Pennsylvania Dental Journal Vol. 77, No. 5 • September/October 2010

19

Evaluating Children’s Access to Dental Services 32

Building Alliances for Better Oral Health 35

Harrisburg Smiles

T H A Y E R

D E N T A L

L A B O R A T O R Y ,

I N C .

Thayer’s discount policy doesn’t rely on coupons or gimmicks . . . Thayer Dental Laboratory has offered the same volume discount to its customers for over 30 years. We don’t offer special coupons to anyone - and we only have one price list for all our customers. Our discount policy treats everyone fairly. Pay your statement balance by the 10th of the month: For balances of $5,000 or more take 10% off your statement balance if you pay by check - or 8% by credit card. For balances of $2,500 to $4,999 take 5% off your statement balance if you pay by check - or 3% by credit card.

... that’s a smart move.

For balances of $250 to $2,499 take 2% off your statement balance if you pay by check. It’s just that simple.

THAYER DENTAL LABORATORY, INC. 131 Old Schoolhouse Lane • P.O. Box 1204 Mechanicsburg, PA 17055 717-697-6324 • 800-382-1240 • fax: 717-697-1412

www.thayerdental.com “ Yo u r

P a r t n e r

i n

M a s t e r i n g

N e w

Te c h n o l o g i e s ”

®

P e n n s y l v a n i a D e n t a l J o u r n a l • w w w. p a d e n t a l . o r g

Dr. Bruce R. Terry (Editor) 85 Old Eagle School Road, Wayne, 19087-2524 (610) 995-0109 • [email protected]

4th...Dr. Michael S. Shuman…2013 ● 1052 Park Road, Blandon, 19510-9563 (610) 916-1233 • [email protected]

Dr. Joseph J. Kohler III (Associate Editor) 219 W. 7th Street, Erie, 16501-1601 (814) 452-4838 • [email protected]

5th...Dr. David R. Larson…2013 ● 1305 Middletown Rd. Ste 2 Hummelstown, 17036-8825 (717) 566-9797 • [email protected]

Dr. Brian Mark Schwab (Associate Editor) 1021 Lily Lane, Reading, 19560-9535 (610) 926-1233 • [email protected] Rob Pugliese (Director of Communications) P.O. Box 3341, Harrisburg, 17105 (800) 223-0016 • FAX (717) 234-2186 [email protected] Dr. Richard Galeone (Editor Emeritus) 3501 North Front Street, Harrisburg, 17110 (717) 234-5941 • FAX (717) 234-2186 [email protected] Dr. Judith McFadden (Editor Emerita) 3386 Memphis Street, Philadelphia, 19134 (215) 739-3100 Officers Dr. William T. Spruill (President) ✸ 520 South Pitt Street, Carlisle, 17013-3820 (717) 245-0061 • [email protected] Dr. Dennis J. Charlton (President-Elect) ✰✸ P.O. Box 487 • Sandy Lake, 16145-0487 (724) 376-7161 • [email protected] Dr. Andrew J. Kwasny (Immediate Past President) 3219 Peach Street • Erie, 16508-2735 (814) 455-2158 • [email protected] Dr. Gary S. Davis (Vice President) ✸ 420 East Orange St. • Shippensburg, 17257-2140 (717) 532-4513 • [email protected]

7th...Dr. Wade I. Newman...2014 Bellefonte Family Dentistry 115 S. School St., Bellefonte, 16823-2322 (814) 355-1587 • [email protected] 8th...Dr. William J. Weaver...2011 ✰ Brookville Dental, 123 Main Street Brookville, 15825-1212 (814) 849-2652 • [email protected] 9th...Dr. William G. Glecos...2012 3408 State Street, Erie, 16508-2832 (814) 459-1608 [email protected] 10th...Dr. Donald A. Stoner...2011 ✸● Oakmont Dental Associates 154 Allegheny River Blvd., Oakmont, 15139-1801 (412) 828-7750 • [email protected] ADA Third District Trustee Dr. Charles R. Weber 606 East Marshall Street, Ste 103 West Chester, PA 19380-4485 (610) 436-5161 • [email protected] PDA Committee Chairs

Dr. Peter P. Korch III (Speaker) ●● 4200 Crawford Ave., NorCam Bldg. 3 P.O. Box 1388, Northern Cambria, 15714-1388 (814) 948-9650 • [email protected]

Communications & Public Relations Committee Dr. David A. Tecosky

Dr. Jeffrey B. Sameroff (Secretary) ●✸ 800 Heritage Dr., Ste 811 • Pottstown, 19464-9220 (610) 326-3610 • [email protected]

Government Relations Committee Dr. Herbert L. Ray, Jr.

Dr. R. Donald Hoffman (Treasurer) ✰✰✸ 105 Penhurst Drive, Pittsburgh, 15235 (412) 648-1915 • [email protected]

Dental Benefits Committee Dr. Tad S. Glossner

Membership Committee Dr. Karin D. Brian Access to Care Committee Dr. Joseph R. Greenberg

Trustees By District

Annual Awards Committee Dr. Craig Eisenhart

1st...Dr. Thomas P. Nordone…2013 ✰ 207 N. Broad Street, Philadelphia, 19107-1500 (215) 557-0557 • [email protected]

Concerned Colleague Committee Dr. Bartley J. Morrow

2nd...Dr. Bernard P. Dishler...2011 ✸ Yorktowne Dental Group Ltd. 8118 Old York Road Ste A, Elkins Park, 19027-1499 (215) 635-6900 • [email protected] 3rd...Dr. D. Scott Aldinger...2012 ✰✸ 8555 Interchange Road, Lehighton, 18235-5611 (610) 681-6262 • [email protected]

2

6th...Dr. John P. Grove...2011 PO Box 508, Jersey Shore, 17740-0508 (570) 398-2270 • [email protected]

September/October 2010 • Pennsylvania Dental Journal

Environmental Issues Committee Dr. Marian S. Wolford Forensic Odontology Committee Dr. Jeff D. Aronsohn New Dentist Committee Dr. Brian Mark Schwab

PDA Central Office 3501 North Front Street P.O. Box 3341, Harrisburg, 17105 (800) 223-0016 • (717) 234-5941 FAX (717) 232-7169 Camille Kostelac-Cherry, Esq. Chief Executive Officer [email protected]

Pennsylvania Dental Journal

Mary Donlin Director of Membership [email protected]

The Official Publication of the Pennsylvania Dental Association September/October 2010 • Volume 77, Number 5

Marisa Swarney Director of Government Relations [email protected]

Features

Rob Pugliese Director of Communications [email protected] Rebecca Von Nieda Director of Meetings and Administration [email protected] Leo Walchak Controller [email protected]

19

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services by Monica Costlow, JD and Dr. Judith Lave

26

A Survey of Senior Dental Students’ Experiences with Young Dental Patients in Pennsylvania by Rochelle G. Lindemeyer, DMD

32

Building Alliances for Better Oral Health by Paul R. Westerberg, DDS

35

Harrisburg Smiles by Rob Pugliese, Director of Communications

Board Committees Legend ✸ Executive Committee ✸✸ Chairman ✰ Budget, Finance & Property ✰✰ Chairman ● Bylaws Committee ●● Chairman

Departments EDITORIAL Board Dr. Daniel Boston Dr. Allen Fielding Dr. Marjorie Jeffcoat Dr. Kenneth G. Miller Dr. Andres Pinto Dr. Deborah Studen-Pavlovich Dr. James A. Wallace Dr. Charles R. Weber Dr. Gerald S. Weintraub

5 7 9 13 17 41 45 47 49 51 55

Impressions Letter to the Editor Government Relations Membership Matters It’s Your Money In Memoriam Cyber Salon Awards & Achievements Insurance Connection Continuing Education Classified Advertisements

The mission of the Pennsylvania Dental Journal is to serve PDA members by providing information about topics and issues that affect dentists practicing in Pennsylvania. The Journal also will report membership-related activities of the leadership of the association, proceedings of the House of Delegates at the annual session and status of PDA programs. PENNSYLVANIA DENTAL JOURNAL (ISSN 0031-4439), owned and published by the Pennsylvania Dental Association, 3501 North Front Street, Harrisburg, 17110, is published bi-monthly: Jan/Feb, Mar/Apr, May/June, July/Aug, Sept/Oct, Nov/Dec. Address advertising and subscription queries to 3501 North Front Street, P.O. Box 3341, Harrisburg, 17105. Domestic subscriptions are available to persons not eligible for membership at $36/year; International subscriptions available at $75/year. Single copies $10. Periodical postage paid at Harrisburg, PA. “The Pennsylvania Dental Association, although formally accepting and publishing reports of the various standing committees and essays read before the Association (and its components), holds itself not responsible for opinions, theories, and criticisms therein contained, except when adopted or sanctioned by special resolutions.” The Association assumes no responsibility for any program content of lectures in continuing education programs advertised in this magazine. The Association reserves the right to refuse any advertisement for any reason. Copyright ©2010, Pennsylvania Dental Association. POSTMASTER: Send address changes to Pennsylvania Dental Association, P.O. Box 3341, Harrisburg, PA 17105. MEMBER: American Association of Dental Editors

