States have exVerDate 11-MAY-2000 13:04 May 23, 2011 Jkt 000000 PO 00000 Frm 00087 Fmt 6633 Sfmt 6633 C:\KATIES\DOCS\64919.TXT KATIE PsN: KATIE
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pressed interest in adopting this successful program. ABCD has

more than doubled the number of young Medicaid children in

Washington to receiving dental care from 40,000 to 107,000—a utilization increase from 21 to 39 percent.

The ABCD program is reducing overall dental costs. Education/

prevention is most cost-effective during the first 2 years of life, and

ABCD is making progress toward increasing the number of children who receive care before their 2nd birthday. In 2008, nearly

22,000 children under age 2—19 percent of eligible children—received dental services. When the program began in 1997, only 3

percent, close to what is probably the national average today of eligible infants and toddlers, received dental care.

While targeted enhanced reimbursements for increased frequency

of preventative interventions for young Medicaid children are extremely important, other elements must be present to ensure the

success of ABCD. The Washington Dental Service Foundation coordinates the program at the State level, and provides 3-year startup grants to launch the program locally so that outreach to families, case management, support services for the dentists, and other

critical activities are included.

In the years ahead, the ABCD program will be expanding the use

of risk assessment tools as exciting technologies are emerging. This

combined with increasing incentives for earlier intervention and for

higher risk children, an expanding partnership to refer the highest

risk children—the highest risk and low-income children—to a dentist as early in life as possible will further improve the oral health

of the program’s children.

We must combat the growing crisis in childhood dental disease

and increase access to care to some of our country’s most vulnerable patients. ABCD is a proven best practice that is working in

Washington State. I thank you for the opportunity to share the success, and we look forward to working with others States across the

country to increase access to dental care.

Thank you.

Mr. KUCINICH. Thank you, Dr. Berg.

[The prepared statement of Dr. Berg follows:]

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Mr. KUCINICH. Dr. Catalanotto, you may proceed.

STATEMENT OF FRANK CATALANOTTO

Dr. CATALANOTTO. Thank you.

Good afternoon, Mr. Chairman and Ranking Member Jordan and

members of the committee.

My name is Dr. Frank Catalanotto. I am Chair of the Department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry. I am here today on behalf

of the American Dental Education Association [ADEA].

ADEA’s membership consists of academic dental institutions who

serve as dental homes for a broad array of racially and ethnically

diverse patients, many of whom are uninsured, underinsured or reliant on public programs such as Medicaid and the Children’s Dental Health Program.

The American Dental Education Association is grateful for the

opportunity to share our perspectives and recommendations for improving the children’s dental program and Medicaid.

First, a couple of comments about academic dental institutions as

safety net providers, and this is the answer to some of your questions, Mr. Jordan.

Academic dental institutions include dental schools and dental

hygiene schools that provide dental care reduced fees and provide

millions of dollars of uncompensated care in our clinics each year.

All 59 U.S. dental schools and over 200 schools of dental hygiene

operate clinics that teach students how to treat a broad array of

patients and conditions as part of our educational mission.

On average, over 53,000 patient visits were conducted annually

at each U.S. dental school, totaling more than 3 million patient visits; and over 50 percent of those patients were on public assistance

programs. At the University of Florida college clinics, we had over

101,000 patient visits in 2008; and 76 percent of those patients

were at 200 percent of the poverty level or below.

A couple of comments about Medicaid dental benefits and academic dental institutions.

Safety net dental programs and community health centers, local

departments and academic dental clinics operating at full capacity

are only able to meet about 8 percent of all the unmet dental needs

in this country. There are few public subsidies that are available

to academic dental institutions to help pay for the uncompensated

care we provide.

Medicaid dental reimbursement levels have also been historically

low. On average, they equal the lowest 10 percent of market rates

in many States. In Florida, for example, our Medicaid reimbursement fees rank at 49th of the States. Therefore, 74 percent of the

18,000 children we saw in the University of Florida college and

university clinics were at or below poverty level. In other words,

they were on Medicaid. And the low reimbursement rates we receive put considerable strain on our ability to continue providing

these services.

I would like to give you two examples of how academic dental institutions can help improve access to care in the United States.

The University of Florida College of Dentistry has a Statewide

network for community oral health that operates five dental clinics

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and is affiliated with nine other clinics throughout the State of

Florida, from Miami to the border of the western part of the State;

and these partners include federally qualified community health

centers, county health departments, and a mobile dental van. The

network serves Florida’s most vulnerable populations and provides

comprehensive dental care in the areas of greatest need around the

State.

The second example, in 2002, the Robin Wood Johnson Foundation and the California endowment funded a program to promote

community based dental education in 23 dental schools with grants

totaling approximately $38 million. One of the dental schools funded was the Ohio State University College of Dentistry. The College’s goal with the Robin Wood Johnson money was to reach populations in need of dental care across the State. Starting in 2003,

when they first received the grant, the dental school had 10 community based sites. By 2007, they had expanded to 46 sites where

their dental students and residents provide dental care to underserved and low-income minority income patients.

