WOW! Michigan increases dental benefits for adult Medicaid recipients!

This is from the Michigan Department of Health and Human Services: As of 4/1/2023, the  State has expanded dental services and now reimburses dentists at 100% of the Average Commercial Rate for Medicaid beneficiaries

I missed this. My son Danny, who passed away last October, was most in need of this. As his seizures increased and other disabilities became more debilitating for him, his safety outside of a hospital setting could no longer be assured. For a number of years, I was so disgusted by the Medicaid dental care that was available to him that he went without. I don't think he ever had a cavity and there was no indication that he was having dental problems, but he required sedation for his teeth to be examined and X-rayed. The Medicaid provider was not willing to do this without putting us through a long period of proving he needed sedation and making us wait for extremely long periods of time for appointments. My son Ian, on the other hand, is surprisingly amenable to having a private dentist and dental hygienists clean his teeth, do X-rays, fill cavities, etc.

I'm sure it will take time for this to have full effect, especially in persuading dentists to take on difficult-to-care-for patients with disabilities, but it is very encouraging.

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MDHHS expands dental benefits for Medicaid beneficiaries
April 03, 2023

To improve access to dental services, the Michigan Department of Health and Human Services (MDHHS) has expanded dental benefits for adult Medicaid beneficiaries and increased rates for dental providers. This redesigned benefit will directly help beneficiaries by increasing access to services, enhancing care coordination and improving health outcomes. Benefit enhancements and service delivery began April 1.

“This positive change recognizes the strong correlation between oral and physical health outcomes,” said Elizabeth Hertel, MDHHS director. “With better services and closer care coordination, we can maximize opportunities to create healthy outcomes for beneficiaries of all ages while also expanding the number of providers so Michigan’s residents can get care where and when they need it.” 

The $85.1 million investment in increased reimbursement and $30 million in redesigned benefits will not result in any loss of services, and many recipients will have new services added. For beneficiaries who are 21 years and older, the following services will now be covered:

    •    X-rays
    •    Teeth cleanings
    •    Fillings
    •    Extractions
    •    Dentures
    •    Deep teeth cleanings (New)
    •    Sealants (New)
    •    Root canals (New)
    •    Crowns (New)
    •    Care to keep your gums healthy (New)
 
Changes reflect input from a broad array of stakeholders and lessons learned from the Healthy Michigan Plan and Pregnant Women dental programs. In addition to the expanded services, MDHHS has made changes to improve beneficiary access and provider participation, as well as expand access to robust care coordination services that ensure beneficiaries are supported in accessing the services they need. 

As a first step in the redesign, a policy that substantially increased reimbursement rates for Medicaid dental services was implemented Jan. 1, 2023. Providers are now being paid at 100% of the Average Commercial Rate, ensuring access and incentivizing providers to treat Medicaid beneficiaries.

“The reimbursement rates for providers were very low under the old adult dental Medicaid program,” said Dr. Vince Benivegna, President of the Michigan Dental Association. “Dentists would lose money by treating adult dental Medicaid patients. As small business owners this was not sustainable. The new rates recognize the value of quality care and will allow more dental health providers to treat Medicaid patients.”

Medicaid beneficiaries will not lose any dental care benefits with these changes; however, the way services are delivered may change slightly. Medicaid beneficiaries aged 21 years and older, including Healthy Michigan Plan beneficiaries and pregnant women who are enrolled in a Medicaid Health Plan, Integrated Care Organization or Program of All-Inclusive Care for the Elderly will receive dental benefits through their health plan. The health plan becomes responsible for the beneficiary’s dental services obtained through the health plan’s dental provider network. The health plans will continue to provide robust care coordination and ensure that beneficiaries are supported in accessing the services they need.

Dental services for beneficiaries who are not enrolled in a health plan will be provided through the Medicaid FFS program.

For questions, beneficiaries can call the Beneficiary Help Line for free at 800-642-3195 (TTY: 866-501-5656) or send an email to beneficiarysupport@michigan.gov.

Providers can call 800-292-2550 or email providersupport@michigan.gov.

Michigan Dental Health

This is an overview of oral health in Michigan, including vulnerable populations, such as seniors, pregnant women, low-income children and other special populations, who are at risk for poor oral health outcomes.

This is part of a presentation from the Dental Access Project of the Michigan Council for Maternal and Child Health.