September/October 2010 • Pennsylvania Dental Journal

3

4

September/October 2010 • Pennsylvania Dental Journal

Impressions Are You My Dentist? Jane Smith (name and details modified to protect her identity) was your average dental patient. She needed a filling but didn’t have dental insurance. She lived in northern New Jersey and found every dentist to be too expensive. She had a friend tell her about Dr. Maria Mendel (her real name). Her friend told her that Dr. Mendel worked out of her apartment and was very cheap. So, Jane made an appointment and went to see Dr. Mendel. The office didn’t look like any other office she had been to before. It looked more like someone’s living room. After an oral exam, Jane was told that she needed a few fillings. No radiographs were taken and Dr. Mendel said that no local anesthetic was needed since the cavities were not very deep. Dr. Mendel didn’t use a drill. She said the cavity was soft and just need to be scooped out with a dental instrument. The fillings were pretty easy to do and Jane thought she had found herself a new dentist. A few weeks later one tooth began to hurt. She went back to Dr. Mendel and was told that everything was fine. She went back a few more times and felt that Dr. Mendel didn’t want to see her any longer. Because her tooth continued to hurt, she went to another dentist who took a radiograph and performed an examination. He thought something looked strange and called Dr. Mendel. Bill Jones (name and details also changed) had heard about a dentist near his apartment in the Atlanta suburb of Roswell, Ga., named Dr. Ardilla-Ramirez (real name). Bill also was looking for affordable dental care. He had lost his job a year earlier

D r. B r u c e R . Te r r y

and had no money or benefits for dental care. He had a badly decayed tooth and wanted an extraction. Dr. Ardilla-Ramirez seemed professional with her lab coat on. Her office had a TV style lounge chair rather than a standard dental chair. Bill thought it was odd, but it was really comfortable. Dr. Ardilla-Ramirez didn’t accept insurance or credit cards. She only took cash. She had three others waiting on a sofa in the same room while she extracted Bill’s tooth. A week later, with an infection, Bill returned to the dentist, but the dentist told him everything was fine. Bill eventually went to an oral surgeon who found half of the roots remaining, and when he asked who the dentist was that did the extraction, the surgeon was surprised that he had never heard of Dr. Ardilla-Ramirez. Dr. Tim Gurley (real name) practiced with his father for nearly 10 years. He helped his dad as he eased into retirement mode. New patients and

some current patients of his father’s became Tim’s patients. He performed extractions, restored implants and made dentures. They were all living the American dream. Hardworking, dedicated practitioners, seeing patients every day. They practiced general dentistry and had many patients. Maria Mendel, 47, from Bound Brook N.J., Martha Gabi Ardilla-Ramirez, 49, of Roswell Ga., and Tim Gurley, 40, of Tampa, Fla. Maria practiced out of her home in northern New Jersey. Martha alsopracticed out of her home in the Atlanta suburb of Roswell. Tim practiced in the Tampa office of his father Dr. Max Gurley. While each practice was different, they all shared one very important attribute. Maria and Martha had each practiced for less than one year while Tim had practiced for nearly 10 years. What was the one thing they all had in common? They were all found to be practicing dentistry without a license! Their respective State Boards caught each of them after numerous complaints were filed. In each case, patients went to a new dentist with a common complaint of poor dental work. When the new dentist questioned the work of the previous dentist, each found that the dentistry was done by someone they didn’t know. Maria worked out of one room with a mix of questionable equipment. She was also in possession of narcotic medication without a license to prescribe or dispense. Martha, originally from Bogotá, Columbia, also practiced out of a room with a lounge chair rather than a standard dental chair (continued on page 6)

September/October 2010 • Pennsylvania Dental Journal

5

Impressions and used mostly hardware store style tools and a Dremel like tool rather than standard dental instruments. Tim had been extracting teeth, among other procedures. Although he was only a dental assistant, he had been practicing dentistry under the supervision of his father, Dr. Max Gurley. None of these individuals went to dental school abroad or in the United States. Maria and Martha hardly had a normal practice. Each worked in her apartment or a rented room. Their patients had to be aware that they weren’t for real. Was it denial because of the affordability? I seriously doubt that these two women accepted dental insurance, so it was a fee-for-service business. All dentists dream of a feefor-service practice. These imposters figured out how to get this coveted patient population into their chairs, DentalEz and Barcalounger alike. One of the biggest medical problems facing our society today is access to dental care. The complexity of the problem has all levels of organized dentistry and government scrambling for solutions. It also has dental patients seeking care in unlikely places. Dentists volunteering their time have been one important solution. Each year, hundreds of thousands of hours are donated around the world to provide needed dental care to those less fortunate. From the far Asian continent to our neighborhoods, dentists, dental students and dental hygienists proudly give their time and materials to help others. Medicaid is another component to the problem. The government reimburses providers at levels so low that it hardly pays to offer their services. With delay of claims and the number of no-show patients, the dental Medicaid system is seriously flawed. But, it continues to operate and

6

provide needed care to many patients. The dentists who stay in this system are the real heroes. Local nonprofit dental clinics also help fill the dental care gap. Dentists either volunteer to work in a clinic or agree to see patients in their own offices at no cost. This is a very generous solution, but there are too many patients and too few dentists. More importantly, we are not going to solve the access issue with charity alone. Dental schools also help, but they operate as a business and do not generally offer free dental care. They must make money to cover their costs. In fact, most dental schools don’t even break even with the fees charged in the dental clinic. It’s time to stop blaming the lack of access to care on someone else and time to start trying to help. Anyone

September/October 2010 • Pennsylvania Dental Journal

who is not for one solution or another must come up with an alternative, otherwise they are just part of the problem. If we try something and it doesn’t work, then we will have to try something else. It’s too easy to just say, “it’s complicated and can’t be solved.” I don’t want to see us mandated to do things. I would rather we continue to solve and promote what we do so well, help others in need. Just do a daily search for the keyword “dental” under Google News and you will see at least three news items each day about dentists helping in their community. That is the message we need to continue to promote – dentists are part of the solution, not part of the problem. As far as unlicensed dentistry, it goes to show you that we are envied by others and trusted by many. —BRT

Letters to the Editor Dear Dr. Terry: In reviewing the Insurance Connection in the May/June 2010 issue of the Pennsylvania Dental Journal, it appears to me that the more things change, the more they stay the same. It absolutely blows my mind to think that fellow practitioners will sign an agreement which allows a third party carrier to dictate the fees which they can charge in their dental office for non-covered services. But, that report says 85 percent of the participants in the UCCI plan signed that contract. Are we really that ignorant, as lambs being led to the slaughter? For years, the PDA committee that addresses dental insurance issues, which has been known by numerous committee titles, in addition to the ADA Council on Dental Benefit Programs, has struggled to protect our inalienable right to charge fees that we think are appropriate based upon the technology, the time, the materials and the difficulty of procedure. Each and every dental office must decide for itself what fee is appropriate for each service that is provided and this is as it should be. However, to acquiesce to the dental insurance industry telling us what fees we can charge is appropriate to dental socialism. The various committees have struggled with this issue because many of our colleagues will readily agree to have a third-party carrier dictate the fees that they charge for specific services. Unfortunately, this puts those of us who refuse to participate in these plans at a distinct disadvantage, as patients will constantly hassle us to reduce our fees or they will leave our practice and go to that of a “participant.”

In Pennsylvania, we are attempting to have legislation passed which will prohibit insurance companies from the practice of dictating fees for services that they do not cover. In the journal article it states that UCCI does not have plans to change this policy unless the Pennsylvania General Assembly passes legislation prohibiting this insurance practice. The bottom line, my dear colleagues, is that we must become proactive and contact our legislators on this important issue. Rest assured that the coffers of UCCI and the other third parties are funding our legislators’ PACs much more than we as individuals can do. However, if we continue to try and remain unified and support this legislative activity, just maybe, we may obtain success in the passing of this important legislation. But, on the other hand, apparently 85 percent of the participants could care less whether or not the legislature acts on this issue. We can only continue to hope. Sincerely, George A. Kirchner, DDS

Dear Editor: I enjoyed reading Dr. Mark Funt’s “It’s Your Money” piece on health care reform (July/August), since it’s always stimulating to read a strong opinion even when you don’t agree with it. I can appreciate Dr. Funt’s pro-free market, anti-big government philosophy, although the idea that government is the problem rather than the solution would seem to have been an easier sell back in the 1980s than in 2010 (Halliburton? BP? Enron? Blackwater? Bernie Madoff?). But I was disappointed that Dr. Funt ended his article by repeating a story that’s

been going around that Congressional staffers, who helped write the Health Care Reform legislation, put in a loophole exempting themselves from the new law. On the face of it, the implication is that these liberal policy wonks, who, despite having devoted years writing and rewriting a national health care bill, in their heart of hearts know the bill isn't any good, and so they surreptitiously hid a clause deep in the bowels of the bill to exempt themselves, and only themselves. Sort of a DaVinci Code scenario. But alas, as with so many sources of right-wing outrage sailing through the Internet and over the radio waves, there is much less fire here than smoke. A nonpartisan website, FactCheck.org, explains that all members of Congress and their staffs are covered by the new health care bill. The exemption issue came up because of some overly specific wording in a Republican amendment to the bill, regarding which government employees would be required to buy their insurance through the new state exchanges. Both parties realize the need to correct the wording. There is no hidden agenda. Passing on a half-truth like this is not harmless. Our nation has been paralyzed by distrust of government, and more and more politicians are elected not to improve government, but to dismantle it. You may believe, as I do, that the health care law is a brave, if incomplete, attempt to right serious injustices in our health care system, or you may believe that the whole thing is a huge boondoggle, but in making our point, let’s not fan the flames of anti-government paranoia. Jay Cohen, DMD (continued on page 8)

