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Michigan Medicaid Addresses Social Determinants of Oral Health through Dental and Medical Contracts
Inequities in dental care are prevalent across the United States, with significant disparities based on age, race, ethnicity, and socioeconomic status. Economic factors, such as ability to pay for dental insurance, and social factors such as food insecurity and access to nutritious food options also play a large role in oral health outcomes.
In Michigan, state Medicaid medical and dental managed care contracts now include requirements to address social determinants of health (SDOH) among enrollees. Examples of these requirements include:
- Incorporating oral health into community health workers’ training curriculum;
- Collaborating with community-based organizations (CBOs);
- Collecting data on enrollees’ SDOH and using it to target outreach and educational activities; and
- Implementing quality assurance and improvement projects that promote equitable access to oral health care.
Michigan’s Medicaid medical and dental managed care contracts demonstrate a proactive approach to identifying and addressing SDOH among Medicaid enrollees. While budget shortages resulting from the COVID-19 pandemic may make it more difficult for states to take on additional initiatives, addressing SDOH in Medicaid contracts can decrease costs and improve oral health outcomes. States that want to encourage dental plans to take on a larger role in promoting equitable access to care and addressing SDOH could adopt initiatives similar to Michigan’s.
These types of Medicaid contractual requirements are important first steps in improving SDOH among enrollees, while strengthening monitoring and enforcement requirements are also critical tools when adequate funding and personnel are available.
Why Focus on Oral Health and SDOH?
SDOH are the conditions in the places where individuals live, learn, and work that may affect their health risks and outcomes. They include factors such as food access, housing stability, educational attainment, poverty, health literacy, and transportation, among others. Social determinants dictate an individual’s access to health care and quality of care, which directly affect physical and oral health and exacerbate health disparities. For example:
- Low-income children are twice as likely to have dental caries (tooth decay) than children from higher-income homes; and
- Individuals who are poor or have less than a high school education have edentulism (toothlessness) at a rate three-times higher than those with higher incomes or more education.
Increasingly, Medicaid medical and dental managed care organizations are implementing initiatives designed to address SDOH among their members in order to improve oral health and promote health equity.
While all states cover dental care for Medicaid-enrolled children under age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits. However, optional adult benefits, such as dental care, may be affected by state efforts to meet continued budget challenges arising from the COVID-19 pandemic. Dental disease, though, not only adversely affects oral health but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Preventive dental care has the potential to improve overall health and well-being and reduce costs.
How Michigan Addresses Oral Health and SDOH
In NASHP’s recent 50-state scan of Medicaid managed care medical and dental contracts, Michigan was one of only three states (out of 19 reviewed) to consistently and directly reference SDOH in their Medicaid dental plan contracts.* Additionally, Michigan’s Medicaid medical managed care organization (MCO) contract includes detailed requirements for addressing SDOH, many of which align with the dental plan’s language and promotes coordination between physical and oral health care. While written contractual requirements do not guarantee that medical and dental plans are actively engaged in implementing SDOH-related initiatives – especially in the absence of funding to monitor these programs – Michigan’s contracts offer valuable examples of potential ways to address SDOH that other states could adopt as a first step.
Michigan Delivery System Overview
Michigan Medicaid uses a managed care system to deliver medical and dental care, and the Medicaid dental benefit is carved out and administered by various dental plans contracted by the state. Michigan Medicaid covers limited dental services for adults, including dental check-ups, teeth cleaning, X-rays, fillings, tooth extractions, and dentures. Additionally, the state offers an enhanced dental benefit for Medicaid-eligible pregnant women that includes emergency dental treatment and some oral surgeries. Michigan also administers the Healthy Kids Dental program, which covers comprehensive oral health care for children under age 21 enrolled in Medicaid.
Dental Contract Language
Michigan stands out because of the state’s frequent and direct mentions of SDOH throughout its Healthy Kids Dental (HKD) model contract. The HKD contract reflects a broad range of required initiatives related to SDOH, including:
- Collaboration with community organizations;
- Data use to target interventions and assess population-wide social needs, and
- Implementation of quality assurance and improvement projects that reduce barriers to oral health care.
Collaboration with Community Organizations
One way dental plans can help address SDOH-related needs is by working with community-based organizations (CBOs). CBOs play an important role in connecting individuals to social services and helping people access health-related social needs, such as healthy food, transportation services, and educational materials that promote health literacy.
Michigan requires dental plans administering the HKD program to “collaborate with community-based organizations to facilitate the provision of enrollee oral health education services to ensure the entire spectrum of social determinants of oral health are addressed, e.g., housing, healthy diet and physical activity.” Michigan also encourages contractors to “build relationships with community partners that will engage in integrated care and promote good oral health practices.”
Through dynamic and active partnerships with CBOs, dental plans can more easily refer individuals to social and community services to help address members’ needs. Additionally, these partnerships with CBOs allow the state to expand its reach to more Medicaid-eligible children through educational initiatives.
Dental plans can also encourage members to work with CBOs and other public health programs by implementing their own educational programs. Michigan lists community-based public health resources on its website, and requires dental plan contractors to institute educational, public relations, and social media programs to increase awareness of available resources, such as CBOs, that can help reduce the impact of social determinants of oral health.
Data Collection, Tracking, and Reporting
While coordinating with social and community resources is an important step in improving health equity, having strong mechanisms in place to collect and track community data is critical to ensure social determinants are addressed. Michigan stands out in its commitment to require that medical and dental plans collect SDOH-related data.
Michigan requires HKD contractors to collect data on SDOH and utilize enrollment files, claims, encounter data, and utilization management data to improve community collaboration and address oral health disparities. The state specifies that the dental plan must “use social determinants of oral health data provided by [the Michigan Department of Health and Human Services] to analyze member-level data to direct the contractor’s efforts of targeted interventions, outreach, enrollee education and health promotion.” Additionally, the dental plan must report on the effectiveness of its population health management programs, including measures identifying the number of enrollees experiencing a “disparate level of social needs,” such as limited transportation access and housing instability.
Michigan’s data utilization requirements range from addressing individuals’ health-related needs to analyzing population-wide equity issues. Plans are required to gather and utilize this information for finetuning their services, such as care management and referrals. However, given that requirements for health plans to collect SDOH-related data are fairly new, and the state has little funding available for this work, the state’s role in monitoring whether data collection is occurring is currently limited. With adequate funding and personnel, states can take a more active role in tracking and data analysis to better understand the social needs of the population and effectively target SDOH-related interventions.
Quality Assurance and Performance Improvement
Michigan is committed to not only reporting on the effectiveness of SDOH-related initiatives, but also working to improve existing systems to better address inequities in oral health. The HKD contract requires the dental plan to have a Quality Assurance and Performance Improvement (QAPI) plan that includes a description of how the contractor will, “develop system interventions to address the underlying factors of disparate utilization, health-related behaviors, and oral health outcomes, including, but not limited to, how they relate to utilization of dental emergency services,” and “ensure the equitable distribution of dental services to contractor’s entire population, including members of racial/ethnic minorities, those whose primary language is not English, those in rural areas, and those with disabilities.”
SDOH can contribute to variances in utilization of dental services and poor oral health outcomes, with factors such as geographic location and language proficiency playing an important role in driving health care access. In addition to using data to better understand the impact of social factors on members’ oral health and population utilization trends, Michigan requires contractors to continue to find new ways to reach all populations and reduce the effects of SDOH on oral health outcomes.
Medical Contract Language
Much of the language related to SDOH included in the Healthy Kids Dental contract is consistent with the language in Michigan’s Medicaid medical MCO contract, which covers adults and children. Both the HKD and MCO contracts require the plan to collaborate with CBOs to provide physical and oral health education and address SDOH, implement community education campaigns to improve public knowledge of community-based resources, report on the effectiveness of SDOH-related population health management initiatives, and promote equitable access to care using Quality Assurance and Performance Improvement (QAPI) projects.
However, the medical contract also offers additional opportunities for investment in SDOH that states could consider implementing in dental contracts. For example, Michigan requires medical MCO contractors to participate in the Medicaid Health Equity Project, which is a statewide effort to address racial and ethnic disparities. Through this project, Medicaid health plans collect and report on data across multiple quality measures, including access to preventive and ambulatory health services. The state then uses data stratification by race and ethnicity to determine how racial and ethnic discrimination affect each quality measure, with the goal of addressing any disparities.
Additionally, the medical contract requires health plans to enter into agreements with CBOs to coordinate “population health improvement strategies,” which address social determinants such as physical environment and socioeconomic status. These agreements with CBOs must include information on data sharing, each partner’s role in care coordination, reporting requirements, and plans for coordinating service delivery with primary care providers.
What are Key Considerations and Next Steps?