More information on the Michigan Dental Access Project: 

Full Report

Interviews with stakeholders

Michigan Maternal & Child Health (MCMCH) Website

The Michigan Dental Access Project has been studying legislation that would allow for Mid-level Dental Therapy as a way to alleviate the need for increased access to dental care. Someone with specialized training or a degree, beyond that of a dental hygienist and similar to that of a physician's assistant or nurse practitioner, could then provide some dental services under the supervision of a dentist that are not currently authorized.

Webinar on Medicaid Dental Coverage for Adults, 2/17/15

This is a notice for a webinar sponsored by the Center for Healthcare Strategies (CHCS) - "Advancing access, quality, and cost-effectiveness in publicly financed healthcare." The webinar will begin at 12 noon eastern time on Tuesday, 2/17/15, and will last for 90 minutes. The event is free, but you must register to participate.

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Dental Coverage and Opportunities for States to Access Medicaid for Adults Webinar

Medicaid programs are required by federal rules to cover comprehensive dental services for children, but dental care coverage for adults in Medicaid is optional for states and is often one of the benefits to be taken off the table when budgets get tight.  The Center for Health Care Strategies (CHCS) will be providing an overview of adult dental coverage in Medicaid during a 90-minute webinar on February 17, 2015 at 12:00 PM ET.  Colorado and Kentucky will be highlighted as Medicaid expansion states and will share their experiences on expanding dental coverage.

While most states offer some form of dental coverage to Medicaid enrolled adults, only 32 states cover services beyond emergency care, and only 16 states offer comprehensive dental coverage.

For more information and to register for the webinar, go to this Website.

Kentucky: Specialty medical clinic for people with DD

Wild Turkey

From the VOR weekly news update, August 8, 2014

Kentucky: A new wave of progress in healthcare is coming
This is from Exceptional Parent Magazine * August 2013 * by Matt Holder, MD, MBA, Chief Executive Officer of the Lee Specialty Clinic and the President of the Academy of Developmental Medicine and Dentistry

Excerpts

  On June 11, 2014, Governor Steven L. Beshear presided over the ribbon cutting ceremony for the Lee Specialty Clinic in Louisville, Kentucky.  While this ceremony celebrated the opening of just one clinic in one city in the United States, this single event marks one of the most significant developments in healthcare for individuals with intellectual and developmental disabilities in decades.

   The Lee Specialty Clinic focuses exclusively on people with intellectual and developmental disabilities. Its core services include primary care medical services, specialty medical services, dental services, psychiatric and behavioral services, physical therapy, occupational therapy, speech therapy, and crisis intervention services. These services are provided in an interdisciplinary fashion, whereby the professionals who provide them communicate with each other for the benefit of the patient. The Lee Specialty Clinic also serves as a teaching and research program where students from any healthcare discipline can learn, intensively, how to care for people with I/DD. Finally, and perhaps most important of all, the clinic model is reproducible. Its funding model has been approved at the federal level and its coordinated through the Medicaid system. This means that any state that desires to create such a model can do so.

YEARS OF COLLABORATION

    The creation of the Lee Specialty Clinic did not occur overnight. In fact, it took years of collaboration between doctors, families, advocates, self-advocates, policy makers and  governmental  professionals,  but  its existence stands as a testament to what can be achieved when all of these groups work together for the benefit of people with IDD. The  origin  of  the  Lee  Specialty  Clinic dates back  to  1999  when  a  dentist,  Dr. Henry  Hood,  a  family  advocate,  Louise Underwood and a state legislator, Representative Jimmie Lee worked diligently  to  create  a  pilot  dental  program.  After three years of advocacy, the Underwood and Lee Dental Clinic opened its doors to the public in 2002. At the time, it was estimated that the clinic might serve two or three hundred people with IDD from the Louisville metropolitan area.  By 2006, the clinic had received multiple awards for its innovative approach and quality outcomes and it was serving around 700 patients from over 30 counties in Kentucky. Some families drove five hours across the state just to come to the clinic.

 Read more...

Community Living: the Medicaid customer service mess

Happy Dan

Government-funded advocates from all over the country are intent on liberating people from institutions that provide them with the care they need to survive and whose families do not want them to leave. The same  advocates have decided that people who do not live in institutions are being oppressed by specialized services that expose them to too many people with disabilities. In their ideological fervor, they are helping states eliminate and limit access to programs and residential options for people with DD. I assume the states could not be happier to have the help of advocates in closing these relatively expensive programs.