September/October 2010 • Pennsylvania Dental Journal

7

Letters to the Editor Editor’s Note: Following is Dr. Funt’s response to some of Dr. Cohen’s assertions. Dear Jay: I agree with your comments on the Enrons of the world, and I addressed that issue in my article. You will be glad to know that I do not believe the recently passed financial regulation bill went far enough in solving such problems, especially in regards to the “too big to fail” concept. I visited the FactCheck website, which is from the Annenberg Public Policy Center out of the University of Pennsylvania. The most recent article on the reform bill that I could find was “More Malarkey About Health Care” dated April 19, 2010. The article does conclude “that some Capitol Hill staff workers may still continue to get coverage the same way they always have,” meaning they will not be subject to the new health care bill. I guess the details still need to be worked out. Finally, I am not anti-government and we could debate what role government should play in the private sector, but the crux of the article was my opinion on how I feel the new health care law will continue to add to our deficit and how that deficit will affect the economy in general and investors in particular. Only time will tell which one of your two scenarios will play out regarding the health care bill. I appreciate your comments. It is our ability to disagree and discuss our differences that makes America great. Mark

8

September/October 2010 • Pennsylvania Dental Journal

Government Relations Pennsylvania General Assembly The Pennsylvania General Assembly returned to Harrisburg in midSeptember as PDA geared up for election season and the end of the legislative session. Many of our legislative initiatives remained undone when the General Assembly adjourned for the summer. Our first priority is to pass SB 1222 before the session ends in November. This bill would prohibit all insurance companies from capping fees on services they do not cover under their plans. We know this is an issue that resonates with many members who participate with insurance plans. PDA continues to monitor and respond to a number of other legislative issues, advocating for the profession and your patients on issues such as assigning benefits to non-participating providers, limiting insurers’ ability to retroactively deny claims, the use of dental amalgam, health care practitioner loan forgiveness and policymakers’ call to assess the ability for the underserved and special needs patients to access dental care. We cannot accomplish these legislative goals without your help. Please take a few minutes to respond to the CapWiz action alerts PDA sends periodically to those members with email addresses, or sign up today to serve as a grassroots contact dentist for your representative and senator. Stay tuned for information about the 2011 Day on the Hill, which is slated for June 14. You’ll find a registration form in the November/December issue of the Journal. All members, spouses and dental students are encouraged to attend.

on convincing members of the House Appropriations Committee to consider the bill. HB 1049 has not moved from this committee.

Below are insights on some of the issues that PDA will address before the end of the year. Legislation that does not pass will need to be reintroduced next year. • SB 1222, prohibiting insurers from capping non-covered services: PDA is working hard to correct an unfair insurance practice that allows insurers to cap those services not covered under their dental plans. This policy will significantly impact your business operation and patients. SB 1222, introduced on PDA’s behalf by Sen. Kim Ward (R-Westmoreland), was a primary focus for attendees during Day on the Hill on June 8. Those who attended were instrumental in having SB 1222 pass out of the Senate Banking and Insurance Committee that same day. PDA is working to educate all senators about the need to pass this legislation. Please refer to the August edition of Transitions to find out how you can help pass this bill. • HB 1049, insurance coverage for general anesthesia when needed for dental treatment for children seven years of age and younger and special needs patients: HB 1049 would allow dentists to use their clinical judgment whether certain children under the age of seven need general anesthesia so they can provide quality dental care. The bill also would extend coverage to any special needs patient of any age. While it is difficult to pass insurance mandates, we are encouraged that this bill has the momentum to pass the House of Representatives. Having been approved by the House Insurance Committee in October 2009, PDA began focusing its energy

• HB 2509, Assignment of Benefits: This legislation would require insurers to assign benefits to those providers who are not participating providers in their patients’ insurance plans. Rep. Thomas Murt (R-Montgomery) introduced HB 2509 on PDA’s behalf and it is now before the House Insurance Committee for consideration. Though it is unlikely this legislation will pass either chamber before the end of session, PDA is now educating lawmakers about this issue, with the intent of reintroducing the bill next session.

State Board of Dentistry The State Board of Dentistry (SBOD) is working on a number of issues impacting the profession, including who has the ability to administer Botox and teeth whitening material. The SBOD is also finalizing its plans for how to implement the new legislation that passed expanding the scope of practice for expanded function dental assistants (EFDAs). Allowing EFDAs to perform expanded duties allowed under Act 19 At its July meeting, the SBOD passed proposed rulemaking that would require all grandfathered EFDAs to complete three hours of continuing education on those duties now allowed by law, specifically coronal polishing. The three-hour requirement is part of the 10 hours currently required. Those EFDAs who will be (continued on page 10)

September/October 2010 • Pennsylvania Dental Journal

9

Government Relations certified for the 2011-12 biennial period would also have to obtain three hours of continuing education. All EFDA programs will integrate training for these expanded functions into their existing curriculums. These regulations are not yet final, but should be in 2011. Regulating Teeth Whitening as the Practice of Dentistry Due to growing concerns about the preponderance of non-dental professionals offering teeth whitening services to the public, the SBOD drafted a policy statement that would effectively regulate teeth whitening services as the practice of dentistry, to be administered by dental professionals only.

10

The SBOD’s draft policy statement states that tooth whitening may be performed by a licensed dentist, or other qualified dental staff (under dentists’ direct supervision). Tooth whitening is defined as any means or methods used to whiten or bleach teeth, or the dispensing of a toothwhitening agent to another person. There is an exemption for those products that consumers can purchase over-the-counter. This policy is still in draft form and must be approved by offices in the Governor’s Administration before it becomes final. However, due to a pending lawsuit against the North Carolina Board of Dentistry regarding its policy restricting tooth whitening as the practice of dentistry, the SBOD is postponing implementation of its policy statement until the lawsuit is settled.

September/October 2010 • Pennsylvania Dental Journal

Regulating the Administration of Botox and Dermal Fillers The SBOD drafted a policy statement stating that it considers it the practice of dentistry when Botox products and dermal fillers are administered to the structures associated with the human teeth or jaws, or associated structures. If passed, this policy statement will provide more guidance to licensees and the public about what is acceptable in the dental office. Dentists who choose to perform this service must be properly trained and obtain informed consent from patients. Stay turned for more information once this policy statement is approved and enacted.

Government Relations A Call To Action As John Adams once said, “Always vote for principle, though you may vote alone, and you may cherish the sweetest reflection that your vote is never lost.” With the 2010 statewide elections just around the corner, it is imperative that grassroots lobbying and volunteer efforts be kicked into full swing. PDA challenges our members to live up to the aforementioned quote of John Adams and cherish the fact that your vote as a dentist means something, even if others may disagree. The time and effort you, as members, put into November’s election will produce a profound result on future legislation. Whether it is contributing money to PADPAC, writing to your state elected officials or congressmen, or putting a candidate’s sign in your front yard, many legislators will feel your influence and appreciate your involvement. When deciding whether to participate, remember the battles of those legislators up for re-election and their push to pass legislation for you. Remember in particular Sen. Jane Orie and Rep. Eddie Day Pashinski and their dedication to the dental profession by sponsoring and helping pass HB 602, the EFDA scope of practice legislation, and those legislators who proudly voted in favor of its passage. Without the aspirations and the drive of these individuals, this bill would still be in limbo in the General Assembly. PDA encourages you to take the time to contact Sen. Orie and Rep. Pashinski especially, and

Become a

Mentor

we face everyday, and like Washington, we too can and will stick together and stay the course to write our own history. Invest in PDA, and we will surely make it worth your while. Together, we can accomplish anything.

thank them for their commitment to the profession. And think about your PADPAC’s achievements and the daunting challenge of finding new ways to interact and voice your concerns to legislators. The importance of PADPAC should not go unmentioned; by continuously donating to PADPAC you are investing in the future. You are investing in those noble men and women who serve our state proudly and who are everyday fighting for the interests of the dental profession. We want you to recognize the advantages of this investment, and challenge you to take a leap of faith and show your support. Legislators want to hear from you, and the more you get out and speak directly to them, the more likely legislators will hear your call. As George Washington once said, “Associate yourself with men of good quality if you esteem your own reputation; for ‘tis better to be alone than in bad company. Speak no evil of the absent, for it is unjust. Undertake not what you cannot perform, but be careful to keep your promise. There is but one straight course, and that is to seek truth, and pursue it steadily. Nothing but harmony, honesty, industry and frugality are necessary to make us a great and happy nation.” George Washington recognized the importance of banding together as an infant nation struggled to persevere through the almost impossible challenges. PDA recognizes the challenges

Remember, the more member dentists speak up and contact legislators, the more we are combating opposition from insurance companies and other lobbies who are working against us. PDA and PADPAC are here to help you in this time of need, and no matter what the issue, we stand firmly behind you. As a reminder, all House of Representatives seats and one-third of Senate seats are up for re-election on November 2. Reach out to your representatives and let them know you care and want to be heard. To find out who your representative is, please visit http://www.legis.state.pa.us. We remind you that we do not back a specific party, but only candidates who fight for your issues and your profession. To further discuss ways to become involved in the election process, donate to PADPAC or find out whom your representatives are, please contact Don Smith, government relations coordinator, at [email protected] or (800) 223-0016, ext. 108. Don Smith is a new member of the government relations team, and would be happy to attend district or local dental society meetings to discuss PADPAC or legislative issues. PDA encourages you to take advantage of this opportunity.