So what are the recommendations we have? My written testimony provides eight specific recommendations that ADEA would

suggest, but I would like to focus on just three of them.

First, fund the expansion of community based dental education

learning programs with academic dental institutions, and the

Robin Wood Johnson pipeline project is an example of the kind of

funding that maybe could be provided at both the Federal and at

the State level.

Second, develop standards and protocols for models of care that

allow other primary care professionals to help gather data, detect

clinically pathological conditions, dental conditions, triage, and

refer patients to appropriate dental professionals for care.

One of the questions asked earlier was about the role of physicians in providing oral health services. You may have noticed in my

background that I have a grant from HRSA to actually train physicians to provide such care to provide oral health preventive services

that are funded by Medicaid, and involving other members of the

health care team is a critical step in this process of addressing access to care.

No. 3, provide Federal funds to States for school-based oral

health promotion, education, and prevention programs. Schoolbased sealant programs are another example. In other words, bring

care to the K–12 school system where the children are.

In conclusion, the American Dental Education Association believes it is critical for Congress to preserve basic medical services

for Medicaid beneficiaries and safeguard essential Medicaid dental

benefits in any reform of the U.S. health care system. ADEA and

its member institutions are prepared to work with Congress and

other health care advocates to identify programs and policies that

will increase access to care for underserved patients in Medicaid.

That is my testimony. Thank you very much.

[The prepared statement of Dr. Catalanotto follows:]

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Mr. KUCINICH. Thank you, Doctor.

Now you gave us three out of eight.

Dr. CATALANOTTO. There were two, sir—my apologies—two of the

ones I wanted to assess. My error.

Mr. KUCINICH. I just wanted to make sure that you feel that you

communicated your major points.

Dr. CATALANOTTO. The other six are provided in detail in the

written testimony.

Mr. KUCINICH. OK. I just want to make sure that you had a

chance to note that. It sounded like you were on a roll there. I

didn’t want to cut you off.

Dr. CATALANOTTO. Thank you.

Mr. KUCINICH. Let’s go to questions for the witnesses.

Dr. Edelstein, in your prepared testimony, you address the situation that occurred in Georgia where vendors cut providers from

their networks to ward off utilization increases imposed by the

States. This is clearly an unintended consequence of reform that

was intended to increase access to care.

In your opinion, what does the evidence suggest about the consequences of relying upon Medicaid managed care organizations to

provide dental coverage to children?

Dr. EDELSTEIN. What I am referencing there is specifically placing managed care companies at financial risk. And, as was mentioned earlier, depending upon the quality of the contracts and the

degree of oversight, it is possible to have a variety of relationships

between a State and a managed care company and still have a satisfactory outcome.

However, in the case of dentistry per se, there is very little that

managed care companies concurrently do to manage the care in

order to effectuate savings; and so the primary technique that they

have left to rely upon in order to protect their profit line—because

these are for-profit at-risk companies—is to control utilization. And

that means that there’s a perverse incentive built into the concept

with regard to dentistry, because there’s very little else that the

managed care company can do to protect its bottom line.

Mr. KUCINICH. Thank you, Doctor.

Drs. Berg and McIntyre, if you could both give a try at answering

this one.

Patient compliance is often cited as a barrier to improving outcomes in State Medicaid dental programs. Both of your programs

have a case management component. And what are some of the

specific interventions of case management?

Before you answer that question—Ms. Mann, I just want to note

something. First of all, you may be one of the only administration

official who has actually stayed to hear witnesses on the next

panel. It’s very rare and refreshing. Thank you.

So, Dr. McIntyre and Dr. Berg, what are some of the specific

interventions of case managers in your programs that increased patient compliance?

Dr. MCINTYRE. I want to start first with a regional—because we

kind of redesigned things with our First Look Program, but we

originally wanted to address the issues that the providers themselves talked about, which was the missed appointment. And what

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ing patients to assist them with getting into their providers’ offices.

You know, they address issues such as the care of the other children, which is something that a lot of times people didn’t think

about. Well, what did they do with the other kids when they really

have an appointment to see the dentist for maybe one or two of

those children, issues such as transportation to the dental office.

And sometimes there were issues that didn’t have anything to do

with the transportation. There were issues concerning, well, I don’t

know how I am going to pay rent tomorrow, so I am not really worried about keeping a dental appointment next week. So that the

care coordinators had to get into not just the issues of the dental

appointment themselves but also the other issues that were surrounding the reasons why these patients wouldn’t keep appointments.

And then one of the things we had to deal with was also to address the dental provider’s problem about behavior in the office,

and we did that also as part of this program. We are trying to educate them on, you know, taking one child and making sure that you

are on time for your appointments.