Addressing SDOH is critical to improving oral health, overall health, and health equity. Increasingly, Medicaid dental plans across the country are collecting data on community needs and implementing initiatives to reduce barriers to oral health care. In a recent 50-state scan of Medicaid managed care contracts, NASHP found that out of 19 dental contracts and 38 medical contracts reviewed nationally, 13 and 37, respectively, require the plan to coordinate with community services. Efforts to address SDOH are also underway, though they tend to be further along on the medical side than the dental side. This provides an opportunity for states to apply medical contracts’ language in their dental contracts, or work with health plans to link existing SDOH-related programs with the dental system.
In response to budget shortfalls resulting from the COVID-19 pandemic, Michigan’s Medicaid program now faces potential rate changes, particularly for dental payments. However, program staff report they see opportunities to establish shared performance metrics between Medicaid MCOs and dental plans in the future. The state is considering ways to standardize and refine SDOH-related data collection and analysis, especially related to dental care. Michigan health officials noted the necessity of first ensuring data was valid and reliable before using it to drive decisions or implement capitation withhold incentive programs. The state is also discussing leveraging Michigan’s health information exchange to transmit standardized SDOH screening information to plans and providers.
Through the Healthy Kids Dental and Medical MCO contract, Michigan has demonstrated a strong commitment to addressing social determinants of oral health. The contracts present an opportunity for states to adopt similar language in order to encourage dental plans to coordinate with CBOs, effectively collect and use SDOH-related data, and implement performance improvement projects aimed at reducing disparities.
* NASHP scanned Michigan’s Healthy Kids Dental model contract and the Michigan Medicaid Medical MCO sample contract.
Acknowledgements: This fact sheet was made possible by the DentaQuest Partnership LLC. The author would like to especially thank Trenae Simpson for her guidance and assistance, and state officials in Michigan for their helpful feedback. The information, content, and conclusions are those of the author’s and should not be construed as the official position or policy of the DentaQuest Partnership LLC.
How States Address Social Determinants of Oral Health in Dental and Medical Medicaid Managed Care Contracts
Inequities in oral health and health outcomes are driven by upstream factors, including diet, education, transportation, and access to care. A growing number of states are working to improve the oral and physical health of Medicaid enrollees and reduce costs by addressing these social determinants of health in their managed care contracts.
Recently, states have used Medicaid managed care contracts and value-based purchasing agreements to address the education, food, and transportation needs of their enrollees. However, less is known about how states leverage their purchasing clout to improve dental care or address social determinants of health (SDOH) directly in dental contracts.
A 50-state review by the National Academy for State Health Policy (NASHP) of Medicaid dental and medical managed care contracts, requests for proposals, and other similar documents publicly available through September 2020, identified how states address social determinants of oral health. Dental contracts were reviewed for a comprehensive list of social determinants and medical contracts were analyzed for references to care coordination, community resources, food access, social determinants of health screening, and coordination with dental contractors. In total, NASHP scanned dental contracts in 19 states and medical contracts in 38 states.
Of the dental contracts, nine referenced coordination between dental plans and medical plans and 13 referenced coordination with social and community services. Other common references in dental contracts included equity/cultural competence, education, and transportation (each referenced in 10 state contracts).
All but one of the 38 medical contracts referenced coordination with social and community services. Thirty-three states referenced food in their medical contracts, 25 referenced adverse experiences (such as domestic violence and child abuse), and 15 referenced care coordination between dental and medical care. Three states (Florida, Michigan, and Virginia) referred to food in both their dental and medical contracts, while only one (Virginia) referenced adverse experiences in both contracts.
State Medicaid Program Delivery of Dental Care
While Medicaid covers some form of adult dental care in 47 states and Washington, DC, and all states cover dental care for children under 21 as part of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits.
States have different options for delivering dental care. Some states with managed care use a carve-in model, where the dental benefit is integrated into medical managed care programs. With a carved-in benefit, managed care organizations (MCOs) may administer the dental benefit or subcontract the dental benefit to another vendor. In carve-out dental programs, states contract with a dental MCO or dental benefits manager (DBM). Alternatively, states with Medicaid managed care medical delivery systems may have fee-for-service dental systems.
Medicaid dental and medical contracts illustrate how states can consider social determinants affecting oral health and overall health through:
- Screening, referral tracking, and follow-up;
- Educational initiatives;
- Staffing and training requirements;
- Data sharing and technology;
- Coordination between dental and medical systems; and
- Performance improvement.
Social Determinants of Health in Dental and Medical Medicaid Contracts
Almost all states scanned have some requirement for plans to refer members to community resources and social services. NASHP focused specifically on requirements that are applicable to the general population, rather than individuals designated as high risk or high needs. States use a variety of strategies to encourage investment in SDOH.
Screening for SDOH Needs
Sixteen states use routine screenings for certain social determinants, including employment status and access to food and transportation. The scan of 14 medical contracts and two dental contracts indicate that states are more likely to require medical plans to conduct needs assessments, often within a specified time frame after enrollment, than dental plans. States may also require medical plans to use this data to appropriately target interventions to meet enrollees’ needs.
While dental plans do not necessarily have the same explicit requirement to conduct a screening, some states do ask their dental plans to use SDOH data to target their educational and outreach activities.
- Michigan’s dental plan is required to use social determinants of oral health data from the state in order to target interventions, outreach, and education efforts.
- Nevada’s dental contract requires the contractor to complete a community-based needs assessment to inform their health promotion and educational activities, including ensuring that any interventions are culturally appropriate and meet the needs of the target population.
Referral Tracking and Follow-up
While screening is an important first step in identifying members’ social needs, it also raises a question of how states use the data to address social determinants. NASHP found that in almost every state with publicly available contracts, Medicaid agencies partner with community-based organizations to meet the social needs of enrollees. For example, plans may facilitate referrals to these community agencies based on information collected through SDOH screenings. States can use tracking, follow-up, and reporting requirements to ensure that referrals to community resources and organizations are effective and successful. Contractors can support these efforts by documenting “closed-looped” referrals that ensure that an enrollee is successfully connected with a community-based organization to address other health and social needs.
- In Louisiana, the Dental Benefit Program Manager is required to connect enrollees with community-based service providers and document referrals and referral outcomes in enrollees’ dental records.
Dental contracts are less likely to require or encourage the plan to monitor referral follow-up. However, dental plans could adopt some of the medical MCOs’ language in order to track the status of referrals, strengthen care coordination between insurance plans and community resources, and ensure individuals are receiving adequate social services that meet their evolving needs. For example, New Hampshire requires MCOs to track the effectiveness of community-based providers and resources, and Oregon requires reporting on referrals to culturally diverse social and support services.
Educational Initiatives
Healthy People 2020 identified health literacy as a component of SDOH, noting that individuals’ ability to access and understand relevant health information affects their health and health outcomes. To help improve health literacy, many states require managed care plans to implement educational initiatives. For dental plans, this includes educating members about the importance of oral health or launching community oral health initiatives designed to help eliminate barriers to dental services and improve population oral health.
- In both Nevada and Texas, the dental contractor must develop and implement programs designed to educate members about nutrition, the importance of oral health, and the relationship between oral health and overall health.
- Florida’s dental plan includes incentives for participation in health education classes. Examples of incentives members can receive that support healthy child development include clothes, food, books, safety devices, publications, and memberships in health and education clubs.
- In its response to Nebraska’s request for proposals (RFP), dental contractor MCNA referenced a program it implemented in Texas that uses the fotonovela (a comic book-style communication popular in the Latinx community) to distribute health information materials to children of migrant farm workers.
Staffing and Training Requirements
Plans may also be responsible for training their employees to better meet members’ needs. In their contracts, states can prioritize the type of training that a plan’s staff receive.
- Nebraska’s dental contract requires all staff to be trained on how social determinants (including food, housing, education, violence, and physical and sexual abuse) affect members’ health and wellness. Staff also receive training on how to find community resources and make referrals.
Both medical and dental plans also employ staff members who are responsible for care coordination, addressing social determinants, and improving access to care for historically marginalized populations.
- Nebraska’s dental contract requires the plan to employ a tribal network liaison to coordinate and expand dental services to Native Americans and connect them to community resources. Arizonaand New Mexico both require medical MCOs to employ someone to coordinate services with Native Americans.
Examples of other medical plans’ required staff positions include a community liaison in Illinois, who connects enrollees with community-based services, and a service coordination director in Kansas, who oversees quality improvement initiatives related to SDOH. Dental contractors could potentially leverage medical MCO positions and their expertise to streamline care experiences for enrollees across medical and dental systems.
Coordination between Dental and Medical Systems
To better integrate dental and medical care, dental and medical managed care use staff members to connect physical health and oral health services across contracts. These staff members also connect Medicaid enrollees to community services to meet social needs.
- In its dental contract, Tennessee requires a coordinator to work with the medical MCO and develop a system to exchange data with the MCO.
- Florida requires MCOs to have a liaison for their prepaid dental health plan to help integrate medical care, behavioral health, and long-term benefits with the dental plan.
- Iowa requires the dental contractor to send a care facilitation plan to the state with information on how the plan will facilitate coordination between dental and medical plans and providers.