PDA recognizes new dentists and dental students as the future of dentistry in Pennsylvania and wants to foster and encourage their participation in the organized dentistry community. Please show your support for new dentists, dental students and the future of organized dentistry by agreeing to be a mentor. Visit www.padental.org/mentoring to register as a mentor.

September/October 2010 • Pennsylvania Dental Journal

11

Membership Matters A Checklist for Moving Your Practice By Tori Rineer, Membership Coordinator Perhaps you’re looking to downsize, expand or relocate your practice to a new area. Let PDA assist with making your move as smooth and successful as possible with the “Moving Your Practice” Checklist. Checklist for Moving Your Practice ❑ Determine a budget for the move ❑ Select new office location ❑ Professional Notifications ❑ Landlord/Lease holder ❑ Accountant ❑ Financial Institution ❑ Patients ❑ Display flyers in the office, discuss during check-in or treatment, have staff give a reminder at check-out ❑ Have new appointment and business cards, stationary, address stamps and return mailing labels made with the new office address ❑ Send postcards announcing the move to all patients ❑ Include a message about the relocation in your “on-hold” messaging system or after-hours answering machine ❑ Pennsylvania State Board of Dentistry (SBOD) • You must notify the SBOD within 10 days of a change of office address. • Contact information Phone: (717) 783-7162 Fax: (717) 787-7769 E-mail: [email protected] Web: www.dos.state.pa.us/dent ❑ Drug Enforcement Administration (DEA) Office – Registration Change • Registration changes (change of address) should not be submitted until an approved state license for the new address is received. Changes will become effective immediately upon DEA approval. • Phone, DEA Call Center: (800) 882-9539 Local Divisions Philadelphia:(215) 238-5160 Pittsburgh: (412) 777-1870 Scranton: (570) 496-1020 E-mail: [email protected] Web: www.deadiversion.usdoj.gov

United States Postal Service: www.usps.com Insurance providers Electronic claims clearing house Credit card companies Professional Associations • Pennsylvania Dental Association (800) 223-0016 We will forward your change of address to ADA and your district/local dental society. ❑ Practice support providers: ❑ Utility companies, municipal services ❑ Practice software company ❑ Website design company ❑ Product supply companies ❑ Answering service company ❑ Patient payment/financing company ❑ Prepare the office ❑ Inventory supplies ❑ Disinfect instruments, countertops ❑ Properly dispose of refuse, chemicals, sharps ❑ Network by attending local dental society meetings in new location ❑ ❑ ❑ ❑ ❑

Additional items for consideration: ❑ Place an advertisement in local newspapers ❑ Send thoughtful expressions of appreciation (flowers, thank you cards or other modest gifts) to businesses or referrals that helped to support your former office ❑ Thank your patients for staying with you and for coming to your new location The following resources can be used to help determine a new location for your practice: • Consider Pennsylvania! - Lists statistics for the number of privately practicing dentists, population, number of patients per dentist, average age of practicing dentists and median household income, all broken down by county. Contact PDA’s Membership Department at (800) 223-0016 to request a copy or simply visit www.padental.org/am/pdf/considerpa.pdf. (continued on page 14)

September/October 2010 • Pennsylvania Dental Journal

13

Membership Matters ADA Library Materials • Dental Office Design: A Guide to Building, Remodeling and Relocating (2002) • ADA Demographic Reports (State and County) The reports are valuable for dentists who are establishing their practices or for those planning to move. These reports also contain dentist profile including county-level estimates of the number of dentists, breakdown by primary occupation, specialty, age and sex, population profile of county level and benchmark data, current population estimates and five-year projections. Reports also include suggestions for evaluating a new practice area. As State and County Demographic Reports are custom-produced, please state the name of the desired county(s) and state when ordering. Please note that these reports are produced on a per-county basis; one report equals one county. ($75 per report) • A Guide to Closing a Dental Practice (2008)

• Practice Management – Starting Your Dental Practice (Revised 2007) • The Ultimate Dental PR Kit for Dentists and the Dental Practice (2002) This guide will help dental professionals develop promotional and public relations campaigns for their practices and shape public opinion about the profession of dentistry. It discusses planning a public relations campaign and provides examples of press releases, speeches, public service announcements and other promotional materials. Many of these materials and more are available through the Members’ Lending Library. All items found in the catalog are free to PDA members, who are charged only nominal shipping and handling fees. Visit www.padental.org/library to view the entire library catalog or to place an order.

Supplemental ADA Materials • New Practice Checklist – provides a list of key issues frequently confronted by dentists opening a new practice.

Welcome New Members! Following is a listing of members who have recently joined PDA, along with the dental schools from which they graduated and their hometowns. Dr. Smriti Bajaj University of Pittsburgh Pittsburgh

Dr. Amy L. Cabe West Virginia University Canonsburg

Dr. William M. Crim University of Maryland Mifflintown

Dr. Jeffrey M. Gelb University of Pennsylvania Bryn Mawr

Dr. Miriam Behpour University of Pittsburgh Pittsburgh

Dr. Elsie M. Casimir Temple University Lower Gwynnedd

Dr. Sonal J. Dave University of Pennsylvania Philadelphia

Dr. Katarzyna I. Glab University of Pittsburgh Pittsburgh

Dr. Brendan P. Bernard University of Pittsburgh Mars

Dr. Jeremy R. Catherman University of Pennsylvania Clearfield

Dr. Kevin F. Dyer New York University Mechanicsburg

Dr. Sai Guduru Boston University Harrisburg

Dr. Nandhini Bogavelli Boston University Harrisburg

Dr. Kavitha D. Chadhalavada Dr. Mohammad B. Elkhatib University of Pennsylvania New York University Blue Bell Cherry Hill, NJ

Dr. Holly J. Branin Temple University York

Dr. Hal L. Cohen Temple University Philadelphia

14

September/October 2010 • Pennsylvania Dental Journal

Dr. Vincent P. Floryshak Temple University Chester Springs

Dr. Kamal Haddad Case Western Reserve Univ. Bethlehem

Membership Matters Dr. William S. Heddaeus Case Western Reserve Univ. Penn Hills

Dr. Karl D. Maloney New York University Basking Ridge, NJ

Dr. Abhishek Pandit University of Pennsylvania Lancaster

Dr. Jacquline Tome University of Pennsylvania Breinigsville

Dr. Pieter H. Heemstra University of Pittsburgh Jefferson Hills

Dr. Richard C. Mandel University of Pennsylvania Springfield

Dr. Raj P. Patel Temple University Langhorne

Dr. Joshua Tran Temple University Tower City

Dr. Jaime L. Horne West Virginia University Three Springs

Dr. Adam L. Martik University of Pittsburgh Pittsburgh

Dr. Matthew C. Poore University of Maryland Binghamton

Dr. Chinchai Hsiao University of Pennsylvania Philadelphia

Dr. Brian S. Martin University of Pennsylvania Blawnox

Dr. Tarik W. Jbarah University of Pennsylvania Reading

Dr. Mary J. Massaro Temple University Media

Dr. Christina R. RabijSchmeler SUNY Buffalo Pittsburgh

Dr. Daniel S. Van Volkenburgh Northwestern College of Dental Surgery Califon

Dr. Aditi Jindal University of Pittsburgh Pittsburgh

Dr. John Paul Matta University of Pittsburgh Poland

Dr. Brandon Kang New York University Wilkes Barre

Dr. Jonise A. McDaniel Howard University Harrisburg

Dr. Venkateswar R. Kapa Boston University Harrisburg

Dr. Amadee B. Merbedone West Virginia University Fairchance

Dr. Steven Jae Doo Kim University of Pennsylvania Philadelphia

Dr. Damian C. Milillo Temple University Clifton Heights

Dr. Joseph A. Kobeski Temple University Chadds Ford

Dr. Bryan D. Mohney University of Pennsylvania Clearfield

Dr. Karessa Kuntz University of Michigan Pittsburgh

Dr. Heidi L. Moos University of Pittsburgh Alexandria, VA

Dr. Harold Ross Lambert University of Pennsylvania Newtown Square

Dr. Long Fnu Mugianto Temple University Radnor

Dr. Michael E. Lisien University of Pittsburgh Coraopolis

Dr. Adam W. Mychak University of Pittsburgh Pittsburgh

Dr. Monali Ma Boston University Philadelphia

Dr. Stephen J. Ollock Temple University Mainesburg

Dr. Rick A. Reinecker Temple University Reinholds Dr. Felipe Rola University of Pittsburgh Lansdale

Dr. William J. Vincent Temple University East Petersburg Dr. Timothy A. Weibley SUNY Buffalo Lemoyne Dr. Lawrence Wong Temple University Philadelphia

Dr. Morgan S. Rutledge University of Louisville Greensburg

Dr. Jie Yang Maple Glen

Dr. Kristen V. Scholl University of Pennsylvania Ardmore

Dr. Qing Yang University of Pennsylvania Philadelphia

Dr. Eric C. Seidel Temple University Gettysburg

Dr. Thadeus G. Zawislak Temple University Oil City

Dr. Maria B. Steed Temple University Cheltenham Dr. Parveen Sultana University of Pennsylvania Philadelphia Dr. Alan J. Tengonciang Temple University Philadelphia Dr. Krishna C. Thumati Boston University Harrisburg Dr. Loris J. Tinianow Bryn Mawr