Mr. KUCINICH. Thank you, Dr. McIntyre.

Dr. Berg, would you like to respond?

Dr. BERG. Yes, Mr. Chairman.

I think you were pointing out that one of the most important aspects of the ABCD is the local ABCD coordinator. It is a county

specific—or local health jurisdiction specific program. And we

found, indeed, that in the smaller local health jurisdictions it’s easier to get access to care through the ABCD program because it’s

easier in the smaller communities to coordinate efforts. We found,

actually, that we had lower no-show rates than some of the ABCD

programs in most jurisdictions then with the non-Medicaid populations. We have evidence to show that.

So these care coordinators are absolutely critical in the scheme

of things to make things work. We have evidence of that in different counties.

Mr. KUCINICH. Thank you, Dr. Berg.

The GAO study reveals that States overwhelmingly would like

additional guidance from CMS. So if we could again hear from Drs.

McIntyre and Berg, from the State perspective, what specific suggestions do you have for CMS to improve the guidance they provide

to State Medicaid systems?

Dr. MCINTYRE. Well, as a State that I think we had a relatively—what could I say—a very good relationship with our regional office when it came down to getting assistance, we didn’t

have any problems recalling. But specifically when it comes down

to recommendations, the main thing is to communicate specifically

what we can and cannot do from a State standpoint. And I think

a lot of times States are under the, I guess, misinformation as far

as with misunderstandings about what policies will allow them to

do or not do.

But we didn’t have it, that particular issue, because we got clear

communication about, well, you know, when it came down to Smile

Alabama!, no one told us that we couldn’t go after outside funding,

so we did. We did a check, and it was OK. So we went after funding in order to do the program.

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But I think there’s something that other States need to know,

that you don’t have to deal with just the money that you have, you

know, within the State coffers, that you can look beyond that and

identify private-public partnerships in order to do some of the programs that you want to do from a State standpoint.

Mr. KUCINICH. Thank you, Doctor.

Dr. Berg, if you could answer. My time has expired, but please

just give a brief answer.

Dr. BERG. Yes, please. I will give specific recommendations.

The State of Montana just adopted an ABCD-like program modeled after Washington State’s program. They actually did what we

would have liked to have done this year, but it wasn’t fundable in

the current legislature, and that is to incentivize earlier intervention where we can separate the highest-risk children.

We know that, as was stated earlier, 80 percent or something of

the cost is spent on 25 percent of the children, and that starts at

about age 21⁄2 or 3. If at age 1 we can identify who they were and

segregate them and have more aggressive intervention for the

higher-risk children, we can save money. We have actually done an

economic modeling of this through our health economist and have

shown that it can work.

So I would absolutely look right now at earlier intervention,

incentivizing earlier intervention, incentivizing higher risk, more

aggressive interventions.

Mr. KUCINICH. Thank you very much.

The Chair recognizes Mr. Jordan.

Mr. JORDAN. Thank you, Mr. Chairman.

Let me thank the witnesses, too, and for your commitment for

helping these children.

You know, the goal is, as Dr. Berg just said, to treat them as

early as possible so we save on costs in the long term and, obviously, hopefully avoid any type of tragedies like with Deamonte.

And I appreciate the work that the universities are doing. It was

great to hear that. I think I got the numbers, 3 million you said.

Dr. CATALANOTTO. Three million dental visits across the 59 dental schools. That does not include any visits that might have occurred at——

Mr. JORDAN. In a year.

Dr. CATALANOTTO [continuing]. Dental hygiene programs.

Mr. JORDAN. Wow. You said at your university you had 100,000

last year.

Dr. CATALANOTTO. 100,000 visits, 76 percent of which were patients at 200 percent of the poverty level or below.

Mr. JORDAN. 100,000 children?

Dr. CATALANOTTO. No, 100,000 dental visits. There were 26,000

children of that 100,000.

Mr. JORDAN. We appreciate all that.

Dr. Edelstein, in your comments you said three things—paperwork, low reimbursement rates, and noncompliant patients—make

it tough for certain providers to do this care. Which of the three

is the one that—if you had to rank order those three, which is the

one that is the most difficult for dentists to deal with?

Dr. EDELSTEIN. The one that is perceived and reported to be the

most difficult is the low reimbursement, and the point I had hoped

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to make clear is that sufficient funding is a necessary but not sufficient condition.

Mr. JORDAN. Would it help—let me ask you this question. I am

going to ask some fundamental questions here.

Would it help if dentists would be able to—for those families who

can pay something, would it help if they could say, OK, Medicaid

covers this much and would you as a family be willing to pay X

amount of dollars to cover the cost of the care? Would that help?