Here's something that might distract these advocates for awhile from undermining the infrastructure of services available to people with DD: Put your efforts into untangling the mess that is Medicaid customer service that causes despair and outrage in anyone trying to penetrate the Medicaid wall of inefficiency and ineptitude.

I've written about this before, but here we go again.

Here's the deal: Danny needs a replacement part on his wheelchair for the tilt mechanism to work. This is vital for repositioning, which he needs frequently for his care and comfort. The wheelchair repair service set the chair in one position to still make it usable. Then they sent in all the paper work for Medicaid to authorize the purchasing of the part. Medicaid has such a huge backlog, that wheelchair repair waited for four weeks for Medicaid to respond. When they called about the authorization for service a week ago, they discovered that Medicaid had no evidence that an authorization request had been sent to them. Wheelchair repair started the process all over, faxing in the paperwork. When I called this morning, the wheelchair service said I might have better luck as a parent finding out what has happened to the order for a replacement part.

I called the Medicaid help line [1-800-642-3195] to begin several rounds of responding to automated menu items and listening to messages about how they probably could not help me on this line. After something about cervical cancer and Medicaid hearings, a message played that said "Check your local phone book for dentists. We do not have lists of dentists who take Medicaid". 

"Why not?", I said to no one in particular. Some of the messages were so well done that I believed I was finally talking to a human being only to find out that I was still on an automated call.

I finally did get through to someone named Dan. To be sure, I do not blame Dan for any of what ensued. He probably is just some guy who is waiting to find a real job and is doing the best he can in the meantime holding on to one of the worst jobs on earth: listening to people like me complain about Medicaid and reminding him that their inefficiencies hurt real people.

Dan quizzed me, first gathering information about me and then information about Danny, including his Medicaid number. I was not listed as Danny's guardian, although I sent in the paperwork for that years ago. Dan was therefore unable to impart any information of a confidential nature. But he did place me on hold for ten minutes, so that he could figure out who I could call, depending on Danny's Medicaid classification.

Dan will send me the form to fill in (again) so that I will be listed as Danny's guardian and will then be permitted to discuss his case more specifically on the phone. What I then learned is that even when I am listed as Danny's guardian, it won't make any difference: I will have to ask the provider of the service to find out about the status of the Medicaid authorization to replace the broken part. While Danny no longer has a workable tilt mechanism on his wheelchair, I will be running around in circles with the provider who is already banging his head against the proverbial wall.

In other words, there appears to be no way for an individual or a guardian to directly intervene to find out about the status of a request for Medicaid authorization for a service.

Meanwhile, I am spending most of my energy on trying to keep government-funded advocates from "helping" to liberate my sons and people like them from the services they need.

Go figure.

More on dental care in Washtenaw County, MI

This is from the website of The Washtenaw Health Initiative, "a voluntary, county-wide collaboration focused on how to improve access to coordinated care for the low-income, uninsured, and Medicaid populations."

Among the findings of the WHI is this:

Dental Care for Low-Income Adults: Lacking and In Great Need 

18,417 adults in Washtenaw County had Medicaid coverage with dental benefits in 2010. Yet, in a 2007 survey of community dentists, only 15% said they accepted Medicaid benefits and only 8% (five practices) said they were accepting new Medicaid patients (more practices accept Medicaid benefits for children under 18 years old). Medicaid’s low per case reimbursement is one of the main reasons dentists said they do not accept Medicaid coverage.[emphasis added]

While there are some community outreach efforts, just three clinics (Hope Clinic, Community Dental Center and the U-M dental school) currently provide low or no cost dental care on a routine basis to adults in the county. Restrictions on who can receive care at such clinics further limit patient options. Emergency departments recorded 4,667 dental-related emergency visits in 2008. The 28 hospital admissions with disorders to the teeth and jaw cost about $534,000 – about $19,000 per patient. [emphasis added]

For the record, Washtenaw County is the home of the University of Michigan with a dental school ranked in the top ten in the country. That has not helped much in delivering good dental care to low-income people.

