Dental Public Health Activities & Practices

Lack of access to dental care is a common problem for people with Medicaid, whether they are covered by traditional fee-for-service programs or by managed care. For people with developmental disabilities who are covered by Medicaid, access to dental care is even more restricted. This situation was recognized at a 1999 state dental summit in Pennsylvania and led to a recommendation that a specialized dental clinic be established to serve Medicaid recipients with severe disabilities. The target population would be patients whose disabilities prevented having their dental care in a dentists’ office due to maladaptive behaviors and physical limitations requiring sedation or general anesthesia for treatment. With the technical assistance of the state Medicaid agency, three managed care programs in the Philadelphia area contracted with a private dental practice to establish a program called Special Smiles, Ltd. This program has a hospitalbased state-of-the-art outpatient dental facility and is able to provide patients full mouth rehabilitation under general anesthesia. The program maintains a recall system for continued comprehensive care establishing a dental home for patients. In addition, the Special Smiles provides education and outreach to parents, patients and direct care staff on the importance of daily oral hygiene and the need for routine professional dental care. The original program goal was to complete full oral rehabilitation for 1,000 individuals annually. Now in its sixth year, Special Smiles is meeting the goal serving approximately 1,100 patients per year at an annual program cost of approximately $1.8M. During the first 5 years of operation, Special Smiles provided 5,400 patient visits, which includes recall visits, for more than 3,500 patients. Contact Persons for Inquiries: Emilee S. Langer, MPH, Consultant, Special Smiles, Ltd., 418 N. Washington Street, Titusville, PA 16354, Phone: 814-827-3785, Email: [email protected] ___________________________________________________________________________________________________ Practice # 42003 Special Smiles, Ltd. 1 ___________________________________________________________________________________________________ Practice # 42003 Special Smiles, Ltd. 2 SECTION II: PRACTICE DESCRIPTION History of the Practice: The impetus for the establishment of the Special Smiles program was a 1999 Statewide Dental Summit that brought together stakeholders representing legislators, advocacy groups, dentists, and managed care organizations (MCOs) to discuss access to care for underserved populations. Following the dental summit, a regional Oral Health Task Force was convened to discuss follow-up strategies. During these Task Force meetings, the idea for a special needs dental center was presented, and the proposal was later developed and presented to the MCOs for a two year pilot program. Special Smiles, Ltd., a private practice able to provide dental treatment under general anesthesia in an outpatient dental facility, opened in September 2001, and has been operational for the past five years. See Special Smiles website at http://www.specialsmilesltd.com/html/our_staff.html. Even before the 1999 Dental Summit, state and local activities were taking place that would lay the groundwork for the Special Smiles program. In 1997, the state Medicaid agency – the Department of Public Welfare (DPW), Office of Medical Assistance Programs – implemented the first mandatory managed care program in the Southeast Zone (Philadelphia area) of the state. As a result, three Medicaid MCOs began serving enrollees; and these are the organizations that eventually contracted with Dr. Mark Goldstein and Dr. Philip Siegel of Pediatric Dental Associates to establish the Special Smiles program. This Philadelphia-based pediatric dental group had a well-established track record of implementing successful programs (e.g., the dental group established a Pediatric Dental Residency at the Episcopal Campus of Temple University and the residency grew from two graduate dental residents to over 15 in ten years achieving full accreditation). In 2000, additional space became available on the Episcopal Campus, which was used to open the Special Smiles facility. Justification of the Practice: The Special Smiles program is a specialized dental clinic for persons with severe disabilities covered by Medicaid) is needed due to inadequate access to care for people with special needs and for Medicaid clients. People with severe disabilities present special challenges that create barriers to care. Individuals with special needs often have difficulty obtaining treatment in the dental office due to physical limitations or aggressive behavior. Many dentists do not have the training or clinical experience to manage and treat patients with special needs. When patients lack the ability to cooperate in their treatment, it often becomes necessary to treat them under general anesthesia in the hospital operating room. However, access to operating room care is often limited due to high cost, limited accessibility for dental procedures, inadequate reimbursement, and the dentist’s reluctance and/or lack of training to treat patients in the hospital setting. The creation of the Special Smiles program was a response to the failure of Pennsylvania’s Medicaid program to provide adequate access to care for people with severe disabilities. Historically, dental care in Medicaid was provided on a fee-for-service basis in Pennsylvania. However, in 1997, the HealthChoices Program, Pennsylvania's mandatory managed care programs for Medical Assistance recipients, was implemented and in spite of concentrated efforts to recruit additional dentists, the program encountered the same access to care problems that existed with the traditional fee-forservice. Under the managed care system, the state has different options for providing dental services for its Medicaid recipients. Dental care can be provided as a benefit by the medical MCO or it can be subcontracted to an independent dental plan. Alternatively, the dental program can be “carved out” of the managed care program in voluntary managed care zones and be provided under the traditional fee-for-service program (seen in areas of Pennsylvania serving more rural populations). It is widely held that by using the managed care system, the state is able to address access problems for special populations through innovative approaches, such as the creation of the Special Smiles program. (Although Medicaid managed care arrangements offer the potential to address access barriers inherent in the dental fee-for-service system, studies indicate that problems still remain.)