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ONE YEAR LATER: MEDICAID’S RESPONSE TO SYSTEMIC PROBLEMS BY THE DEATH OF

DEAMONTE DRIVER

HEARING

BEFORE THE

SUBCOMMITTEE ON DOMESTIC POLICY

OF THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

SECOND SESSION

FEBRUARY 14, 2008

Serial No. 110–164

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

(

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

http://www.oversight.house.gov

(II)

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

——— ———

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

JIM JORDAN, Ohio

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

DAVID MARIN, Minority Staff Director

SUBCOMMITTEE ON DOMESTIC POLICY

DENNIS J. KUCINICH, Ohio, Chairman

TOM LANTOS, California

ELIJAH E. CUMMINGS, Maryland

DIANE E. WATSON, California

CHRISTOPHER S. MURPHY, Connecticut

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

BRIAN HIGGINS, New York

BRUCE L. BRALEY, Iowa

DARRELL E. ISSA, California

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

CHRIS CANNON, Utah

BRIAN P. BILBRAY, California

JARON R. BOURKE, Staff Director

(III)

C O N T E N T S

Page

Hearing held on February 14, 2008 ....................................................................... 1

Statement of:

Smith, Dennis, director, Center for Medicaid and State Operations; Dr.

Jim Crall, director, Oral Health Policy Center, professor and Chair,

Section of Pediatric Dentistry; and Dr. Burton Edelstein, founding

Chair, Children’s Dental Health Project, professor and Chair, Social

and Behavioral Sciences, Columbia University College of Dental Medicine ................................................................................................................. 16

Crall, Dr. Jim ............................................................................................. 30

Edelstein, Dr. Burton ................................................................................ 45

Smith, Dennis ............................................................................................ 16

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

Crall, Dr. Jim, director, Oral Health Policy Center, professor and Chair,

Section of Pediatric Dentistry, prepared statement of ............................... 34

Cummings, Hon. Elijah E., a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 100

Edelstein, Dr. Burton, founding Chair, Children’s Dental Health Project,

professor and Chair, Social and Behavioral Sciences, Columbia University College of Dental Medicine, prepared statement of ............................ 47

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

of Ohio:

Letter dated October 2, 2007 .................................................................... 54

Prepared statement of ............................................................................... 6

Various letters ........................................................................................... 60

Smith, Dennis, director, Center for Medicaid and State Operations, prepared statement of ........................................................................................ 19

Watson, Hon. Diane E., a Representative in Congress from the State

of California, prepared statement of ........................................................... 28

(1)

ONE YEAR LATER: MEDICAID’S RESPONSE TO

SYSTEMIC PROBLEMS BY THE DEATH OF

DEAMONTE DRIVER

THURSDAY, FEBRUARY 14, 2008

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON DOMESTIC POLICY,

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 3:15 p.m., in room

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

(chairman of the subcommittee) presiding.

Present: Representatives Kucinich, Cummings, Watson, Issa, and

Shays.

Staff present: Noura Erakat, counsel; Jean Gosa, clerk; Emily

Jagger, intern; and Vic Edgerton, legislative director, Office of Congressman Dennis J. Kucinich.

Mr. KUCINICH. The subcommittee will come to order.

Just for the attention of those who are in the audience and those

who are here to testify, the House is in session right now. We have

a series of votes. There has been a brief interruption for a motion

of personal privilege. That discussion could go on for a while.

So in the interest of expediting this hearing and respecting the

schedules of the witnesses, I have come here to start the hearing.

At some point my colleague, Mr. Issa, will join us. I want to proceed right now, though, given the hour and the fact that the House

will be finished when it completes this series of votes. I just want

to make sure that we respect your time.

This is the Domestic Policy Subcommittee of the Oversight and

Government Reform Committee, a hearing on Reform of Dental

Care in Medicaid.

[Slide shown.]

Mr. KUCINICH. One year ago, a 12-year-old boy, Deamonte Driver, died of a brain infection caused by an untreated tooth decay.

Deamonte lived in Prince George’s County, Maryland, and was eligible for Medicaid, but he hadn’t seen a dentist in more than 4

years.

In May 2007, my subcommittee held a hearing to examine the

circumstances that led to Deamonte’s preventable death. Today we

will examine what corrective actions the Center for Medicaid and

State Operations [CMS], has taken since Deamonte’s death to reform the pediatric dental program for Medicaid-eligible children.

During our hearing last May, we learned that Deamonte’s mother, Alyce Driver, tried to obtain oral health services for her son and

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his brothers. But there was a problem: there were no dentists

available for her Medicaid-eligible children enrolled by United

HealthCare Co. [United]. According to Laurie Norris, the Driver

family lawyer and a witness at last year’s hearing, ‘‘it took one

mother, one lawyer, one help line supervisor, and three case management professionals to make a dental appointment for one Medicaid child.’’

After the hearing, I instructed my subcommittee staff to investigate the adequacy of the dental provider network available to

Medicaid-eligible children enrolled in the same managed care company that was responsible for Deamonte.

My subcommittee investigated United’s dental network and

records of claims submitted for services rendered to United beneficiary children in 2006. Our staff found that Deamonte was far

from the only child in Maryland who hadn’t seen a dentist in 4 or

more consecutive years. In fact, nearly 11,000 Maryland children

enrolled in United had not seen a dentist in four or more consecutive years, putting them in the same precarious position that

Deamonte was at the time of his death.

The investigation also revealed that United’s dental provider network was not nearly as robust as they had claimed. We discovered

that 55 percent of all dental services rendered in 2006 in the county where Deamonte resided were conducted by only seven dentists.

We also discovered that 19 of the dentists listed in the dental provider network in the county provided zero services to Medicaid-eligible children in 2006.

United has concurred with all of the subcommittee’s findings and

they are cooperating with the subcommittee’s broader investigation

as well.

There is no dispute that Federal law, specifically Section 1902 of

the Social Security Act, mandates that Medicaid-eligible children

are entitled to routine dental services and any necessary treatment

on a periodic basis. Why, then, were there no dentists available to

deliver that care to Deamonte? More importantly, why didn’t CMS,

the Federal agency responsible for administering Medicaid, do

something about it?

At our hearing last May, we asked Mr. Dennis Smith, the Director of CMS, that question. We asked him why he did not take any

action in Maryland after he learned that only 24 percent of its children got any dental care in 2004, and he responded. And I think

some of you are familiar with the quotes, but here they are.

[Slide shown.]

Mr. KUCINICH. ‘‘The enforcement tools . . . are to sanction the

State financially. . . . I have not sanctioned States for the access

issue in dental care.’’

[Slide shown.]

Mr. KUCINICH. He went on to say: ‘‘Enforcement is about taking

financial penalties against states.’’

But financial sanctions are absolutely not the only enforcement

tools available to CMS. The Director of CMS has many enforcement

tools available to him, and in a May 17, 2007 letter that Congressman Cummings of Maryland and I sent to Mr. Smith, we enumerated just a few of them.

[Slide shown.]

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Mr. KUCINICH. We suggested that CMS—and these are our suggestions: Conduct a critical incident review of Deamonte Driver’s

death; make children’s access to dental care a CMS enforcement

priority and communicate this priority to all States; establish a

standard or goal for the percentage of eligible children to receive

preventive dental services; improve current reporting requirements,

namely, make the CMS 416 forms more reliable and accurate; identify the poorest performing States and assess why those States are

performing poorly and suggest ways they can improve their performance; rank the States in order of performance vis-a-vis the provision of dental care; ensure that administrators of Medicaid programs have ready access to the policy guidance they need in order

to cover children’s dental services with respect to reimbursement

rates and managed care oversight; issue a letter to State Medicaid

directors reminding them of their legal obligations and ask them

to submit plans of action for ensuring that children will have adequate access to dental services; assess civil money penalties against

any managed care organization that has contracted with a Medicaid agency and has failed to do so.

What a difference a year makes. Since our hearing, Medicaid has

indeed used several tools to enforce Federal law. We will learn

about some of these actions today.

But time doesn’t heal all wounds. In important ways, Medicaid

still hasn’t learned the most important lessons from the preventable death of Deamonte Driver.

According to experts, one of the most important things that CMS

can do is address the issue of reimbursement rates at a national

policy level.

In 2000, CMS contracted with the American Association of Pediatric Dentists [AAPD] to draft a Guide to Children’s Dental Care

in Medicaid. This contract stipulated that the Guide was to provide

policy guidance to the State Medicaid agencies about implementing

and managing Medicaid’s Early and Periodic Screening, Diagnostic,

and Treatment [EPSDT] system.

[Slide shown.]

Mr. KUCINICH. The AAPD submitted the completed Guide to

CMS in 2001. However, CMS did not publish it until 2004, and

when it finally did publish it, under the authority and leadership

of Mr. Smith, the entire policy section on reimbursement rates and

managed care oversight was redacted.

[Slide shown.]

Mr. KUCINICH. Now, I don’t understand why Mr. Smith would do

that, when, at our hearing last year, he himself said, ‘‘The key to

improving access principally from the provider perspective is to increase reimbursement rates.’’

Clearly, Mr. Smith understands the nature of the problem, as

well as a cornerstone to its solution. Yet, as Director of CMS, we

have not seen sufficient evidence that he would use his understanding to solve that problem or, at the very least, to improve it.

In our letter to him, Mr. Cummings and I urged Mr. Smith to

revise the Guide and incorporate information relating to provider

reimbursement and managed care oversight that was edited out of

the 2004 version. Alternatively, we asked him to send a State Medicaid Director letter that provided this critical policy information.

4

[Slide shown.]

Mr. KUCINICH. We have not received cooperation on our request.

Mr. Smith explained, in slide 7: ‘‘States have ready access to all

Medicaid policy on reimbursement and managed care oversight

through existing Federal publications and documents.’’ That answer that we received is not acceptable.

In Georgia, that information was available when its three managed care organizations cut their reimbursement rates and limited

their dental services in 2006. That was a profit-boosting move on

their part. In Maryland, that information was available when

Deamonte died of a brain infection caused by untreated tooth

decay.

In the District of Columbia, Virginia, and 20 other States, that

information has been available as Small Smiles—an abusive, possibly criminal, multi-State dental provider—preys on Medicaid-eligible children to generate a profit. Because inadequate reimbursement rates are often insufficient to cover even an honest dentist’s

costs, Small Smiles conceived of another way to make a profit: a

predatory mill where multiple, sometimes unnecessary, procedures

are imposed, assembly-line style, on children with little regard for

their welfare or proper dental practice.

Small Smiles routinely barred parents from their children’s side

during dental procedures, and in separate instances performed

more than a dozen root canals on a child’s baby teeth, and, in Arizona, fatally overdosed a child with anesthesia. While CMS certainly doesn’t condone these unscrupulous and horrific practices,

the silence on reimbursement rates creates economic incentives for

these kind of practices to flourish.

CMS’s role as Federal administrator of Medicaid is not just to

have information available, but to make sure that the States have

and use that information and comply with Federal law.