Proposal for Medicaid Dental Clinic in Washtenaw County, MI

The Reader

The day before I take my son Danny for his annual cleaning to a private dentist who does not accept Medicaid dental insurance, I read in my local paper that there are plans afoot to establish a clinic specifically for people insured by Medicaid. Danny is one of those people who is on Medicaid, but in recent years, of the dentists who will accept his insurance, we have not felt that his dental care was adequate to his needs. I am all for the new clinic as a way to serve more people who need and deserve better care.

An article in ANNARBOR.com, "Washtenaw County considers dental clinic for Medicaid patients" by Amy Biolchini on 4/10/13, provides details on the need for a clinic and looks at a proposal for funding and operation of a clinic specializing in Medicaid patients.

The Washtenaw County Director of Public Health Dick Fleece, three of the County's 9 Commissioners, the County Executive Verna McDaniel, and the staff from the Universtiy of Michigan's Dental Clinic met to discuss a proposal to build a new dental clinic in the County.

Because of the low reimbursement rate for Medicaid dental care, less than 1% of the 300 dentists in Washtenaw County accept Medicaid patients. [How's that for an effective way for the state to get credit for providing dental insurance for low income people while not following through by funding it adequately?] While there are other free dental clinics in Ann Arbor, they are limited to people who do not have insurance, or they are limited in the number of people they can treat or are not able to treat people with medical or behavioral problems. Fleece, the Director of Public Health is asking for funding from the County to build the clinic that would be paid back over the next 10 - 20 years.  If the clinic is associated with a local health department, it is eligible for a higher reimbursement rate for Medicaid dental services.

He proposes that the clinic be run by "Michigan Community Dental Clinics Inc., a nonprofit company that runs dental clinics for 22 health departments in the state". The County Executive Verna McDaniel is supportive of the idea and "directed her staff to further pursue the logistics to creating a dental clinic".

“We have met people who are ashamed to smile, and that’s embarrassing. Their self-worth is lowered. Their ability to interact with people is diminished, and their ability to apply for a job is diminished,” says Fleece. Add to that people who cannot tell you if they are suffering from pain associated with poor dental care and whose pain is often misinterpreted as bad behavior or just taken for granted as another manifestation of their disability. The need for a new clinic is certainly justified.

Penny Wise and Pound Foolish: States cut Medicaid dental coverage for poor and disabled adults

An article in The Huffington Post by Daniel Lippman - "States Drastically Cut Dental Care For Adults on Medicaid" (10/02/12) - describes how states are cutting Medicaid dental services to restrain Medicaid spending.

According to the article, states that have recently cut Medicaid coverage of dental care for adults include: Pennsylvania, Massachusetts, Illinois, California and Washington. States are limiting or eliminating dental care for adults because they can. Dental care for adults is an "optional" service under Medicaid and is therefore an easy target for cost-cutting when budgets are tight.

• Washington State has preserved coverage for developmentally disabled adults and people in long-term care, while eliminating care for other poor and disabled adults. 
• Massachusetts will cover fillings, dentures, and root canals for front teeth hoping to make it easier for people on Medicaid to get and retain jobs, but back teeth (out-of-sight, out-of-mind?) are not covered.
• Illinois used to cover front teeth, but no longer. They will still cover emergency procedures such as extractions. 
• According to an NPR report on the lack of Medicaid coverage for adults in California, "In interviews with dozens of dentists and safety-net clinics around California, providers say patients are forgoing routine cleanings and delaying care until the pain is unbearable." 
• Pennsylvania has reduced Medicaid dental care for adults to basic services - cleanings, fillings and extractions.

Michigan is not mentioned in the Huffington Post article. Although the state continues to cover dental services for adults, the number of dentists who will see people on Medicaid has been drastically reduced by low reimbursement rates. This makes the program a virtually rationed system available to those who are lucky enough to find appropriate care or can find other ways to pay for it. Whether this saves money for the state is doubtful. There is increased reliance on emergency room visits to obtain painkillers and antibiotics to treat dental problems and more hospitalizations resulting from poor care.

Here is more coverage of dental issues in The DD News Blog.

This is the Medicaid Data Base describing Michigan's Medicaid coverage of dental care.

PBS's Frontline on "Dollars and Dentists" and more...

After spending a week at VOR's annual meeting and Washington Initiative (more on this later), I am catching up with all the things I didn't do while I was in Washington, D.C. One of the looming deadlines is July 2, 2012, when comments are due on the most recent attempt by the Center for Medicare and Medicaid Services to narrow the definition of community and limit spending with Medicaid waivers to services that the CMS finds acceptable. 

