Maternal, Child, and Adolescent Health – Page 12 – The National Academy for State Health Policy

How States Addressed Health-Related Social and Economic Factors in 2019

December 16, 2019/in Policy Blogs, Featured News Home Blending and Braiding Funding, Chronic Disease Prevention and Management, Health Equity, Healthy Child Development, Housing and Health, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Jill Rosenthal

During 2019, the National Academy for State Health Policy (NASHP) has tracked the progress of many of the plans governors outlined in their 2019 state of the state and inaugural addresses that focused on the social and economic factors that influence health. The governors’ initiatives included social inequity, housing, education, the environment, jobs, and other priorities.

In addition to identifying new initiatives, 10 governors unveiled plans to reconfigure their cabinets to better address the conditions that affect health. They proposed cross-agency and public-private collaborations to leverage siloed state resources and coordinate services more efficiently.

In recent months, NASHP has highlighted states that have followed up with initiatives and policies to implement their governors’ and legislatures’ shared goals through the use of executive orders, legislation, or budget appropriations. These analyses are captured in the following NASHP blogs that provide a snapshot of some of the innovative approaches states are taking:

States Take the Lead to Address Climate Change, December 2019
Minnesota and Indiana Governors Work to Improve Social Equity and Health in Every Zip Code, September 2019
States Take Action to Improve Health through Housing, August 2019
States Take Action to Improve and Expand Early Childhood Education, June 2019 and
Across the Nation, State Leaders Are Tackling the Global Issue of Environmental Protection, May 2019

In 2020, NASHP looks forward to following these and other innovations as state leaders identify new approaches and take additional actions. NASHP seeks to showcase states that are looking upstream to tackle these issues. Please email jrosenthal@oldsite.nashp.org information about your state’s progress so we can share your accomplishments nationally.

New York Recommends Pediatric Preventive Care Improvements in its First 1,000 Days on Medicaid Report

December 16, 2019/in Policy New York Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Elinor Higgins

By age three, a child’s brain has grown to 80 percent of its adult size and experiences during the first 1,000 days are critical to healthy brain development and social, emotional, cognitive, language, and physical development. Preventive measures taken in the first few years of life can have a significant and lasting impact on a child’s future health outcomes and overall success. New York is honing strategies to support healthy development during the first 1,000 days through primary care and trauma prevention strategies.

In October 2019, New York released recommendations from its Final Report of the First 1,000 Days Preventive Pediatric Care Clinical Advisory Group as part of the First 1,000 Days on Medicaid redesign initiative, which was launched in July 2017. It recognizes the critical role that Medicaid can play in the early life of children to help set them up for future success. The initiative also aims to work collaboratively with education programs and other sectors to deliver better results for children in New York.

Later in 2017, a group of stakeholders from different sectors and agencies, including education, child welfare, community-based organizations, public health, and mental health, convened to produce a plan for 10 proposed activities to be part of this initiative. Their first goal was to create a Preventive Pediatric Care Clinical Advisory Group that would develop a framework model for how to organize pediatric care in order to implement the Bright Futures guidelines. The framework model would identify barriers, possible incentives, and new system approaches to deliver the most effective care possible during well-child visits.

The advisory group included members from several child- and family-serving sectors that frequently partner with pediatric primary care, such as education, Early Intervention, and child welfare, and the group also sought feedback and participation from family representatives and community groups. The report, produced in October for the New York Medicaid program, details the group’s Model of Pediatric Population Health, which aims to build on the patient-centered medical home model with higher standards of care and care coordination. The focus of the model is on practice transformation to address the social determinants of health related to poverty, racism, and other environmental influences, and it integrates behavioral health care with traditional clinical care. The model lays out three tiers for integrating behavioral health:

Tier 1: Services received by all children:
- Screening: Age-appropriate screenings for child development, maternal depression, and adverse childhood experiences (ACEs), social-emotional development, social determinants of health, and interpersonal violence
- Culturally sensitive anticipatory guidance focused on social-emotional/family health (e.g., Reach Out and Read, Vroom, lactation counseling, parent access for questions)
- Information about community resources (e.g., Head Start)

Tier 2: Services received when a child or parent has an identified need: (Examples include developmental delay, housing or concrete services need, trauma, or maternal anxiety)
- Short-term counseling by early childhood mental health-trained professionals
- Care coordination by staff knowledgeable about early childhood services to facilitate connection with community resources
- Follow up and escalation to Tier 3 if needed
- Care delivered in a collaborative care model by the primary care provider, with support from mental health professionals either in the practice or remotely via tele-health