Prior to Mr. Smith’s taking the reins at CMS, the former CMS

director understood this concept and issued a State Medicaid Director letter requesting information on State efforts to ensure children’s access to dental services under Medicaid. The letter indicated that CMS would undertake intensive oversight of States

whose dental utilization rates, as indicated on the CMS–416 annual reports, were below 30 percent, including site visits by regional office staff.

States with utilization rates between 30 and 50 percent would be

subject to somewhat less stringent review. All States were asked

to submit ‘‘Plans of Action’’ detailing how they would improve access to oral health care within 3 years. The letter not only sent a

message to States that oral health was a Medicaid priority but,

that as a provider of half of the States’ Medicaid budgets, CMS was

monitoring their performance closely.

Significantly, Maryland was among the States with utilization

rates below 30 percent. But between 2001, when Maryland submitted the information to CMS, and February 2007, when Deamonte

died, CMS, under the leadership of Mr. Smith, hasn’t done anything to followup with these poorest performing States.

The new administration in Maryland under Governor O’Malley

has laudably taken initiative since Deamonte Driver’s death. Maryland’s Medicaid Administration has taken a number of significant

5

actions. They did that on their own in light of all the local attention Deamonte’s tragic death earned. But what has CMS done nationally, in other States besides Maryland, to prevent the situation

that led to Deamonte’s death? Today we are going to find out.

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

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Mr. KUCINICH. With that, I am going to go and vote. I will be

back and we will continue the hearing.

[Recess.]

Mr. KUCINICH. The committee will resume.

Mr. Smith, Dr. Crall, Dr. Edelstein, thank you for being here. I

ask that you proceed. Thank you.

STATEMENTS OF DENNIS SMITH, DIRECTOR, CENTER FOR

MEDICAID AND STATE OPERATIONS; DR. JIM CRALL, DIRECTOR, ORAL HEALTH POLICY CENTER, PROFESSOR AND

CHAIR, SECTION OF PEDIATRIC DENTISTRY; AND DR. BURTON EDELSTEIN, FOUNDING CHAIR, CHILDREN’S DENTAL

HEALTH PROJECT, PROFESSOR AND CHAIR, SOCIAL AND BEHAVIORAL SCIENCES, COLUMBIA UNIVERSITY COLLEGE OF

DENTAL MEDICINE

STATEMENT OF DENNIS SMITH

Mr. SMITH. Thank you, Mr. Chairman. I am happy to be with

you again this afternoon. I will be very brief. We have a statement

for the record, so I won’t go through all of the detail that we have

provided in terms of the steps that we have taken since the subcommittee hearing in may of 2007.

In the President’s budget that came out last week, Medicaid spending, Federal and State combined, is estimated to exceed $347

billion in fiscal year 2009, $2 trillion over the next 5 years, $5 trillion over the next 10 years. Total Medicaid spending on children

will exceed $400 billion over the next 5 and $1 trillion over 10,

which is approximately 20 percent of Medicaid’s spending on children. We serve more than 29 million children in Medicaid. In 2009,

the estimated per capita cost for a child for a full year on Medicaid

is nearly $2,900.

Medicaid is directly administered by the States. States enroll

providers at reimbursement rates and negotiate managed care contracts. Medicaid is a matching program; Federal dollars follow

State dollars. In general, we do not have separate authority to

make direct grants to States for different activities, although Congress has periodically created specific grant programs, such as the

Medicaid Transformation Grants under the Deficit Reduction Act of

2005, and the Real System Change Grants previous to that.

In terms of our response to the issues in Maryland specifically,

as you are aware, we did perform a focused review of Maryland

dental services that we began in October of last year. We have

completed that review and submitted that to the subcommittee for

its review. In general, CMS found that although Maryland took

steps in 2007 to hold managed care organizations responsible for

providing dental services, additional accountability and oversight

was needed. The draft findings were issued on November 28th of

last year, which included six findings and recommendations for the

State to respond to.

Those recommendations centered on ensuring the individual that

information provided to beneficiaries on accessing dental services

was easy to find and culturally appropriate; establishing an internal service to independently verify MCO dental provider directories; instructing MCOs to track and report on children not receivVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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ing dental services and to escalate steps to reach such children;

documenting the oral health needs of special needs children and

the adequacy of dental specialists to meet their needs; requiring

MCOs to monitor and report on dental provider utilization; and

conducting appropriate reviews to determine the need to initiate

appropriate corrective actions, including sanctions, against any

MCO not meeting its contractual obligations.

In particular to the quote from the May hearing, I am concerned

that the quote left the impression that we would not pursue sanctions. I want to assure you that we had—my recollection is—a general discussion, conversation with Mr. Waxman about it. If I gave

the impression that we were taking sanctions off the table, I certainly did not mean to give that impression. We specifically raised

the issue of sanctions in particular on the MCOs with Maryland

and Maryland specifically needed to address whether or not sanctions needed to be taken. Maryland ultimately recommended that

sanctions not be taken in the corrective actions of the MCOs in

general and the work of the Dental Action Committee.

Maryland formed a Dental Action Committee last June with a

broad variety of community leaders. I understand that Dental Action Committee has submitted a report to the Maryland General

Assembly, which is ultimately responsible for providing the necessary funding to support the recommendations for increased reimbursement.

We will not be stopping with our work in Maryland. Although we

have seen progress in the utilization of dental care for children in

Medicaid, in 1996 only one in five children in families with income

below 200 percent of the Federal poverty level had a dental visit

the previous year. Our current CMS Form 416 data for 2006

showed that one in three individuals under age 21 received a dental service. That is an increase of 10 percent over 2003, 22 percent

increase from 2000. But we agree that, certainly, further progress

is needed.

In that respect, in our oversight role, we began a series of

EPSDT dental reviews this week that will occur in 15 States between now and early April. CMS Central Office and Regional Office

Staff——

Mr. KUCINICH. Mr. Smith, excuse me. I am sorry to interrupt

your testimony, but since we have been joined by our ranking

member, Mr. Issa, and since his presence now makes this an official meeting, what I would like to do is to ask you and all the others to stand and be sworn. You continue with your testimony and

then if Mr. Issa has anything after Mr. Smith is complete, we will

ask Mr. Issa to enter his statement.

So would you raise your right hands?

[Witnesses sworn.]

Mr. KUCINICH. Let the record show that the witnesses have answered in the affirmative. I thank you for your cooperation.

You may proceed, Mr. Smith.

And I thank Mr. Issa for his presence here.

Mr. ISSA. Thank you. And I apologize for not being here earlier.

Mr. KUCINICH. Listen, we are both in a tight schedule today, so

it means a lot that you are here.

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Mr. Smith, you will proceed. Then I will come back to Mr. Issa

and then the other two witnesses. Go ahead.

Mr. SMITH. Thank you, Mr. Chairman.

As I just mentioned, we began a review that will occur between

now and early April for 15 States. We have developed, and staff in

the central office and the regional offices have now been trained,

on a dental review protocol that will be used to assess States in

seven key areas: informing families, periodicity schedules and

inter-periodic services; access to dental services; diagnosis and

treatment services; support services; coordination of care; and data

collection, analysis, and reporting. These 15 States have been identified and, as I said, we began this week and we expect to issue

final reports to the States during the summer.

In my testimony, I have a list of a number of activities that we

have undertaken. I won’t go through all of those now, but they, I

believe, demonstrate that we have taken action on the area of dental access and I believe that we have engaged the States appropriately in improving services to children, improving access to the

dental care.

We believe that we have expanded both the use of the dental

services among children and our ability to report on that progress,

and this is an area that we often find ourselves in terms of gaps

and information in our reporting systems. We are not always able

to provide the data that policymakers and the subcommittee would

like to have, and I have personally expressed my frustration many

times on our ability to be able to report timely, accurately, and in

the various different ways that we would want to to be able to

measure the real progress that we have taken.

I also, in terms of being able to respond to—the chairman raised

an issue of practices that we have now seen in terms of inappropriate care of children, providing care that is not medically necessary

and, in fact, may in fact lead to detrimental impact on children’s

health. We are very much aware of those and we are participating

in those reviews, and I assure you that our program integrity

group, in cooperation with Medicaid fraud control units and the Department of Justice are participating in those reviews.

Thank you again for inviting me this afternoon.

[The prepared statement of Mr. Smith follows:]

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Mr. KUCINICH. Thank you very much, Mr. Smith. I appreciate

your presence here and your willingness to cooperate with us.

Thank you.

Mr. Issa.

Mr. ISSA. Thank you, Mr. Chairman. Once again, I would like to

apologize for the overlapping schedule of multiple committees. Mr.

Chairman, I want to personally thank you for doing what this committee should do, which is to hold hearings, shed light on a problem that exists, particularly within Government-managed programs, and then give Government management an opportunity to

work on those problems, and last, as today, to come back and tell

us what they have done to see whether or not we need to address

it further.

Certainly, I think that this will not be the last visit on health

care, Government-sponsored health care before this committee. I

am confident that as we seek to deal with the problems not just

of S-CHIP and other Federal programs, but the broader problem of

health care availability in this country and, as Mr. Smith said,—

and I couldn’t agree with you more—the fact that under-medication

and over-medication can occur separate from whether or not there

is insurance. These problems and more need the constant attention

of professionals at the front line and then periodic review by this

committee and others.

So I want to thank the chairman for bringing this up today. This

is an issue that we are both passionate about. We both, sadly

enough, are Clevelanders and come from an area that today is suddenly in greater need of these kinds of services and more.

So with that, Mr. Chairman, I would ask unanimous consent to

put my entire opening statement in the record and go on to the rest

of the hearing.

Mr. KUCINICH. I appreciate that. I look forward to having your

entire statement in the record. And, again, the Chair wants to

state how much I appreciate our working partnership here in the

public interest. Thank you.

Before we move on, does the gentlelady from California have

anything that she wants to say?

Ms. WATSON. I want to thank the chairman for holding this important hearing on reforming the pediatric dental program for

Medicaid-eligible children.

In 2007, the subcommittee held a hearing on the unfortunate

death of Deamonte Driver, a 12-year-old boy from Prince George’s

County, Maryland, who died of a brain infection caused by tooth

decay. Deamonte’s death shines light on our Nation’s Medicaid program that has become increasingly unglued due to the fact that

fewer and fewer dentists are willing to take Medicaid patients. As

noted in the 2007 hearing, Prince George’s County has approximately 45,00 to 50,000 child Medicaid participants, some 200 dental offices that are listed as Medicaid providers. But, in reality,

only 25 percent, or 50 offices actually see child Medicaid patients.

The ratio of patients to providers is obviously unacceptable.

It pleases me that the subcommittee has continued its oversight

of the Center for Medicaid and State Operations since the 2007

hearing and has provided the members of the subcommittee with

a brief update on its ongoing investigation. The committee memoVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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randum notes, quite disturbingly, ‘‘On October 2nd, 2007, the subcommittee issued its review of United’s documents and revealed

that nearly 11,000 Maryland children enrolled in the United had

not seen a dentist in four or more consecutive years, putting them

in the same precarious position that Deamonte was in at the time

of his death.’’