Dr. EDELSTEIN. I have no idea, except to suggest that it would

create a significant—as small business people, it would create significant billing hassles and problems trying to deal with the copayments. As a practitioner who actively participated in both Medicaid

and CHIP in Connecticut where copays were allowed for some

CHIP patients in Connecticut, we did confront significant problems

with trying to manage that cost-sharing portion.

Mr. JORDAN. OK.

So, again, you started—I think you were starting to say that

what you hear typically is low reimbursements is the single biggest

reason given for not accepting these patients. But it sounds to me

like that’s not what you believe. What do you believe?

Dr. EDELSTEIN. Well, the ‘‘but’’ was that our study nearing completion now tried to assess the impact of different levels of fee increase on utilization; and what we discovered were a couple of

things. First off that with the increases, generally, you have the

same providers who were already seeing Medicaid patients seeing

many more Medicaid patients, rather than bringing a lot of new

providers into the actual provision of care.

Now, that’s when fees are the primary intervention. As Dr. McIntyre mentioned, in Alabama, there was additionally some case

management and reductions in paperwork with prior authorizations. So a multi-pronged approach did help.

On the other hand, even in Alabama, with all of its tremendous

effort, we see that relative increase was tremendous, but we still

hit the same sort of barrier, hitting the top levels that any States

have hit in the 40 to 45 percent range. And it’s tempting to think

that barrier really represents parents’ failure to pursue care, but,

in fact, parents are able to obtain significantly higher levels of

medical care, raising the question about whether the doors to the

dental offices are truly open.

Mr. JORDAN. OK. What—you mentioned noncompliant patients

as one thing here. Do you think that’s a real problem or not?

Dr. EDELSTEIN. Well, the noncompliance has to do with appointment keeping; and I think Dr. McIntyre explained how complex

some of these individuals’ lives are. But there’s an excellent example that I cite in my written testimony from New York State,

Tompkins County, where a county level care coordinator liked what

the American Dental Association has suggested, as the community

dental health coordinator acted as a case manager.

Mr. JORDAN. Let me just ask this question of all of you and see

what you thought. And I brought this up, I think, in the very first

round of our first panel.

You know, there are all kinds of taxpayer assistance that the

typical Medicaid-eligible family receives. I kind of come from the

school of thought that says, if you want responsible behavior, you

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should reward it and irresponsible behavior, there should be some

kind of penalty for it.

Do you think it would make some sense if, in fact, parents aren’t

complying with the appointments that they have, aren’t doing what

needs to be done for their kids relative to dental care, if there was

some kind of sanctioning or some kind of penalty in—you know,

typical families getting nine or ten different types. They are getting

TANF. They are getting housing. They are getting food stamps. On

and on it goes.

Some kind of sanctioning process, do you think that would be

helpful, along with what Dr. McIntyre, I think, and Dr. Berg referred to in a previous answer, the care coordinator and the case

manager approach as well?

Let’s go down the line.

Dr. EDELSTEIN. I personally am more of a carrot than a stick person, thinking that as soon as there is a clear understanding of

what the child’s needs are that there be an effort to engage the

family in a positive way. My concern is the child and recognizing

the complexity of some of these lives to get to whatever benefits the

children.

Mr. JORDAN. Yes. It seems to me—look, I know we did well for

reform in the State of Ohio. I was the guy who did the language

on the time limits component, and we said we are going to make

sure kids get health care. We are going to make sure kids get, you

know, the food they need. But at some point, if an individual is not

willing to work and they are an able-bodied adult, they are no

longer going to receive cash from the taxpayers. And it was a long

period of time, and we gave them job training and everything else.

But at some point if you don’t have that deadline, if you don’t

have—I would say deadlines influence behavior. And if you don’t

have that out there as some kind of thing that everyone has to

think about—we all have to function. Everyone in the world has to

function under those kinds of responsible things and those kinds of

deadlines. It seems to me there might be an approach in there that

can work and still make sure that these kids get what they need.

Dr. EDELSTEIN. Perhaps when dental access is readily available,

when those office doors really are open and parents can have success in pursuing their desire to find treatment for their kids, then

perhaps it would be time to think about the sticks.

Mr. JORDAN. Mr. Chairman, if I could, real quick——

Mr. KUCINICH. If you can give a quick answer.

Mr. JORDAN. I thank the chairman’s indulgence.

Real quick——

Mr. KUCINICH. Just give a brief answer.

Dr. MCINTYRE. From the standpoint—I am like Burt. I look at

the carrot versus the stick. And the reality is that sanctions will

really hurt the children. Because what we are looking at is you are

sanctioning the parents for behavior that the kids have no control

over. And then what happens is they don’t get into care. So really

it would only hurt them.

Mr. JORDAN. The only thing I would say is——

Dr. BERG. I would agree with the last part of Dr. Edelstein’s

statement as well, that when the access problem is solved and

there is much more readily available access, then we could look at

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some pilot projects perhaps to study that. I think we don’t have

enough information to know if it’s effective or not. I would want to

study it on a small scale to see what kind of effectiveness we have.