Tier 3: Services received when a more complex need is identified for a child or parent
Therapeutic intervention (e.g., dyadic therapy, parental mental health and substance use treatment) in the practice
- Referral to community-based mental health services when needed
- Case management (with early childhood skills) for all needs, including navigation across services

The report recognizes that there will be an increased need for behavioral health staff if the three-tier model is to be implemented successfully. The group envisions that half of the Tier 1 and Tier 2 services could be reimbursed under Medicaid based on diagnoses and fee-for-service payments, but that a capitated payment model might be more effective. For Tier 3 services, the report recommends a parallel to the value-based payment model used to fund collaborative care for adults through Medicaid. Capitated payments through value-based contracts between Medicaid managed care organizations and pediatric practices have been suggested by stakeholders as a potential path for a child-focused, population-based arrangement.

The goal of this model is to achieve health equity for all children and families by addressing systemic disparities, fostering trust between families and medical providers, promoting community linkages, and providing two-generational, trauma-informed, culturally competent, and integrated primary and behavioral health care.

The advisory group also produced a list of recommendations about committing to the Pediatric Population Health model through activities like investment in its core programs, including sustaining the HealthySteps model and sites funded by the NYS Office of Mental Health HealthySteps pilot, and the documentation of progress and outcomes for children as different aspects of the model are piloted. The other planned activities included in the First 1,000 Days on Medicaid initiative include a focus on early literacy, home visiting, development of data systems for cross-sector referrals, and a peer family navigators pilot program.

New York is not the only state focusing on the first few years of a child’s life as a critical period for improving health outcomes across the lifespan. Rhode Island’s First 1,000 Days of RIte Care, the state Medicaid program, aims to improve rates of developmental screening and coordination between pediatric care with family home visiting and Early Intervention. California’s Medicaid program, MediCal, is collaborating with the state’s Office of the Surgeon General to address ACEs with trauma screenings and provider training on trauma-informed care. As states continue to look for ways to improve health at all ages, early childhood is a period where increased coordination across sectors and agencies can lead to preventive strategies that have a lasting impact.

This blog is supported by the David and Lucille Packard Foundation. To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

All 50 States and Washington, D.C. CHIP Fact Sheets for all years

December 12, 2019/in Policy CHIP, CHIP, Eligibility and Enrollment, Health Coverage and Access, Maternal, Child, and Adolescent Health /by admin

All of the CHIP Fact Sheets published are listed below in Adobe Acrobat PDF format. Either right mouse click and choose Save As.. or click on the link and save in Adobe Acrobat when the document opens.

ALL 50 2014 CHIP State Fact Sheets
ALL 50 2016 CHIP State Fact Sheets

Alabama

Alaska

Arizona

December 12, 2019/in Policy Featured News Home, Maps CHIP, CHIP, Health Coverage and Access, Maternal, Child, and Adolescent Health /by NASHP

State Officials Consider Patient Preferences when Evaluating Telehealth Evidence

December 2, 2019/in Policy Alaska, California Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Population Health, Safety Net Providers and Rural Health /by Johanna Butler

When exploring new evidence about the effectiveness of telehealth, state policymakers want to know which interventions consumers prefer and are scalable for a range of populations. In addition to working to ensure that new telehealth tools are evidence-based and effective, officials want to make sure both patients and providers are interested in utilizing them.

The National Academy for State Health Policy’s (NASHP) Telehealth Affinity Group recently convened to discuss two studies funded by the Patient-Centered Outcomes Research Institute (PCORI):

One ongoing study in rural Alaska is testing how well a new school-based screening and referral process – combined with a telemedicine consultation – can expedite the diagnosis of hearing loss in children. In the 15 participating communities, children are screened for hearing loss at school. Under the usual model, parents of children identified as needing a follow-up consultation are sent a letter with a request to take their child to a clinic. Under the intervention, the school and clinic work together to schedule a telemedicine appointment, during which a community health aide who is on-site at the local clinic works with specialists at a remote location to do follow-up testing. While the study does not yet have full results, the region saved $18 million in 2016 and 91 percent of patient travel to specialists was avoided. Data will be collected until February 2020.
Another study investigated the use of patient portals – secure websites where patients can view health records and electronically communicate with doctors – among adults with chronic diseases in the Kaiser Permanente Northern California health system. Researchers wanted to understand how portal use impacted patients’ utilization of health care services. Among the eligible participants, 68 percent of patients created a patient portal. Portal use was associated with more office visits, fewer emergency department visits, and fewer preventable hospitalizations. Although portal use was connected to better outcomes, the results were somewhat limited as the study focused on a closed health care system. It is also difficult to discern if patients’ portal engagement impacted their behavior. For instance, it is unclear if these patients may have been proactive participants in their care even without the portal.