The review also revealed that United Health Group Companies,

the health company that manages the CMS program, dental provider network was not nearly as robust as they had claimed. Fiftyfive percent of all dental services rendered in 2006 in the country

were conducted by only seven dentists.

So, Mr. Chairman, we see, in 1 year, that the basic situation has

not changed that much. Thousands of children in Maryland alone—

and undoubtedly hundreds of thousands of children across the Nation—are in danger of having their health systems seriously compromised at a young age due to lack of access to dental care. So

I look forward to the hearing and to hearing from the witnesses as

to how we go about fixing a serious problem that will have health

consequences for many of these same children who reach adulthood

decades later. The age-old adage by Ben Franklin ‘‘an ounce of prevention is worth a pound of cure’’ is certainly applicable to the situation we have before us today. So thank you so very much.

[The prepared statement of Hon. Diane E. Watson follows:]

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Mr. KUCINICH. I want to thank the gentlelady from California for

her participation and let you know that Mr. Smith had already

given his testimony when Mr. Issa arrived. Out of fairness, I wanted to make sure that you had a chance to submit your statement,

and you have, and I am grateful for that.

We are going to proceed with Dr. Crall, and you are welcome to

stay as long as you would like, of course.

Dr. Crall, you may proceed, and thank you.

STATEMENT OF DR. JIM CRALL

Dr. CRALL. Thank you, Mr. Chairman and members of the subcommittee for the opportunity to participate. My testimony is organized into three sections corresponding to requests in your letter of

February 4, 2008.

I will begin with a quick overview of the significance of oral

health to overall health, which has been extensively documented in

scientific publications, governmental reports, including the Surgeon

General’s Report on Oral Health.

Oral diseases and developmental disturbances are common afflictions for children and adults. Tooth decay, often referred to as dental caries, is the most common chronic disease of childhood. Over

50 percent of U.S. children experience tooth decay by the time they

enter kindergarten and nearly 80 percent by late adolescence. Children covered by Medicaid and other public programs acquire this

disease early in life, have higher rates of caries and more severe

forms of the disease and greater unmet treatment needs. The early

onset of caries, especially in low-income children, underscores the

importance of providing ongoing dental care and what we refer to

as a dental home beginning early, that is, by age one.

Gingivitis, inflammation of the gums, also common in children,

can progress to periodontal disease, which is an inflammatory disease that destroys bone and spreads infection. Infants, children,

and adults also experience a wide variety of developmental abnormalities, such as cleft lip and cleft palate and abnormal formation

of teeth and jaws. Also, in adults, oral and pharyngeal cancers are

relatively common.

The consequences of oral diseases and development disturbances

can be profound for overall health and quality of life. The infectious

disease that causes tooth decay can spread to the bloodstream and

lymph system. These infections cause pain, swelling, loosening of

teeth, and can spread to other areas of the body, such as the brain,

heart, and lungs; and they can trigger serious co-morbidities. The

death of Deamonte Driver is a tragic reminder of the potential consequences of untreated tooth decay. Periodontal disease is also

caused by bacteria that can spread throughout the body and has

been associated with a variety of conditions, including cardiovascular disease, type 2 diabetes, adverse pregnancy outcomes,

pneumonia, and osteoporosis. Developmental disturbances such as

cleft lip and cleft palate and oral cancers have obvious impacts on

individuals’ ability to speak, eat, their appearance, self-esteem, and

social interactions, as can tooth decay and periodontal disease, especially for individuals of low, socio-economic status.

The messages of the Surgeon General’s Report on Oral Health

have not been effectively translated into public policy or public proVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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grams. Despite Federal EPSDT statutes, access to dental services

for children covered by Medicaid remains a significant chronic

problem. Most States and Medicare do not coverage for basic restorative dental services for adults. Failure to implement the Surgeon General’s findings in public programs via legislative authority

and appropriations, regulatory oversight, and effective program implementation remains a significant detriment to overall health and

quality of life for millions of U.S. children and adults.

Next, I would like to turn to the importance of reimbursement

rates to ensuring access to dental care among Medicaid beneficiary

children. Regular dental care is one of three key elements considered to be central to sustaining good oral care. The other two have

to do with dietary practices and what we call oral hygiene or selfcare routines. Access to ongoing dental care is especially important

for children at elevated risk for common dental diseases, that is,

children in low-income families and children with special health

care needs who generally are covered by Medicaid.

Reimbursement that is sufficient to engage in adequate number

of dental professionals having the knowledge and skills to meet the

full range of dental care needs of Medicaid children is fundamental

to ensuring access and sustaining good oral health. Approximately

24 million children were enrolled in Medicaid each month in 2007.

Providing access to ongoing dental services for this large number

of children requires that a very substantial number of private sector dentists—who provide over 90 percent of dental services—as

well as public sector—often referred to as safety-net dentists—be

engaged as Medicaid participating providers in each State.

Could I have the first slide, please?

[Slide shown.]

Dr. CRALL. Studies conducted by Federal agencies report that inadequate reimbursement is the most significant reason why dentists do not participate in Medicaid. GAO reports note that Medicaid payment rates often are well below dentists’ prevailing fees and

that, as expected, payment rates closer to dentists’ full charges appear to result in improvement in service use.

[Slide shown.]

Dr. CRALL. This slide shows trends in total U.S. dental expenditures and Medicaid dental expenditures following enactment of

Federal Medicaid legislation in 1965. The dark blue line depicts

total U.S. spending on dental services. The yellow line represents

aggregate public expenditures for dental services, largely Medicaid.

With a few recent exceptions, chronic under-funding over a period of several decades has translated into reimbursement rates

that provide limited or no financial incentives for most dentists to

participate as Medicaid providers in most States.

Medicaid programs frequently base reimbursement schedules on

a fundamentally flawed application of the concept of usual, customary, and reasonable fees, which does not provide a valid reflection of market-based dental fees for several reasons, which are detailed in my written testimony. Moreover, most Medicaid programs

have no provisions for updating fee structures on a regular basis

for inflation.

And if I could have the next slide.

[Slide shown.]

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Dr. CRALL. This slide illustrates a 50 percent loss in purchasing

power over a 14-year period. Unfortunately, it is an interval which

is not uncommon for Medicaid rate adjustments in many States,

with a 5 percent annual inflation rate.

[Slide shown.]

Dr. CRALL. Next slide shows the effects of applying discounts of

17 percent or 35 percent to dentists’ average charges. The results

are reimbursement rates that are below, and often substantially

below, the usual charges of 75 percent to 90 percent of dentists.

And, beyond that, discounts of over 50 percent off of average

charges are not uncommon in State Medicaid programs.

Next slide, please.

[Slide shown.]

Dr. CRALL. Beginning in the late 1990’s, following a series of oral

health policy academies organized by the National Governors Association, several States moved to increase Medicaid reimbursement

rates to levels consistent with market-based approach. As the GAO

noted, Medicaid payments that approximate prevailing private sector market fees did result in substantial increases in dentists’ participation in Medicaid, as shown on this slide.

[Slide shown.]

Dr. CRALL. More directly to the point, the next slide shows data

from CMS 416 reports illustrating substantial increases in utilization in five States subsequent to rate increases that approach market-base levels.

[Slide shown.]

Dr. CRALL. And my final slide provides a comparison of one

State’s Medicaid payment rates for illustration. This State’s Medicaid program paid $18.08 for a periodic examination, an amount

that only 2 percent of dentists in this State would see as equal to

or greater than their current charges. It is the second percentile of

fees.

Of particular note, for 9 of the 15 selected procedures on this

slide, the respective Medicaid payment rates are less than the

usual charges reported by any dentist in this State. They are less

than the first percentile of fees. From an economic perspective,

these payment levels would not provide adequate incentives for

dentists to participate in Medicaid.

Finally, I was asked to comment on CMS’s redaction of the section on policy guidance relating to provider reimbursement and

managed care oversight in the Guide to Children’s Dental Care in

Medicaid that I authored for the American Academy of Pediatric

Dentistry. I will just point out that the entire section of the document that AAPD submitted to what was then HCFA, now CMS, on

program financing and payments, Section C in the submitted table

of contents, was deleted from the published version of the Guide.

That material primarily related to the previous statements on reimbursement.

Additional information was provided in the redacted sections on

relevant actuarial studies, which showed that roughly $14 to $17

in 1998 or 1999 dollars per enrolled beneficiary, often referred to

as PMPM, would be necessary to pay for dental services for children enrolled in Medicaid at market rates comparable to those

used by commercial dental benefit plans for employer-sponsored

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groups, or $17 to $20 PMPM for administering a Medicaid dental

benefits program.

This information was included to provide a guide or benchmarks

that State Medicaid programs could use to assess their current allocation levels for dental benefits for children enrolled in Medicaid.

Available information suggests that many States allocate only a

small fraction of the financial resources suggested by these actuarial studies. Some were on the order of $5 to $7 per child per month.

Other sections that were redacted included information on a

number of topics that have potential relevance to the program administration and managed care organizations, such as legislative

and regulatory requirements; basic program requirements;

screenings and referrals for diagnosis and treatment; reimbursement for behavior management; integration of dental services and

EPSDT screening services; continuity of care and case management; and contracts, development, and enforcement.

Two appendices on actuarial estimates and a document developed by a joint HCFA-HRSA-supported Maternal and Child Health

Technical Advisory Group on Policy Issues in the Delivery of Dental Services to Medicaid Children and Their Families also were not

included.

These sections were included in the version submitted by AAPD

because, at the time, information on these topics, as well as differences between how medical and dental benefits are organized

and financed, were not well known or understood by State policymakers, especially those who are not dental professionals. This information could have helped State officials understand important

aspects of the dental care delivery system and how it relates to

Medicaid policies, especially in the absence of regulations corresponding to changes made in OBRA 1989 that were never carried

out.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Crall follows:]

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Mr. KUCINICH. I thank the gentleman.

Dr. Edelstein, thank you. Proceed.

STATEMENT OF DR. BURTON EDELSTEIN

Dr. EDELSTEIN. Mr. Chairman and members of the subcommittee, I appreciate the opportunity to address the issue of children’s

dental services in Medicaid.

In my role now as a professor of health policy, I teach my students that public policymaking is that process that you folks exercise in allocating resources to competing interests, and we can’t

help but note how poorly dental tends to fare in that competitive

arena. We observe that it not only fares poorly, but, objectively, it

fares poorly in that only one in three children now is obtaining

dental services in Medicaid, contrasted with nearly two in three in

commercial coverage.

And, yes, I do appreciate that there has been a significant increase since so many of us committed so much effort, starting in

1998, to improve the proportion of children who do receive care in

Medicare, but the assertion that it has come as a result of CMS

action, that CMS has been able to expand dental services is one

that I hope I will have an opportunity to discuss during the question period.

We also recognize that CMS has many options available to it to

improve the situation, and I would suggest that there are three

such options: exercising leadership, providing technical assistance,

and holding States accountable to required performance.