I followed some links from e-mails I received this morning and found one that is especially interesting to everyone caught in the Medicaid dental dilemma - dental coverage by Medicaid but few dentists who are willing or able to provide the services needed.

According to the NPQ Nonprofit Quarterly, "Sarrell vs. ADA Dental Drama Topic of PBS Documentary", this case and other problems with Medicaid dental care will be featured on Frontline on most PBS stations on June 26th, 2012. A preview of the program called "Dollars and Dentists" is posted in the article.

Another article is a New York Times Op-Ed by Mike Ervin called "Will the Reformers Come for Me, Too?".  In the op-ed, the author recounts events in Illinois: 

"Last week, here in Illinois, the governor signed into law $1.6 billion worth of Medicaid 'reform.' The ax came down on disabled children and young adults who are M.F.T.D. — medically fragile, technology dependent — those who have tracheostomies, are ventilator-dependent or need central intravenous lines. New co-payments and income caps could mean that many of these young people will no longer be able to receive care at home and will have to be institutionalized. No more free lunch for them!"

The author is himself severely disabled and he describes how he and his wife make ends meet with Medicaid waiver services allowing him to live at home. He always thinks common sense, justice, empathy, etc. will eventually prevail but now he is not so sure:

"But that’s gotten harder to believe after this latest round of cuts. It’s a nightmare: the vicious, man-eating Reformasaurus has gone berserk. Even holding up M.F.T.D. kids as human shields can’t ward it off these days. If it will swallow them up, what chance is there for a bearded, sarcastic, unsympathetic character like me?"

Mike Ervin has a blog called "Smart Ass Cripple: Expressing pain through sarcasm since 2010". I run a nice family-friendly blog here, but Mike doesn't. Don't say I didn't warn you. He is direct, politically incorrect, often vulgar, and, I think, hilariously funny. 

Here is a sample on Mike's giving up the use of the "r" word on his blog:

"Fair enough. We’ll not use the word “r” here at Smart Ass Cripple. Consider the word stricken, in spite of its element of comic allure. I am not 'r' so who am I to tell them what they have to call themselves? And I can kind of see their point. Some people referred to the 'r' kids at the cripple elementary school I attended as 'delayed.' That’s a helluvan identity to have to carry around. 'Hello, I’m delayed.'"

 

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.

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

Medicaid dental services reinstated for adults in Michigan

Dental services for adults on Medicaid have been reinstated with passage of the budget bills for fiscal year 2011. Beginning October 1st, 2010, adults 21 and over may again receive dental services. For a comprehensive look at the services available, see the Dental Database for 2010.

Funding that made it possible to restore dental benefits is temporary, however, and will probably not be available next year. Even before the next fiscal year begins in October 2011, the next Governor could rescind these benefits through an executive order.

Some dental services require prior authorization from Medicaid before the service is provided. To assure that needed dental work gets done, adults on Medicaid should see a dentist as soon as possible to get authorization for Medicaid covered procedures. As long as authorization is obtained now, these services will be covered.

Michigan's Medicaid budget approved by Legislature

A Detroit Free Press article reports that the Michigan Medicaid budget for the 2011 fiscal year has finally passed both houses of the Legislature and awaits the Governor's signature. With $650 million of federal stimulus money, the Department of Community Health has avoided a threatened $50 million cut in mental health services and has restored dental, podiatry, and vision care for all Medicaid recipients. A 4% cut in reimbursement to physicians and hospitals has also been avoided.

In usual fashion, the Legislature has ignored the problem of future deficits starting in 2012 when the stimulus funds are no longer available. Next year, there will be a $500 million gap in the budget, but who cares? It's an election year and a large number of legislators will be gone or will have shifted to another house because of term limits. Tax increases for next year have been suggested by Republican Senator Roger Kahn from Saginaw Township, who predicts that the next Legislature will "enact a combination of spending cuts, reforms and tax increases to avoid a deficit."

Dental care without Medicaid

Now that Michigan Medicaid no longer pays for preventive dental care for adults, we are not relying on dentists that accept Medicaid for our sons' routine dental care. The state's decision to drop dental care is cruel and short-sighted, but finding a dentist who was willing to try a different approach with our son Danny was an eye-opening experience.