In response to these telehealth studies, affinity group members expressed their interest in understanding:

How can an intervention be scaled to diverse populations? Would the rural, school-based intervention also work in urban areas? Could a similar telehealth invention be successful for adults who need follow-up care?
How do patient preferences impact the adoption of telehealth? To what extent does the evidence support the success of a specific intervention itself, versus a specific population’s interest in utilizing it?
What is the appropriate role of state officials in promoting evidence-based telehealth?

Scaling Interventions to Broad Populations

As affinity group members explore new evidence about telehealth, they expressed the desire to better understand how an intervention can be scaled to meet the needs of the populations they serve. The Alaska hearing loss study is of particular interest to officials because it offers a promising approach that could be adapted to connect a range of rural or underserved communities to specialists. The affinity group was very interested in the projected savings and how the community-focused design could be applied to their own states.

Members expressed skepticism about the applicability of the patient portal tool for the populations they serve. State officials questioned how this intervention might be scaled beyond a closed, integrated health system like Kaiser Permanente. For example, would an investment into an online portal for a state’s Medicaid population – some of whom may not have the same access to the internet as other higher-income populations – yield the same improved health outcomes?

Patient Preferences Impact Telehealth Adoption

A prominent theme from the discussions of both of the studies was the importance of patient preferences for care. Officials noted that evidence-based interventions that improve outcomes or lower costs must still be supported by patients and providers in order to warrant investment. As more telehealth evidence emerges, particularly relating to patient-focused tools, policymakers want to understand how likely members of their targeted populations are to use telehealth.

The Role of State Officials in Promoting Telehealth

Beyond adaptability, state officials want to know how they can invest or most effectively promote the adoption of telehealth through their roles as payers and/or regulators. Officials wonder if there could be opportunities to use existing funding to pay for or incentivize use of patient-directed telehealth tools, like an online portal, to work toward improved health outcomes for targeted populations. There is also interest among the affinity group in considering how state agencies could promote or encourage community-level collaboration, similar to the Alaska example, to implement a successful telehealth intervention.

While the two studies prompted more questions, state officials value the research investment in telehealth. While the affinity group discussions often raise issues outside the scope of testing specific interventions, researchers may benefit from understanding the broader context state officials work within when making or changing policy. It is critical for state officials to understand scalability, how to engage diverse, dynamic populations or to have tools to decide whether or not their states can make the investments needed to implement new interventions.

NASHP’s Telehealth Affinity Group will continue to meet and discuss emerging PCORI research on telehealth in the coming months. To learn about the group’s first meeting, read the NASHP blog, States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth.

Infographic: State Team-Based Care Strategies for Medicaid-Eligible Women

December 2, 2019/in Policy District Of Columbia, Minnesota, Montana Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration /by Eddy Fernandez

For more information, please click the program titles and read NASHP’s State Medicaid Quality Measurement Activities for Women’s Health.

Acknowledgement: Thank you to the officials in Washington, DC, Montana, and Minnesota for reviewing their respective highlighted strategies. This infographic is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, 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 Increase Access to Oral Health Services and Support Overall Health

November 25, 2019/in Policy Child Oral Health, Community Health Workers, Health Coverage and Access, Health Equity, Maternal, Child, and Adolescent Health, Oral Health, Population Health, Workforce Capacity /by NASHP Staff

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.

Blog: States Increase Access to Oral Health Services to Support Overall Health
Fact Sheet: AZ Uses Dental Hygienists to Improve Hospital Patient Safety
Fact Sheet: MN Uses CHWs and Dental Therapists to Advance Equity

States Increase Access to Oral Health Services and Support Overall Health

November 25, 2019/in Policy Arizona, Minnesota Blogs, Featured News Home Chronic Disease Prevention and Management, Community Health Workers, Health Coverage and Access, Health Equity, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Workforce Capacity /by Carrie Hanlon and Neva Kaye

State officials continue to develop new approaches to increase access to oral health services, and many of their innovations were highlighted at National Academy for State Health Policy’s 2019 conference. There are ongoing initiatives, such as deploying community health workers in Minnesota, a New Hampshire Medicaid and Women, Infants, and Children Nutrition Program pay-for-prevention, bundled payment pilot for children’s preventive oral health services, and implementation of new Medicaid policies to expand access in Arizona and Utah.