When we look at dental care in Medicaid, my students and I

can’t help but notice how little, how infrequent, and how inadequate are those Federal efforts to ensure that children have the

basic coverage that they need for their essential growth, health,

and function. Most surprising has been the paucity of new action

in this last year, given that it is almost now the first anniversary

of Deamonte Driver’s death.

As a consultant to the Department of Health and Human Services from 1998 to 2000, I came to know the dental Medicaid

through a formal HRSA-CMS dental access initiative. Under the

two prior national Medicaid directors, a 10-year vacancy in the

CMS chief dental officer position was filled, and it was filled with

a person who had direct reporting authority to the Medicaid director, a place that no longer is true; a joint technical advisory group

[TAG], was formed; the regional office capacities to assist the

States was bolstered; CMS and HRSA joined forces with the Governors Association and the National Conference of State Legislatures to work with the States; CMS funded demonstrations in prevention that proved that you could have better outcomes at lower

costs; the Medicaid Guide was commissioned; the 416 Report was

strengthened; States were required to report to CMS on their efforts. A variety of things were done and, as we now know, not one

of these efforts was followed through in the last 7 years, until the

recent announcement of the reinstitution of the TAG and the reinstitution of the focused reviews.

However, before coming to my consultancy with Government, I

was a participating pediatric dentist, a clinician, and it was in that

role that I personally came to understand this poisonous mix of low

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payment and unnecessarily burdensome administration. Parents

continue to struggle to find participating providers. Yet, my practice experience with another governmental program, the Tricare

program for children who are military dependents, is very different,

and it shows that when Government does seek to truly provide

dental services, it can find a way.

Now, I understand that Medicaid kids are a different population

than are the dependent children in the military, but the programs

function so differently that I think it is telling about differences in

priorities and commitments that the government has to these two

different groups of children.

So, in brief, I would suggest there are three things that CMS

could be doing now that would make a significant difference and

continue to move us toward the two in three children receiving

dental services instead of the one in three.

First, CMS could exercise definitive leadership. CMS could assure that the CMS staff, the staff in all of the regional offices, the

State Medicaid directors all know that dental care is not only required under EPSDT, but is a priority of the administration. It

could promote evidence-based early intervention that starts dental

care well before the disease begins by focusing on that periodicity

schedule from OBRA 1989 that never got moved. With little expenditure of time and money, CMS could partner with HRSA

again, but also with CDC, ARQH, NIH, IHS, WIC, Head Start, private organizations, foundations, professional associations to really

use its bully pulpit, its leadership, to leverage the capacities of others.

Second, CMS could provide meaningful technical assistance.

CMS could provide intensive and extensive technical assistance,

best practices, guidance, release of the Guide, release of the TAG

findings from all those years ago, develop and disseminate model

contracts, convene States again to learn from one another, ensure

that there is a competent cadre of people in the regional offices who

can really help the States, make suggestions about what can be

done under HIFA and DRA to improve dental services. And when

problems flare up, as they did in this last year in Georgia and now

in Connecticut, CMS could be there to broker solutions and to provide technical assistance to the States.

Last, I would suggest that CMS could more substantially exercise

meaningful oversight. CMS has clearly demonstrated its willingness and its capacity to act forcefully on a number of issues, including, for example, the August 17th stringent guidance on State program expansions. Why CMS has not acted as forcefully on dental

issues is inexplicable unless one believes that even the death of a

child does not sufficiently highlight the importance of basic dental

care. A Federal directive to States that compliance with reporting

and service requirements under the law is of serious import to the

agency would go a long way.

So, taken together, I would suggest that leadership, technical assistance, and oversight could bring dental care to the forefront, it

could honor Deamonte Driver’s life, and it could assist the millions

of children in Medicaid who currently have so little access to essential dental services. Thank you.

[The prepared statement of Dr. Edelstein follows:]

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Mr. KUCINICH. Thank you very much.

Before I begin with my questioning, did you have an opening

statement? OK. All right. If you would like, you could submit one

for the record at any time.

Mr. SHAYS. The only statement I would make, since you have invited that, is to thank our witnesses for coming and to thank you

for having this hearing. This issue presented itself in a very shocking way and, frankly, I was stunned that—and I plead ignorance—

that bad dental care could result in what it resulted in in the case

of the young man, Mr. Driver.

Mr. KUCINICH. I thank my colleague.

A subcommittee investigation revealed that there are 10,780

Medicaid beneficiary United enrollee children in Maryland who

have not received dental services in at least four consecutive years,

so I would like to begin this discussion with Mr. Smith.

What is the total number of Medicaid beneficiary children, those

that are enrolled in the Medicaid managed care organizations, in

Maryland who have not received dental services in at least three

consecutive years?

Mr. SMITH. Mr. Chairman, we don’t have the data at this point

to be able to track individuals. The data that comes to us on the

416, for example, is dated that is in the aggregate. To track specific

individuals, the States have that information; they are the ones

that process the claims, etc. But under our current data collection

systems and the capacity that we have, we don’t track individual

claims.

Mr. KUCINICH. Do you think it would be helpful if—for example,

do you have anybody on your staff that would pick up a phone and

say, hello Maryland, what is the total number of Medicaid beneficiary children who haven’t received dental services? Do you ever

do that? Do you collect data in that way? Do you do it informally

if the formal systems aren’t working?

Mr. SMITH. Mr. Chairman, our lack of data collection is a great

frustration to me. Yes, we can—and oftentimes, unfortunately, that

is what we end up doing, responding to all types of requests for

data, but that is what we are left with, is picking up the phone,

calling, oftentimes—and, again, even in the 416. The 416 we still

have five States outstanding to where we don’t have two States

still have not even submitted the data yet from 2006. The other

three States we are not satisfied that they are reporting accurately.

So accurate reporting and our data systems, although I believe we

have great improvement over previous years, we are still a long

ways from what is satisfactory.

Mr. KUCINICH. I understand your frustration. I want to point

something out, that our staff actually contacted Maryland and

found out that approximately 22,555 children ages 5 to 14 have not

received care in three consecutive years, and the numbers would be

even greater if we considered the CMS 416 standards, which are

children ages 4 to 20; it widens out the age groups.

I would just like to submit to you that as a Federal administrator, in addition to whatever data base issues exist here, it might

be helpful if you could find a way for your own staff to be able to

access the kind of information that a relatively small congressional

staff has been able to get. It occurs that during your EPSDT review

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in Maryland, you may have been able to find that out, and I just

want to point out that another way of getting this information is

by asking the Medicaid managed care organizations.

As part of our investigation of United, my staff asked them how

man of their beneficiary children had not seen a dentist in 1, 2, 3,

4, 5 consecutive years, and we have a letter somewhere that I want

to enter into the record by unanimous consent. As I mentioned earlier, there are nearly 11,000 children enrolled in United that have

not seen a dentist in 4 consecutive years, putting them in the same

position that Deamonte was when he died. So, without objection,

this will go into the record.

[The information referred to follows:]

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Mr. KUCINICH. Now, in addition to Maryland, there were 14

States that had less than a 30 percent utilization rate in 2001.

They reported their utilization rates in response to the January 18,

2001 State Medicaid letter, and I just wondered if you could help

us and tell us, in each of these States, what is the total number

of Medicaid-eligible children that have not received dental services

in at least three or four consecutive years, if you have any of this

information. I am going to go over a list, and just tell me if you

have any information. If you don’t, we would like you to get it. We

think these figures exist. We are looking for Alabama. Do you have

that?

Mr. SMITH. Mr. Chairman, I don’t have—as I responded earlier,

we have data in the aggregate. We can go back to the States that

you would like to——

Mr. KUCINICH. OK, our staff is going to provide you with a list.

I didn’t invite you here to embarrass you, I just want to point out

that we have some difficulties that exist, I think, that perhaps are

impediments to the efficient management at a Federal level to permit higher rates of utilization. I am going to ask staff to present

this list.

OK we have correspondence from Maryland, North Carolina, and

from CMS that we are going to put into the record with unanimous

consent.

[The information referred to follows:]

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Mr. KUCINICH. We have eight States which have a utilization

rate below 30 percent, and that is 5 years after that first report in

2006, after this was first addressed. Five States still have utilization rate below 30 percent, which means that those young people

eligible for those services, there is only 30 percent of all the eligible

children are getting care, or less than that, in these States: Arkansas, Delaware, Florida, Michigan, Missouri, Nevada, New Jersey,

and Wisconsin. We really need to find out these numbers and to

submit those, and I would like you to help us and get these numbers and submit them to the subcommittee.

Mr. SMITH. Mr. Chairman, we would be happy to work with you

to track down the numbers from the States. We will try to get you

the data and will assist in collecting the information from the

States.

Mr. KUCINICH. I want to just share something with Mr. Shays

before I turn this over to him.

We are trying to work with Mr. Smith in a cooperative way so

that he can produce this information. I met with him yesterday,

and he has indicated his frustration in the way these information

systems are set up, but CMS not being aware of it is really a barrier to being able to make sure that these services get delivered.

I mean, that is just one of the issues. So I thank my friend. If you

would like to join in, I would appreciate it.

Mr. SHAYS. I would like to ask a few questions. Again, Mr. Chairman, thank you.

When this story came out, I was stunned, frankly, because I had

not heard of how debilitating and then life-threatening the lack of

care of your own teeth could be in your mouth, and I want to ask

was this a really isolated case? I mean, like, was this one out of

a few or does this young man represent tens of children in each

State? So tell me that. And I throw it open to any of you.

Dr. EDELSTEIN. Mr. Shays, it is an excellent question, and it is

something that has not been thoroughly researched. What we do

know—I am currently working with a dental resident who is looking just at greater metropolitan New York City hospital records.

What we have learned so far is that the frequency of head and

neck-associated brain abscesses is really quite a bit higher than

any of us had anticipated. What we are trying to sort out now is

how many of those are related specifically to dental origin.

It turns out that, talking to the neurologists and neurosurgeons,

what was really different about Deamonte Driver is that he succumbed to a brain infection. So it is not the——

Mr. SHAYS. So the answer is that this is something that we are

checking out. So you are not coming back to me and saying, hello,

Mr. Shays, we have 100 of these in each State or something like

that, cases like that. That is not the case right now.

Dr. EDELSTEIN. Well, actually, I think——

Mr. SHAYS. We just don’t know.

Dr. EDELSTEIN. Well, we don’t know. What we do know is that

there are many, many brain infections, airway infections, and

major facial infections.

Mr. SHAYS. And so what is causing that, is it a dental issue?

Dr. EDELSTEIN. That are from teeth, yes.

Mr. SHAYS. Great.

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Dr. Crall.

Dr. CRALL. I was going to say that shortly after Deamonte’s

death, many of us are on a variety of listservs, and certainly in the

dental public health world it lit up over individuals who, over the

years, had accumulated files of similar types of death, and in the

same week a youngster died on a school bus in Mississippi from a

dentally related condition.