September/October 2010 • Pennsylvania Dental Journal

15

It’s Your Money Fixed Income Investing (Part 1) By Mark J. Funt DMD, MBA So far in this series, I have generally written about investing in equities (stocks). In this piece, I am going to begin the discussion on fixed income investing. Fixed income runs the gamut from risk free, very short-term savings/money market accounts, to very risky long-term bond investing and everything in between. The bond market, a very large part of the fixed income market, is a market no different than the stock market. Prices on bonds, like stocks, fluctuate on an intra and inter day basis. As a matter of fact, some people buy bonds like they do stocks, in hopes of capturing capital appreciation as well as a fixed rate of return. Bonds come in all shapes and sizes. There are ultra-short, short, intermediate and long-term bonds. There are zero coupon, savings and Build America Bonds. There are low, medium and high quality bonds, taxable and tax free bonds, very safe and very risky bonds as well as low and high yielding bonds. Just like stocks, the bigger the risk you take in bond investing, the greater the potential return. The yield on bonds is generally based on the past and present interest rates, the year of maturity as well as the credit quality of the issuer of the bond. Bonds can be bought at par, at a premium or a discount, the details of which will be explained in a future article. In order to be a serious bond investor, you need to have some understanding of the economy and how fiscal and monetary policy affects the economy, as well as how the economy affects interest rates. As always, I will try to explain these factors

in an over-simplified manner. The first thing you need to know is that the economy goes through natural cycles of booms and busts. There are periods of economic growth and economic slowdowns that can lead to recessions and even depressions. After 6-7 years of economic growth, the economy slipped into a recession, which is defined as two consecutive quarters of negative GDP (Gross Domestic Product). Due to a series of several very unfortunate economic mishaps, which I have written about in previous articles, this recession is much worse than previous ones. In many cases, the strength of the economic expansions and severity of the economic downturns has to do with how well the economy is managed by the federal government. The truth of the matter is that the President of the United States has very little control over the success and failure of the economy, although he will get the blame when the economy is failing and the credit when it is strong. The president, with approval of Congress, can only do two things in controlling fiscal policy — increase or decrease governmental spending and/or increase or decrease taxes. The Bush administration opted to lower taxes whereas the Obama administration opted to increase government spending. Some would question whether spending money the government does not have is a good idea to try to get us out of a recession, but time will tell who is and isn’t correct. The much more powerful branch of the government is the Federal Reserve Board, the body that controls monetary policy. Although the Federal Reserve Chairman is appointed by the President and approved by the Congress, at this point the Federal Reserve is completely

independent and autonomous from the executive and legislative branches of the government. The Federal Reserve has many tools at its disposal on how to accomplish its goals of keeping the economy growing at a healthy pace and keeping inflation low, a daunting task to say the least. The most powerful tool the Fed has is to lower or raise interest rates. The Fed tries to stay ahead of the curve and be proactive with its monetary policy. However, like the stock market, the Fed often goes too far, too fast or too slow in accomplishing its goals, causing bubbles in the economy. As I previously stated, besides promoting economic growth, the Fed is very concerned about controlling inflation. Inflation is simply defined as too many dollars chasing too few goods. This is a simple supply and demand equation. If lots of people have lots of money to spend, businesses will increase the price of their goods and services. A perfect example is the recent housing bubble. As the Fed lowered interest rates, more and more people could get loans as money became more available and the prices of homes “literally” went through the roof. Of course, one of the causes of our present economic tsunami is that the banks gave loans to people who could never afford to pay them back. Many people blame Alan Greenspan (the former Fed chairman) for lowering rates too low too fast, creating the housing bubble. However, as bad as inflation is, the Fed is much more concerned about deflation. Deflation is defined as a decrease in prices. Deflation is more destructive to the economy then inflation. If businesses have to lower prices, this will cut into their profits and may mean layoffs

September/October 2010 • Pennsylvania Dental Journal

17

It’s Your Money or even shutting their doors. It is actually better for the economy when a business has pricing power as opposed to no pricing power. Again, look at home prices. The deflation in prices has caused a lot of people to see the value of their homes decline dramatically. In some cases, the prices dropped so low, their mortgage was worth more than their home and they just walked away (foreclosed) on their home. This negative wealth effect not only makes people feel poorer but also takes away the ability for them to borrow from their home, which many people did as a source of funds for many of their larger purchases, not to mention what it did to the construction industry. The Fed, like the stock market, looks at a myriad of economic reports to determine what decision it will make regarding the lowering or raising of interest rates in order to strike that balance between fostering economic growth and stable inflation. These indicators include but are not limited to GDP, housing starts, durable goods orders, consumer and producer price indices and the unemployment report. All of these stats are readily available to anyone who wants to ascertain them. The Fed can only control very short-term interest rates and the market and market forces will determine long-term interest rates. In many cases, the bond market will bid up longer term interest rates in anticipation of the Fed increasing short-term rates or lower rates if the market feels the Fed will be cutting interest rates. In some cases, if the bond market feels the Federal Reserve is ahead of the curve when it increases shortterm interest rates, longer term bonds interest rates will actually decrease. Although this may seem contradictory to what I have written, this phenomenon is referred to as a bear flattening; because the market believes the tight-

18

ening of monetary policy will keep inflation in check even if this means a slowing of the economy, which will eventually lead to a lowering of interest rates. I know it gets confusing. Bond prices respond directly to these interest rate changes. There is an inverse relationship between interest rates and the prices of bonds. As interest rates increase, bond prices decrease and as interest rates decrease, bond prices will increase. Remember, just like stocks, bond prices are changing all the time. Of course, there are other factors that can affect the prices of bonds as well. However, you cannot be a serious bond investor without understanding interest rates and having some idea as to which direction interest rates are headed. For example, if you think interest rates are going up, you may want to

September/October 2010 • Pennsylvania Dental Journal

buy short-term bonds so you can take advantage of buying longer term bonds when interest rates increase. On the other hand, if you think interest rates are going down, you may want to not only lock in higher interest rates with longer term bonds, but also take advantage of capital appreciation of your bond as rates decline. You are probably wondering how you know which way interest rates are going. First of all, as I write this article, interest rates are at a historical low and can only go up because they just cannot go any lower. Secondly, as mentioned before, you must keep abreast of economic indicators. Finally, you must understand and be able to interpret something known as “the yield curve” which fortunately, will be the next article in this series on fixed income investing. Stay tuned!

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services By Monica Costlow, JD and Dr. Judith Lave

Introduction

Medicaid Importance

A recent report by the Pew Center on the States estimates that 17 million low-income children in the United States, about one in five of all those between the ages of one and eighteen, go without dental care each year.1 The same report assessed all 50 states and the District of Columbia on ensuring dental health and access to care for disadvantaged children. Pennsylvania, along with eight other states, received a poor grade. In this article, we examine dental care for disadvantaged children in Pennsylvania, specifically focusing on the Medicaid program. Eligibility criteria, covered dental services, expenditures, and access to and quality of services are discussed. We describe initiatives undertaken by the state and examine policy options for further improvement. We find that the Medicaid program in Pennsylvania plays a very important role in the provision of dental services to low-income children.2

The Medicaid program, called Medical Assistance in Pennsylvania, is the underpinning of the health care safety net. Medicaid was created by Congress in 1965 under Title XIX of the Social Security Act. It pays for medical and long-term care for eligible low-income American citizens and certain legal immigrants. Financed by the federal government and the state, Medical Assistance provides health care coverage – the key to accessing care – for the Commonwealth’s neediest, most vulnerable residents, while paying providers such as hospitals, dentists, doctors, and pharmacies for treatment that would otherwise go largely uncompensated. Children can qualify for Medical Assistance by either meeting an income requirement or having a disability determination. As shown in Table 1, income eligibility is specified in terms of the federal poverty level (FPL) and varies by age and family size. For example, children

September/October 2010 • Pennsylvania Dental Journal

19

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

ages 1-6 are eligible for Medical Assistance if their family income is equal to or less than 133 percent of the FPL, which is $33,728 for a family of 4. Table 1: Medical Assistance Income Eligibility Requirements for Children Age

% of the FPL Income limit for a family of 4 (2010)*

0-1

185%

$46,916

1-6

133%

$33,728

6-19

100%

$25,360

*https://www.cms.gov/MedicaidEligibility/Downloads/POV10Combo.pdf

Children also qualify for Medical Assistance if they meet the Social Security Administration (SSA) level of disability. A child under age 18 is considered disabled if he or she has a medically determinable physical or mental impairment which results in marked and severe functional limitations and (i) can be expected to result in death or (ii) has lasted or can be expected to last for a continuous period of not less than 12 months.3 In Pennsylvania, a child who meets the disability standards is eligible for Medical Assistance regardless of the family’s income and assets.4 In FY09, 35.5 percent of children in Pennsylvania, or about one million children, were covered by Medical Assistance.5 Across the counties, coverage ranged from a high of 60 percent of children in Philadelphia County, to a low of 14.6 percent in Chester County (Figure 1).6 Figure 1: FY09 Percentage of Children Covered by Medical Assistance by Pennsylvania County Source: Pennsylvania Department of Public Welfare Medical Assistance Enrollment Data and estimates from the US Census Bureau