Danny has severe cerebral palsy and profound mental retardation. Most importantly, when it comes to working on his teeth, he has a severe aversion to touch, especially around his face, mouth, hands and arms. And, at 33, he is strong. His movements are mostly uncontrolled, and if he is agitated, he is capable of inadvertently smashing you in the face, if you are not careful.

In the past, the only sedation that Danny received before dental appointments was Valium. Danny would have a nice Valium-induced nap on his way to the dentist and be fully awake and agitated during the dental exam and cleaning. Then, on the way home, he would have another nap before the Valium wore off. This time, we sought out someone who would try IV sedation before working on his teeth. As it turned out, Danny got the most thorough dental exam and treatment ever with a minimum of trauma.

Danny is generally healthy, with no heart or respiratory problems and with a history of tolerating both IV sedation and general anesthesia well. An experienced nurse anesthetist worked with the dentist and dental hygienists to sedate Danny and keep him "under" enough so they could work on him. The nurse anesthetist monitored Danny the whole time for blood pressure, heart rate, and oxygen saturation. Danny also received fluids through the IV and oxygen at least part of the time. The nurse controlled and monitored the amount of medication throughout. When it was all over, Danny came out of it immediately and was just fine. While Danny was under sedation, they did a complete set of X-rays, photos of his teeth, and a thorough deep cleaning. Danny had inflamed gums, but no cavities or periodontal disease. He did not need any other dental work, but the dental team was prepared for anything. His teeth are so clean now, he could eat off them.

It was costly, but having talked to a friend who looked into work being done on her child at a local hospital under general anesthesia, the expense was a fraction of what that would have cost.

This could have been done a long time ago, but we were discouraged from even contemplating it by one dentist who insisted that IV sedation didn't usually work on "people like Danny". Another dentist said it was too expensive, unsafe, and Medicaid would probably never approve it. He also said it was unsafe to use sharp pointy objects to clean Danny's teeth and thought brushing his teeth with anti-bacterial mouth wash every day was sufficient. He would not recommend using anesthesia unless Danny had more obvious dental problems, like loose teeth and rotting gums (he used more technical language than this). Then I asked, if we could pay to have him anesthetized ourselves rather than trying to get approval from Medicaid, would they do it? Suddenly, the issue of safety dropped from consideration and he said he could probably arrange for the hospital to do it. We decided to look for a less ethically challenged dentist.

Danny is fortunate in many respects: he has a good set of choppers, he is relatively healthy despite all his problems, and he has family who are able to pay for good dental care. But I question the wisdom of the state allowing a whole segment of the population to go without access to preventive dental care, knowing the bad effects this has on general health that we will all pay for eventually, and knowing that some people like Danny who cannot communicate whether the pain and discomfort they are experiencing comes from a tooth ache or a belly ache, will suffer needlessly from the lack of care.

Look here for more information on trauma-free dental care.

Free dental exams, November 14, 2009

I received this information from the University of Michigan Dental school. Just so you know, before attempting to participate in this, the Dental School does not treat people with unusual medical or behavioral problems. If you have a DD family member who is able to cooperate during the exam you might give it a try. They are only giving exams to the first 150 people who show up, so there may be lines.

This is available to anyone over the age of 5 regardless of income. If you know someone who needs a dental exam, whether they have a disability or not, let them know about this opportunity. This is just an exam - X-rays, oral cancer screenings, and oral hygiene instruction. Treatment is not being offered.

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Each year, the University of Michigan School of Dentistry Student Council sponsors Dental Health Day, offering free dental screenings to Ann Arbor and surrounding communities. Because of the increasing cost of dental care, lack of information about dental services and changes in insurance coverage, many people refrain from seeking dental evaluation and service until they are experiencing pain, or find themselves in an emergency situation. Dental Health Day was designed to allow more people, who would otherwise refrain from seeking dental treatment, to receive basic dental health care, free of charge, reducing risks of emergencies.

This year, the 2009 Dental Health Day will be held on November 14. Individuals regardless of income, and as young as five, can participate in the program between 9:00 a.m. and 2:00 p.m. An appointment is not necessary. However, patients will be seen on a first-come, first-served basis. Treatments will not be provided. Registration will start at 8:30 and will continue until 12 noon or until 150 patients have been evaluated. All participants will receive FREE oral exams, FREE oral cancer screenings, FREE dental x-rays and FREE oral hygiene instruction.