Mr. SHAYS. I mean, it is clearly something we should look at, and

that I am not trying to minimize, but what it is saying is, as you

are pointing out, we need statistics and documentation.

I have seen adults with teeth that are rotting, and I realize I

pass judgment like, you have to be a real fool taken care of, but

then I think, I would sooner die than you stick me in an MRI in

a tube, where I am—I would not do it; you would have to knock

me out to get me to do it. So some of the problem, just a phobia

about sitting in a dental chair and that simply people just are

deathly afraid to have that kind of experience. In other words, is

the fear that I have of being claustrophobic, which would keep me

from doing things that could help me, is that the same kind of fear

that somebody has when they have to sit in a dental chair?

You are looking at me, Mr. Smith, like what the hell is he asking. I am not communicating with you. I know adults who are so

afraid to go to the dentist they would sooner let their teeth rot. I

have no sympathy for that. And yet I think, well, you know what,

there are certain things I wouldn’t do because of a phobia I might

have.

Dr. CRALL. I think I would make two responses to that. One is

that, yes, it is true that some adults actually really have a serious

phobia about going to the dentist, but situations like that are much

more common when they have had bad experiences early on, and

that is generally from the not getting care in a timely way. So that

the experience going to the dentist is not the routine experience

that most of us happen to experience. That is why we really try to

emphasize the importance of the ongoing care and the routine care,

because even as unpleasant as some people may feel getting a filling or a restoration is, it really is a substantial issue.

The other is the financial side of things. I used to be at the University of Connecticut. We did a study for NIH that looked at the

reasons for tooth loss in adults, and it was very clear that there

are many, many salvageable teeth, as well as lots of unsalvageable

teeth——

Mr. SHAYS. I do have a few more questions.

With your permission, if I could continue for two or three more

minutes. Is that all right?

Is the threat of bad dental care more severe to a child versus an

adult? In other words, can an adult have bad teeth and not have

them affect him or her the same way as if he were a child? Is the

outcome the same and is it as quick in terms of deterioration?

Dr. EDELSTEIN. It is not as quick in terms of deterioration. The

adage about children is that they get sicker faster, they get better

faster.

Dr. CRALL. But blindness, death, all of those things are consequences that can occur in adults as well as children.

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Mr. SHAYS. The technology has improved. I happen to visit the

dentist more than I would like, so I feel like I am an expert on new

technologies. It is pretty impressive. Is that technology not available as much for a child under Medicaid, given that those who are

poorer may not be able to go to doctors who have the best technology, or is that not an issue?

Dr. EDELSTEIN. I believe that the technology that is available to

children, if they can find their way into a dental office, is equivalent. The problem is getting into the dental office.

Mr. SHAYS. We have community-based health care clinics in our

district that are stunning and serve the whole community. Is that

one way to really start to reach more young people?

Dr. EDELSTEIN. Without question, the safety net is an important

place that needs to be bolstered. If you take a look, though, at the

dental programs in, for example, FQHCs, there are many FQHCs

that have no dental facilities and many dental facilities in FQHCs

that have no dentists.

Mr. SHAYS. Finally, let me just make this point.

Thank you, Mr. Chairman.

Our staff has written some excellent questions that I didn’t

choose to go to because I was so curious about my own, but if they

could extend a few questions that you might be willing to respond

in writing, that would be helpful.

Again, Mr. Chairman, thank you. I am going to get on my way,

but I thank you very much.

Mr. KUCINICH. The Chair would like to associate himself with

your request.

So we would appreciate your cooperation in responding to Mr.

Shays’ questions. And the point that you made, even beyond the

statistics, there is the human factor here about children’s lives

being put at risk, which is why these hearings become very important.

The person who has been one of our partners on this is Mr.

Cummings from Maryland, who is very familiar with this case. I

am going to ask Mr. Cummings to continue this hearing and to

take the chair, and we will proceed shortly.

[Pause.]

Mr. CUMMINGS [presiding]. Thank you very much. I want to

thank you all for being here this evening. Hopefully, we won’t hold

you too much longer.

But I must say that when we held our hearing last May, we invited three major stakeholders to testify before us: Mr. Dennis

Smith, from the Centers for Medicaid and Medicare Studies; Ms.

Susan Tucker, from the Maryland Department of Health and Mental Hygiene; and Dr. Alan Finkelstein, from the United Health

Group. Only one of those individuals sits before us today, and that

is Mr. Smith, and this is not without reason. In the intervening

months since our May hearing in the year since Deamonte’s death,

the State of Maryland has stepped up to the plate in its efforts to

improve children’s access to dental health.

Governor O’Malley, who I was just with a few minutes ago—and

that is the only reason I am late, because we had a delegation

meeting—convened a Dental Action Committee which developed

seven recommendations to better serve our children, including:

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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 2009 budget and he is currently working with

the Dental Action Committee to implement the others, and I certainly applaud him for that.

Similarly, the United Health Group has stepped up to the plate

to do its part. Following our hearing in May, the company 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 education to pediatric and family practice

residents.

The company is now working to develop a similar partnership

with Howard University that will reach across the Maryland border to Deamonte’s hometown in Prince George’s County.

I wish I could say that our Federal partners have been as cooperative as our State and private sector ones have been. Sadly and

painfully, I cannot.

In our May hearing, Mr. Smith, you repeatedly implied that you

had no enforcement tool for ensuring that children get access to

dental care under the Medicaid program. So we sent you a seven

page letter outlining the various steps you could take. To be sure,

you have taken some of these steps, but I am significantly

underwhelmed by your lack of urgency. Our children simply cannot

wait. They can’t wait.

I understand that since our last meeting CMS has completed an

audit of the State of Maryland and is currently planning to audit

15 other States. Notably, the Maryland audit was completed in October, but CMS did not finalize it until February, after the subcommittee informed CMS of our intention to hold this hearing. In

addition, target dates for the other 15 States range from February

11th to April 7th of this year, all after CMS received notice that

this hearing would take place. I find it extremely troubling that

CMS failed to initiate this investigation without pressure from this

subcommittee.

Further, I understand that you, Mr. Smith, met with the chairman and staff yesterday to discuss CMS’s work on this issue and

did not know the answers to even the simplest questions about

what the agency has done. I can’t even begin to tell you what I am

feeling with regard to the job that you are doing. Your own lack

of knowledge illustrates the priority with which you treat this

issue. I certainly hope that you are better prepared to answer questions today.

On that light, can you tell me more about the investigation and

why it did not begin sooner? And then I have a whole series of

questions.

Mr. SMITH. Thank you, Mr. Cummings. I think we began the review in October. That review included issuing a draft to the State

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of Maryland, giving them the opportunity to respond, which we received in mid-December. And we wanted to have their response before we completed the review, which is why, the day after we sent

the review to Maryland, we sent it up to the subcommittee as well.

Mr. CUMMINGS. Mr. Smith, as we understand it—and you correct

me if I am wrong—CMS played a negligible role in Maryland’s reform. In fact, Maryland’s Department of Health and Mental Hygiene wrote a letter to Chairman Kucinich on this matter.

The letter makes it very clear that CMS had nothing to do with

Maryland’s dental reforms. Mr. John Colmers, Maryland’s DHMH

Secretary, explains that he initiated the Dental Action Committee

in June 2007 and that CMS did not even begin its audit in Maryland until October 2007, and only finalized its findings early in

February of this year. And I understand what you just said about

December.

In fact, Mr. Smith, rather than help Maryland enact those reforms, you may have hindered their efforts. Let me explain.

According to your final report on Maryland’s EPSDT program,

with the focus on dental services for children—which I would like

to enter into the record by unanimous consent—Maryland’s DHMH

states that it funds an outreach and care coordination unit in each

local health department to provide outreach and education for the

hard-to-reach non-compliant patients.

However, you informed Maryland that ‘‘This is no longer considered an appropriate Medicaid administrative activity, so Federal

matching funds will no longer be available for these local health

department programs that have been providing assistance since

health choice began 10 years ago.’’ Are you familiar with that?

Mr. SMITH. I am familiar, sir.

Mr. CUMMINGS. Can you explain that to me so I can have a better understanding?

Mr. SMITH. I would be happy to. I think what the State was referring to was an entirely separate regulation on school-based administrative costs. For the State of Maryland to send in employees

of the State to go in and to do outreach, to do enrollment, those

are all reimbursable administrative expenses that the Federal Government would match. The issue of the school-based administrative

claiming guide was due to issues that have dated back a number

of years regarding abuses in the system in schools to where many

different things were being billed to the Medicaid program, including school construction. Again, I certainly am not taking issue with

the importance of school construction, but we don’t believe that is

properly billed to the Medicaid program.

Mr. CUMMINGS. Well, what have you done to help Maryland?

Mr. SMITH. I’m sorry?

Mr. CUMMINGS. What have you done to help Maryland? To me,

it seems like you—well, it appears that there are roadblocks, but

what have you done to help them, Maryland?

Mr. SMITH. Well, I would like to think that our review did help

Maryland in terms of——

Mr. CUMMINGS. How so?

Mr. SMITH. In terms of helping to identify areas that we believed

were weaknesses in the program, that they agreed were weaknesses in the program, and I would like to think that we are workVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00089 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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ing with Maryland as good partners. John Folkemer, who is the Director, used to work in our agency. We have a good relationship

with Maryland. I would like to think that we continue to have a

good relationship.

Mr. CUMMINGS. Now, the things that you came out with, did

those come out after the recommendation of the Dental Action

Committee?

Mr. SMITH. The Dental Action Committee made their report prior

to our review.

Mr. CUMMINGS. And so, what, are you trying to take credit, in

part, for what the Dental Action Committee had already done?

Mr. SMITH. No, sir, I am not trying to take credit for it.

Mr. CUMMINGS. And the reason why I say that is because the

Dental Action Committee, I think, has done an outstanding job.

And I guess what I am getting at is I want to make sure the Federal Government is doing its part to help States. I just left Governor O’Malley, and one of the things that he was saying to us in

the delegation is that he wanted the Federal Government to step

up to the plate not just in this, but in general, to help States accomplish the things that they need to accomplish.

And I am just wondering are there other things that you see that

you might be able to do to help Maryland?

Mr. SMITH. Well, as I said, I hope that our review was helpful

to Maryland.

Mr. CUMMINGS. Anything beyond the review, Mr. Smith?

Mr. SMITH. Specifically, Mr. Cummings, we match State dollars,

so the State puts up its money first, and then we match that. I

think what Maryland did in terms of the review and the Dental Action Committee, they have a good plan. We hope——

Mr. CUMMINGS. Is it one of the better plans that you have seen

throughout the country? Are you familiar with other plans in other

States?

Mr. SMITH. A number of States previously had plans. We are

going out to review 15 States between now and April to look at

what they are doing and, certainly, we share information between

what we see are best practices. We have on our Web site now three

States that we identify as best practices specifically in the dental

area. States have a tendency to learn from each other, to pick up

the information from each other. We have re-instituted the Oral

Technical Assistance Group that we are working with the American Public Health Association. The Medicaid directors work

through APHSA. They had some turnover on their staff, but we are

discussing with them re-instituting the oral health TAG.