These oral health policies underscore the critical relationship between increased access to oral health for overall health, a relationship that is highlighted in two new NASHP fact sheets that explore how states are expanding their oral health workforce: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity and Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.

For ventilator-assisted patients, good oral health supports patient safety. As an Arizona Department of Health Services representative discussed at NASHP’s conference, state legislation enacted in May 2019 changed scope-of-practice laws to allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician.

A volunteer project enabled Arizona to test the use of dental hygienists to provide oral health care to ventilator-assisted patients — a strategy recommended by the US Centers for Disease Control and Prevention to reduce ventilator assisted pneumonia (VAP). VAP, which is usually caused by oral bacteria, was the leading cause of death from nosocomial infections in critically ill patients and significantly increased hospital costs. This project identified the scope-of-practice law, which required supervision by a dentist, as a key barrier to having dental hygienists in hospitals to improve oral health to support the overall health of ventilator-dependent patients. To learn more, read Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.

Good oral health also supports overall health among adults with substance use disorder (SUD). As a representative from the Utah Department of Health’s Division of Medicaid and Health Financing highlighted at the conference, the state added dental benefits for targeted adult Medicaid beneficiaries with SUD in January 2019. The beneficiaries receive dental care at the University of Utah School of Dentistry and affiliated providers. The policy builds on the innovative Project FLOSS – Facilitating a Lifetime of Oral Health Sustainability for Substance Use Disorder Patients and Families. Project FLOSS demonstrated that providing comprehensive integrated dental and SUD care was associated with increased SUD treatment completion, employment, and drug abstinence, along with reduced homelessness among adults.

Emerging health professionals, such as community health workers (CHWs), promote overall health and health equity. Minnesota is one of just a few states that include a specific CHW role to promote oral health — helping to link oral health and overall health. In 2005, Minnesota became the first state to implement a for-credit, transferrable-credit CHW certificate program through its state college system and private higher education institutions. CHWs work under the supervision of eligible Medicaid providers in the state, including dentists. By providing culturally competent, high-quality access to services and increasing the health knowledge of the individuals they serve, CHWs can help reduce disparities. To learn more about the role of CHWs and dental therapists, read Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity.

In 2020, NASHP will continue to track state policy changes and efforts to increase access to pediatric and adult oral health services as part of states’ commitment to promote overall health.

The DentaQuest Partnership for Oral Health Advancement supported the conference session and these fact sheets.

State Medicaid Strategies to Promote Early Identification and Treatment of Pregnant Women with Substance Use Disorder

November 18, 2019/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health Equity, Health IT/Data, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health /by Carrie Hanlon, Taylor Platt, Eddy Fernandez and Lyndsay Sanborn

States face rapidly rising rates of substance use disorder (SUD) and overdoses among pregnant women and increases in maternal deaths and poor birth outcomes, such as neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS).[1] To understand how states promote early identification of SUD and treatment access for pregnant women, the National Academy for State Health Policy (NASHP) researched Medicaid quality measures and targeted initiatives for pregnant women with or at risk of SUD in every state and Washington, DC. This issue brief highlights state strategies, such as developing a state Medicaid Opioid Strategy with a focus on pregnant and parenting women, and leveraging financial incentives, quality measures, waivers, and public-private partnership to improve maternal and birth outcomes and curb state costs associated with SUD.

Introduction

Key Terms

Substance use disorder (SUD) occurs when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.
Opioid use disorder (OUD) is a problematic pattern of opioid use leading to clinically significant impairment or distress.
Medication-assisted treatment (MAT)is an evidence-based treatment treatment approach for individuals with SUD that combines medications with counseling and behavioral therapy.
Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or misused during pregnancy.
Neonatal opioid withdrawal syndrome (NOWS) occurs when in-utero opioid exposure leads to a well-described complex of withdrawal signs and symptoms.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice to identify, reduce, and prevent problematic substance use and dependence.