20

September/October 2010 • Pennsylvania Dental Journal

Dental Services Delivery of Dental Services Two delivery models are used to provide dental services in Medical Assistance: managed care and fee-for-service (FFS). About 73 percent of children enrolled in Medical Assistance receive their dental services via managed care, while 27 percent access dental services via the FFS network.7 Covered Dental Services for Children For Medicaid enrollees under the age of 21, federallymandated services and benefits are provided under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. EPSDT is intended to assure the availability and accessibility of medically needed medical care and to help children and families use them effectively.8 Dental services are an EPSDT benefit. Pennsylvania Medical Assistance covers all medically necessary dental services for children, including9: • Periodic oral exams • Diagnostic dental services • Preventative dental services, such as sealants and topical fluoride treatment • Emergency treatment for control of pain and infection • Oral and maxillofacial surgery • Fillings and tooth extractions • Root canal treatments • Prosthetic appliances, such as dentures and crowns • Orthodontics for children who qualify

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

• Periodontal services for children who qualify • Radiographs/diagnostic imaging Dental Expenditures for Children In 2008, Medical Assistance spent about $124.9 million on dental services for children, or approximately $109 per enrolled child.10 There was considerable variation in expenditures across the counties in Pennsylvania. The expenditures ranged from $72 per child in Tioga County to $223 in Fayette County.11 These expenditures are low relative to the national average for all children, which we estimate was about $284 in 2008.12 Pennsylvania dental expenditures are relatively low in part because Medical Assistance dental fees are low. The Pew Center on the States reported that Pennsylvania’s Medical Assistance reimbursement rates were 53.2 percent of dentists’ median retail fees in 2008.13 Access to and Quality of Dental Care for Children in Medical Assistance

DPW requires Medical Assistance managed care organizations (MCOs) to report on two performance measures related to access to dental care: (1) the proportion of children aged 3 to 20 who had an annual visit and (2) the proportion of enrollees age 4 to 21 with developmental disabilities who had an annual dentist visit. Figure 2 shows the proportion of children ages 3 to 20 enrolled in a Medical Assistance MCO who had an annual dental visit from 2005 through 2009.16 While in 2009, less than half of the children enrolled in Medical Assistance had an annual dental visit (42.8 percent), this proportion has been increasing over time. There is considerable variation across the plans. In 2009, the proportion of children who had an annual dentist visit ranged from 37.6 percent at AmeriHealth to 45 percent at Health Partners. Figure 2: Proportion of Medical Assistance Children in Managed Care Age 4 to 21 with an Annual Dental Visit from 2005 through 2009

Access to Care The Pennsylvania Department of Public Welfare (DPW) provided us with the most recent data on annual dental visits for children who are enrolled in ACCESS Plus (FFS Medical Assistance). Table 2 shows that among all children and within each age group, the proportion of children with an annual dental visit increased from 2006 through 2009.14 In 2006, only 38.72 percent of children had an annual dental visit, while over 55 percent of children did in 2009.15 Table 2: Proportion of Medical Assistance Children in FFS Age 4 to 21 with an Annual Dental Visit from 2006 through 2009 2006

2007

2008

2009

2-3 years

13.39%

19.58%

22.25%

23.95%

4-6 years

44.51%

50.89%

58.68%

59.91%

7-10 years

47.95%

51.97%

59.56%

60.80%

11-14 years

44.22%

47.54%

53.11%

55.50%

15-18 years

40.32%

43.25%

48.01%

50.21%

19-21 years

27.45%

28.39%

35.21%

38.49%

Total

38.72%

42.68%

48.90%

50.59%

Source: Department of Public Welfare Data

Source: Office of Medical Assistance Programs, Division of Quality Assessment. HealthChoices Performance Trending Reports for 2007 and 2009. http://www.dpw.state.pa.us/Resources/Documents/Pdf/ AnnualReports/2009HealthChoicesPerfTrendingReport.pdf and http://www.dpw.state.pa.us/Resources/Documents/Pdf/AnnualReports/20 07HealthChoicesTrendRpt.pdf

Figure 3 shows the proportion of Medical Assistance MCO enrollees with developmental disabilities who had an annual dental visit from 2005 through 2009. Overall, 44 percent of these enrollees had an annual visit in 2009. Between 2008 and 2009, there was a slight improvement in performance of all plans with the exception of AmeriHealth. Again, there is wide variation in each plan’s performance. In 2009, the proportion of children with developmental disabilities that had an annual dental visit ranged from 33.4 percent in AmeriHealth to 53 percent in Health Partners.

September/October 2010 • Pennsylvania Dental Journal

21

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

Figure 3: Proportion of Medical Assistance Children in Managed Care Age 4 to 21 with Developmental Disabilities Who had an Annual Dental Visit from 2005 through 2009

Source: Office of Medical Assistance Programs, Division of Quality Assessment. HealthChoices Performance Trending Reports for 2007 and 2009. http://www.dpw.state.pa.us/Resources/Documents/Pdf/ AnnualReports/2009HealthChoicesPerfTrendingReport.pdf and http://www.dpw.state.pa.us/Resources/Documents/Pdf/AnnualReports/20 07HealthChoicesTrendRpt.pdf

Dental Provider Participation in Medical Assistance In order for children covered by Medical Assistance to receive dental services, their families must be able to find a dentist who accepts Medical Assistance payment. Analysts often use the dental participation rate or the proportion of overall dentists who treat individuals covered by Medical Assistance as an indicator of potential access. Source: Office of Medical Assistance Programs, Division of Quality Assessment. HealthChoices Performance Trending Reports for 2007 and 2009. http://www.dpw.state.pa.us/Resources/Documents/Pdf/ AnnualReports/2009HealthChoicesPerfTrendingReport.pdf and http://www.dpw.state.pa.us/Resources/Documents/Pdf/AnnualReports/20 07HealthChoicesTrendRpt.pdf

Quality of Care The proportion of Medical Assistance children who receive dental sealants is one indicator of quality of care. Figure 4 presents recent trends in the proportion of Medical Assistance children enrolled in a MCO who turned 8 years old and had a protective dental sealant applied to their teeth during the three years prior to the eighth birthday. Between 2005 and 2009, performance on this measure has improved in five of the six plans for which we have data.17 In 2009, the proportion of children reaching the age of 8 who had dental sealants ranged from 27.6 percent at Unison to 56 percent at AmeriHealth. Figure 4: Dental Sealants for Medical Assistance Children in Managed Care from 2005 through 2009

The Total Number of Pennsylvania Dentists Every other year, the Pennsylvania Department of Health (DOH) surveys all dentists licensed in Pennsylvania. Based on the findings of its last survey in 2009, the DOH estimates that there were 6,261 practicing dentists in Pennsylvania in 2009.18 However, since the DOH estimates do not include the 398 dentists19 who were licensed for the first time in Pennsylvania that year, the total number of practicing dentists should be increased to 6,659. Pennsylvania Dentists Who Accept Medical Assistance There are two sources of data on the number of dentists who accept Medical Assistance in Pennsylvania: DOH and DPW. • Pennsylvania DOH asked dentists in the biennial survey discussed above: “Do you accept any of the following coverage plans: Medicaid, Medicare and Private Insurance?” Using the data from the survey, DOH estimates that 871 dentists in Pennsylvania accepted Medical Assistance in 2009.20 • DPW maintains information on every dentist who is enrolled in Medical Assistance. (A dentist must be enrolled in Medical Assistance to be paid for providing services for Medical Assistance recipients in either the FFS program or managed care plans.21) DPW prepares separate reports on the number of dentists currently enrolled in Medical Assistance and the number of dentists who received a payment in any given year (active dentists). DPW indicates that between May 2009 and April 2010, there were 1,723 active Medical Assistance dentists in Pennsylvania.22

22

September/October 2010 • Pennsylvania Dental Journal

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

We used the DPW data for the number of dentists who accepted any Medical Assistance payment in 2009, as our estimate of the number of dentists participating in Medical Assistance. We did not use the DOH estimate because it underestimates the number of dentists who accept Medical Assistance, particularly in counties where managed care is mandatory. For example, according to the DOH data, 127 dentists accept Medical Assistance in Allegheny County.23 However, directors of two large Medical Assistance managed care plans in Allegheny County indicated that their plans had contracts with 220 and 205 unique dentists, respectively.24 Using our estimates of the number of practicing dentists (6,659) and DPW data on the number of dentists who accepted Medical Assistance (1,723), we estimate that about 26 percent of the practicing dentists in Pennsylvania accepted Medical Assistance in 2009.25 There are no recent data on the proportion of dentists nationally who treat Medicaid patients. In 1999, the United States General Accounting Office surveyed state Medicaid programs.26 Of 39 states that provided information about dentists’ participation in Medicaid, 23 reported that fewer than half of the states’ dentists saw at least one Medicaid patient during 1999.27 These, and other findings, indicate that dentist participation in Medicaid, across all states, is low. Pennsylvania Dentists Accepting New Medical Assistance Patients There is considerable turnover (leaving the program and then reenrolling) among the Medical Assistance population, particularly children. Therefore, it is important to know whether Pennsylvania dentists are accepting new Medical Assistance patients. Using DOH data, we estimate that approximately 94 percent of dentists who treated Medical Assistance patients in 2009 are accepting new Medical Assistance patients.28 This is a rough estimate given, that the DOH data do not include all Pennsylvania dentists who treat Medical Assistance patients. Medical Assistance Program Improvements Between 2005 and 2010, Pennsylvania undertook a number of initiatives to improve the dental portion of the Medical Assistance program. Most of these changes were directly applicable to Medical Assistance dentists who worked in FFS, although some were targeted to Medical Assistance MCOs.