For more information, contact the School of Dentistry at (734) 763-6933 or by e-mail (dentalhealthday@umich.edu).

Kate Ratliff
Dental Health Day Chair
University of Michigan School of Dentistry
Student Council

University of Michigan School of Dentistry
1011 N. University
Ann Arbor
Please enter the School of Dentistry at the North University Avenue entrance. Parking will be available at the Fletcher Street parking structure.

Class action lawsuit to compel Michigan to restore Medicaid dental benefits to adults

In July 2009, Michigan's Governor issued an executive order to discontinue funding for Medicaid dental benefits for adults over 21 years old. Preventive dental care was eliminated and treatment was limited to emergencies to treat pain and/or infection only. After the state legislature failed to restore funding for preventive dental care during budget negotiations in October, a class-action lawsuit was filed on behalf of 400,000 adults on Medicaid to "ensure that their federally-protected rights to a certain minimum level of medical services are protected."

A statement by Dykema, the law firm handling the suit, claims that "Michigan is violating key federal regulatory and statutory mandates". These claims include:

• Michigan has failed to adopt and maintain programs and policies that operate to make dental care available for Medicaid beneficiaries throughout Michigan;
• The state is acting in violation of the efficiency. economy, and quality of care provisions of Medicaid;
• Michigan has failed to properly notify the federal Medicaid program that Michigan has discontinued providing dental services to adult Medicaid recipients.

Revenues for the state have declined precipitously over the last year, and the reduction in Medicaid services was part of sweeping cuts to services funded by the state. The actions of both the Governor and the state legislature have probably aggravated the state's budget problems. To "save" $5 million for dental benefits out of a total budget of more than $8 billion, the state will forego $16 million in federal matching funds from the federal government to fund Medicaid dental services.

The suit was filed October 28, 2009, in the U.S. District Court for the Western District of Michigan in Grand Rapids.

Medicaid dental benefits denied to adults in Michigan

Cutting off Medicaid dental benefits to adults with developmental disabilities is no small matter. In May of 2009, Governor Granholm did just that in an executive order in response to budget-wrecking declines in state revenues.

The cuts eliminating Medicaid-funded preventive dental care for adults over 21 years old, took effect on July 1st, 2009. They are described in changes to the state's Medicaid Provider Manual : "The adult dental benefit is limited to the following emergent/urgent services for the relief of pain and/or infection only... Routine examinations, prophylaxis, restorations, and dentures will not be covered. " In short, if you go to an emergency room with a toothache, Medicaid will pay for X-rays to diagnose the problem and for an extraction and maybe some painkiller, but will not pay to treat the underlying problem (such as periodontal disease), to fill a cavity, or to prevent the problem from occurring again.

For anyone who was already authorized for treatment of a dental problem before July 1st, 2009 and has a prior authorization on file, "providers have 180 days from the date the PA was approved to complete the services, according to existing Medicaid guidelines."

There are both short and long-term consequences to neglecting the dental health of people with severe disabilities: in the short-term, a tooth or gum infection that goes undiagnosed can result in pain, misery, infection, the loss of teeth, and even death. Ignoring gum and tooth disease may result in more expensive emergency room visits that fail to treat the cause of the problem. In the long-term, a lack of preventive dental care has also been implicated in the development of chronic diseases such as diabetes and heart disease.

As a parent, I mostly worry about someone like my Danny, who can't tell you that he is in pain or why he is uncomfortable. He can only show you in vague ways that something is the matter: he might have more seizures, be unable to sleep, scream (more than usual), or not want to eat. How do you rule out dental problems unless he has routine examinations, X-rays, and cleanings to diagnose problems early and either fix them or keep them under control? And what about people who have to be anesthetized for even routine dental evaluations? How bad will the problem have to be before Medicaid will authorize treatment or hospitalization or, in emergency situations, a dentist will have any confidence that a procedure will be covered by the person's Medicaid benefits?

There has been at least one death in Michigan since Medicaid adult dental benefits were substantially eliminated. According to The Grand Rapids Press in a story by Kyla King, Northern Michigan woman's death raises calls to restore adult Medicaid dental benefits, 10/22/09, a severely developmentally disabled woman from Alpena died reportedly from an untreated infection in her mouth. The woman had been scheduled for surgery in June 2009, but had other problems that postponed the surgery. Because of her severe disability, she needed to be hospitalized and anesthetized for the procedure. The dentists at the clinic in Cheyboygan, Michigan, were going to perform the procedure without charge, but the woman died while waiting for Medicaid approval of the $5,000 in hospital charges. The Michigan Department of Community Health admits that the death was indeed tragic and is looking into confirming the circumstances of the death.