Data Sharing and Technology
Eleven states require some form of data sharing between dental and medical plans, or between plans and community organizations. Requirements for integrating different agencies’ social determinant data and sharing information across systems allow medical, dental, and social services to work together to coordinate care for members and encourage referrals and follow-up tracking.
- In Tennessee, the dental benefits manager must facilitate data exchange with school-based health programs to coordinate any needed follow-up care.
- Washington State tasks its dental contractors with using health information technology and health information exchanges to coordinate care between physical health, behavioral health, and social services and other community-based organizations.
Other states are creating their own online platform or mobile applications to improve access to social services for their Medicaid enrollees. These platforms are mentioned specifically in medical managed care plan contracts, but have the potential to be used by dental contractors as well.
- Kansas developed a web-based, mobile-friendly application that connects service coordinators to community resources, such as food banks and pantries, housing, clothing, legal resources, and transportation.
- Medicaid Prepaid Health Plans in North Carolina will use a telephonic, online, and interfaced IT platform to refer members to social services and track the outcomes of these referrals.
Performance Improvement
A number of states encourage both dental and medical plans to engage in performance improvement projects (PIPs) in order to address SDOH.
- In Nevada, dental vendors are required to conduct both a clinical and non-clinical PIP every year. Non-clinical PIPs can focus on cultural competency and accessibility of services, among other SDOH.
- Oregon Coordinated Care Organizations (CCOs) must implement PIPs that address at least four of eight designated focus areas, which include addressing SDOH and equity, and integrating primary care, behavioral health care, and/or oral health care.
Through these PIPs, state managed care plans (both dental and medical) can launch pilot interventions to improve health outcomes by addressing SDOH and reducing barriers to care.
Conclusion
Research shows that addressing individual social needs leads to better oral health outcomes. Despite having different levels of funding and varying Medicaid adult dental benefits, states across the country are finding ways to invest in SDOH. While not all states have started to include SDOH requirements in their dental contracts, these examples show potential opportunities for dental plans to integrate some of the medical plans’ language and guidance into their own work. To learn more about how state Medicaid programs include SDOH-related language in their dental and medical Medicaid managed care contracts, view this interactive map.
Acknowledgements: This blog and map were made possible by the DentaQuest Partnership LLC. The authors would like to especially thank Trenae Simpson for her guidance and assistance, and Trish Riley and Jill Rosenthal for their helpful feedback. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of the DentaQuest Partnership LLC.
State Levers to Support Dental Care in COVID-19’s Public Health and Economic Emergency
COVID-19 has greatly impacted dental care and oral health access in the United States. From closed offices to an increased need for personal protective equipment (PPE), states and providers are both facing challenges to connect patients to dental care. With reduced tax revenue and looming budget crises, states are also facing difficult budget decisions – despite the knowledge that dental benefits can lead to health care savings.
As states confront these challenges, they are using innovative solutions, such as teledentistry, to support providers and connect patients with dental care.
In March, 2020, the Centers for Disease Control and Prevention and the American Dental Association (ADA) released a joint recommendation halting elective dental procedures. As a result, during March and April, over half of all dental workers lost their jobs – accounting for 35 percent of all lost health care jobs during that period. The Health Policy Institute at the ADA estimates that dental care spending will decrease by 66 percent in 2020 and 32 percent in 2021. As states reopen, many have allowed dental practices to resume elective dental procedures, but the ADA recommends the highest level of PPE for dental providers, and the Federal Emergency Management Agency (FEMA) has prioritized PPE supplies for dental providers .
Economic Downturns and Medicaid Dental Care
COVID-19’s impact on the economy will also affect how states provide dental care. Currently, state Medicaid programs are required to cover dental care for children under age 21, but 35 states and Washington, DC also cover dental services for adult Medicaid enrollees. During challenging economic times, such as the Great Recession, states historically cut optional benefits in their adult Medicaid programs. Between fiscal year (FY) 2010 and 2012, 19 states rolled back dental coverage for adults and only eight states have restored their programs between 2013 and 2016.
States are currently expected to face a $290 billion dollar shortfall in FY 2021. Medicaid makes up a large portion of state budgets and is expected to be impacted by state budget reductions in the next year. The Families First Coronavirus Response Act provides a 6.2 percent increase in the Federal Medicaid Assistance Percentage (FMAP) – the federal government’s share of most Medicaid expenditures –creating an influx of federal dollars to states. The FMAP increase also requires that states continue their current eligibility criteria under Maintenance of Effort, a challenge for states as they work to balance budgets.
Some states are prioritizing dental coverage during budget cuts. For example, Maryland’s Gov. Larry Hogan has proposed a $1.45 billion dollar budget cut, but is delaying implementation of postpartum dental coverage in Medicaid rather than cutting the program. West Virginia also is moving forward with implementing a comprehensive adult dental benefit in its Medicaid program.
Support for Dental Coverage in Medicaid Programs
CARES Act Provider Relief Fund. The Provider Relief Fund provides $15 billion to providers, including dentists, who participate in Medicaid and the Children’s Health Insurance Program (CHIP). Dentists can be reimbursed 2 percent of their annual reported revenue from patient care from the fund. The purpose of the fund is to cover expenses lost as a result of COVID-19 and can be used to cover additional expenses like PPE, COVID-19 testing, data reporting, and workforce training.
The US Department of Health and Human Services (HHS) extended the relief fund deadline to Sept. 13, 2020, based on feedback from providers. HHS also plans to release a simplified application form for providers. States can work with managed care organizations and Medicaid providers to raise awareness about the opportunity.
- California’s Medi-Cal Dental Division sent an email to stakeholders reminding them about the opportunity to apply for funding through the Provider Relief Fund.
- Texas Gov. Greg Abbott encouraged Medicaid and CHIP providers in a press release to apply to the fund.
If future federal dollars become available to support providers, states can continue to advertise these opportunities with their stakeholders.
Rewarding dentists who accept Medicaid. As states make difficult decisions about their budgets, several are moving forward with Medicaid rate increases for dental providers. These actions are designed to increase the number of dentists who accept Medicaid and ensure network adequacy for consumers.
- Kansas recently included $3 million in its FY 2020 budget to increase reimbursement for dental providers. Previously, dental providers in Medicaid had not received a reimbursement increase since 2001 and Kansas’ state plan amendment was approved by the Centers for Medicaid & Medicare Services in 2019. This year, the state is appropriating an additional $3 million to reimburse dental providers participating in the state’s Medicaid program, KanCare.
- Louisiana included $2 million in its FY 2020 budget to increase reimbursement for Medicaid dental providers. Louisiana Medicaid promulgated an emergency rule to increase reimbursement for dental exams for children up to age three and restorative dental services.
Use of Teledentistry to Address Gaps in Access to Care
Telehealth can be a tool for patients to stay connected to care when social distancing and stay-at-home orders are in effect. According to the ADA, teledentistry is “the use of telehealth systems and methodologies in dentistry” and can include live, two-way video interaction, storage of digital information, and remote patient monitoring and mobile communication. Teledentistry can be used for consultation and patient education and pain management, and it also can reduce transportation barriers and increase access. This delivery service requires an upfront investment in infrastructure that can be a barrier for service.
Due to COVID-19, 17 states have updated their Medicaid program guidance to include coverage and reimbursement for teledentistry. The Center for Connected Health Policy is tracking state action on telehealth, and new state Medicaid teledentistry guidance is highlighted in this table.
Updated State Medicaid Teledentistry Guidance in Response to COVID-19
| Teledentistry Service | States |
| D0140: Limited oral evaluation – problem focused. | Illinois, Iowa, Kansas,* Louisiana, Nebraska, New Jersey, North Carolina, North Dakota, Pennsylvania, Tennessee,* Utah, Washington, DC, Wisconsin |
| D0170: Re-evaluation – a limited, problem-focused (established patient, not a post-operative visit). Assessing the status of a previously existing condition. | Kansas,* Nebraska, Montana, New Jersey, North Carolina, North Dakota, Tennessee,* Utah, Washington, DC |
| D0171: Re-evaluation – post-operative office visit. | Montana, Nebraska, North Dakota, Utah |
| D0191: Assessment of a patient | New Jersey |
| D9110: Palliative (emergency) treatment of dental pain. | Tennessee* |
| D9310: Consultation, diagnostic service provided by dentist or physician other than requesting dentist or physician. | New Jersey |
| D9430: Office visit for observation (during regularly scheduled hours) – no other services performed. | California |
| D9992: Dental case management- care coordination. | Montana |
| D9995: Teledentistry – synchronous, real-time encounter. | Colorado, Illinois, Iowa, Louisiana, Montana, New Jersey, North Carolina, Pennsylvania, Tennessee,* Utah, West Virginia |
| D9996: Teledentistry – asynchronous, information stored and forwarded to a dentist for subsequent review. | Illinois, Montana, North Carolina, Tennessee,* Utah |
Note: Some states require codes to be used in conjunction with other codes.
Source: Center for Connected Health Policy
*Guidance has expired.
