NMDA Journal Winter 2019

18 New Mexico Dental Journal, Winter 2019 Forensic engineers investigate failure. It should not be surprising that an entire discipline of engineering is dedicated to such analysis. Failure is all too common. What might be surprising however, is how often the reason for failure is that something was designed in a way that made such failure inevitable. Sometimes it comes from simply not anticipat- ing all the less common variables, but sometimes it is simply lack of understanding the system for which it was designed. If you have ever watched one of those newsreel archives showing people’s failed at- tempts at flying, you will understand. Those can be funny to watch until someone is hurt or killed. Then it becomes a tragic failure. Dental Medicaid in New Mexico is such a failure. It may not be total failure. Like those flying machines that get you off the ground but can’t keep you there, dental Medicaid for children in New Mexico ap- proaches encounter rates comparable to commercial insurance in many areas. In other areas, it would be hard to conclude that Medicaid was anything other than a failure. What is particularly tragic is that this failing system is responsible (or irresponsible) for half of our citizens. Perhaps most disappointing is that this failure, in many cases, is a flaw in the design. Medicaid, as a whole, is copied after medical fee-for-service and man- aged care systems. Both provide, to some extent, health promotion and insurance against catastrophic loss. While there are undoubtedly issues that challenge the adequacy of the system, they are primarily operational. While a New Mexican covered by Medicaid may encounter some inconveniences as a result of their coverage, they will typically be able to receive treatment comparable to commercial coverage. Argu- ably, Medicaid coverage opens full access to medical care. Dental coverage, in both the public and private sector, has often been treated as an afterthought. Dental benefits are a small percent- age of overall health costs. Policy decisions are often in the hands of administrators with health rather than dental expertise. As a result, dental Medicaid has been modeled after commercial benefits. What administrators fail to realize is that the rules they’ve adopted are de- signed to limit utilization and participation, so a program that is meant to provide access to care is really just replacing one barrier with an- other. The design discourages dentists from participating or providing comprehensive care. It adds to administrative burden for offices while reimbursing at less than the cost of providing care. Rules that are de- signed to be utilized with patient co-payments to encourage personal responsibility, are applied without the co-payment rendering them ineffective or worse, counter-productive. Some other states are trying alternative models to address these is- sues. These models have resulted increased participation by dentists and in at least one case there are measurably positive oral health outcomes. Michigan has a program called “Healthy Kids” that utilizes a large commercial network and administrator. Offices appreciate having an interface they already use and welcome patients covered by Healthy Kids. The program is limited to patients under 21. It started as a pilot 18 years ago and has since expanded to cover the entire state. Because Healthy Kids has been operating for so many years, they have been able to measure improvement among participants. Wisconsin is currently piloting a Medicaid program that indexes re- imbursement at 80% of median fees which can be workable for most offices. They have seen a marked increase in participation. The pilot utilizes the ADA’s Health Policy Institute to create a baseline and evalu- ate the impact of the program and oral health outcomes on a quar- terly basis. The design of the pilot to develop data in real time allows monitoring and rapid evaluation. This program includes both children and adults. Medicaid: Designed to Fail