Dr. CATALANOTTO. Just to emphasize that, in Florida, for example, only 10 percent of Florida dentists see Medicaid patients. Our

numbers are worse than the rest of those States. We only have 25

percent of children achieving any kind of dental visit.

So until you solve the access problem, it’s not—I don’t think it’s

appropriate to talk about punishment for the parents, which ultimately punishes the child. We need to fix the access problem first.

Mr. KUCINICH. I thank the gentleman.

The Chair recognizes Mr. Cummings.

Mr. CUMMINGS. Dr. McIntyre—thank you, Mr. Chairman.

Tell me, what part did—first of all, the folks who you all hire,

are these a lot of community people? In other words, that have the

kind of sensitivity that you are talking about?

I think they first have to understand—it really reminds me of

Healthy Start. In other words, you have people who understand the

complexity of people’s lives. They understand that punishment is—

I could have answered that question. That’s not going to get it, because then they will drop out of the system.

Dr. MCINTYRE. They will.

Mr. CUMMINGS. But so you must be—you must look at a certain

type of worker who has a certain level of sensitivity.

Dr. MCINTYRE. We didn’t hire anyone. Let me get that straight.

This is—remember when I talked about public-private partnerships? We actually worked with the Health Department to get care

coordinators in the community.

Mr. CUMMINGS. I see.

Dr. MCINTYRE. So that many of these people were folks that

knew people already, that people were comfortable with. They were

at the community level. They were on a county level. So that when

you are calling to get a child in that a lot of times these people

really know who the children are.

Mr. CUMMINGS. I see.

Dr. MCINTYRE. So I think in that standpoint we didn’t go out and

hire a bunch of people. We worked with the Health Department to

get care coordinators at the county level in order to work to put

this program into place.

And that’s the whole thing about working together with all of the

different entities within the State. It’s not just a Medicaid issue.

It’s an issue that involves the entire State, and it involves all the

people that are there coming together to try to come up with a solution.

Mr. CUMMINGS. Dr. Edelstein, we were talking about the whole

idea of—you were here earlier when we talked with the other panel

about this whole idea of a campaign to educate parents with regard

to the significance of dental care for their children. Tell us, how do

you feel about that? I mean, do you think that is very significant?

Dr. EDELSTEIN. Yes. The parents clearly have a critical role, particularly, as Dr. Berg mentioned that the disease onset is very

early in life. And so we need to get to parents very early in life,

as required now by CHIPRA.

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But one of the roles for the parents is the day-to-day, momentto-moment decisions that they make that either predispose their

kids to have this problem or predispose their kids to avoid this

problem. And so the education needs to be about more than dental

care but has to be about managing the risk factors for developing

the disease in the first place.

Mr. CUMMINGS. You know, I visited Kennedy Krieger in my district. They have this clinic for severe dental problems for kids, and

they showed me some kids who had had phenomenal damage as little kids. I mean, who literally had to go through major surgery as

a little kid—I mean, like 3 years old—because of things like a bottle with sugar, like juice bottles, and the sugar gets to the tooth.

And a lot of people don’t realize how significant those little things

are. And I just think that education is so significant.

The other thing I was going to ask you about is these federally

qualified health centers. One of the things that I pushed hard for

is making sure that they could contract with dentists. Because a

lot of times that’s a missing piece, and those help centers are located smack dab in the middle of places where people would not

normally be able to get health care.

You might want to comment on that, too, Dr. McIntyre——

Dr. EDELSTEIN. Well, if I might reflect on the value of that contracting, it has so many values. The first is that it allows dental

practitioners who are not Medicaid providers to contract with

FQHCs to see Medicaid patients and thereby become familiar with

the patients as people, as patients who they can become more comfortable with and discover really face the same kinds of dental

issues that others do and can be readily accommodated in their

practices.

The second is that it expands the capacity of the federally qualified health center. So many of the health centers are limited either

by not having dental facilities themselves or having facilities and

no dentists, because there is a shortage in the FQHC system. So

that allows them to contract with dentists to expand their capacity.

So, on both sides, it benefits the patients, it benefits the dentist,

it benefits the health centers. And we anticipate that experience

the dentists will have will lead them more likely to become active

Medicaid providers.

Mr. CUMMINGS. Dr. McIntyre, did you have a comment on that?

And thank you.

Dr. MCINTYRE. Yes, I wanted to comment that, in looking at the

public-private partnership, the FQHCs are vital in making sure

that we identify all of the resources available.

And some of the things we did was also identify not just the

Medicaid dentists per se but also for uninsured—because a lot of

our uninsured go on and off, you know, their own Medicaid; then

they have no insurance at all—to make sure that those resources

are available for them.