Substance use during pregnancy is a contributing factor in maternal deaths, poor birth outcomes among infants, and NAS/NOWS, which have significant impact on women, children, families, and society.^[2] Additionally, it is costly for states to treat infants with NAS.[3] Medicaid is the largest payer of pregnancy-related and behavioral health care, including SUD treatment. Medicaid spends an estimated $8.7 billion annually on opioid use disorder (OUD)-related health care costs.^[4] The Substance Abuse and Mental Health Services Administration (SAMHSA) projects that the total share of Medicaid spending on SUD services will increase from 21 percent in 2009 to 28 percent in 2020.[5] As a key payer, Medicaid plays a significant role in covering and delivering services to identify and treat SUD in pregnant women.

Pregnant women and new mothers with SUD have unique needs. As a result of stigma, pregnant women with SUD are more likely to delay prenatal care and experience limited access to critical care during pregnancy.[6] During the postpartum period, women with SUD can experience stigma while caring for an infant with NAS and may lack child care required for them to attend treatment.[7] In addition, pregnant and parenting women may be hesitant to seek SUD treatment or prenatal care for fear of criminal justice or child welfare involvement.[8] Health centers can play a key role in providing high-quality care to pregnant women covered by Medicaid. Seventy-four percent of women attending health centers have early entry into prenatal care and many centers can provide SUD treatment along with prenatal care.[9] Several medical and professional associations recommend universal screening of pregnant and postpartum women for mental health and substance use disorders through a brief counseling intervention and appropriate referral as the standard of care.[10] Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice that providers, including obstetricians and gynecologists, can use to identify, reduce, and prevent problematic substance use and dependence.[11] Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy, including preeclampsia, gestational diabetes, cystic fibrosis, and anemia.[12]

NASHP researched how Medicaid agencies meet the unique needs of pregnant women with SUD by assuring quality measurement addresses that needs are met or other related targeted initiatives. States engage Medicaid providers and managed care organizations to address this issue through a variety of strategies, including a statewide Medicaid opioid strategy, quality measures, financial incentives, waivers and public-private partnerships. Through these efforts, states promote early identification and screening, support provider education, facilitate referral and follow-up, increase access to medication-assisted treatment (MAT), and monitor birth outcomes.

Medicaid SUD Coverage and Benefits for Pregnant Women

State interagency strategies to promote early identification and access to treatment among Medicaid-eligible women with SUD:

Expand postpartum coverage for SUD treatment and facilitate transitions between care settings.
Implement innovative care delivery models that integrate reproductive health care and SUD treatment, offer family-centered treatment, or provide community-based supports to address women’s unique needs.
Consider workforce policies such as provider licensing changes or use of peer support specialists or telehealth to increase access to SUD care in rural areas.
Align financing and policy across systems, such as health care and child welfare.
Educate providers and patients to reduce the stigma associated with pregnant and parenting women accessing SUD treatment.
Involve women who are in recovery in policy design and implementation.

Source State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, NASHP, October 2018.

There is no formal federal definition for the services to pregnant women that states must cover, beyond inpatient and outpatient hospital care. Each state determines the specific scope of maternity benefits for beneficiaries, including those related to SUD identification and treatment. However, state benefits must meet essential coverage guidelines. Behavioral health and SUD minimum essential coverage includes: behavioral health treatment such as psychotherapy and counseling; mental and behavioral health inpatient services; and SUD treatment.^[13]^,[14] Covered SUD services vary from state to state, but typically include detoxification, individual and group therapy, and MAT.

Federal law –The Support for Families and Patients (SUPPORT) Act – underscores the importance of MAT as a treatment approach. The SUPPORT Act requires all states to cover MAT, including all Food and Drug Administration-approved treatment, counseling, and behavioral therapy by 2020.[15] All states currently cover MAT medications, but vary in terms of which medications are covered (buprenorphine, naltrexone, methadone).[16] Currently, more state Medicaid programs cover buprenorphine and naltrexone than methadone. Both buprenorphine and methadone are safe and effective treatments for OUD during pregnancy.^[17]

The SUPPORT Act also provides states with different opportunities to increase access to services for pregnant women with SUD. For example, its Medicaid SUD waiver demonstration seeks to increase Medicaid provider capacity. Fourteen states and Washington, DC received an 18-month planning grant to support ongoing assessment of SUD treatment needs and to bolster the network and treatment capacity of Medicaid providers who offer SUD treatment or recovery services.[18] States also have the opportunity under the SUPPORT Act to waive the exclusion of coverage for services provided in institutions for mental diseases (IMD). This waiver allows states to receive federal financial participation for the continuation of substance use services in residential treatment facilities.[19] Currently, 25 states have waived the IMD exclusion and four states have waiver applications pending.[20]

Examples of State Medicaid Coverage and Quality Improvement Strategies

There are a number of ways states can promote early identification and access to SUD treatment among pregnant and parenting women (see textbox). NASHP’s research identified the following four key strategies that state Medicaid agencies are implementing addressing coverage or quality improvement.