Twenty-three states include the practice of teledentistry in their statues and/or regulations. Teledentistry is not new, but more states are participating under the public health emergency. Teledentistry models such as the California Virtual Dental Home for Children are safe, cost-effective and can prevent advanced, costly-to-treat dental issues. These state experiments will be useful to inform the future of teledentistry coverage and reimbursement after the public health emergency ends.
Despite budget shortfalls, states continue to work to improve access to dental and oral health care. Prioritizing access to dental care has been shown to reduce overall health costs. The National Academy for State Health Policy recently convened state dental leaders and will continue to monitor state action to improve access to dental health care amid the public health and economic challenges laid bare by COVID-19.
Three States’ Efforts to Use Accountable Care to Improve Oral Health Services in Medicaid
Recognizing that improving oral health significantly affects overall health, Medicaid agencies in Colorado, Maine, and Oregon have begun to leverage their primary care-based accountable care programs to improve the delivery of oral health care to adults and children.
Introduction
| What’s an accountable care program?In an accountable care program, groups of providers (called accountable care organizations or ACOs) share responsibility for the quality of care, health outcomes, and cost for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment to an ACO and its affiliated providers depends, at least partially, on the ACO’s performance on defined metrics. |
For almost a decade, state Medicaid agencies and the federal government have worked to reform the health care system to produce better quality health care at a lower cost by implementing accountable care programs. States recognize that Medicaid enrollees often have difficulty accessing oral health services, even in states whose Medicaid programs cover dental services for adults. There has also been a growing consensus that integration of primary care and oral health services would help improve oral health.
The Medicaid programs in Colorado, Maine, and Oregon cover dental services provided to both adults and children. Although results are not yet available in Maine, Colorado and Oregon’s accountable care programs have generated promising results.
- Oregon’s program produced increases in the number of children receiving dental sealants on permanent molars and the number who received an oral health assessment upon entering foster care.
- Colorado’s program produced an increase in the percent of Medicaid members who had at least one dental visit.
- The accountable care programs in Colorado, Oregon, and Maine have also all produced savings. It is, however, not known how much of the savings was due to including dental services in the model.
Policymakers seeking to improve the delivery of oral health services will benefit from an understanding of these states approaches and outcomes. In addition, as states face significant COVID-19 pandemic-related revenue declines, most will need to find ways to contain costs. As an optional Medicaid benefit, adult dental services could be targeted for cost cutting. As policymakers face difficult choices, the experience of these three states can inform those deliberations.
Each of these states established policies that address oral health in the areas of ACO payment and performance. Beyond this shared, high-level approach, the states have little in common. There is a some overlap in the measures the states chose to assess ACO performance. Both Colorado and Oregon assess ACO performance by measuring the percent of enrollees receiving preventive dental visits and factor that metric into ACO payments. Also, both Maine and Oregon assess ACOs’ performance in their rate of topical fluoride applications, but only Maine chose to factor that performance into its ACO payment. The following explains the policies developed by each state.
Colorado’s Regional Accountable Entities
| Colorado: • Considers oral health in three performance areas; • Factors performance on one oral health measure into ACO payment; and • Increased the percent of Medicaid enrollees with at least one dental visit. |
In Colorado, most Medicaid services are delivered to program enrollees through seven regional accountable entities (RAEs). RAEs support a local network of primary care medical providers (PCMPs) that deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members. RAEs are paid through a combination of per member per month (PMPM) payments, capitation (for behavioral health services), and incentive payments. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs.) The total administrative PMPM available to the RAEs is $15.50. RAEs receive $11.50 of the administrative PMPM as a monthly payment and Colorado Medicaid withholds the remaining $4 to fund Key Performance Indicator (KPI) payments. There are seven KPI metrics, including one oral health measure. The Medicaid agency assigns each KPI a specific PMPM amount and, if a RAE produces sufficient improvement in the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is also distributed to the RAEs based on performance.
Although dental health services in Colorado are delivered under a separate contract and not through the RAEs, Colorado’s RAE contract requires RAEs to consider oral health services in several areas of operation. Examples include:
- Care coordination: RAEs must establish a relationship and communications with the Medicaid agency’s dental contractor to foster the RAEs’ members’ access to oral health services.
- ACO payment: One of the seven KPI measures is an oral health measure called “dental visit,” which is defined as the “percent of members who received professional dental services.” This measure is worth up to $0.571 PMPM.
- Provider payment: Each RAE is required to share incentive payments with providers that are in its “health neighborhood,” which consists of the providers (including dentists) and facilities that work with an enrollee’s PCMP to meet all of the person’s health needs.
During the RAEs’ first year of operation, they increased the percent of Medicaid enrollees who had at least one dental visit from 33.83 percent during the baseline period (from July 1, 2017 to June 30, 2018) to 37.63 percent for the 12-month period from July 1, 2018 to June 30, 2019.
Oregon’s Coordinated Care Organizations
| Oregon: • Considers oral health in six performance areas; • Factors performance on four oral health measures into its ACO payments; • Increased the percent of children receiving dental sealants; and • Increased the percent of children entering foster care system who received an oral health assessment. |
In Oregon, almost all Medicaid services are delivered through regional coordinated care organizations (CCOs). Oregon’s CCOs are community-governed organizations that bring together physical, behavioral, and oral health providers to deliver coordinated physical, behavioral, and oral health care for their members. CCOs are funded through a global budget. CCOs also earn retroactive quality pool payments based on their performance on selected “incentive metrics” during the contract year. In 2018, the quality pool was $188 million, which represented 4.25 percent of the total amount all CCOs were paid in 2018. The slate of quality measures, which are selected by the Metrics and Scoring Committee, changes each year. In 2019, there were 19 incentive measures and in 2020 there are 13. CCOs must pay for all Medicaid-covered services (including dental services) provided to CCO members. CCOs may also use their funding to test new models of care and to provide services in addition to those covered by Medicaid. Finally, Oregon encourages CCOs to distribute quality pool payments to network providers, including oral health providers. Oregon’s CCO contract requires CCOs to consider oral health services in several areas of operation. Examples include:
- Network and covered services: CCOs must contract with sufficient dental providers to deliver oral health services to their Medicaid enrollees, including those who may have difficulty accessing dental care, such as children in foster care or adults in nursing facilities.
- Care coordination: CCOs must coordinate physical and dental providers to ensure that enrollees who need to receive dental care in an outpatient hospital or ambulatory surgical center can do so.
- Quality: Each CCO must develop a transformation and quality strategy (TQS) that addresses oral health integration as one strategy for improving quality. CCOs must regularly report progress on implementing the TQS.
- Population health: Each CCO must develop a community health improvement plan that addresses oral health needs, among others. CCOs may also invest in health-related services, which are cost-effective, evidence-based non-covered services or community benefit initiatives that improve “care delivery and overall member and community health and well-being.” One CCO invested in a community-based dental program which, among other things, delivered oral health supplies to participants’ homes.
- ACO payment: Four of the incentive measures used in either 2019 or 2020 measured oral health performance:
- Assessments for children entering foster care including oral health assessment;
- Dental sealants on permanent molars for children;
- Oral evaluation for adults with diabetes; and
- Preventive dental visits for children ages 1-5 and 6-14. (Oregon also measured the number of children and adults who had access to dental services and received any dental service and topical fluoride varnish use, but does not include these measures in its pay-for-performance program.)
- Provider payment: CCOs must have value-based payment (VBP) for oral health in place by 2024. The state has committed to helping both CCOs and oral health providers develop and implement the VBP models.
Since Oregon began incentivizing performance on these measures, CCOs have increased the percent of children receiving dental sealants on permanent molars from 18.5 in 2015 to 24.8 in 2018. The increase was greatest for younger children — that number increased from 20.7 to 27.8 percent for children ages 6 to 9. The CCOs also increased the percent of children who received an oral health assessment (along with physical and behavioral health assessments) upon entering foster care from 27.9 in 2014 to 86.7 in 2018. (The other measures of oral health performance described above had not been in place long enough to produce documented trends.) An evaluation of Oregon’s program found that CCOs were more likely to produce improvements in measures that were part of the incentive program than those that were not—emphasizing the importance of tying ACO payment to performance.
Maine’s Accountable Community Partnerships
| Maine: • Considers oral health in two performance areas, and • At ACO’s option, will factor performance on one oral health measure into ACO payments. • No performance data has been published to date. |
In Maine, primary care practices can voluntarily form networks, identify a lead entity to administer the network, and contract with the Medicaid agency to become Medicaid ACOs, called Accountable Community Partnerships (ACs). Between Aug. 1, 2018 and July 31, 2019, the four ACs that were participating in the program included 90 practices that served 59,443 patients. Primary care providers that participate in an AC receive fee-for-service payment for the services they provide and those that qualify as a health home or behavioral health home receive PMPM care management fees.
ACs are paid through one of two payment models.
- Model 1 is open to ACs that serve at least 1,000 patients and features shared savings but not losses.
- Model 2 is only open to ACs that serve more than 2,000 members, and it features both shared savings and losses.