But there is a shortage. When we talk about addressing access

issues, one of the things I wanted to bring out was this: Overall,

in our State, as of May, we had a shortage of 288 dentists. Now

this is not Medicaid dentists. This is a shortage in dentists in the

counties.

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So, in addressing the issue, we have to address the work force

in order to—like, he was talking about are their doors really open?

Well, the doors are open, but who gets in it to see is something that

you have to consider when you are looking at that. Because the

work force itself is part of this problem.

Mr. CUMMINGS. Thank you.

Mr. KUCINICH. I thank the gentlewoman.

The Chair recognizes Mr. Issa.

Mr. ISSA. I thank the gentleman.

I thank the chairman for holding this hearing, because I do believe it is important that we as a committee that looks at waste,

fraud, and abuse also look at government efficiency; and that’s, I

think, a great deal of what we want to work on here today.

Before I do my comments, I would like to yield to the gentleman

from Ohio for his question.

Mr. JORDAN. Well, just a quick comment, and I do have to run

to an RC thing.

I could tell the panel didn’t particularly like my suggestion about

holding parents more accountable. But I would just point out this.

We heard from the previous panel that the number was one in

three kids, 33 percent, were getting the treatment, according to the

study done in 2008. And since that time Ms. Mann’s answer was

it has been improved all the way up to 36 percent now.

So, obviously, what we are doing isn’t working. Maybe it makes

sense, you know, to try the same old, same old, giving us the big

increase of 3 percent. Maybe it makes sense to try something different and go the route that I suggested. That’s my only point. I

know it’s worked in other parts of welfare reform. It has worked

in the State of Ohio.

So I would just offer that and thank the gentleman for yielding

me a few seconds.

Mr. ISSA. Now I am going to take a slightly different line of questioning.

I guess I have an MD, a DMD, and two DDSs, so that probably

gives me all of the passel of opinions.

When I was growing up in Cleveland, Ohio, right next to but

slightly down the street from the chairman, we still had a great

deal of, if you will, the public health care system; and a lot of the

services at that time were delivered through nonprivate means if

they were going to be delivered. I got my shots through the public

system and so on. And that delivery system for the working poor

and even up tiptoeing through the middle class and certainly for

what we would call the most indigent among us today was an accepted part of society.

It appears to me as though, as we have divested ourselves of

that, and the Medicaid system has been about money being delivered, often, often not at the same rate, haven’t we moved away

from—at least germane to today—if preventive medicine, recognizing that dentistry expands to fill the amount of money you have,

that if you have enough money—and we here on the dais don’t

have a dental plan—or at least it’s not standard in our program.

If you have enough money, you don’t get amalgam. If you have

enough money, you don’t get false teeth; you get implants. If you

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sive levels of care. And I think you are all aware of just how phenomenal dentistry can be if you have the dollars for it.

But aren’t we here today talking fundamentally about the least—

trying to find the most efficient, least expensive, most universal for

the poor delivery of evaluation, cleaning, and prevention? And isn’t

our system somewhat broken in that if that’s what you wanted to

provide, would you provide it the way you do today? And this is regardless of 3 percent more money, 6 percent less money.

I would like your comments on that. Because, for this committee,

we do try to think in the sense of organization of government.

I will go right down the line. Thank you, Doctor.

Dr. EDELSTEIN. Interestingly, this problem is not unique to the

United States; and underserved populations having lack of dental

care is a global phenomenon. So if we look at other countries like

ours—Great Britain, New Zealand, Australia, the Netherlands—to

see how they have approached this, they do it primarily with the

advent of different kinds of providers. I wouldn’t say that it’s necessarily a public delivery system, as opposed to a private delivery

system, but it’s a more readily accessible, more limited in scope

provider who is more like the vulnerable population being treated.

And there are a number of ideas, from the American Dental Hygienists Association, the American Dental Association, new legislation in Minnesota, experiments and new programs in Alaska, a variety of approaches that bring dental therapists to increasing the

capacity for the delivery of services. So, looking at other countries,

that might be one direction of particular value.

Mr. ISSA. As you go down the list, the reason I said ‘‘public’’ is

that I understand that dental practice and State regulations tend

to predetermine certain things such as a hygienist being able to

work on their own or not, an assistant work on their own or not.

I used the term ‘‘public’’ because it’s a preemption for the poor potentially that would allow us to find the most efficient way to provide preventive medicine that might not be universally available in

some States. Being in California now, I am aware of that.

Please, Doctor.

Dr. MCINTYRE. Well, as a physician, one of the things that I

started out with our group, when we first formed our task force in

our coalition, was that the mouth is part of the body and that for

some reason we have kind of separated it out and I think a lot of

problems came from that.