Develop a statewide Medicaid opioid strategy with a focus on pregnant and parenting women.

Medicaid agencies can leverage contracts with managed care organizations (MCOs) to prioritize outreach and enrollment for pregnant women to ensure early identification of SUD, access to services such as MAT, and coordination of services. Tennessee Medicaid (TennCare) has developed an opioid strategy[21] that includes women of childbearing age as a priority population. Tennessee incorporated multiple data sources, including medical claims, pharmacy claims, dental claims, and data from the state’s Prescription Drug Monitoring Database. Then, the state requires the MCOs to use data to engage with and directly outreach to women of childbearing age who may be at risk for developing use disorder and/or having an NAS/NOWS birth. The member engagement and outreach focuses on patient education and linkage of members to primary care, SUD treatment, and behavioral health services. As a result, all MCOs have increased their screening and care coordination efforts and focused on expanding access to high-quality MAT services. A major emphasis has been placed on training and increasing the number of high-quality MAT providers across the state. Additionally, TennCare’s opioid strategy includes partnering with the MCOs and pharmacy benefit managers to implement opioid prescribing guidelines and benefit limits to reduce opioid overexposure for first-time and non-chronic users.

Implement Medicaid incentives or measures to promote SBIRT and increase pregnant women’s access to SUD treatment.

Medicaid agencies can promote women’s access to SBIRT and follow-up treatment through quality measures, provider or MCO incentives, and performance improvement projects (PIPs). (To learn more about state Medicaid agency quality improvement approaches, explore NASHP’s State Medicaid Quality Measurement for Women’s Heath 50-state map). For example, Connecticut’s Department of Social Services (DSS) introduced its Obstetrics Pay-for-Performance (OBP4P) Program in 2013 in order to improve care for pregnant women and the outcomes of their newborns covered by Medicaid.[22] Providers participating in the OBP4P program receive an additional payment on top of the current fee-for-service payments. In 2019, DSS introduced the newest cycle of its OBP4P program which, in addition to improving care for pregnant women and outcomes of newborns, seeks to decrease the incidence of avoidable maternal mortality and morbidity by identifying risk factors, such as substance use.[23] These payments incentivize providers to provide a postpartum visit between 22 and 84 days after delivery in which substance use, along with other health and risk factors, may be addressed.[24]

Florida Medicaid recently kicked off Birth Outcomes Initiatives to reduce primary cesarean-section, pre-term birth, and NAS rates. The state’s Medicaid health plans have committed to achieving regional targets for reducing the rate of NAS each year over a five-year period. The baseline NAS rates statewide were 19.6 per 1,000 live births in 2016 and 17.7 per 1,000 live births in calendar year 2017. The common interventions the health care plans are implementing to reach their targets include substance misuse treatment programs, healthy behavior programs, provider engagement, and value-based payment/incentive programs. Specific interventions for substance use programs include early identification of pregnant women using opioids and increased access and referrals to MAT. The Healthy Behavior Programs include incentives to reward members for meeting medication and substance use treatment milestones. Different ways to engage providers include education on early identification and referrals as well as training in SBIRT.[25]

Leverage waivers to expand coverage and access to SUD treatment.

States use Medicaid waivers to promote innovation, including expanding coverage and access to SUD treatment. Within federal Medicaid waiver guidance, states can specifically focus on care for pregnant women with SUD. Vermont’s 1115 waiver facilitates a multi-faceted approach to addressing the opioid epidemic that includes:

Preventing SUD/opioid use disorder (OUD);
Creating a continuum of care for SUD/OUD treatment and recovery;
Aligning with the American Society of Addiction Medicine Level of Care guidelines;
Using evidence-based patient placement criteria; and
Monitoring provider capacity.