We have a number of different things going on with the dental

officers themselves, the medical directors, that we hope will bear

fruit from those discussions. The Association for Community-Affiliated Plans, which are kind of the not-for-profit managed care organizations, we have had discussions with them to help identify,

again, good practices and how to spread that among the different

States.

Mr. CUMMINGS. Do you believe that every child ought to have appropriate dental care?

Mr. SMITH. Yes, Mr. Cummings.

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Mr. CUMMINGS. And do you believe your agency is doing everything in its power to work with the States to make that happen?

Mr. SMITH. I think, Mr. Cummings, that it is a shared responsibility and a shared role. I think that what we have—I think the

focus on dental benefits in particular over the last several months

are very important. We are happy to be a partner of that.

Mr. CUMMINGS. Do you——

Mr. SMITH. If I may, you mentioned the Dental Action Committee report in Maryland, which is a great example, but if the Maryland General Assembly doesn’t fund it, they can’t get Federal dollars if they don’t put up their dollars.

Mr. CUMMINGS. Well, did you encourage States to increase rates

when you redacted the section from the Guide? Remember we had

that discussion about the Guide?

Mr. SMITH. We did have that discussion, Mr. Cummings. Again,

I tried to explain. I thought it simply didn’t belong in to what was

a clinical guide.

Mr. CUMMINGS. So did you encourage the States to increase the

rates? Did you encourage them?

Mr. SMITH. I’m sorry?

Mr. CUMMINGS. Did you encourage the States to increase the

rates?

Mr. SMITH. As I said at the previous hearing, and what we have

said subsequent to that, I think there is a widespread recognition

that reimbursement rates in Medicaid are low and they are behind.

Again, I guess I am struggling a little bit when I have clearly said

I understand that rates are low and I have clearly said that there

are a couple of key areas about gaining access, and reimbursement

is certainly one of those key points.

But the Guide itself, it was my judgment that it just didn’t belong in what I thought was a clinical—I mean, I can understand

the concern if I were saying the opposite and I wanted to take

something out that I didn’t agree with, but I clearly have been saying that reimbursement in Medicaid is low and that is one of the

major barriers to access.

Mr. CUMMINGS. Do you believe that some children ought to be

left behind?

Mr. SMITH. No, sir.

Mr. CUMMINGS. Because you know that is what is happening,

right?

Mr. SMITH. All Medicaid children should be receiving the care

that they get. I believe that we have made progress. I think there

is certainly more progress to be made, and the children on Medicaid should not have any less access than any other child. It is complicated, though, in terms of 38 percent—I believe the percentage

of 38 percent of rural counties in America have no dentist. So I

can’t produce a dentist in a rural county for a Medicaid child if

there is not a dentist for any other child as well. Those types of

things that we find are, again, to overcome those takes a partnership, it takes, again, in many respects, in the Medicaid program it

comes from the States putting up their share of the dollars.

If I may, the Federal Government funds direct grants. Congress

has given money to CDC; Congress has given money to HRSA.

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When you hear about conferences or special initiatives, it is because that is where the money has gone to.

In Medicaid, we don’t have direct grant-making authority for

those types of activities all on our own. We spend money because

the States have spent money.

Now, there have been some exceptions to that. Congress specifically created, for example, the Real Systems Change Grants, helping people to get out of institutions and back into their own homes.

But Congress specifically appropriated that, created that fund and

funded the dollars for it. The Children’s Health Act of 2000, where

Congress again created grants. Unfortunately, funding was never

appropriated for those specific grants. I believe it was $10 million

a year. But those dollars were not appropriated.

So, generally, when Congress has set out funding, they have put

it in the public health service rather than CMS.

Mr. CUMMINGS. Did you have a comment, Dr. Edelstein? I saw

you scribbling.

Dr. EDELSTEIN. A couple of thoughts. One is that the example of

rural access is absolutely true, but an absolutely marginal issue.

Children in areas where other children have ready—children in

Medicaid in other areas where the children not in Medicaid have

ready access to dental care also don’t have access to dental care.

In other words, the majority of places where children do readily access care, Medicaid children cannot. So it is not a question of

whether there are enough dentists out there, period; it is a question of whether there are enough dentists whose offices are open

to the children.

On the issue of CMS taking a leadership role in demonstrations,

I don’t know the internal financing and working of CMS—nor do

I believe I should be expected to—but I do know that it was CMS

that funded the demonstration in North Carolina that proved

through the Into the Mouth of Babes program that you can enjoy

better health outcomes at lower costs. And that was funded entirely by CMS, to the best of my knowledge.

Mr. CUMMINGS. Do you think we can do more of that, Mr. Smith?

Mr. SMITH. Mr. Cummings, if I may——

Mr. CUMMINGS. First of all, do you know if it was funded by you

all?

Mr. SMITH. We funded it for 2 years. HRSA picked it up and they

are funding it. So, again, we see it as a partnership with other

partners that are involved.

Mr. CUMMINGS. And that money comes out of a certain pot? How

does that work?

Mr. SMITH. I don’t know what they are using.

Mr. CUMMINGS. Dr. Crall, did you have a comment?

Dr. CRALL. I believe CMS has funded demonstrations on a variety of issues, continues to fund demonstrations on a variety of

issues, which I think would be very helpful in this case, as well as

evaluation dollars, other types of things that could really identify

key elements and programs that are working, elements and programs that are working better in some States than in others.

Mr. CUMMINGS. I look at this agreement that we were able to

work out in Maryland with United. I mean, it is not a lot of money,

it really isn’t, $170,000. I mean, that is not a lot of money, but you

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are able to do a whole lot with it. I kind of think that we just need

to have not only the will to do these things, but we have to make

them happen.

When I see that little boy’s face, I am just reminded of the way,

Mr. Smith, that we get reports constantly from the University of

Maryland that they are working with these young people, and they

tell us that there are more and more kids that are just shy of

where Deamonte was before he got real sick, in other words, that

they are coming in to the dental chair and they have infections,

some of them, and the infection goes to the eye, as I understand

it, and it has not gotten to other organs.

But the fact is that these children are in trouble. And, fortunately, a lot of them are caught before that time, but this is America, this is the United States, and I think we can do better.

And I think that one of the things that has concerned me overall—and it is just not in this area, but generally—is that I think

we are operating in a culture of mediocrity, where we kind of allow

people to fall to the wayside as if it is OK. But it is not OK, because if it were your child, I am sure that you would do everything

in your power to make sure that child had the kind of care that

child needs. I just think that we could probably be a little bit more

innovative and do a little bit more so that we can touch these children before they leave us.

Before I get to Ms. Watson, one of the things that I am always

thinking about is how we, as adults, have a responsibility to our

children to make sure that they are OK, and I just think we can

do more. I just really do. And I think that if we cannot do more,

then we don’t need to be in the jobs that we are in. We really don’t.

We need to go and do something else, and let somebody else come

in who can do those jobs so that we don’t leave children behind

with infections going to their eye sockets. I mean, this is not some

Third World country, and you are the man, you know?

Mr. SMITH. Mr. Cummings, if I may, I provided in my opening

statement——

Mr. CUMMINGS. I am sorry I missed it. I am sure it was spellbinding.

Mr. SMITH. Medicaid will spend $2,900 per child for a full year.

And, again, the general impression kids are healthy, they don’t cost

much because they are healthy, I think that is generally true, but

Medicaid will be spending $2,900. I mean, I agree with you passionately, why aren’t we getting better value for the investment

that we are making and the dollars that we are spending? And I

think the health care spending in general—and Medicaid is going

to be similar to what else is going on—but health care spending is

driven by under-utilization and over-utilization, and to get them

right is the optimum dollars. I mean, we do talk a great deal about

the cost of health care in the United States, about how much we

spend more than any other country.

Mr. CUMMINGS. Let me go to Ms. Watson. My time has been up.

And then we will come back to revisit this.

Ms. Watson.

Ms. WATSON. Thank you so much. I must apologize for going out.

While Representative Kucinich was here, I know that he was hopVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00093 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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ing that I would raise some of the issues that he would like to

raise.

If I am repeating the questions that have already been asked,

would you stop me, please?

I am going to address Mr. Smith, because I know that you are

aware of the Omnibus Budget Reconciliation Act of 1989, and it

significantly revised the EPSDT benefits as enumerated in the Social Security action with regard to dental care, the OBRA exempted

dental services from requirements of the general health screening

services, and created a separate regulatory scheme for them.

Among other changes, the OBRA mandated that each State develop its own periodicity schedule for dental services and examinations, and I know you are aware of that. Regulations outlining the

OBRA amendments were never promulgated. Instead, the then existing HCFA wrote Part 5 of the State Medical Manual, which is

only guidance and does not have the force of regulation. So, today,

Federal law is contradictory, because whereas the statute requires

that each State must develop a periodicity schedule, existing regulations say that dental schedules will be federally set and dental

referrals must be made by a physician at the age of 3. That is for

a child.

So this is rather confusing, Mr. Smith, and does not make clear

what the law is. So my question is, to you, how many States have

developed a specific dental periodicity schedule in consultation with

the dental professional organizations, are you aware?

Mr. SMITH. Ms. Watson, we do expect every State to have their

periodicity tables. That is one of the things that we will be checking on our review to make certain that they have the periodicity

tables.

Ms. WATSON. As I understand, there are only two States that

have such schedules. Is that true?

Mr. SMITH. I don’t think that—we would have to check. That

doesn’t sound——

Ms. WATSON. Well, if my information is true, that means that 48

States have not complied with Federal law, and this may be in part

the results of lack of clarity on the CMS plans. And I would like

you to look into it so you can get back to us. I think we are seeing

the results of States not having these plans, and my colleague

would agree, because—did Deamonte live in your district?

Mr. CUMMINGS. No, he didn’t, but, Congresswoman Watson,

Maryland is a small State, so I guess he would be about 40 minutes away from me. He was more like in Wynn’s district, closer to

Washington.

Ms. WATSON. So it is very important to us—and one of the reasons why we are having this hearing—to explain, because it is a

contradiction and we need to see that all States have such plans.

Mr. SMITH. I agree, Ms. Watson. If I may expand a little bit. The

law itself under EPSDT makes it clear that a Medicaid child does

have the benefit of preventive care, restorative care, etc. So, in

many respects, whether the State—the current periodicity table

is—the child, if they need care, is entitled to that benefit regardless

of whether the State ever did a periodicity table.

Ms. WATSON. Well, maybe we should clarify that.

Dr. Crall.

91

Dr. CRALL. Yes, Ms. Watson. In my opinion, the real value of periodicity schedules are that they not only deal with the broad

rights of the child under a program, but they are definitive in

terms of accommodating professional guidelines about when children should receive certain types of services and what services they

should receive on an ongoing basis. Those are incredibly important

for States translating that information into coverage decisions and

also just sending the message about the need for early care and ongoing care for children, and periodicity schedules do that. And they

do not exist in——

Ms. WATSON. You are from UCLA, aren’t you?