• DPW required Medical Assistance managed care plans to report on three dental variables. • To reduce the administrative complexity of the program, the number of procedures that required prior approval by DPW was decreased. In addition, DPW changed the coding system to create uniformity in coding for both private insurance and Medical Assistance patients. And, finally Medical Assistance dentists are now able to file for payment electronically. • DPW increased reimbursement levels for dental services, as shown in Table 3. Between 2005 -2008, fees were increased as much as 76 percent for certain procedures.29 Table 3: Medical Assistance Dental Services With Increased Fees Year

Service

2005

Sedation/anesthesia Behavior management services (these are services such as that make it easier for dentists to manage complex patients )

2006

Behavior management services; Orthodontic services

2007

Prophylaxis, fluoride treatments, endodontics, crowns and extractions

2008

Fluoride varnish, endodontics, dentures, extractions and orthodontics

Source: US Department of Health and Human Services: Centers for Medicare & Medicaid Services, Region III (Pennsylvania EPSDT Review Report- Dental Services. April 2008 Site visit) Final Report. December 31, 2008.

• DPW expanded the Access transportation system to help ensure that Medical Assistance children make their dental appointments.30 • In 2008, an ACCESS Plus Dental Care/Disease Management Program was implemented to encourage greater access to care and to establish dental homes for individuals less than 21 years of age.31 • DPW added language to the contract that contains provisions for expanded activities related to the management of dental services and provider network development for ACCESS Plus. September/October 2010 • Pennsylvania Dental Journal

23

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

• Pennsylvania increased the types of Medical Assistancecovered dental providers. In 2010, the Pennsylvania General Assembly passed legislation to expand the duties of expanded function dental assistants (EFDAs).32 The expanded function dental assistants can now perform coronal polishing, apply fluoride varnish, and take impressions of teeth for athletic appliances. Currently, Medical Assistance does not directly reimburse expanded function dental assistants for services, but it reimburses the supervising dentist for dental services provided by expanded function dental assistants. • On April 1, 2010, Medical Assistance began to reimburse enrolled physicians and certified registered nurse practitioners for the application of topical fluoride varnish for eligible children.33 However, although children of all ages can benefit from fluoride varnish, Medical Assistance restricts the application of fluoride varnish by physicians and certified registered nurse practitioners to children from birth through four years of age. • In 2010, the state added a dental-related measure to the pay-for-performance program. We cannot assess the impact of these policies on Medical Assistance children’s use of dental services, although we suspect that the impact of these changes is positive. We note that there was a significant increase in annual dental visits among all children aged 4-21 covered by Medical Assistance FFS and MCOs. Options to Consider for Improving Dental Care for Children Under Medical Assistance Pennsylvania has a shortage of Medical Assistance dentists, especially in rural areas. This deficit could be addressed in part by making greater use of other medical providers. Children in Pennsylvania see primary medical care providers such as pediatricians, physicians, nurse practitioners, physician assistants, and nurses for checkups and evaluations for school. It is generally understood that the primary care setting may be an ideal place to deliver preventive dental services, such as an oral health assessment, fluoride varnish and parental education, for children enrolled in Pennsylvania Medical Assistance. As a result, many state Medicaid programs are reimbursing physicians, certified registered nurse practitioners or physician assistants for dental services. North Carolina’s Into the Mouth of Babes, a preventive dentistry program 24

September/October 2010 • Pennsylvania Dental Journal

that targets children from birth to three years of age,34 utilizes pediatricians, family physicians, nurse practitioners, nurses, physician assistants and other public health workers in community health clinics to provide dental services to Medicaid children. After successfully completing a training period, providers are eligible to bill Medicaid up to six visits for oral care provided during the first three years of a child’s life.35 The covered dental services include: risk assessment, oral screening, prevention services such as fluoride application and education for parents and children.36 Pennsylvania has taken a step in this direction with its current policy to reimburse enrolled physicians and certified registered nurse practitioners for the application of fluoride varnish to children aged zero through four. Pennsylvania could go even further by directly reimbursing other medical providers to expand the availability of dental care for Medical Assistance children, similar to the North Carolina medical model. Another approach is the state of Washington’s Access to Baby and Child Dentistry (ABCD) program. ABCD works to: enroll Medicaid-eligible children by age one; educate families about dental hygiene and eating habits; provide outreach and case management; train dentists in best care practices for young children; and create referral networks of pediatric dentists for children with more difficult treatment needs.37 From 1997 to 2008, the number of Medicaid children under age six who received annual dental care more than doubled because of ABCD.38 Pennsylvania could consider a pilot program similar to ABCD to improve children’s dental health. We acknowledge a final option is to continue increasing dental fees to reach the national Medicaid average of 60.5 percent of retail fees.39 However, budget constraints may cause this to be impossible in the current fiscal and political climate. Conclusion About one-third of the children in the Commonwealth receive dental care services through the Medical Assistance program. Although the proportion of Medical Assistance children that had an annual dentist visit has increased markedly overtime, but is still low by national standards. According to the Kaiser Family Foundation, about 60 percent of children covered by public insurance had an annual dental visit.40 An important factor influencing access to care is dental provider participation in Medical Assistance. We estimated that only 26 percent of Pennsylvania’s practicing dentists treated and billed for at

Pennsylvania Medical Assistance: Evaluation of Children’s Access to Dental Services

least one Medical Assistance patient in 2009. That proportion is low. This is concerning because 55 Pennsylvania areas are experiencing a shortage of dental professionals and the number of licensed dentists has decreased.41 Pennsylvania has also undertaken a number of important initiatives to streamline and improve the Medical Assistance program. We believe that these changes should have a positive effect on children’s dental health, but future data and formal evaluations of the initiatives will reflect Pennsylvania’s grade. It will probably be difficult to increase the proportion of Pennsylvania dentists without a major increase in fees, which is currently unlikely. In the meantime, Pennsylvania may be able to increase children’s access to dental services by considering policies to improve the delivery of dental services in the Medical Assistance program, similar to the North Carolina and Washington models. Monica Costlow, JD is a Senior Policy Analyst with the Pennsylvania Medicaid Policy Center at the University of Pittsburgh. Ms. Costlow earned her JD from the University of Pittsburgh School of Law, in addition to an Advanced Certificate in Health Law. She previously worked as a compliance consultant for a multi-specialty physician practice. Dr. Judith Lave is a Professor of Health Economics, Director of the Health Administration Program, Director of the Pennsylvania Medicaid Policy Center and co-director of the Center for Research on Health Care at the University of Pittsburgh. Prior to coming to the University of Pittsburgh, she was the Director of the Office of Research at the Health Care Financing Administration, now CMS. She received her PhD in economics from Harvard University. She is the author of more than 140 scientific publications. FOOTNOTES 1 The Pew Center on the States, The Cost of Delay: State Dental Policies Fail One in Five Children, February 2010. 2 The focus of the article is on children’s dental services, but we would like to acknowledge that Pennsylvania Medical Assistance covers a comprehensive dental package for most enrolled adults and limited emergency dental services. 3 Disability Evaluation Under Social Security, September 2008. http://www.ssa.gov/disability/professionals/bluebook/general-info.htm 4 If a disabled child is in a family that has a private insurance policy, than the private health insurance policy is the primary payer. Medical Assistance covers those services that are not covered by the private health insurance policy. 5 Pennsylvania Department of Public Welfare Medical Assistance Enrollment Data, Author calculation 6 Id. 7 US Department of Health and Human Services: Centers for Medicare & Medicaid Services, Region III (Pennsylvania EPSDT Review Report- Dental Services. April 2008 Site visit) Final Report. December 31, 2008. 8 Id. 9 Medical Assistance Handbook, http://www.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/Table%20of%20Contents.htm 10 Department of Public Welfare Data, Author calculations 11 Id.