But we have actually started using our primary care providers,

physicians, more because dental caries is a disease and, like any

disease, in order to get away from the disease later, we have to

prevent it. So if we can start early, when children first get their

teeth—you know, when they get those first two in the mouth, even

before they get their teeth, we start educating mothers when they

are pregnant about what they need to do. They get brochures and

information from the care managers about how to take care of the

teeth and the babies aren’t here. They are more likely to listen before the babies are born. Then when they get here, then doctors

who see children and give them their shots is an ideal opportunity

to educate, assist, and refer; and that’s what we are trying to do

to utilize the system.

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Mr. ISSA. If we could narrow the answer just to the organizational one, because I am testing the chairman.

Mr. KUCINICH. Please respond, the gentleman’s time has expired.

Dr. MCINTYRE. And that is part of the organization.

Mr. ISSA. Thank you.

Dr. MCINTYRE. Using physicians to do part of the work, OK.

Dr. BERG. My comment is a summary of what has been stated

before. That dental caries, cavities in kids is almost entirely preventable; and the earlier you intervene, the more preventable it is.

And the other nondental providers who aren’t treated in the surgical aspects of dentistry can assist us in the risk assessment of

prevention. You know, the fluoride varnish is not the cure. But the

risk assessment, determining who is at greatest risk and providing

more aggressive and frequent interventions, that is the solution.

So I think we need to segregate the surgery and not think about

dentistry as surgery. We have dentists who can do surgery. We

need some assistance in the earlier intervention for those folks, as

mentioned, who do see the children earlier.

Mr. ISSA. Thank you. Please.

Dr. CATALANOTTO. The other part that I would mention about

this is that there is a fundamental problem, though, in the dental

public health infrastructure. What I mentioned in my testimony is

that, assuming you had, at full capacity, the existing public health

infrastructure, the dental institutions, county health departments,

federally qualified community health centers, they can only address

about 8 percent of the dental need that’s out there.

So part of your solution that you need to look at is improving the

dental public health infrastructure.

Mr. ISSA. Thank you. Thank you for your indulgence, Mr. Chairman.

Mr. KUCINICH. Thank you.

The Chair recognizes Ms. Watson.

Ms. WATSON. Thank you very much, Mr. Chairman.

I want to address this particularly to Dr. McIntyre and Dr. Berg.

I think your two States have participated in some promising practices that were posted by CMS; and, in a survey that was taken

by GAO, there were 37 States who indicated a need for more information on other States’ efforts. And have you then shared that information? Have you been part of it, Promising Practices, that was

initiated by CMS? And can that Web site then be promoted to other

States that need this information?

Dr. McIntyre.

Dr. MCINTYRE. Well, we have actually provided information to a

number of people, including CMS.

Now, as far as whether it’s part of the Promising, I know that

we have actually published articles. We put out information on our

Web site. We mailed out brochures to all 50 States. It’s, you know,

basically in the past, to actually give them the information about

what we were doing. So—and we actually put the information

where it is accessible, and we are willing to share it with anyone.

Ms. WATSON. One of the things that concerns me is that many

of the dentists kind of look at the Medicaid beneficiaries and say,

I really don’t want them. What’s with that attitude?

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Dr. MCINTYRE. I mean, I think that’s a matter of education as

well; and it goes on both sides. Part of what we did as part of our

provider education and outreach was to educate providers that it

was a two-way street. And that in order to receive, you know, the

behavior that they were expecting, they also needed to be willing

to treat people with respect. So we came up with a dental rights

and responsibilities sheet that addressed the provider on what they

could expect and what the patient could expect from the provider

and for both of them to sign it.

And the reason for that is—and I am saying this because, as a

child who grew up with no insurance and no access to health care,

OK, and people a lot of times are looking down on people just because of their income levels, is something that we have to go beyond. And that is one of the things that we address with the providers, that, you know, if you expect people to behave a certain

way, you have to treat them so that they will behave that way. If

you expect bad behavior, you will get bad behavior. So that’s part

of the education that we deal with our dental task force.

Ms. WATSON. Dr. Berg.

Dr. BERG. Yes, I think, part of the success of ABCD is training

and cultural sensitivity. That’s a big part with the staff, and it’s

effective. You know, that there are unique needs of this different

population, their circumstances are different, and that has been

critical to the success. So I will just add that statement.

Ms. WATSON. Well, let me give you a pet peeve of mine.

I had a bill for the last 8 years to look at dental amalgams.

Amalgams are, as you know silver fillings. They are 50 percent

mercury. Mercury is the No. 1 toxic element. And I have been getting to the dentists. In fact, the minority dentists came in, and they

are adamantly opposed to it because they say it’s cheaper to put

an amalgam filling in.

Well, the research shows that when you have mercury in your

fillings, it is constantly—gases are constantly escaping, particularly

with children. So I find a real problem with the dentist that says

to me, it’s a matter of cost. And, you know, we have now, in your

States, Medicaid providing dental health care; and then we don’t

have this kind of patient result. However, when you get the industry saying to you, it’s a matter of cost, black people don’t like to

go to the dentist, so this is the cheapest we can give, I think that’s

a violation of ethics. How do we continue to educate these dentists?