Dr. CRALL. Yes, ma’am.

Ms. WATSON. That is my alma mater. I was in California in the

State senate and I chaired the Health and Human Services Committee for 17 years. I have been away from there since 1998. Do

the math. Ten years. And one of the things I did was to be sure

that every patient walking into a dental office would be aware of

amalgams. Do you know they did not do that? I had to hold hearings here. I have been away a long time. I came here in 2001. And

we had to have hearings to force some leadership.

So what I would like to say, Mr. Smith, is that we need leadership. We need you to stay on these States, the 48. I will give that

two States have promulgated the—and really understand what the

mandate is. For your leadership to be effective, you need to see

that they follow through. We can’t have another death like we experienced with Deamonte. That is a shame on all of us. So I wish

you would followup with that.

Will you be doing anything to come up with new regulations in

accordance with OBRA?

Mr. SMITH. OBRA 1989?

Ms. WATSON. Yes.

Mr. SMITH. At this time, we don’t have plans to do further regulations on OBRA 1989. Again, one of the things that we are doing

in the review of the 15 States that we started this week and will

be doing through April, I think that we have a number of different

areas that we are looking at from support and coordination, beneficiary information, that sort of thing. So I think what we are—the

strategy that we are really using is to be able to do those reviews

and, as Maryland responded through the Dental Action Committee,

where deficiencies were acknowledge and owned up to and the

State came up with a plan to make those improvements, I believe

we will see those same types of strategies take place.

Ms. WATSON. I see that Dr. Edelstein might want to add to this

discussion.

Dr. EDELSTEIN. Ms. Watson, if I could. I would like to relate the

tremendous importance of OBRA 1989, which, as you note, was

never acted upon. Eighteen years now. I would like to relate that

to prevention, because the real answer to improving children’s

health—not just whether or not they get a dental visit, but whether

they are healthier than they are now—relies on prevention and disease management.

In those 18 years, the professional guidance on the appropriate

age to start dental services has changed. With the recognition that

tooth decay is an infectious disease that is established before age

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2, periodicity schedules that call for starting at age 3 are, on the

face of it, inappropriate. You can’t start doing preventive services

the year after a child acquires a disease.

So the importance of OBRA 1989 enactment—and now the regulations that need to follow from that—is that a clear message

would be sent to the medical community, to the dental community

that Medicaid is up to speed with what the science says about the

importance of starting early. And having a periodicity schedule

that calls for anything less than age 3 should be rejected by CMS

based on the science.

Thank you.

Ms. WATSON. Mr. Sherman, I am just reminded of the hearings

that you participated in with such leadership yesterday, when we

were looking at the use of these enhancing drugs and steroids and

so on, and what I saw as the purpose was to send a message out

to young people, because we are involved with wellness. Dr. Smith,

if we would keep people well, then the cost of Medicaid and Medicare would start to diminish. And, you see, America has to start

looking at wellness, how to prevent illness, kind of like the Chinese

system, where they pay the doctors to keep their patients well; and

when they become ill, they must provide the health care free. We

work the other way around and we pay the medical professionals

big bucks after a person becomes acutely ill.

So we have to change our way of thinking. I am going to ask you,

Mr. Smith, if you will look at at least checking to see what happened to those other 48 States that have not promulgated the regulations and get back to this committee in writing.

Mr. SMITH. We will do that, Ms. Watson.

Ms. WATSON. Please.

Mr. SMITH. Again, that is specifically a part of our protocol as we

go out to the 15 States.

Ms. WATSON. Good. And I did hear you say the cost, and it is our

responsibility, and we are dealing with a budget proposal for 2009,

and one of the things I want to see, Mr. Chairman, is that we really look at Medicaid, Medicare and how we then start to put the dollars in, because we talk about homeland security. It is not about

the land, it is about the people on the land, and we have to start

with our young people and keep them healthy.

So thank you so much, and I want to thank the witnesses for

being here. And thank you, Mr. Chairman, for giving me all this

time.

Mr. CUMMINGS. Thank you very much, Ms. Watson. I just want

to pick up where you left off.

To you, Mr. Smith, in looking over the fiscal year 2009 budget,

I was surprised to see there are no increases for dental care, and

I am trying to figure out why not additional funds, particularly

when we know that there is such a tremendous need, Mr. Smith.

Mr. SMITH. Mr. Chairman, there will be an increase in funding

as the services show up in the service categories. So it is all put

together into medical assistance, it is not broken out separately.

But Medicaid spending on dental care continues to increase every

year.

Mr. CUMMINGS. OK. And how much did it increase over the last

2 years?

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Mr. SMITH. I don’t know offhand, Mr. Cummings, but we can provide that.

Mr. CUMMINGS. Can you get that to me?

Mr. SMITH. There is—the spending would be both on the fee-forservice side and the managed care side. On the fee-for-service side,

that shows up because of their individual claims are submitted, but

under a risk-based managed care it wouldn’t show up because it

would have been built into the rate that was paid to the managed

care. So what we would provide would only be on the fee-for-service

side, it would not include the managed care side.

Mr. CUMMINGS. Dr. Crall, in your testimony you talked about the

importance of reimbursement rates to improving children’s access

to dental care. I want to turn our conversation to the State of Georgia. In your testimony, you have a table that shows that reimbursement in the State was raised to the seventy-fifth percentile and

dentist participation went up. Is that correct?

Dr. CRALL. That is correct, Mr. Cummings.

Mr. CUMMINGS. So it went up about five, five and a half times,

is that right?

Dr. CRALL. Yes.

Mr. CUMMINGS. But that is not the end of the story. Then we had

the folks trying to pull out, is that right? Can you explain that,

what happened, what you think happened?

Dr. CRALL. I will explain it to the extent that I am aware of the

situation.

Mr. CUMMINGS. And then, Mr. Smith, you can tell us what you

did about this.

Dr. CRALL. My understanding is that Georgia was using a global

managed care arrangement and, therefore, payments were going to

managed care organizations, who then would subcontract with

other organizations to provide the dental services. And decisions

were made to actually curtail and to reduce a number of significant

providers of dental services within Georgia. I presume that was related to budgetary considerations, but that is typical of what often

happens in a State where the significant changes are made in the

rate structure.

The first thing that is going to happen is that the expenditures

are going to go up. And if someone doesn’t prioritize dental services

and have a commitment to maintaining the effectiveness in increasing utilization that ensues because of those increases, what

typically happens in States is they go through and they will cut

dental expenditures along with many other programs. And dentists

are aware of that situation and are very reluctant to join in to

Medicaid because they get whipsawed around on this payment approach.

Now, we realize that many State budgets are under a fair

amount of strain, but there are examples of other States—South

Carolina and most recently in Texas and even in Connecticut—

where they have recognized that the importance of giving their

Medicaid rates into the market for dental services and have found

ways to at least ensure that a solid core of limited—and not too

limited, but a core of somewhere between the range typically goes

from 45 to 80 procedures at least that cover basic dental services

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that children need to take care of their disease are at a level that

dentists will find to be acceptable.

So what happened in Georgia is typical of what has occasionally

happened in other States, that the changes made, the increase in

utilization ensues, expenditures go up, but then, all of a sudden,

the rug is pulled out from under the program and that sends a very

poor signal to other providers in the State about participating in

Medicaid.

Mr. CUMMINGS. Do you want to comment on that, Dr. Edelstein?

Dr. EDELSTEIN. I would only add that Georgia is a particularly

good example of how inappropriate contracting practices led to a

squeeze on profits for for-profit Medicaid providers such that their

only solution to protect their profits was to undo the very success

that the program was intended to produce. The program is intended to produce care for children.

Mr. CUMMINGS. Right.

Dr. EDELSTEIN. In doing that, it costs too much for not the State,

but the managed care company that was caught in the squeeze.

Mr. CUMMINGS. Right.

Dr. EDELSTEIN. They, therefore, cut services; the exact opposite

of what the program is for.

Now, my question, and what I added in my testimony, was where

was CMS at that time.

Mr. CUMMINGS. Yes. That is a good question.

Mr. SMITH. Mr. Cummings——

Mr. CUMMINGS. Well, I want you to know I was going to ask that

question, but Dr. Edelstein beat me to the punch.

Mr. SMITH. In terms of Georgia specific, I would have to go back

and find out the specifics on Georgia. In general, I know a couple

of things have happened in Georgia. Georgia did switch to managed

care, they switched into their S-CHIP program as well, and, as a

result, Georgia expenditures have increased substantially.

Part of the reason why Georgia went to managed care was a

loophole in the law that allowed managed care entities to pay a

provider tax that, in essence, was paying the funding of the State

appropriations. So the underlying finance of the Medicaid program

created an incentive for Georgia to adopt almost a self-financing

model, things like that which we have been trying to close off.

In managed care, though, in general,—and certainly my colleagues here can talk more sort inside the association than I can—

dentists tend not to like managed care, regardless of it is in Medicaid or not. So Medicaid, yes, there is a piece of it there, but there

is also something bigger than just Medicaid in terms of those relationships.

Mr. CUMMINGS. Yes, Dr. Crall.

Dr. CRALL. I certainly agree with the statement about dentists’

hesitation about getting involved in managed care arrangements.

Some of that stems from the fact that in the world of Medicaid dental services there have been managed care rates as low as $2 to

$3 per child per month to provide care for Medicaid beneficiaries.

No self-professionally respecting dentist would enter into any such

arrangement. The only way that kind of an arrangement can work

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lect payments for each child, but collectively allow them to work on

the few children that you treat.

So I think that while that is very true, I think that it also highlights the fact that when States learn about that and when they

come to understand the way the systems work and the way the

providers work, that has led many States to go to carve-outs from

these managed care arrangements, to take their dental programs

out of these global managed care arrangements and to deal with

that particular issue.

And, in fact, it also reminds me of comments I made in my testimony about the series of policy academies that the National Governors Association initiated in the late 1990’s. That gave us a great

opportunity—and there was strong demand from the States; over

30 States applied for those. But it gave us the opportunity to really

spend some time with some State officials to help them understand

the fundamental issues, and I would say that every State that is

on that list that I provided of States that made substantial changes

and where we saw the increases in dentist participation and utilization, those States were States that participated in those processes. So anything that can be done to make it a priority within

the, State to get the State officials involved, strong leadership

State officials involved, and to work with Federal partners to make

that happen, I think we have a truncated track record of where

that process can work.

Mr. SMITH. And, Mr. Cummings, if I may, we have had discussion with the Medicaid directors in terms of their managed care

plans overall. We do believe that States need greater expertise in

developing their managed care contracts, etc. Again, you often find

you have a policy. The policy is just fine, but if you can’t

operationalize it correctly, then you have other problems. We did

managed care in Virginia, and on the medical side, at the very

least, managed care was very good for Medicaid beneficiaries in

terms of the great increase in access, especially to specialists. That

was lacking in the fee-for-service world.