Model 2 pays ACs a greater share of the savings they produce than does Model 1. Savings and losses are calculated by comparing the total cost of care (TCOC) for providing a defined package of services to the members assigned to the AC with their projected TCOC absent the AC. Each AC decides whether it will include dental services in the defined package of services. If actual TCOC is less than projected, the difference is savings – if actual TCOC is more than projected, the difference is a loss. In order to receive any portion of the savings it produces, an AC must achieve a specified level of performance on a set of quality measures (fifteen core measures, four elective measures, and one monitoring-only measure). Then, the exact portion of the savings an AC receives depends on its performance on these same measures. Maine’s AC contract requires ACs that choose to include dental services in their TCOC calculations to consider oral health services in two areas of operation:
- Network and covered services: ACs that are responsible for oral health services must contract with a sufficient number of dentists to serve their assigned population.
- ACO payment: The cost of dental services is factored into shared savings and loss calculation of those ACs that choose to be responsible for dental services. Also, effective August 2018, Maine began allowing ACs to choose to factor an oral health measure into the calculation of their shared savings/losses calculation: “primary caries prevention intervention as offered by primary care providers, Including dentists.” This measure is defined as, “Percentage of members ages 1-20, who receive a fluoride varnish application during the measurement period.”
Although no AC has yet chosen to factor the cost of dental services into its TCOC calculations, one did choose to use the oral health measure in the 2018-2019 performance year.
Conclusion
Although accountable care programs focus on primary care, Colorado, Maine, and Oregon are all leveraging these programs to improve the delivery of dental care. Although it is still too early to assess Maine’s results, Colorado’s RAEs and Oregon’s CCOs have shown improved performance on measures of oral health care performance. It is important to note that even states such as Colorado that do not deliver dental services through Medicaid ACOs can still use the ACO structure to improve oral health care. Colorado, for example, incorporated a measure of oral health access (the percent of members who received oral health services) to reinforce the contract requirement that the ACOs foster connections between primary care and oral health providers. Importantly, however, the measure was also one that the RAEs’ contracted primary care providers could impact. States that seek to improve oral health services through Medicaid ACOs should consider taking the following steps.
- Measure and publicly report ACO performance on oral health measures that an ACO can impact. Even if the performance is not factored into ACO payment, knowing that its performance will become public could cause the ACO to devote resources to improve performance in that area.
- Articulate oral health requirements in contractor performance standards to establish clear expectations for ACO performance in the area. Some of these performance standards will be chosen based on program structure. Others are likely to be chosen because they are areas the state would like to see improvements in and believes the ACO can produce.
- Factor the cost of oral health services into ACO payments. Factoring oral health services into TCOC calculations and/or incentive payments is the most direct way to incent an ACO to change its delivery of oral health services. In addition, Oregon found that its CCOs were more likely to improve performance on incentivized measures. However, factoring oral health into payment is best done in conjunction with performance measurements and performance standards to ensure that the changes result in the desired improvements.
Acknowledgements: The author thanks state officials in Colorado, Maine, and Oregon who graciously reviewed a draft of this publication. Trish Riley, Carrie Hanlon, and Ariella Levisohn of the National Academy for State Health Policy provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UD3OA22891, National Organizations of State and Local Officials. This information, content, or conclusions are those of the author’s and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
Iowa’s I-Smile Program Promotes Dental Care for Children, Pregnant Women, and Adults
Through a unique partnership between the Iowa Medicaid and public health agencies, Iowa’s I-Smile program addresses the disproportionate impact of dental disease on low-income individuals. I-Smile and its related I-Smile @ School for children and I-Smile Silver for adults help promote preventive oral health services and reduce barriers to dental care across the state.
I-Smile Background
In children, dental caries is the most common chronic disease, affecting 60 percent of individuals ages 5 to 17. Additionally, studies indicate that up to 40 percent of pregnant women experience periodontal disease, and 25 percent of adults over age 65 lack their natural teeth. Additionally, significant disparities exist. In 2016, Medicaid recipients accounted for more than half of dental-related emergency room visits, and in 2019, 44 percent of low-income adults had untreated tooth decay.
Dental disease not only adversely affects oral health, but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Fortunately, preventive oral health care, including sealant and fluoride treatments, can save money and lives. While many states are expecting budget cuts in response to COVID-19-related revenue declines, increasing access to preventive dental care through programs like Iowa’s I-Smile may minimize long-term dental and overall health costs by effectively reaching underserved populations.
In May of 2005, Iowa passed the IowaCare Medicaid Reform Act, which includes the provision that every child age 12 and younger enrolled in Medicaid must have a designated dental home. In addition, the legislature sought to ensure that children are provided with the dental screenings and preventive care identified as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program’s oral health standards. I-Smile was created in response to this 2005 legislation and funded via a Memorandum of Understanding (MOU) between the Iowa Department of Human Services (IDHS) and the Iowa Department of Public Health (IDPH).* IDPH holds the majority of the responsibility under the MOU and contracts with local Title V agencies (public or private non-profit organizations), that administer I-Smile and ensure access to oral health services for children and pregnant women across the state.
Oral Health in Iowa at a Glance:
- In 2002, Medicaid reimbursement for preventive oral health services became the standard of care for dental screening centers in Iowa.
- In 2018, $22 million of a total $31 million spent on preventable dental surgeries for children ages 5 and younger was billed to Medicaid.
- In 2019, 73 percent more Medicaid-enrolled children in Iowa saw a dentist than in 2005.
- In 2018, 50 percent of Medicaid-enrolled children received a dental service, including two out of every three children ages 3 to 12. Iowa rates surpassed both the national average of 34.6 percent of low-income children receiving preventive dental care, as well as the Healthy People 2020 goal of 33.2 percent.
- In 2018, more than 30,650 children received preventive dental care in public health locations, including Women, Infants, and Children (WIC) clinics, schools, and Head Start centers. This number is almost four-times as many as in 2005.
- Medicaid costs per child (ages 0-12) per year have remained relatively steady since the start of the program in 2005. After accounting for inflation and a 1 percent rate increase in 2014, the average cost was $150.75 in 2005 and $170.74 in 2019.
- Iowa met the Healthy People 2020 goal to reduce the proportion of adults 65-74 years old that have lost all of their teeth; in 2014, 13 percent of Iowa adults ages 65-74 years were without their natural teeth, well under the goal of 21.6 percent.
*The MOU for I-Smile does not include I-Smile @ School and I-Smile Silver.
I-Smile in Practice
I-Smile’s mission is to connect Iowa children with “dental, medical and community resources to ensure a lifetime of health and wellness.” I-Smile primarily targets the 47 percent of Iowa children ages 0-12 who are enrolled in Medicaid in order to provide dental care and disease detection early in life and limit costly, preventable dental procedures. Additionally, given the link between mothers’ oral health and their infants’, I-Smile also serves pregnant women.
Twenty-three I-Smile coordinators are responsible for implementing I-Smile strategies within all 99 Iowa counties by serving as a point of contact with the dental network. I-Smile coordinators work with families, dentists, medical professionals, schools, businesses, and local non-profits to assess community needs, coordinate dental care, improve oral health literacy and reduce barriers to care. I-Smile uses multiple approaches to improve dental care, including:
- Partnering with WIC clinics, schools, Head Start centers, preschools, and child-care centers to provide dental screenings and fluoride application;
- Coordinating dental appointments, including scheduling, setting up transportation assistance, and helping parents find payment sources for dental care;
- Training medical professionals to administer fluoride varnish and screen for dental disease; and
- Educating community members about the importance of oral health through public events, health fairs, and online informational tools.
I-Smile @ School
I-Smile @ School is a division of I-Smile that helps children access dental care by providing dental screenings, sealants, fluoride varnish, and oral health education in elementary and middle schools during the school day. I-Smile @ School strategies include:
- Assessing oral health needs of schoolchildren;
- Developing networks with dental offices; and
- Providing oral health education, preventive dental services, and care coordination.
I-Smile @ School is administered by 19 Title V agencies across the state. Funding sources include the Title V block grant, Medicaid reimbursement, a Centers for Disease Control and Prevention grant, and the Delta Dental of Iowa Foundation. Schools must have a minimum of 40 percent of students on free or reduced lunch plans to participate in the program. In the 2018-2019 school year, 43.4 percent of children who received a dental sealant through I-Smile @ School were enrolled in Medicaid, and an additional 9.8 percent had no dental insurance.
I-Smile @ School’s goals align with the Healthy People 2020 and Healthy Iowans 2017-2021 objectives, which include increasing dental sealants and preventive dental services for children and reducing untreated dental decay. In its Strategic Plan for 2018-2023, the program identified three outcome measures:
- Increase the number of schools served from 63 to 74 percent;
- Provide sealants to 5 percent more children; and
- Increase the sealant program consent return rate from 42 to 52 percent.
The strategic plan also identified a number of focus areas, including building cross-agency partnerships, implementing a state system for data collection, creating a communication plan for disseminating oral health information, and improving I-Smile @ School’s infrastructure.