Anybody want to take a swipe at that?

Dr. BERG. You are talking about the amalgam question specifically?

Ms. WATSON. Yes.

Dr. BERG. I think, first of all, to remind them that only about 6

percent of their total cost is materials, including amalgam and

other materials; and the real cost is how efficient they are at running their practice. And I think there are best practices and ABCD

has an annual meeting where our champions come together and

talk about how do I run efficiently in my office. And by changing

those behaviors in their office, they can do well by doing good and

be much more efficient. So I think that’s the focus we give.

By the way, I think, in our State, I wouldn’t say there’s any differentiation in any population in terms of who gets what, restoraVerDate 11-MAY-2000 13:04 May 23, 2011 Jkt 000000 PO 00000 Frm 00115 Fmt 6633 Sfmt 6633 C:\KATIES\DOCS\64919.TXT KATIE PsN: KATIE
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tive procedure. We don’t happen to do many amalgams, because

there are alternatives today. Some do. But I think we like to educate that it’s the efficiency of running the practice where they are

going to save the money, not—difference of materials are really

minuscule compared to staff costs and other costs in the practice.

Ms. WATSON. Thank you.

Thank you, Mr. Chairman.

Mr. CUMMINGS [presiding]. Thank you very much.

We are going to conclude this hearing. But I want to thank all

of you for your testimony.

As a representative from the State where Deamonte Driver died,

this hearing means a lot. I have often said that Deamonte Driver

was a little boy who was suffering from an infected tooth, and he

died in one of the richest States in one of the richest counties in

one of the richest countries in the world. There is something wrong

with that picture, and we can do better.

Dr. McIntyre, I was just thinking, as you were talking about this

whole idea of people just getting respect, a lot of times people don’t

realize it, but people feel so often that folks are talking down to

them, and they don’t—so they don’t—they feel that they are not respected.

When we look at health care disparities, for example, one of the

things that is clear is that there is a divide and some type of misunderstanding between, sometimes, those people who are trying to

treat and those who need treatment. And so I think it’s very important that, when we look at the Deamonte Drivers, we look at all

the kinds of things you have talked about here today.

And I was glad that Ms. Mann stuck around to hear some of this.

One of the things that Ms. Mann said was—not Ms. Mann but

our gentlelady, Ms. Iritani, said was that they wanted—these other

States wanted to know best practices. Duh. I mean, this is not

rocket scientist stuff. This is basic common sense and trying to

work things out and treating human beings as human beings.

So I just kind of think—I know we made a lot of headway, but

I just wanted to take the time to thank all of you all every day because you are affecting children.

I mean, and I say over and over again, children come on this

Earth with gifts. They bear gifts. Every one of them bears gifts.

They are born on the day that they are born to deliver gifts at certain points in their lives. But what happens is that, if we don’t

treat them right and we don’t nurture them and nourish them and

help them develop, they will never deliver those gifts. And if they

are sitting, as I did as a little boy, sitting in elementary school

thinking that cavities was a part of life. It wasn’t a question of—

it was like a headache. You are supposed to have cavities. And a

lot of people are still thinking that today.

That’s why this whole education thing is so significant, letting

people know. And that whole idea of letting them know there is a

direct relationship between the body and teeth, they don’t think it.

So I think all of us—I mean, the testimony that you all have provided today is basics. And, hopefully, somebody is listening, somebody will come to you all—because you all seem to know where you

are going, and you are on the right path—and allow you to help

others to get it.

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Now, the question becomes sometimes not whether people get it

but whether they want to get it, whether they have the will to do

what’s necessary; and that’s where we are going to come in. We are

going to try to do everything in our power to make sure that our

children, that the providers, that the States, and that all others

have the kind of information they need so they can touch our children in a positive way and look out for generations yet unborn.

Finally, let me say this. This is about—this is bigger than us.

This is bigger than us. When you were talking—Dr. McIntyre

talked—you know, it’s a great idea to educate mothers before they

give birth. Because, you know, all that excitement you have when

you find—you know, I am not a woman, so I don’t know, but folks

get real excited about their first birth in particular. And they go

and they prepare the room and all that kind of good stuff.

And then the question becomes, you know, shouldn’t part of that

preparation be making sure that you are prepared for the teeth of

that child and the dental health?

And what I was telling my aide, you know, was that the wonderful thing about it was that if you then educate, first, the mother

delivering the first child, then that sets a pattern for the other children that may come. But it does something else. It then teaches

the child as the child grows up how to take care of their teeth and

then hopefully generations—you have generational cycles of good

teeth, taking good care of your teeth. That’s what it’s all about.

So thank you all very much. This hearing is now adjourned.

[Whereupon, at 5:05 p.m., the subcommittee was adjourned.]

[Additional information submitted for the hearing record follows:]

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