Michigan dental care for uninsured and low-income people: when more costs less

On March 17, 2012, the Lansing State Journal featured an article, "Growing numbers of people heading to emergency rooms for dental problems" by Laura Misjak, and an editorial, "Michigan must solve dental care puzzle", urging the state to increase access to dental care.
 
Although Michigan reinstated a preventive dental care benefit to people on Medicaid in 2010, there are not enough dentists who will treat Medicaid patients. According to the the Michigan Dental Association, of the state's 6,715 dentists, only 1,666 accept Medicaid for adult patients. This is because the rate of reimbursement for basic dental care is only about 30 to 40%. 95% of Dentists responding to a recent survey by the MDA said the reimbursement rate would have to be above 50% for them to participate in the Medicaid program.
 
People who are uninsured or who can't find a dentist to treat them, often end up in emergency rooms where they typically receive antibiotics, painkillers, and a referral to a low-cost dental clinic. There are sometimes long waits to be treated in dental clinics and patients may end up back in the Emergency room before they can get in to see a dentist. An emergency room visit typically costs around $200. Sometimes dental problems that are not treated properly can result in longer term hospitalizations that can cost almost $20,000 for a 2 1/2 day stay. 

According to the article, some officials estimate that the number of emergency room visits for dental pain is " …as high as 100,000 per year in Michigan, with more than 1,000 hospitalizations annually for preventable dental problems."
 
"As with so many issues, spending money on prevention will save money in the long run. Michigan must must move access to dental care higher on its priority list," says the LSJ editorial.

Preventing abuse with background checks

A small item in today's AnnArbor.com caught my attention as an easy topic for a short blogpost: Michigan's Governor Rick Snyder signed into law two state Senate bills, SB 787 and SB 788, that "amend existing statute to require that criminal background checks are done through the FBI for owners, operators, and certain other workers in adult foster care homes and homes for the elderly." A person who has been found guilty of a felony or who has been found guilty of a misdemeanor in the last ten years for the crime of abuse of a vulnerable adult can be denied a license.  

“We have a responsibility to ensure the best and safest care for Michigan’s elderly,” Snyder said in a statement. “A thorough background check of caregivers ensures only the most dedicated and scrupulous Michiganders work with our vulnerable citizens.”

Here is a brief summary of the bills. The law requires state background checks through the state police, as well as the FBI.

This one little article brings up a lot of questions that I am embarrassed to say I don't have answers for: Does the state require background checks for all direct care workers who work in these homes? What about the proliferation of unlicensed settings where people with developmental disabilities receive care and other services? Are agencies or individuals who provide care in these settings subject to background checks? Are there requirements that local Community Mental Health agencies do background checks on caregivers and others who interact with the DD population? The purpose of background checks is to prevent abuse, but do the laws extend far enough to have a significant effect?
 
I can see I have my work cut out for me. Abuse of severely developmentally disabled adults like my sons is a real and justified fear. At least I know this: it is a crime to abuse a vulnerable adult, "an individual age 18 or over who, because of age, developmental disability, mental illness, or physical disability requires supervision or personal care or lacks the personal and social skills required to live independently." This applies to any caregiver no matter the setting. Anyone found to have abused a vulnerable adult can face criminal penalties including prison and stiff fines. Here is the statute:

THE MICHIGAN PENAL CODE (EXCERPT)
Act 328 of 1931
 

750.145n Vulnerable adult abuse; first degree; second degree; third degree; fourth degree; authority to prevent vulnerable adult from being harmed or harming others not prohibited; applicability of section to act carried out by patient advocate.
Sec. 145n.
(1) A caregiver is guilty of vulnerable adult abuse in the first degree if the caregiver intentionally causes serious physical harm or serious mental harm to a vulnerable adult. Vulnerable adult abuse in the first degree is a felony punishable by imprisonment for not more than 15 years or a fine of not more than $10,000.00, or both.
(2) A caregiver or other person with authority over the vulnerable adult is guilty of vulnerable adult abuse in the second degree if the reckless act or reckless failure to act of the caregiver or other person with authority over the vulnerable adult causes serious physical harm or serious mental harm to a vulnerable adult. Vulnerable adult abuse in the second degree is a felony punishable by imprisonment for not more than 4 years or a fine of not more than $5,000.00, or both.
(3) A caregiver is guilty of vulnerable adult abuse in the third degree if the caregiver intentionally causes physical harm to a vulnerable adult. Vulnerable adult abuse in the third degree is a misdemeanor punishable by imprisonment for not more than 2 years or a fine of not more than $2,500.00, or both.
(4) A caregiver or other person with authority over the vulnerable adult is guilty of vulnerable adult abuse in the fourth degree if the reckless act or reckless failure to act of the caregiver or other person with authority over a vulnerable adult causes physical harm to a vulnerable adult. Vulnerable adult abuse in the fourth degree is a misdemeanor punishable by imprisonment for not more than 1 year or a fine of not more than $1,000.00, or both.
(5) This section does not prohibit a caregiver or other person with authority over a vulnerable adult from taking reasonable action to prevent a vulnerable adult from being harmed or from harming others.
(6) This section does not apply to an act or failure to act that is carried out as directed by a patient advocate under a patient advocate designation executed in accordance with sections 5506 to 5515 of the estates and protected individuals code, 1998 PA 386, MCL 700.5506 to 700.5515.

The risks of dental sedation and how to make it safer

My son Danny is one of those impossible dental patients who cannot be worked on safely without sedation. A little Valium before a dental appointment does not do the trick. It may be enough to put him to sleep during the van ride to the dentist, but as soon as anyone gets near his mouth or touches his face he is a wide-awake wild man. 

