Oral Health:

Efforts Under Way to Improve Children's Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns

GAO-11-96: Published: Nov 30, 2010. Publicly Released: Nov 30, 2010.

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The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) required GAO to study children's access to dental care. GAO assessed (1) the extent to which dentists participate in Medicaid and the Children's Health Insurance Program (CHIP) and federal efforts to help families find participating dentists; (2) data on access for Medicaid and CHIP children in different states and in managed care; (3) federal efforts to improve access in underserved areas; and (4) how states and other countries have used mid-level dental providers to improve children's access. To do this, GAO (1) examined state reported dentist participation and the Department of Health and Human Services's (HHS) Insure Kids Now Web site for all 50 states and the District of Columbia and called a non-representative sample of dentists in four states; (2) reviewed national data on provision of Medicaid dental services and use of managed care; (3) interviewed HHS officials and assessed certain HHS dental programs; and (4) interviewed officials in eight states and four countries on the use of mid-level and other dental providers.

Obtaining dental care for children in Medicaid and CHIP remains a challenge, as many states reported that most dentists in their state treat few or no Medicaid or CHIP patients. And, while HHS's Insure Kids Now Web site--which provides information on dentists who serve children enrolled in Medicaid and CHIP--has the potential to help families find dentists to treat their children, GAO found problems, such as incomplete and inaccurate information, that limited the Web site's ability to do so. For example, to test the accuracy of the information posted on the Web site, GAO called 188 dentists listed on the Web site in low-income urban and rural areas in four states representing varied geographic areas and levels of dental managed care and with high numbers of children in Medicaid. Of these 188 contacts, 26 had wrong or disconnected phone numbers listed, 23 were not taking new Medicaid or CHIP patients, and 47 were either not in practice or no longer performing routine exams. Although improved since 2001, available national data show that in 2008, less than 37 percent of children in Medicaid received any dental services under that program and that several states reported rates of 30 percent or less. Further, although some data indicate that children in Medicaid managed care may receive less dental care than other children, comprehensive and reliable data on dental services under managed care continue to be unavailable despite long-standing concerns. Although HHS has not required states to report information on the provision of dental services under CHIP, CHIPRA requires states to begin reporting this information for fiscal year 2010. Two programs that provide dental services to children and adults in underserved areas--HHS's Health Center and National Health Service Corps (NHSC) programs--have reported increases in the number of dentists and dental hygienists practicing in underserved areas, but the effect of recent initiatives to increase federal support for these and other oral health programs is not yet known. Despite these increases, both health centers and the NHSC program report continued need for additional dentists and other dental providers to treat children and adults in underserved areas. Mid-level dental providers--providers who may perform intermediate restorative services, such as drilling and filling teeth, under remote supervision of a dentist--are in limited use in the United States. The only currently practicing mid-level dental providers in the United States serve Alaska Natives. Efforts to supplement the U.S. dental workforce with mid-level and other types of providers are under way. GAO interviewed officials from eight states with varied state laws related to dental providers. Some states have made efforts to increase children's access by reimbursing dental hygienists and primary care physicians for providing certain dental services. Some countries have long-standing programs that use mid-level dental providers, also known as dental therapists, who the countries report have improved children's access to dental services. GAO recommends that HHS take steps to improve its Insure Kids Now Web site and ensure that states gather complete and reliable data on Medicaid and CHIP dental services provided under managed care. HHS agreed with the recommendations, citing specific actions it would take.

Recommendations for Executive Action

  1. Status: Open

    Comments: CMS has reported taking steps to improve data on the Insure Kids Now website, including conducting validation surveys in 2011, 2012, and 2013, and establishing a system to check that data are in the correct format. The agency has not yet addressed the need for states and particpating dentists to have a common understanding of what it means to indicate that a dentist can treat a child with special needs.

    Recommendation: To enhance the provision of dental care to children covered by Medicaid and CHIP, and to help ensure that HHS's Insure Kids Now Web site is a useful tool to help connect children covered by Medicaid and CHIP with participating dentists who will treat them, the Secretary of HHS should establish a process to periodically verify that the dentist lists posted by states on the Insure Kids Now Web site are complete, usable, and accurate, and ensure that states and participating dentists have a common understanding of what it means for a dentist to indicate he or she can treat children with special needs.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: The 1-877-KIDS-NOW phone number is listed on the home page and every state specific web page, as a back up for when links from the website are not functional.

    Recommendation: To enhance the provision of dental care to children covered by Medicaid and CHIP, and to help ensure that HHS's Insure Kids Now Web site is a useful tool to help connect children covered by Medicaid and CHIP with participating dentists who will treat them, the Secretary of HHS should provide alternate sources of information, such as HHS's toll-free 1-877-KIDS-NOW telephone number, on the Insure Kids Now Web site when a page or link from the Web site is not functioning or taken offline for maintenance.

    Agency Affected: Department of Health and Human Services

  3. Status: Open

    Comments: CMS reported that it does not require states to verify that excluded providers are not listed on the Insure Kids Now website, nor does it conduct any such verification itself.

    Recommendation: To enhance the provision of dental care to children covered by Medicaid and CHIP, and to help ensure that HHS's Insure Kids Now Web site is a useful tool to help connect children covered by Medicaid and CHIP with participating dentists who will treat them, the Secretary of HHS should require states to verify that dentists listed on the Insure Kids Now Web site have not been excluded from Medicaid and CHIP by the HHS-OIG, and periodically verify that excluded providers are not included on the lists posted by the states.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: CMS has revised the instructions for its Form-416, beginning in FY 2014, to specify that fields collecting data on dental service utilization be inclusive of Medicaid beneficiaries enrolled in managed care.

    Recommendation: To enhance the provision of dental care to children covered by Medicaid and CHIP, and to strengthen CMS oversight of Medicaid and CHIP dental services provided by dental managed care programs, the Administrator of the Centers for Medicare & Medicaid Services (CMS) should take steps to ensure that states gather comprehensive and reliable data on the provision of Medicaid and CHIP dental services by managed care programs.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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