I-Smile Silver
Iowa is one of 19 states (including Washington, DC) in which Medicaid covers extensive adult dental benefits. Through Iowa’s Dental Wellness Plan, Medicaid enrollees ages 19 and older can access full benefits, provided they complete “Healthy Behaviors” annually, which include an oral health self-assessment and preventive services. Despite this, adults, and especially senior citizens, report widespread barriers to care and low utilization rates. In 2016, 38 percent of Iowa seniors had not seen a dentist in five years, and 53 percent reported they could not afford dental care.
| In Iowa, full adult dental benefits cover the following: Diagnostic and preventive dental services Exams Cleanings X-rays Fluoride Fillings for cavities Surgical and nonsurgical gum treatment Root canals Dentures and crowns Extractions |
I-Smile Silver is a pilot program implemented across 10 Iowa counties designed to help adults ages 21 and older access dental care. I-Smile Silver is administered by the Iowa Department of Public Health using funding from the Delta Dental of Iowa Foundation and a Health Resources and Services Administration grant. The pilot project began in November 2014. IDPH contracts with three county health departments (covering 10 counties) to conduct the project. Each contractor has a dental hygienist as the local I-Smile Silver coordinator who is responsible for implementing strategies that include:
- Assessing needs and assets related to oral health;
- Providing training for medical providers, direct care staff, and home care providers;
- Creating referral networks with dental and medical offices to address oral health needs;
- Working with hospitals and health systems to address oral health related to chronic disease;
- Promoting oral health through participation in community events and distribution of materials; and
- Providing care coordination and preventive dental services.
In 2017, the IDPH conducted its first screening survey of older adults’ oral health. The project will continue to grow over the next two years, with the hope that its importance will be recognized and the program will receive funding to allow for statewide expansion of the pilot.
Key Takeaways:
- Through an MOU, states can create cross-sector partnerships in order to fund oral health initiatives and create clear implementation responsibilities across agencies.
- States can effectively reach low-income children and pregnant women by partnering with local organizations to provide dental services and oral health education, including leveraging Title V agencies and schools.
- Providing strong care coordination services is a critical tool for helping individuals access preventive dental care.
Challenges and Next Steps
While Iowa continues to make strides in increasing access to dental and oral health care, particularly among Medicaid-eligible children, some challenges remain. Compared to 60 percent of children ages 3-12, only one in five Medicaid-enrolled children under age 2 saw a dentist in 2019. To increase these numbers, I-Smile started the Cavity Free Iowa campaign to train pediatricians to provide preventive oral health care, including fluoride varnish applications, and education on the importance of oral health.
Additionally, though the number of children on Medicaid is increasing, Iowa is experiencing a decline in dentists who accept Medicaid. Providers note that Medicaid has lower reimbursement rates than private insurance, and often comes with additional administrative burdens.
Finally, as the COVID-19 public health emergency continues to unfold and dental offices address the pandemic’s effects, the long-term impact on oral health care remains unknown. Especially for children who receive dental services through school-based programs such as I-Smile @ School, the pandemic raises concerns about children’s ability to continue to be screened and treated should schools remain closed in the fall. Moreover, older citizens, who are at increased risk for COVID-19, may not feel comfortable leaving their houses to go to the dentist.
To address some of these concerns, Iowa is working to increase the use of silver diamine fluoride, a preventive treatment that can arrest dental decay. The state anticipates there will be fewer dentists accepting new Medicaid patients in the future, and is therefore emphasizing the importance of preventive oral health now to limit future complications requiring care. Iowa is also looking at new points of contact to reach children and adults. As a result of COVID-19, IDPH is preparing to play a bigger role in the dental delivery system by screening for disease, triaging who needs to be seen within a dental office and collecting diagnostics to send electronically to dentists to complete a telehealth exam. While the pandemic may require I-Smile @ School and I-Smile Silver to revise some of their strategies, in the months and years to come programs like I-Smile will undoubtedly play a crucial role in helping Medicaid-eligible children, pregnant women and adults obtain necessary dental services.
Acknowledgements: The author wishes to thank the state officials in Iowa who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Neva Kaye, and Carrie Hanlon of NASHP provided helpful guidance and assistance. Finally, thank you to the Health Resources and Services Administration officials who provided thoughtful input.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
States Increase Access to Oral Health Services and Support Overall Health
Across the nation, states are developing innovative approaches to increase access to oral health services. These policies underscore the critical relationship between overall health and oral health. This blog and two new National Academy for State Health Policy fact sheets explore how several states, including Minnesota and Arizona, are expanding their oral health workforce to increase access to care and promote health equity and patient safety.
Medicaid Incentives, Performance Measures, and Workforce Innovations Foster Access to Pediatric Oral Health Care
While state policymakers across the country grapple with oral health care access challenges, California, Pennsylvania, and Connecticut are incentivizing their Medicaid plans and providers to deliver pediatric oral health services in innovative ways, with a special focus on community-based solutions.
- Under its Medicaid section 1115 waiver, California incentivizes dental care coordination by community health workers and the use of telehealth.
- Pennsylvania has a number of Medicaid managed care strategies in place to foster innovation, including making dollars available to managed care organizations (MCOs) to engage public health dental hygiene practitioners.
- Connecticut similarly includes oral health in its statewide Medicaid payment and delivery reform.
Through these incentives and performance measures, explored below, Medicaid agencies are supporting workforce innovations to address children’s oral health.
The Case for Oral Health Workforce Innovation in Medicaid
Dental decay is preventable, yet it is the most common chronic condition among children.[1] Because oral health and overall health are interconnected, unmet oral health needs can negatively affect overall health by making chewing difficult, leading to lost school days, and damaging self-esteem.[2],[3],[4] Inability to access dental care can be fatal – in 2007 Deamonte Driver, a 12-year-old boy enrolled in Medicaid, died after an untreated tooth infection spread to his brain.
Medicaid is a key lever in addressing oral health care needs, particularly for children, because the Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit requires dental coverage for children and adolescents. The Centers for Medicare & Medicaid Services (CMS) encourages state Medicaid agencies to increase children’s access to dental services through Medicaid and the Children’s Health Insurance Program (CHIP).[5] The Child Core Set of measures that Medicaid agencies can report to CMS includes dental and oral health. The 2011 CMS Oral Health Strategy outlines options for state Medicaid agencies to increase children’s access to care, including workforce strategies, such as provider outreach and recruitment, and reimbursement for services provided by additional types of providers to deliver preventive services.
Workforce strategies are critical to address children’s oral health needs in part because oral health care provider shortages persist across the country. Health Professional Shortage Areas (HSPAs) for dental care exist in 49 states.[6] Rural communities have significantly fewer oral health providers than urban communities and therefore less access to services.[7] To offset shortages, states are introducing new provider types or expanding the services existing providers can deliver. Dentists and dental hygienists (working independently or under dentist or physician supervision) practice in every state. Pediatricians and other primary care medical providers deliver preventive oral health services and refer children to dentists.[8] In 10 states, dental therapists can provide preventive and restorative care.[9] Five states have introduced legislation for advanced dental hygiene practitioners, and 21 states allow community dental health coordinators to assist in community-based care coordination and prevention outreach.[10],[11]
To address children’s oral health needs and access to care, Medicaid officials in California, Pennsylvania, and Connecticut use payment and performance-based strategies to engage the providers authorized to deliver oral health services in their states in the continuum of care.
California’s Dental Transformation Initiative
California’s current 1115 waiver focuses on transforming health care service delivery and quality for Medicaid (Medi-Cal) members, and it includes the Dental Transformation Initiative (DTI). The DTI aims to increase pediatric preventive dental service utilization, diagnose early childhood caries[12] through caries risk assessment (CRA) and disease management, and continuity of care for children enrolled in Medicaid. The DTI budget is up to $740 million over five years (through 2020) for provider incentive payments in four domains: pediatric preventive dental service utilization, caries risk assessment and disease management, continuity of care, and local dental pilot programs (LDPPs).
DTI incentives include:
- Semi-annual payments to dental service office locations or safety net clinics that provide preventive services to more children;
- Payments to dentists for performing pre-identified treatment plans for children ages 6 and younger (where treatment plans include CRA with motivational interviewing, nutritional counseling, and antimicrobials; fluoride varnish application; toothbrush prophylaxis; exams; and increased frequency of services depending on risk level);
- Annual, tiered payments to dental service office locations that provide exams to an enrolled child (up to age 20) for continuous years (e.g., tier one payments are provided on a per-child basis for those with two or more exams from the same service location for two consecutive years); and
- Payments specific to each LDPP program.