As part of its continuum of care for SUD/OUD treatment and recovery, Vermont offers several residential programs for people covered by Medicaid, Medicare, or commercial insurance and for self-payers. A specialized 26-bed residential program exists specifically for pregnant women and mothers with children under the age of five. These programs provide access to a variety of professionals and services, including services for individuals with co-occurring needs and clinically necessary MAT services.[26] The Department of Vermont Health Access and the Department of Children and Families are responsible for quality oversight of this specialized residential program.[27]

Participate in public-private partnerships to promote access to coordinated, team-based care for women

State Medicaid agencies also can participate in innovative public-private partnerships that help finance care for pregnant women with SUD. The partnerships can support pilots to demonstrate impact or help scale up initiatives with demonstrated success. Hospital-based quality improvement projects support innovation in coordinated inpatient care. In Florida, Medicaid is on the steering committee of the state’s Perinatal Quality Collaborative (FPQC) and administers two of the FPQC’s performance improvement projects. The Neonatal Abstinence Syndrome (NAS) Performance Improvement Project is working to standardize NAS management with Florida NICUs and decrease the length of stay related to NAS. The Maternal Opioid Recovery Effort (MORE) Performance Improvement Project focuses on improving treatment and care within hospital delivery systems for pregnant women affected with OUD. These quality improvement projects run in parallel with each other with the overall goal of improving birth outcomes, identification, clinical care and coordinated treatment for pregnant women and their infants.^[28]

Montana Medicaid and the Montana Health Care Foundation partnered to form the Perinatal Behavioral Health Initiative (PBHI). PBHI aims to improve timely access to care and outcomes for pregnant and postpartum women experiencing behavioral health challenges. The initiative will provide funding and technical assistance to allow medical practices to implement a coordinated and team-based approach for women with SUD or mental illness. The teams will include obstetric providers, behavioral health specialists, and care coordinators.[29]

Conclusion

States are innovating new ways to provide access to SUD treatment for pregnant women enrolled in Medicaid. Promoting early identification of SUD, increasing access to MAT, and focusing on improving birth outcomes are strategies states use to improve treatment and outcomes for pregnant women with SUD. State Medicaid agencies leverage waivers, public-private partnerships, MCO guidance and engagement, and performance-based measures and incentives to promote early identification and access to treatment for Medicaid-eligible pregnant women to decrease costs and improve the lives of women and their families.

Notes

[1] Jilani SM, Frey MT, Pepin D, et al. Evaluation of State-Mandated Reporting of Neonatal Abstinence Syndrome — Six States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;68:6–10. DOI: http://dx.doi.org/10.15585/mmwr.mm6801a2

[2] Winkelman, Tyler NA, Nicole Villapiano, Katy B Kozhimannil, Matthew M Davis, and Stephen W Patrick. “Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014.” Pediatrics 141, no. 4 (April 2018). https://pediatrics.aappublications.org/content/141/4/e20173520.

[3] Corr, Tammy E., and Christopher S. Hollenbeak. “The Economic Burden of Neonatal Abstinence Syndrome in the United States.” Addiction 112, no. 9 (June 13, 2017): 1590–99. https://doi.org/10.1111/add.13842.

[4] Corwin Rhyan, “The Potential Societal Benefit of Eliminating Opioid Overdoses, Deaths, and Substance Use Disorders Exceeds $95 Billion Per Year,” Center for Value in Health Care, November 2017, https://altarum.org/sites/default/files/uploaded-publication-files/Research-Brief_Opioid-Epidemic-Economic-Burden.pdf

[5] Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020.pg 41. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. https://store.samhsa.gov/system/files/sma14-4883.pdf

[6] Davida Schiff et al., “Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts,” Obstetrics & Gynecology 132, no. 2 (August 2018): 466-474, https://doi.org/10.1097/AOG.0000000000002734

[7] Normile, Becky, Carrie Hanlon, and Hannah Eichner. “State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.” National Academy for State Health Policy, October 30, 2018. https://www.oldsite.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf.

[8] Normile, Becky, Carrie Hanlon, and Hannah Eichner. “State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.” National Academy for State Health Policy, October 30, 2018. https://www.oldsite.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf.

[9] “Quality of Care Measures.” Health Center Data. Health Services Resource Administration. Accessed November 1, 2019. https://bphc.hrsa.gov/uds/datacenter.aspx?q=t6b&year=2018&state=.

[10] Opioid Use and Opioid Use Disorder in Pregnancy.” ACOG Committee Opinion, no. 711 (August 2017). https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy.

[11] Opioid Use and Opioid Use Disorder in Pregnancy.” ACOG Committee Opinion, no. 711 (August 2017). https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy.