12 Hiroko et al estimated that in 2005 average dental expenditures per child were $252, which is about $284 in current dollars. (Hiroko I. et al. “Dental care needs, use and expenditures among U.S. children with and without special health care needs.” J Am Dent Assoc 2010; 141; 79-88.) More current data on expenditures per child are not available. 13 The Pew Center on the States, The Cost of Delay: State Dental Policies Fail One in Five Children, February 2010. This is the FFS Medical Assistance reimbursement rate. Managed care payment rates are proprietary. 14 Department of Public Welfare Data. These data relate to children who are continuously enrolled (i.e. they may have no more than one enrollment gap of 45 days) over the measurement year, which goes from January 1 to December 31. 15 Id. 16 The dates in the graphs are for the reporting year and actually refer to use in the prior year. In addition, Medical Assistance MCOs determine utilization rates using either 10 or 12 month continuous enrollees. CMS uses the total number of children enrolled in Medical Assistance, which they determined to be 27 percent in their 2006 report. 17 Note that data for Gateway for 2008 and 2009 are not available because of administrative errors by a dental contractor. Information provided to authors by Gateway Health Plan. 18 Pennsylvania Department of Health, “2009 Pulse of Pennsylvania’s Dentist and Dental Hygienist Workforce.” Volume 4, October 2009. 19 Pennsylvania Department of State Data 20 Pennsylvania Department of Health, “2009 Pulse of Pennsylvania’s Dentist and Dental Hygienist Workforce.” Volume 4, October 2009. 21 Medical Assistance MCOs are able to negotiate fees and reimburse Medical Assistance non-participating dentists for services rendered on an out-of-network basis. 22 Department of Public Welfare Data 23 Id. 24 Information provided to authors. These dentists may identify the Medical Assistance managed care plans as being private insurance. 25 Pennsylvania Department of Health, “2009 Pulse of Pennsylvania’s Dentist and Dental Hygienist Workforce.” Volume 4, October 2009. 26 United States General Accounting Office, “Oral Health: Factors Contributing to Low Use of Dental Services by Low-Income Populations,” GAO/HEHS-00-149, September 2000. 27 Id. 28 Pennsylvania Department of Health, “2009 Pulse of Pennsylvania’s Dentist and Dental Hygienist Workforce.” Volume 4, October 2009. 29 US Department of Health and Human Services: Centers for Medicare & Medicaid Services, Region III (Pennsylvania EPSDT Review Report- Dental Services. April 2008 Site visit) Final Report. December 31, 2008. 30 Id. 31 Id. 32 Previously HB602, now Act 19 33 Pennsylvania Department of Public Welfare, Medical Assistance Bulletin http://www.dpw.state.pa.us/PubsFormsReports/NewslettersBulletins/0036731 69.aspx?BulletinId=4526 34 R. Gary Rozier, et al. Prevention of Early Childhood Caries in North Carolina Medical Practices: Implications for Research and Practice. Journal of Dental Education, Volume 67, Number 8. 35 Shelly Gehshan and M. Wyatt, “Improving Oral Health Care for Young Children.” National Academy for State Health Policy, April 2007. 36 Id. 37 The Pew Center on the States, “Washington’s ABCD Program: Improving Dental Care for Medicaid-Insured Children” June 2010. 38 Washington Dental Service Foundation, “Access to Baby and Child Dentistry Program,” http://www.deltadentalwa.com/Guest/Public/AboutUs/ WDS%20Foundation/Strategic%20Focus%20and%20Programs/Access%20to %20Baby%20and%20Child%20Dentisty.aspx 39 The Pew Center on the States, The Cost of Delay: State Dental Policies Fail One in Five Children, February 2010. 40 The Kaiser Commission on Medicaid and the Uninsured, “Dental Coverage and Care for Low-Income Children: the role of Medicaid and SCHIP.” January, 2008. 41 Pennsylvania Department of Public Welfare, Dental Information for Stakeholders and Advocates, http://www.dpw.state.pa.us

September/October 2010 • Pennsylvania Dental Journal

25

Kristopher Bennion, DMD1, Andres Pinto, DMD, MPH2, Jena Roath3, and Rochelle G. Lindemeyer, DMD4 Private Practice New Braunfels, Texas1, University of Pennsylvania School of Dental Medicine, Department of Oral Medicine2 , Dental Student, University of Pennsylvania School of Dental Medicine3, and University of Pennsylvania School of Dental Medicine, Division of Pediatric Dentistry4

A Survey of Senior Dental Students’ Experiences with Young Dental Patients in Pennsylvania

*Corresponding author: Rochelle G. Lindemeyer, D.M.D Department of Pediatric Dentistry University of Pennsylvania School of Dental Medicine 240 S. 40th Street Philadelphia, PA 19104 [email protected] Telephone: 215-776-6671 FAX 215-590-5990 ABSTRACT The purpose of this study was to determine graduating dental students’ perceptions about their training and experience in examination and treatment of infants and their plans to examine infants upon graduation. A survey was distributed to dental students graduating from Pennsylvania dental schools in 2007 and 2008. Of the returned surveys, 47.9 percent correctly identified 12 months as the recommended age for the first dental exam. Sixty-five percent of responders felt they would be comfortable performing exams on young children. This study’s primary objective was to test the association between performance of a clinical exam in a young child, enjoyment of clinical and didactic pediatric dental experience, plans for additional training in pediatric dentistry and willingness to see children younger than two years old in practice. Performing a clinical exam on a young child was associated to willingness to see children younger than two years of age in practice. Early exposure (lecture or clinical) to young pediatric patients while in dental school was significantly associated to perceived comfort with oral exam of young patients but not to reported willingness to see them in practice. Key words: pediatric dentistry, dental education, infant dental care 26

September/October 2010 • Pennsylvania Dental Journal

A Survey of Senior Dental Students’ Experiences with Young Dental Patients in Pennsylvania

INTRODUCTION According to the Third National Health and Nutrition Examination Survey (NHANES III), although the incidence of dental caries is concentrated among 20-25 percent of children, dental caries remains one of the more prevalent childhood diseases. For most Americans, oral health status has improved during the period of 1988-1994 and 1999-2004. However, for youths 2-5 years of age, dental caries in primary teeth has increased.1 A study in 2002 concluded that a substantial number of children in this country do not receive professionally recommended preventive care, particularly dental care.2 In response to pediatric dentistry’s move away from a surgical model of treatment and toward a model concentrated on preventive medicine, the American Academy of Pediatric Dentistry recommended in 1985 that the first visit for every child occur no later than 12 months of age. The goals of this first visit are to assess the risk for dental disease, initiate a preventive program, provide anticipatory guidance and decide on the periodicity of subsequent visits.3 In spite of these recommendations, several studies have indicated that there is a misunderstanding or disagreement among general practitioners about these guidelines.4-8 In a 2001 random survey of general practitioners representative of the 9 regions of the U.S., only slightly more than half (53 percent) of the respondents were aware of the ADA and AAPD recommendation that a child’s first dental visit should be no later than 12 months.5 General dentists will often be asked to see children for their initial dental visits, as the current shortage of pediatric dentists makes it impossible for all age one dental visits to be performed by pediatric dentists. Although general dentists may be available in areas of shortage of pediatric dentists, studies have shown a general lack of willingness of general dentists to treat young pediatric patients under the age of two years.6, 9, 10 Several studies have explored possible reasons for this, including lack of training or exposure to young pediatric dentistry patients while in dental school.11, 12 There is a strong association between a dentist’s willingness to perform certain dental procedures and their dental school training.13, 14 Studies have shown that when dental students were provided with a program directed toward more exposure to young pediatric patients, they were more prepared to provide care to these patients after graduation.4, 14-17 A survey sent to 3,559 randomly selected general dentists in Texas found that the level of dental school training was significantly associated with the dentists’ attitudes toward providing dental care to Medicaid-enrolled preschool-aged children.4 Pre-doctoral clinical infant oral

health programs were established at the University of Michigan School of Dentistry15 and the University of North Carolina at Chapel Hill.16 Surveys were distributed and respondents who had attended these programs felt better prepared to conduct oral examinations in children aged 0 to 36 months than those who had not participated in the programs. Similarly, dental students who rotated through a public health based “Infant Oral Health Program” in Iowa were reported being more willing to see very young children when compared to dentists who did not rotate through such a program.14 Academic and clinical training in pediatric dentistry pose a similar challenge. Faculty shortages nationwide have impacted the pediatric dental workforce. As discussed by Seale and Casamassimo,11 the educational system has a shortage of faculty trained in the care of children and increasingly relies on general dentists to teach pediatric dentistry. As a result, the teaching pool becomes limited to manageable children with a low level of disease. They further suggested that a relative lack of hands on experience treating young children in predoctoral pediatric dentistry programs might negatively affect access to care in the U.S. Most schools are teaching the first dental visit at 12 months or younger, but only half provide actual experiences with infants.18 The purpose of this study is to survey graduating dental students from the three dental schools in Pennsylvania on their perceptions on training in infant oral health (IOH), examining young pediatric patients and their perceived willingness to do so upon graduation in their own practices. The primary hypothesis tested is that there is an association between performance of a clinical exam on a young child, desire for additional training in pediatric dentistry, enjoyment of clinical and didactic training in pediatric dentistry and willingness to see children younger than 2 years of age in practice. The second hypothesis that will be tested is that there is a difference between exposure to the clinical exam of a young child in a lecture setting versus a clinical setting and subject’s perceived comfort to do an exam in a young child. The third hypothesis to be tested is that there is a difference between observing an operative procedure on a child younger than 5 years of age versus performing the procedure, and subject’s perceived comfort with an oral exam in a young child. The purpose of the analysis is to observe if the “intensity” of exposure has any influence on the subSeptember/October 2010 • Pennsylvania Dental Journal

27

A Survey of Senior Dental Students’ Experiences with Young Dental Patients in Pennsylvania

ject’s comfort level with clinical examination of young children and perceived willingness to provide care to young children in practice.

Fig 1. Graduating dental students’ exposure to infant oral examination on patients younger than 2 years of age. YES

M AT E R I A L S A N D M E T H O D S Subsequent to Institutional Review Board approval, anonymous paper surveys were distributed by mail to graduating dental students from the three Pennsylvania dental schools: University of Pennsylvania School of Dental Medicine, Kornberg School of Dentistry Temple University and University of Pittsburgh School of Dental Medicine. The survey consisted of 15 questions divided into 3 main categories and based on the guidelines for infant oral health from the American Academy of Pediatric Dentistry. Five questions related to student’s pediatric dental didactic education with respect to infant oral health. Six questions related to student’s experiences in examining pediatric patients younger than two years of age, and four questions related to student’s intentions to examine pediatric patients in their practices upon graduation. Statistical Analysis No formal sample size calculation was performed as the intent was to capture the universe of graduating senior dental students in Pennsylvania. Chi-Square analysis was used to determine if a statistically significant association existed between variables of interest. A double tailed analysis was set up with a significance level of p