The LDPPs use innovative strategies to address the primary DTI aims of pediatric preventive dental service utilization, risk assessment and disease management, and/or continuity of care. Community organizations submitted applications for LDPPs, and as of July 2019, the state Medicaid agency had contracts with 13 LDPPs. Many LDPPs employ workforce strategies such as telehealth and care coordination or case management to meet the DTI goals.[13]
- Five LDPPs are piloting a virtual dental home (VDH)[14] — in this system children receive preventive and other oral health services in community settings, such as schools. Dental hygienists and assistants with special training collect information and provide preventive services. Using technology, dentists in a different physical location review the information and may direct provision of additional services. The VDH also connects children with complex dental needs to a local dentist. The VDH model began at The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry. A Health Resources and Services Administration (HRSA) State Oral Health Workforce Grant to the California Department of Public Health enabled expansion of the VDH to additional sites.[15],[16]
- The Sonoma County LDPP (“Cavity Free Sonoma”) is training and integrating community dental health workers (CDHWs) into dental teams at seven federally qualified health centers (FQHCs) to decrease dental disease among Medicaid-eligible children ages six and younger. The CDHWs provide culturally appropriate oral health information to caregivers and children, assist with caries risk assessment, track patient data, and provide dental case management. CDHWs help caregivers navigate medical and social service systems, and they follow up with caregivers to ensure children complete appointments.
A number of state policies underpin and support the DTI. The VDH was initially tested under the state’s Health Workforce Pilot Projects Program, which allows organizations to test or evaluate new or expanded provider roles before changing licensing laws. Based on the VDH results, the state made scope-of-practice changes for dental hygienists and dental assistants, amended the state Medicaid plan to allow allied dental professional enrollment and billing, and to cover the technology used in VDH. These changes facilitated additional VDH piloting and implementation.
Additionally, the state legislature directed a portion of state tobacco tax revenue to be used for supplemental payments to dentists for certain services, and a $30 million loan repayment program for dentists who commit to serve Medicaid patients for five or ten years.[17] (The American Dental Education Association maintains a list of loan repayment programs by state). Dentists in California can receive up to $300,000 through the loan repayment program, and awardees must agree to ensure Medicaid beneficiares comprise 30 percent of their patient caseload. In July 2019, the Medicaid agency announced $10.5 million in loan repayment awards to 40 dentists.
The Medicaid agency and public health department collaborate through these efforts and the statewide oral health plan,[18] which complements and references the DTI. As part of the oral health plan, California aims to support community-clinical linkages by maximizing the use of trained personnel, such as community health workers and public health nurses, as well as co-locating medical and dental providers.[19]
DTI results to date indicate improvement. The statewide pediatric preventive service utilization rate increased 7.48 percentage points from 2014 to 2017, and continuity of care increased 2.6 percentage points from 2015 to 2017.[20]
Pennsylvania’s Medicaid Managed Care Strategies
Pennsylvania also encourages MCOs and providers to increase access to dental care for children in a number of ways that promote workforce innovation. Two specific strategies are performance-based incentives and allocating a portion of MCOs’ capitated payments to initiatives that focus on community-based care management, including for oral health.
Pennsylvania has a carved-in (or comprehensive managed care) Medicaid dental delivery system in which MCOs (physical health – PH – MCOs in the state) are responsible for medical and dental services. The state has an MCO and provider dental pay-for-performance (P4P) measure with related performance improvement projects (PIPs) to improve access to pediatric oral health services.[21]
The measure is annual dental visit for youth ages 2 to 20. The PH-MCO receives an incentive payment for meeting the state benchmark and an incremental improvement compared to past performance on the measure. PH-MCOs are eligible to earn a double payout for meeting certain benchmarks or being responsible for a double offset if they do not meet those benchmarks. PH-MCOs also must include an incentive for the dentist as part of provider P4P for the measure. The dental P4P consists of two age bands, 0-5 years and 6-20 years. There is an emphasis placed on the lower age band and children who have not received a preventive dental service within the previous calendar year in order to increase education and obtaining early preventive dental care.
To improve access, some PH-MCOs offer incentives to pediatricians who make dental referrals for children who then receive a dental service (as evidenced by a dental claim). Some PH-MCOs partner with FQHCs to improve access by supporting co-location of primary medical and dental care. Examples of other innovative plan efforts to increase access include the use of a mobile dental unit with pediatric dental providers and the implementation of a small dental home pilot project.
What services can Pennsylvania’s Public Health Dental Hygiene Practitioners (PHDHPs) provide?
In Pennsylvania, a registered dental hygienist can be certified as a PHDHP to provide dental hygiene services without dentist supervision in specific public health practice sites, such as schools, correctional facilities, health care facilities, and FQHCs. PHDHPs can clean teeth, take X-rays, polish fillings, identify cavities, evaluate patients, and provide oral health education to patients without dentist supervision.
The P4P dental measure and related dental PIPs have been successful. From 2016 to 2018, annual dental visit rates increased by 3.09 absolute percentage points, making the annual dental visit rate 63 percent statewide. Every Pennsylvania plan is currently above the 50 percent national benchmark, and while there is still room for improvement, each plan has improved since the inception of these projects. The state will continue to monitor progress in these areas and especially look at demographics and oversight of the managed care program. A specific area of focus is examining racial/ethnic or geographic disparities in dental care.
Another managed care strategy in Pennsylvania is the availability of Community-Based Care Management (CBCM) dollars for PH-MCOs to implement innovative initiatives that increase access to oral health services. CBCM dollars must be used for community-based projects, either for staffing or for the initiatives themselves. With this funding, PH-MCOs have embedded registered nurses or community health workers (CHWs) in care settings, helped enrollees with transportation to appointments, and conducted public education. Some PH-MCOs use CBCM dollars for oral health services, including mobile dental vehicles, and working with public health dental hygiene practitioner (PHDHP) initiatives. MCOs can enroll PHDHPs, and CBCM guidance specifically requires PHDHP initiatives. In this way, CBCM dollars assist plans in meeting P4P benchmarks and PIP goals.
An Emerging Model: Connecticut’s Oral Health Focus in Medicaid Payment and Delivery Reform
Connecticut’s State Innovation Model (SIM) initiative aims to improve overall community health, access to and quality of care, and health equity through payment and delivery reform. One component of SIM, the Community and Clinical Integration Program (CCIP), provides technical assistance to help provider organizations and FQHCs improve primary care delivery and patient outcomes.[22] CCIP has three core standards: comprehensive care management, health equity improvement, and behavioral health integration, as well as three elective standards, one of which is oral health. This standard includes screening for oral health risk factors and symptoms, developing treatment plans, providing treatment, and tracking oral health outcomes and improvement over time. Although implementation is in the early stages, one participating FQHC has chosen this oral health elective standard. Connecticut recognizes the importance of oral health as it relates to overall health and this awareness will be a consideration in any future practice transformation and payment reform efforts.
Considerations and Conclusion
Some lessons from these state efforts to promote pediatric oral health care access through workforce innovation include:
- Engage the dental community. States with comprehensive managed care can elevate dental care within MCOs, for example, by requiring each plan to have a dental director. Pennsylvania has seen increased dental provider engagement since implementing this change.
- Consider pilot programs. Pilot programs offer the opportunity to start small, build buy-in, and receive early input. They also can help states determine possible impact and address challenges on a small scale before rolling out statewide.
- Leverage multiple funding streams, when possible, and consider a multi-pronged approach for oral health workforce innovation. California has leveraged tobacco tax revenue and federal grants to support innovations across Medicaid and public health, and with an academic partner.
- Consider the unique needs of FQHCs and safety net providers. FQHCs often can lead the way in co-location of dental and overall health services and providers, but some safety net facilities/organizations establish contracts for dental care with the private sector. Additionally, due to federal law, FQHCs bill Medicaid agencies for services differently than other providers.[23] These realities can create challenges tracking utilization or other data. A contractor and a dental consultant have provided assistance engaging and supporting safety net providers who opt in to participate in the California DTI.
Dental decay is preventable, yet unmet oral health needs persist. Payment and quality measurement policies in California, Connecticut, and Pennsylvania demonstrate how Medicaid agencies — often in collaboration with public health agencies — can promote oral health workforce innovation to help Medicaid-eligible children access needed dental and oral health care. While states often face financial and data barriers, emerging efforts to engage providers, such as community dental health workers, or dental hygienists and assistants, with advanced training, and to leverage telehealth show promise.
Notes
[1] Centers for Disease Control and Prevention. “Dental Caries (Tooth Decay).” Hygiene-related Diseases. September 22, 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.
[2] Jackson, Stephanie L., William F. Vann, Jonathan B. Kotch, Bhavna T. Pahel, and Jessica Y. Lee. “Impact of Poor Oral Health on Children’s School Attendance and Performance.” American Journal of Public Health 101, no. 10 (2011): 1900-906. doi:10.2105/ajph.2010.200915. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222359/
[3] Kelekar, Uma, and Shillpa Naavaal. “Hours Lost to Planned and Unplanned Dental Visits Among US Adults.” Preventing Chronic Disease 15 (2018). doi:10.5888/pcd15.170225.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772383/
[4] Health Policy Institute, American Dental Association. “Oral Health and Well-Being in the United States.” https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/OralHealthWell-Being-StateFacts/US-Oral-Health-Well-Being.pdf?la=en.
