Are Improvements to the MassHealth Dental Program Increasing Access to Care?

Many poor and disabled citizens of Massachusetts are eligible for dental services from dentists who are paid by MassHealth. Unfortunately, there are not enough dentists under contract with MassHealth to provide care to all of the insured. A federal court decision in the law suit, Health Care For All et al versus Mitt Romney et al (HCFA v. Mitt Romney), is forcing the Commonwealth of Massachusetts change. Are these changes attracting enough dentists to become providers for MassHealth? What does organized dentistry think of the changes? Two years after HCFA v. Mitt Romney, court ordered changes are in place, are MassHealth recipients finding it easier to obtain care?

MassHealth is how Massachusetts brands their Medicaid program. The federal Department of Health and Human Services (HHS) published an overview of Medicaid on their web site, www.HHS.gov:

Title XIX of the Social Security Act is a Federal/State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. This program, known as Medicaid, became law in 1965 as a cooperative venture jointly funded by the Federal and State governments (including the District of Columbia and the Territories) to assist States in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America's poorest people.

The federal government mandates health coverage of select groups, such as children living in poverty, and each state tailors their Medicaid program to work best for its own citizens. Medicaid evolves depending on need, regulation, and resources.

HCFA v. Mitt Romney began in April 2000, as an effort to provide access to dental care for covered children. The HCFA web site (www.hcfama.org) follows the lawsuit from the beginning:

In April 2000, Health Law Advocates filed a class action lawsuit in federal court on behalf of Health Care For All and several MassHealth families. The case, Health Care For All v. Romney, charged that state officials were in violation of federal law because they had failed to ensure access to dental care for MassHealth members.

Two fast facts:

• While there are approximately 5,000 practicing dentists in Massachusetts, less than 12% actively participate in the MassHealth program.
• Of the approximate 500,000 children enrolled in MassHealth, less than 1/3 received any kind of dental care in the last year.

  (HCFA v. Romney - Fighting for MassHealth Dental Care, http://www.hcfama.org/index.cfm?fuseaction=Page.viewPage&pageID=405)

On July 14, 2005, US District Court Judge Judge Rya Zobel issues her decision in favor of HCFA.

As stated above, in April 2000, less than 600 dentists are providers for the MassHealth Dental Program. According to the Massachusetts Oral Health Report of 2006, that number rises to about 900. Doral, a subsidiary of DentaQuest, which is a for profit subsidiary of Dental Service of Massachusetts (AKA Delta Dental of Massachusetts, which is a non-profit organization), administrates MassHealth since February 2007. Doral is responsible to market MassHealth to potential providers, recruit and certify those providers, process claims, and provide information and support services to both providers and the insured. On that day, there are about 1000 providers.

Dr. Michael Monopoli, Director, Public Health Policy of Dental Service of Massachusetts (Delta Dental of Massachusetts) reports that 200 more dentists have signed up with MassHealth since February. "I think that this represents a steady increase and is probably a combination of the work that the [Massachusetts Dental Society (MDS)] has done to encourage new providers and improvements that have been made to the system with Doral."

The Massachusetts Dental Society has thrown the weight of their endorsement behind MassHealth participation. On May 11, 2007, the MDS officially approved a resolution encouraging all of its over 4000 members to enroll in the MassHealth program.

The improvements that are responsible for attracting new providers are thorough, beginning with the application process. Recently, the author applied to become a provider for MassHealth. The author was required to prove to the Commonwealth of Massachusetts that his dental practice is a legal entity by submitting his most recent federal tax return and filling out a lengthy application. Dr. Timothy Martinez, Dental Director of MassHealth, said in a phone interview on November 8, 2007, "As of yesterday, no tax documents are required." Dr. Martinez cited significant improvements that streamlines the application process shortening the time it takes to bring a new provider.

Dr. Martinez' position was created in the aftermath of HCFA v. Romney. The position of Dental Director, and the MassHealth Dental Advisory Committee, a group of dentist-advisors to the MassHealth program are requirements of the court decision. Additionally, Judge Zobel appointed Dr. Catherine Hayes, D.M.D., Dr.Med.Sc., Professor and Chair of the Department of Public Health and Community Service at the Tufts University School of Dental Medicine, as Independent Remediation Monitor. Dr. Hayes monitors the progress of the changes in the MassHealth program and offers recommendations of her own based on her observations.

In the semi-annual "Plaintiff's Progress Report on Implementation of Judgment" of February 28, 2007, HCFA decries delays of the previous months in implementation of the third party administration by Doral and other improvements. The document enumerates a myriad of recommendations that would simplify and widen the scope of MassHealth coverage. Recommendations of the advisory committee include allowing dentists to provide various treatments without the delay of waiting for approval, allowing non-dental health care providers such as physicians to provide dental exams and fluoride treatments to young patients and increasing reimbursement rates to attract more providers.

The state appears to be complying with the letter and the intent of HCFA v. Mitt Romney. The comments of Dr.s Martinez and Monopoli are eager and hopeful. The MDS is supportive of increasing enrollment. Dentists who participate in MassHealth are generally satisfied with the improvements in the system. Most significant is the right of dentists to limit the number of MassHealth insured that they care for. Previously, the Commonwealth required dentists to take any MassHealth insured that requested service or none. Are the increasing numbers of providers increasing access to care?

Dr. Hayes is not satisfied. "As of today we are not seeing an improvement in access to care for MassHealth children (under age 21). Although we have seen the increase in number of providers by 15% as you mentioned, we need to have many more providers sign on. Currently there are 469,000 children enrolled in the MassHealth program. With slightly more than 1000 providers we are unable to meet the needs of these children." Dr. Hayes indicates that were 4500 dentists to enroll with MassHealth, that to ensure 100% coverage, each of those dentists would have to accept 94 children.

Unfortunately, this target may be unrealistic for two reasons. First, of the 5000 dentists practicing in Massachusetts, many do not treat children. Of the dentists who do treat children, many will not accept any form of insurance. Some of these dentists provide unreported pro bono treatment for people in their communities.

Second, many parents will not take their children to dentists. Even when parents have insurance coverage for their children, they do not always take advantage. MassHealth, medical and dental providers, educators, and the Department of Social Services must provide education and support services to encourage utilization.

Two exciting programs that are under study for early implementation are the use of schools and physicians to provide dental care and education. School presents a welcome opportunity for health education for parents and children. In some cases, examinations, preventive treatment, and referral to dentists as exemplified by the Smart Smiles program in the Boston school system and the partnership of Boston University and the Chelsea Dental Program.

A recommendation by the MassHealth Dental Advisory Committee to initiate medical professionals as dental health care providers and educators is in its infancy. The response of young physicians to this new responsibility is encouraging. Describing a recent lecture on pediatric dentistry presented to the Tufts Family Practice residents at Cambridge Health Alliance's Malden location, Dr. Timothy Stephens, Academic Chief Resident, wrote, "We already are starting to talk about plans to include the idea of a dental referral as part of our electronic documentation of the well-child visits to increase our screening rates. This is a much needed area of our training as primary care physicians..."

How can the public help to shape the future of the MassHealth dental program? Dr. Hayes suggests that citizens, "...call legislators to let them know how important oral health is to overall health and that poor children need to have access to high quality dental care. Thus the MassHealth program may need more money to continue to increase the reimbursement rates paid to providers."