NMDA Journal Spring 2020

nmdental.org 9 may be misleading because fee-for-service constitutes such a small percentage of Med- icaid eligible patients. The number of encounters indicates that roughly 60% of Medicaid-eligible kids saw a dentist last year. Although that represents a significant amount of unidentified and untreated dental disease, the rate of encoun- ters is roughly the same amount that kids with commercial coverage report. The con- clusion should be that the barriers to children receiving care are not unique to Medicaid- eligible populations but are a factor of the overall culture. Fluoride In the section labeled “Background,” there is a discussion of both fluoride varnish and sil- ver diamine fluoride. It is unfortunate that the report fails to indict the Medicaid division for the years they failed to make fluoride var- nish a benefit when it had been identified repeatedly as an essential benefit. While it is laudable that it is now covered, the lack of responsiveness of the department is illustra- tive of Medicaid’s problems. The identification of silver diamine fluoride as an important service to be included in Medic- aid is significant, however the implication that it will result in cost-savings is question- able. There is not clear evidence and the statement is questionable on its face since ultimately teeth that need restoration will have to be restored. Moreover, application of silver diamine typically requires multiple encounters and is not an insignificant cost itself. Obviously, coverage for silver diamine fluoride is a desirable benefit but it should not be represented as a significant cost- savings, unless that can be demonstrated. Ironically, the report did not include a men- tion of the number of Medicaid recipients that do not have access to optimally fluori- dated water supplies. This would have a sig- nificant impact on the cost of care over a lifetime which is based on well-documented evidence. Reimbursement This is certainly a factor that everyone agrees is a barrier to Medicaid participation, how- ever a 3% increase is arbitrary and funda- mentally inadequate to address the problem. The level of reimbursement that would spur increased participation is not so mysterious. Commercial dental benefits plans know and have relevant experience with building net- works. What is mysterious is why Medicaid doesn’t utilize this resource in determining reimbursement levels that would encourage participation and develop an adequate net- work. The managed care organization most certainly recognize that the medical Medic- aid program is market-driven and adjust their program accordingly. Dental Medicaid is tied to the department’s fee-for-service rates which almost completely ignore the marketplace. The recommendation to pilot a program sim- ilar to Michigan’s Healthy Kids program is a good start, at least for kids. Such a pilot should be viewed not only as one alternative model, but also as developing a source of relevant market data to be applied to the programmore broadly. Access This section does a good job of identifying many of the barriers that prevent kids from receiving the care they need. Most of the rec- ommendations are reasonable and should be given due consideration. Nonetheless, there are a couple of omissions. First, the availability of a dental teammember, the Community Dental Health Coordinator (CDHC), is not mentioned. Encouraging the incorporation of this teammember in differ- ent settings would begin to address many of these problems. Medicaid could play a cru- cial role, but the report fails to mention this solution. The report also fails to mention that, as a result of HB308 in 2019, NM students will be required to have dental examination prior to starting school. Although parents may choose to opt-out, Medicaid could play an important role in encouraging families to establish a dental home by facilitating these exams and providing incentives for compli- ance. The report also recommends a signifi- cant investment in school-based clinics. There is certainly value in making an invest- ment in this delivery model, but it should be understood that school-based services have limited value unless they ultimately lead to establishment of a dental home. School clin- ics should be conduits rather than substi- tutes unless they can offer the full range of services and provide responsible long-term case management. Cost-savings This is certainly an area that needs to be addressed. Clearly, the measure that we pro- vide the greatest savings is preventing dis- ease. There are a number of measures that could be considered along with the recom- mendations of the report. Some of these should involve changes to the Medicaid pro- gram itself to encourage early and compre- hensive treatment rather than repeated visits to address the same problem. Also, the rec- ommendation that referrals be made espe- cially to FQHC’s is questionable. The system would be best served by improved access in multiple delivery venues that would most conveniently serve that patient’s needs. Although the report focuses on children’s Medicaid, the cost-savings issue is best addressed by considering the entire system including adults and seniors. Workforce The Task Force identifies a number of impor- tant barriers including student debt and the difficulties of attracting new dentists to rural areas and some practice models. The ratio- nales for debt repayment programs and practice incentives are sound and parallel the recommendation of Focus 2020. The sta- tistical background is somewhat misleading. There are certainly more than 17 students in American dental schools from New Mexico. Students that utilize the WICHE program for dental schools’ numbers around 60. There are almost certainly other students from New Mexico that attended out-of-state undergraduate schools that don’t utilize WICHE. New Mexico has seen fewer appli- cants in the last couple years and this needs to be addressed. The ethnic and cultural demographics of NM students still does not reflect the diversity of our state adequately. The report should have included some infor- mation on the efforts to create a partner- ship with the new school Texas Tech is opening in El Paso (SM59). Such a partner- ship could have a significant impact on addressing the diversity and distribution issues, particularly if paired with an in-state undergraduate BA/DDS program as was recommended in Focus 2020. The task force did well in identifying most of areas that need improvement. The report generally focuses attention where it is needed. Hopefully the report will continue to be refined to reflect more of the most rele- vant information and expand the recom- mendations to create the program New Mexico really needs. This article represents the opinions of the author and not necessarily the views of the New Mexico Dental Association. Dr. Schripsema was a participant in the task force’s deliberations.