[5] CMS recently completed the Medicaid Innovation Accelerator Program Children’s Oral Health Initiative Value-Based Payment Technical Support Opportunity for states focused on selecting, designing, and testing a value-based payment approach to improve children’s oral health outcomes. See https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-functional-areas/value-based-payment/index.html
[6] National and State-level Projections of Dentists and Dental Hygienists in the U.S.: 2012-2025. Washington, D.C.: U.S. Deparment of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Information and Analysis, 2015. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nationalstatelevelprojectionsdentists.pdf
[7] National Advisory Committee on Rural Health and Human Services, Improving Oral Health Care Services in Rural America: Policy Brief and Recommendations. December 2018. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2018-Oral-Health-Policy-Brief.pdf
[8] For example, see: Centers for Medicare and Medicaid Services. “Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents.” September 2013. https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf; Cantrell, Chris. “Engaging Primary Care Medical Providers in Children’s Oral Health” (National Academy for State Health Policy, 2009). https://www.oldsite.nashp.org/engaging-primary-care-medical-providers-childrens-oral-health/.
[9] “New Mexico’s Passage of Dental Therapy Law Builds National Momentum for Changing Provision of Dental Care Amid Oral Health Crisis.” Community Catalyst. March 29, 2019. https://www.communitycatalyst.org/news/press-releases/new-mexicos-passage-of-dental-therapy-law-builds-national-momentum-for-changing-provision-of-dental-care-amid-oral-health-crisis.
[10] American Dental Hygienists’ Association. “The Benefits of Dental Hygiene-Based Oral Health Provider Models.” April 2016. https://www.adha.org/resources-docs/75112_Hygiene_Based_Workforce_Models.pdf.
[11] American Dental Association. “Solutions: About CDHCs.” Action for Dental Health. https://www.ada.org/en/public-programs/action-for-dental-health/community-dental-health-coordinators.
[12] Early childhood caries is the presence of one or more decayed, missing, or filled tooth surfaces in a primary tooth in children younger than six years of age. See American Academy of Pediatric Dentistry, “Definition of Early Childhood Caries” https://www.aapd.org/assets/1/7/D_ECC.pdf
[13] California Department of Health Care Services, “Medi-Cal 2020 Waiver Dental Transformation Initiative, Domain 4 Summary of Local Dental Pilot Program Applications,” March 8, 2018. https://www.dhcs.ca.gov/provgovpart/Documents/DTI/Domain%204/Medi-Cal_2020_DTI_D4_LDPP_Summary_030818.pdf
[14] University of the Pacific, Arthur A. Dugoni School of Dentistry. ”About Virtual Dental Home” https://dental.pacific.edu/departments-and-groups/pacific-center-for-special-care/innovations-center/virtual-dental-home-system-of-care
[15] University of the Pacific, Arthur A. Dugoni School of Dentistry. “Pacific Center Receives More than $3.5 Million in New Grants for Virtual Dental Home Projects,” October 13, 2017.
[16]California Department of Public Health Office of Oral Health. “Oral Health Program Projects.” https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/Pages/OralHealthProgram/OralHealthProjects.aspx
[17] See www.CalHealthCares.org to learn more about loan repayment program eligiblilty and requirements.
[18] California Department of Public Health Office of Oral Health, Statewide Oral Health Plan 2018-2028, January 2018. https://www.cdph.ca.gov/Documents/California%20Oral%20Health%20Plan%202018%20FINAL%201%205%202018.pdf
[19] Kumar, Jayanth. “Public Health and Dental Care Collaboration in California.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.
[20] Jackson, Alani. “California Oral Health Innovations.” Webinar presentation for the National Academy for State Health Policy. July 30, 2019.
[21] To learn more about relevant PIPs, see Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for States. Centers for Medicare & Medicaid Services Oral Health Initiative, 2015. https://www.medicaid.gov/medicaid/benefits/downloads/pip-manual-for-states.pdf
[22] Connecticut State Innovation Model (SIM) Report of the Practice Transformation Taskforce on Community and Clinical Integration Program Standards for Advanced Networks and Federally Qualified Health Centers. Core Elective Standards. CT.gov, 2016. https://portal.ct.gov/-/media/OHS/SIM/PracticeTransformationTaskForce/CCIP-Reports-and-Publications/ccip_report_standards_updated_12_30_16.pdf?la=en
[23] To learn more, see for example, Medicaid and CHIP Payment and Access Commission. Medicaid Payment Policy for Federally Qualified Health Centers, December 2017. https://www.macpac.gov/publication/medicaid-payment-policy-for-federally-qualified-health-centers/
Acknowledgements
The authors wish to thank the state officials in California, Connecticut, and Pennsylvania who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Kitty Purington, and Elinor Higgins of NASHP provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
States Showcase New Programs that Integrate Oral Health and Primary Care
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Prevention and collaboration were the key themes as state policymakers explored innovative and cost-effective strategies to integrate oral health and primary care during #NASHPCONF18’s session, Cross Currents: Integration of Oral Health and Primary Care.
Speakers underscored the importance of high-quality and regular dental care in preventing major oral and physical health problems and delivering cost savings to state Medicaid budgets. Mary Fliss, deputy of Clinical Strategy and Operations at Washington’s State Health Care Authority, reviewed her state’s Oral Health Connections Pilot Project. The project, recently authorized by the state legislature, will track how providing enhanced dental benefits to adult Medicaid clients in three counties impacts access to dental care, health outcomes, and medical costs. The project will specifically target individuals with diabetes — because of the links between periodontal health and chronic conditions — and pregnant women because improved periodontal health also benefits overall health.
Dentists who treat those two populations will receive enhanced reimbursement for periodontal treatment of Medicaid beneficiaries. The project is funded by the Arcora Foundation and state general funds. The state will seek federal approval for the project through a Medicaid state plan amendment.
One critical element of the project will be increased coordination between medical and dental providers. A referral tool, DentistLink, will provide a collaborative approach to documenting patient information and facilitating patient referrals and scheduling appointments.
California is also making strides toward medical-dental collaboration. Alani Jackson, chief of the Medi-Cal Dental Services Division within the California Department of Health Care Services, spoke about Local Dental Pilot Programs (LDPPs) that are testing new types of collaboration. The LDPPs are a component of the state’s Dental Transformation Initiative, which was authorized by a Medicaid 1115 waiver. Many of the LDPPs train primary care providers to conduct dental assessments to look for oral health risk factors and to administer basic preventive dental care like fluoride varnish.
For example, the LDPP run by the California Rural Indian Health Board places an oral health coordinator into primary care settings to complete dental decay risk assessments. By placing coordinators in primary care settings or in other venues such as after-school programs, California’s LDPPs are meeting people where they already are to improve access.
Another innovator takes a reverse approach by placing a physical health care provider in dental offices. Maria Dolce, associate professor at Stony Brook University School of Nursing, described the Nurse Practitioner and Dentist (NPD) Model for Primary Care, implemented by the Harvard School of Dental Medicine in partnership with Northeastern University School of Nursing. The NPD model places a nurse practitioner in a dental setting to act as a gateway to comprehensive care and to deliver primary care.
The program ensures that patients receive an annual wellness visit in combination with a dental visit for an integrated approach to care. The wellness visit is conducted by the nurse practitioner and includes a check on health and mental health risk factors as well as a review of a patient’s current health care providers.
These nurse practitioners already have the training to carry out these assessments in primary care offices – but under this program they conduct them in dental office settings. This unique model provides a personalized and patient-centric approach at potentially lower costs. To maximize resources, states considering this model could review their nurse practitioner scope-of-practice regulations to, for example, allow nurse practitioners to practice independently of physicians if they are not currently permitted under existing regulations.
Preliminary results suggest the NPD model is effective in improving overall health and managing chronic conditions. Because the wellness visit takes place in the dentist’s office, both dental and medical preventive services are provided.
The NPD model also addresses another critical theme raised during the session: how to secure long-term funding for these initiatives. Emphasis on the cost-saving benefits of these prevention initiatives could be key to moving them forward, as state policymakers contend with making these innovative practices, which emphasize cross-sector collaboration and prevention, a sustained program under Medicaid.
To learn more about strategies to incorporate oral health into medical care for chronic conditions, read State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for People with Chronic Medical Conditions. Both the report and this conference session were supported by the DentaQuest Foundation.
State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for People with Chronic Medical Conditions
State health policymakers know oral health is an essential component of overall health and well-being, but state Medicaid programs face increasing costs and growing demands. Many of their enrollees struggle with high-cost, chronic conditions — often linked to oral health issues.
To explore possible approaches to improve oral health care, NASHP interviewed key Medicaid officials from Alabama, Missouri, Ohio, Rhode Island, South Dakota, and Washington State about integrating oral health into Medicaid health homes or other chronic condition payment or delivery models.
In this new report, supported by the DentaQuest Foundation, state leaders recommend first steps to incorporating oral health, such as sharing Medicaid health home members’ dental data with both dental and medical providers and including oral health questions in health home screening tools.
Read or download State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for Chronic or High-Cost Medical Conditions
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