The story in the Grand Rapids Press did not explain why there was a problem getting approval from Medicaid for the procedure when it was already scheduled for June, but was postponed. Was there not already authorization to do the surgery that would have covered the procedure for 180 days? Regardless of the details of the story, it is chilling that an infection in the mouth of a severely disabled woman could have resulted in death while awaiting Medicaid approval of coverage for a procedure that might have saved her life. How many more preventable deaths will it take before funding is restored for Medicaid preventive dental care?

Trauma-free Dental Care

I don't know who is traumatized most by my son Danny's dental appointments. Danny? Me? The dental hygienists (it takes at least two)? The brave group home staff person who is in charge of keeping Danny's head still while juggling the sunctioning device? The dentist? We are all victims.

Danny has severe cerebral palsy, profound mental retardation, severe visual impairment, and an extreme aversion to touch, especially around his face, mouth, arms and hands. He is 32 and has been this way since he was a baby, although his tolerance of touch has improved some over the years.

The worst dentist we ever encountered had no idea what he was in for. He ignored everything I told him about Danny's aversion to being touched and the problems that every dentist and dental hygienist had with him over a period of at least 15 years. The dentist plunged in without warning, jamming his fingers in Danny's mouth to do an examination. Danny flailed his arms, screamed,
gritted his teeth and shook his head back and forth until the dentist finally extracted his fingers from Danny's mouth and proclaimed that Danny had a "behavior problem".

No, the dentist had a "behavior problem".

A determined dental hygienist with the full support of a dentist and the rest of the team, can get Danny's teeth pretty clean. Fortunately, he has never had a cavity or needed other work on his teeth, so cleaning has been the greatest challenge so far. But I have often wondered why we can't just knock him out for 20 minutes every 6 months to do a really good cleaning and examination? He has had several surgeries with no problems with anesthesia, his breathing is good, and he is generally in good health.

I know there is a risk to placing a person under anesthesia and perhaps dentists worry about safety, the expense and who will pay the bill, and lawsuits when something goes wrong. But consider the risks of periodontal disease and its connection with serious health problems, such as heart disease, strokes, kidney disease, and diabetes. There are also horrendous stories about people with developmental disabilities whose behavior spun out of control until it was determined that the underlying cause was tooth decay or gum disease.

An article in the May 2009 issue of Exceptional Parent Magazine, caught my attention. "Anesthesia in Dentistry for People with Developmental or Acquired Disabilities" is by Anthony Charles Caputo, a Dental Anesthesiologist (DA). DAs specialize in providing a full spectrum of anesthesia services for special needs patients and dentists. They are trained to manage pain and
anxiety. A postdoctoral Dental Anesthesia residency is a 2-year program that must include experience providing anesthesia for patients with developmental or acquired disabilities. Most DAs provide office-based anesthesia (OBA) services in the offices of other dentists. By having the most modern anesthesia monitors, medications, and equipment normally found in operating rooms, DAs can provide safe and effective anesthesia and other pain and anxiety management in a regular dentist's office.

Dr. Caputo makes the point that just because "dentistry was able to be done" with a patient using milder forms of sedation, does not mean that it was done well. Dental anesthesia allows the dentist to focus on the needed treatment and not worry about the management of the patient. A paper published this year in the Special Care in Dentistry Journal concludes that when considering the risk of anesthesia with the benefit of delivering quality dental care, the risks were minimal and benefits significant to both the patient and the dentist.

The EP article concludes that,

With the full spectrum of sedation and anesthesia services available to dentists in the office-based setting, it is possible to treat the vast majority of patients successfully with sedation or OBA whether it is accomplished by the dentist or a separate anesthesia provider. Sedation and anesthesia techniques are available to dentists so that when other approaches to care are not successful, these treatment modalities are possible allowing the patient to receive treatment safely, comfortably, and successfully.

For more information go to the American Society of Dentist Anesthesiologists and the Special Care Dentistry Association.

Danny's dentist is going to hear about this.