[12] Wright, T.E., Terplan, M., Ondersma, S.J., Boyce, C., Yonkers, K., et al. (2016). The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics & Gynecology, 215(5), 539-547.

[13] “Mental Health and Substance Abuse Health Coverage Options.” HealthCare.gov. Accessed October 16, 2019. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/.

[14] Gifford, Kathy, Jenna Walls, Usha Ranji, Alina Salganicoff, and Ivette Gomez. “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey.” The Henry J. Kaiser Family Foundation, June 19, 2019. https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-perinatal-benefits-results-from-a-state-survey/.

[15] Walden, and Greg. “H.R.6 – 115th Congress (2017-2018): SUPPORT for Patients and Communities Act.” Congress.gov, October 24, 2018. https://www.congress.gov/bill/115th-congress/house-bill/6.

[16] Published: Jun 03, 2019. “Medicaid’s Role in Addressing the Opioid Epidemic.” The Henry J. Kaiser Family Foundation, July 15, 2019. https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/

[17] National Institute on Drug Abuse. “Treating Opioid Use Disorder During Pregnancy.” NIDA, July 2017. https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy/treating-opioid-use-disorder-during-pregnancy.

[18] “Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act: Section 1003.” Medicaid.gov. Accessed October 16, 2019. https://www.medicaid.gov/medicaid/benefits/bhs/support-act-provider-capacity-demos/index.html.

[19] Cash, Judith. Strategies to Address the Opioid Epidemic, Strategies to Address the Opioid Epidemic § (2017). https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf

[20] “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State.” The Henry J. Kaiser Family Foundation, October 9, 2019. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.

[21] “TennCare’s Opioid Strategy.” Tennessee State Government – TN.gov. Accessed October 17, 2019. https://www.tn.gov/tenncare/tenncare-s-opioid-strategy.html.

[22] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2014). https://www.huskyhealthct.org/providers/provider_postings/Obstetric_Pay_for_Performance_Program.pdf.

[23] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2019). https://www.huskyhealthct.org/providers/provider_postings/OBP4P_PayForPerformance.pdf

[24] Obstetric Pay for Performance Program, Obstetric Pay for Performance Program § (2019). https://www.huskyhealthct.org/providers/provider_postings/OBP4P_PayForPerformance.pdf

[25] Statewide Medicaid Managed Care Quality Initiatives Public Meeting, Statewide Medicaid Managed Care Quality Initiatives Public Meeting § (2019). https://ahca.myflorida.com/Medicaid/Policy_and_Quality/Quality/QI-initiatives/Stakeholder_Meeting_Presentation_FINAL012519_v1_Shared.pdf.

[26] Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017, Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017 § (2017). https://dvha.vermont.gov/global-commitment-to-health/vt-gc-1115-waiver-sud-amendment-draft-for-public-notice.pdf.

[27] Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017, Section 1115(a) Demonstration Amendment Request to CMS – Draft for Public Notice 12/14/2017 § (2017). https://dvha.vermont.gov/global-commitment-to-health/vt-gc-1115-waiver-sud-amendment-draft-for-public-notice.pdf.

[28] “Florida Perinatal Quality Collaborative.” Florida Perinatal Quality Collaborative | USF Health. Accessed October 17, 2019. https://health.usf.edu/publichealth/chiles/fpqc.

[29] “The Meadowlark Initiative.” Montana Healthcare Foundation – Helping to change the lives of people across Montana through innovative healthcare services. Accessed October 17, 2019. https://mthcf.org/the-meadowlark-initiative/.

Acknowledgements: Thank you to the officials in Connecticut, Florida Tennessee, Montana, and Vermont for reviewing their respective highlighted strategies, and to our project officer Kelsi Feltz and her colleagues at the Health Resources and Services Administration for their feedback and guidance. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, 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.

Medicaid Incentives, Performance Measures, and Workforce Innovations Foster Access to Pediatric Oral Health Care

November 15, 2019/in Medicaid Managed Care Featured News Home, Reports Child Oral Health, CHIP, CHIP, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Health IT/Data, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Oral Health, Population Health, Program Design, Safety Net Providers and Rural Health, Special Populations and Services, Workforce Capacity /by Carrie Hanlon and Malka Berro

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.

Source: Pennsylvania Code, Chapter 33, section 33.205b

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.

https://dental.pacific.edu/news-and-events/news-archive/pacific-center-receives-more-than-35-million-in-grants-for-virtual-dental-home

[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.

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