So I don’t want to just—managed care has a place. It needs to

be done correctly and States need the expertise to be able to do

good bids, to make certain there are actuarially sound rates. If

those rates are actuarially sound, if they are built off solid data,

if they are built off service utilization, then those should be good

rates. But if you don’t have that component, then you are going to

end up with rates, and then your networks are going to fall apart.

Mr. CUMMINGS. All right, Ms. Watson.

Ms. WATSON. Thank you, Mr. Chairman.

We understand that CMS is preparing to re-institute the TAGs,

and these are the technical advisory groups, the Oral Health Technical Advisory Groups. Is that so?

Mr. SMITH. Yes. We already have a number of TAGs, and we are

in discussions with the Medicaid Directors Association. They need

to be able to support it from their side. We have told the Medicaid

directors we would like——

Ms. WATSON. So there is no guaranteed funding for them.

Mr. SMITH. We have contracts with APHSA currently. We probably have to add a little bit more to that, but we have expressed

an interest and willingness on our end to do so. And they have exVerDate 11-MAY-2000 12:21 Jun 11, 2009 Jkt 000000 PO 00000 Frm 00099 Fmt 6633 Sfmt 6633 U:\DOCS\49775.TXT KATIE PsN: KATIE
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pressed a willingness also. They have had a transition and turnover in their staff.

Ms. WATSON. I see. But you do see a way to fund these TAGs

through some kind of arrangement?

Mr. SMITH. The oral health TAG?

Ms. WATSON. Yes.

Mr. SMITH. That is our intent, to re-institute the TAG.

Ms. WATSON. And I understand in the 1990’s and in 2000 that

the oral health TAG was convene to respond to questions from the

States and from providers, but, to our knowledge, the findings have

never been released. Can you comment why the findings that came

out of the TAGs have not been released?

Mr. SMITH. I am not certain of what happened in the 1990’s. The

TAGs——

Ms. WATSON. In 1999, 2000.

Mr. SMITH. The TAGs themselves are a way to raise issues and

they are a kind of ongoing discussions. I don’t know that the TAGs

themselves produced specific documents that would be public.

Ms. WATSON. Well, I would say that there should be an accounting of those discussions so that we could then fix the oral health

system where there are failures, and that is another thing I would

like you to look into for our knowledge, what yet needs to be done.

Those TAGs were set up to have that two-way dialog, and I would

hope that there would be some reporting as to what was found,

what was learned, what we need to address. And if you could go

back into the records, it would be very helpful to us.

Mr. SMITH. I would be happy. Again, we have 10 or 11 or 12

TAGs already.

Ms. WATSON. Yes, but what happened back when they were put

together in the end of the 1990’s?

Mr. SMITH. But in terms of the format, I don’t know that they

produced minutes, even. I would have to go back and find out.

Ms. WATSON. Dr. Edelstein, can you enlighten us on this?

Dr. EDELSTEIN. I would be happy to. I was privileged to serve as

a technical advisor to the oral health TAG when it was formulated

in 1999. The express purpose of the TAG at that time was to collect

questions from the States regarding technical issues in the administration of Medicaid dental programs and, therefore, to share the

responses of the experts back to the States. The first part happened; the second part never did.

Ms. WATSON. All right. So there is a collection, wouldn’t you say?

Dr. EDELSTEIN. There is a document——

Ms. WATSON. A document.

Dr. EDELSTEIN [continuing]. That has each of the questions

raised by the States and the answers responded to by the TAG.

Ms. WATSON. What was the title? What was the document title,

do you remember? It would be TAG something.

Dr. EDELSTEIN. It is the report of the oral health TAG.

Ms. WATSON. OK.

Dr. EDELSTEIN. And Dr. Crall was also involved.

Ms. WATSON. Dr. Crall.

Dr. CRALL. Yes. The questions and the answers from that TAG

can be found in Appendix D, I believe, of the material that the

American Academy of Pediatric Dentistry submitted to CMS as

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part of the dental guide. If it was not seen fit to publish that material in that form, I wholeheartedly concur with you that information does need to be made in some sort of public, ongoing basis—

internet, CMS internet site, wherever.

Of course, as regulations change over time, the answers to those

questions need to be adapted to reflect current policy, and I would

really encourage CMS to make that an ongoing dynamic set of information that someone could go to and know the questions won’t

change that much. It is the answers that change as regulations and

program changes. But the questions are the fundamental questions

that people administering these programs in the State need to

know to be able to operate their programs consistent with current

policy.

Ms. WATSON. Through the Chair, I would ask Mr. Smith—and I

am sure you have staff sitting behind you—if you could find that

report. Good, you have already made—and I am going to ask my

staff to make a note so I can raise this question in the full committee, Mr. Chairman, because I think that it would be very, very

helpful to dentistry and to the practitioners and to us, as we plan

ahead and as we budget, to know what the dialog, what the questions were, what the input was, what the assessment of all that

was, from the TAG. And this is the reason why it was set up, so

we will know what the dentists and I guess the patients, too—there

will be some reference to patients, as well.

And if you could find that document and share it with us. And

I think that needs to go out publicly, and we need to show that we

are working to improve dental services to Americans, particularly

to our children. So we want to know just what comes out of those

advisory groups and how we can move forward with this.

So if it can be relayed to the subcommittee Chair, Mr. Chairman.

Mr. CUMMINGS. I have it. We will take care of that. I promise

you.

Ms. WATSON. OK, good. Thank you so much.

Mr. CUMMINGS. I am just going to take two more minutes. First

of all, I want to thank you all for your patience. I know you all

have had a long day.

I have a request of you, Mr. Smith. We are concerned about

Georgia and its recent cut in reimbursement rates. We want to find

out if they are in violation of Federal law. Can you find that out

for us?

Mr. SMITH. We will, Mr. Cummings.

Mr. CUMMINGS. What would be the procedure for accomplishing

that?

Mr. SMITH. We will have to go back to see. If Georgia is not on

our list, we will put them on our list and find out what happened.

Mr. CUMMINGS. So you have a list of States that you are trying

to determine whether or not they are in violation of Federal law,

is that what you are trying to tell me?

Mr. SMITH. We have a list of the 15 States to which we are starting to do our reviews.

Mr. CUMMINGS. Are you questioning whether or not they violated

Federal law?

Mr. SMITH. I think that we would make that assessment based

on the review.

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Mr. CUMMINGS. OK. I just didn’t know whether that was one of

the reasons why you were looking at the 15 States. Do you follow

what I am saying?

Mr. SMITH. I think there are seven different areas that we are

looking at in the protocol.

Mr. CUMMINGS. OK. All right. The other thing I guess that I am

concerned about, I just want to make sure that we are doing all

that we can. You send all these guidelines out and you make all

these requests of the various States, telling them what they can’t

do. I guess what I am hoping is that you will do more of telling

them what they can do so that they can help kids. But it just

seems to me like that is so much that is done to try to put the limitations on, but at the same time there doesn’t seem to be a lot done

to push them along to get them to do more. You follow me? And

I know you may disagree with that. Talk to me.

Mr. SMITH. I think, again, as I said, we are spending $2,900 per

child, and if we are not communicating the value that we are getting for that in the Medicaid program, or if we are not doing an

adequate job communicating what we think that, as we have laid

out in our testimony and our strategy, we do believe that those will

lead to increased quality and increased access. Clearly, the conclusions of the reports for the individual States we will certainly share

with the subcommittee. We believe that we are pursuing strategies

that involve multiple partners—not just the States, but the associations as well—and we believe that will be a successful strategy.

Mr. CUMMINGS. It is interesting that you cut guidance on how to

oversee MCOs from the Guide. Are you familiar with that? Do you

know that?

Mr. SMITH. Going back to the dental guide discussion we had,

yes.

Mr. CUMMINGS. Yes. Because you had these philosophies about

what shouldn’t be in the Guide and what should be in the Guide,

and I guess what I am trying to say is that some kind of way, Mr.

Smith—and I say this with all the humility I can muster—I just

think you could do a better job. I really do. And it pains me to even

say that. But you are the person who has been put in a certain

place at a certain time, and that position is to take care of a lot

of human beings who may not have even been conceived six or 7

years ago.

Let me finish.

And I guess, I tell my staff that we are all given certain positions

at certain points in our lives, and we are put there specifically to

carry out a task and be effective and efficient. And if we can’t do

it, for whatever reason,—and I say this over and over again—do

something else. Go play golf. Do something. But let somebody else

come in there who will make a difference.

Because I don’t want anymore Deamontes. And I say that. They

live in my neighborhood. There are little Deamontes and little

Chantes walking around in my neighborhood right now. When you

go and eat dinner and celebrate Valentine’s Day with your wife,

they are going to be still in vulnerable positions tonight.

So I just think that we, as a country, can do better, and your organization has certain responsibilities. And Dr. Crall and Dr.

Edelstein, I know, just listening to them, they have—I can hear

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it—a level of frustration, and I guess it is very frustrating to me,

because I just think that this is our watch. This is our adult watch.

So I am going to end there. Did you have anything else, Ms. Watson?

Ms. WATSON. No.

Mr. CUMMINGS. All right, thank you all very much. Unless you

all wanted to say something else. I apologize. Did you have something else you wanted to say, Dr. Crall?

Dr. CRALL. Well, I would just close in saying that of the $2,900

per child that is being spent, there are three actuarial studies that

I am aware of that could send a signal to the States about the

amount of resources that they ought to be putting into their dental

programs. And I think that anything along those lines, as well as

the periodicity schedules, that would send a clear message about

exactly the types of services that children are supposed to receive

and when they should receive that, those kind of signals need to

be out there on an ongoing basis to emphasize this. And I couldn’t

agree with you more, we don’t need anymore Deamontes.

Mr. CUMMINGS. If there are things, by the way, that you all feel

that we need to be doing, you can get them to us in writing. We,

hopefully—well, not hopefully. Next year there will be a new administration, and we may have to start there to try to get the new

administration to begin to push on these things so that we can get

some things done. But we welcome your advice because you all

have dedicated your lives to touching these young people and you

are where the rubber meets the road—you are there—and you do

it everyday, so we want that information. So any recommendations

that you would have for us, please pass them on, please.

Dr. Edelstein.

Dr. EDELSTEIN. I only wish to say that it is nearing the first anniversary of Deamonte Driver’s death, and I wanted to recognize,

on behalf of all the children who you and others are helping, how

much you have not let down one moment in this year to highlight

the importance of children’s oral health, and we are anxious, all of

us are anxious to work with you to continue to help to provide the

technical information that will make it possible for you to do that.

Thank you.

Mr. CUMMINGS. Again, as you have heard me say, Dr. Edelstein,

when I was growing up, we expected to have cavities in our

mouths. Low expectations. But a lot of our parents didn’t know any

better. But this is 2008 and we can do better as a Nation. We can

do better.

Thank you, Ms. Watson. I know you had a long flight.

Thank you all. Happy Valentine’s Day.

[Whereupon, at 5:55 p.m., the subcommittee was adjourned.]

[The prepared statement of Hon. Elijah E. Cummings and additional information submitted for the hearing record follow:]

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