Danny has had his teeth cleaned successfully using IV sedation, but this is not a risk-free procedure. A Detroit Free Press article from February 19, 2012, "Painless, at what price? Risks of dental office sedation prompt calls for tighter regulation" by Patricia Anstett, exposes the risks of dental sedation and how to improve training for dentists and the overall safety of sedation procedures.

The use of dental sedation is growing most with the use of conscious or moderate sedation involving the use of oral or intravenous medicine to relax a person. Deaths from dental sedation are rare but alarming, especially because some of the deaths have occurred in children with cerebral palsy.

According to the article:

• "Michigan has not updated state laws to comply with 2007 national recommendations from the American Dental Association calling for more training of doctors performing sedation, and it is one of only two states that don't require permits for providers doing the procedures." 
• "Michigan's Board of Dentistry has been reviewing ways to strengthen dental sedation regulations, which have been largely unchanged since 1997. The board expects to adopt new standards this year and is likely to address them at its April 12 meeting, said Rae Ramsdell, director of the Bureau of Health Professions in the Michigan Department of Licensing and Regulation…The rules are likely to require more training for dental practices offering moderate sedation."
• Deaths from dental sedation are difficult to track. Many deaths and complications are never recorded as dental-related because they may occur at home or in a hospital.

 
The Michigan Board of Dentistry will be releasing a final draft of regulations to improve the training of dentists and the safety of dental sedation soon. It must hold a public hearing on the new regulations and publish the standards.
 
How to comment on the proposed regulations: Write: Michigan Board of Dentistry, Department of Licensing and Regulation, Bureau of Health Professions; P.O. Box 30670, Lansing 48909

Michigan DCH sponsors additional forum in March

The Michigan Department of Community Health will host two public meetings in March 2012 to present its proposal for integrating care for people who are eligible for both Medicare and Medicaid:

Tuesday, March 20 from 1:30 to 4:00 PM at the Best Western Plus Hotel in Lansing (formerly Causeway Bay Hotel)

Thursday, March 29 from 1:30 to 4:00 PM at the Greater Grace Temple in Detroit

You are welcome to attend either meeting, where attendees will have an opportunity to ask questions and provide comments on the proposal.

The state’s proposal will be posted for public comment for 30 days beginning the week of March 5.

More information about the March meetings, including details on how to register to attend, will be sent this week.

To read the plan, go to the Integrated Care Website and click on "Integrated Care Proposal". The MDCH will receive comments on the plan for 30 days.

Disabled adults with nothing to do

This is an article from the VOR Weekly Update:

Founded in 1983, VOR is a national 501(c)(3) organization governed by a volunteer board of directors and funded solely by dues and donations. VOR receives no government support.

Throughout its history, VOR has been the only national organization to advocate for a full range of quality residential options and services, including own home, family home, community-based service options, and licensed facilities. The organization supports the expansion of quality community-based service options and opposes the elimination of the ICFs/MR (institutional) option.

VOR represents primarily individuals with  intellectual disabilities and their families/guardians. VOR advocates that the final determination of what is appropriate depends on the unique abilities and needs of the individual and desires of the family and guardians. 

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Many Adults With Disabilities Do Nothing All Day


A new study concludes that people with developmental disabilities who are inactive each day are also more likely to have severe disabilities, receive fewer resources, and have parents who were less able to provide care. In these cases, a large percentage of siblings also reported having poorer mental and physical health than other siblings as well as weak relationships with their brother or sister, calling into question their viability as long-term caregivers.

Unfortunately, the study’s findings did not consider the impact of residence on level of daily activity. The study included individuals in all settings with the majority (88.9%) living in family homes, group homes, and other small settings, and the remainder in licensed facilities (11.1%). 

VOR feels that the detrimental impact on aging caregivers – parents or siblings – is predictable. People with severe developmental disabilities take more care, more time and energy and over time such caregiving takes its toll. Caregivers have less energy and motivation to search for more services, especially considering the many obstacles to finding services that are often in place. It is our experience that many local agencies do not tell families all that is available or families are discouraged from asking for services due to lack of funding and long waiting lists.

Many years ago, author Fern Kupfer addressed this very real concern:

“No politician is going to say he is against caring for the handicapped, but he can talk in sanctimonious terms about efforts to preserve the family unit, about families remaining independent and self-sufficient. Translated, this means, ‘You got your troubles, I got mine.’” (Kupfer, F., (December 8, 1997). My Turn: Home Is Not For Everyone. Newsweek).

In response to the "Do Nothing" study, one VOR Board Member remarked, “I hope this study is not interpreted as a need to better educate parents to become better caretakers, rather than actually providing services.”

Read related article here from the Website disabilityscoop.

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The study by Julie Lounds Taylor and Robert M. Hodapp, "Doing Nothing: Adults With Disabilities With No Daily Activities and Their Siblings",  is published in AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2012, Vol. 117, No. 1, 67–79

MDCH sponsors a forum on Michigan plan to integrate dual eligibles

 This is an announcement from the Michigan Department of Community Health:

The Michigan Department of Community Health will host a public forum on Tuesday, March 20, 2012 from 1:30 to 4:00 PM at the Causeway Bay Hotel in Lansing to present its plan for integrating care for people who are eligible for both Medicare and Medicaid. Attendees will have an opportunity to ask questions and provide comments on the plan during the forum.

The state’s draft plan will be posted for public review and comment for 30 days beginning in the week of March 5.

More information about the March 20 forum and instructions for registering to attend the event will be sent soon. Please watch for another e-mail from the MDCH in the next week.