The FDA to Medicaid: Don’t rob Baby Peter to pay Adult Paul

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The Agency for Health Care Administration (AHCA) intends to wrap children’s dental services into medical managed care plans when the successful prepaid dental health program sunsets in October 2014.

AHCA suggests that wrapping dental services into Medicaid health plans will permit coverage for adults as well as children.

But the problem is that the state doesn’t intend to pay any more for dental care than the pittance it does now. Does AHCA expect health plans to spread the already miniscule dollars that used to be meant for children to pay for care provided to adults?

One clear answer: keep children’s dental out of it.

AHCA’s first rationale for this move is to avoid “fragmentation.” 

Unfortunately, integrated pots of money don’t equal integrated care. If anything, batching dental with health plans will only fragment access more.

This is so for many reasons.

First, Medicaid managed care plans generally subcontract dental services out to the same prepaid dental groups that currently run the program.  This means that health plans will take already paltry reimbursement fees and divvy them up further, keeping a chunk in the process as the middle man.

“This simply pays another layer of administration versus getting maximum dollars out to providers and patients,” says Dr. Terry Buckenheimer, president of the Florida Dental Association.

Second, unlike traditional Medicaid plans, prepaid dental plans are able to maximize payments in areas where dentists are most needed, and to pay a little less in areas where dentists are plentiful because access is not a problem.  

This market-based approach has allowed prepaid plans to create dental networks and increase access to care in ways that the state has never been able to do on its own. 

Because of this, prepaid dental has been able to achieve a dramatic turnaround in access to care for low-income children, a turnaround that the state has recently and rightly bragged. 

To Dr. Buckenheimer, the effort to promote adult dental care by somehow combining it with children’s dental may be well-intended but will only exacerbate problems in the future. 

“If we don’t start changing things for children we will have a couple of generations of problems down the road,” he said.

If adult dental is something that the state cares to offer, nobody is stopping the Legislature and Medicaid from paying health plans more to do so.  But robbing Baby Peter to pay Adult Paul isn’t the way to get there. 

Finally, AHCA is rightly focused on the successful rollout of statewide managed care.  However, contrary to some impressions, maintaining prepaid dental poses no threat to that process or timeline.

CMS, which must ultimately approve Florida’s Medicaid design, has expressed that an amendment to the state waiver to continue with prepaid dental would not be a burdensome request. Considering that Florida’s abysmal record on children’s dental health is well known, efforts to build on progress through prepaid dental would be well received by the feds.

The Legislature should extend the statewide prepaid dental managed care program for at least three more years, during which time a full review can take place to validate the tangible improvements we have finally started to see.

By doing so, Florida can avoid the fate it is heading for, and one that many other states have faced. Other states have tied dental care into overall health plans only to have go back later, remove dental, and return these services to their own ‘carved-out’ environment.

“Keeping dental separate will ensure there aren’t disruptions to children’s care,” Buckenheimer said.

And that’s what actually matters.

Karen Cyphers, PhD, is a public policy researcher, political consultant, and mother to three girls. She can be reached at [email protected]