Kristen Hwang at CalMatters: A typical dental office cannot perform general anesthesia nor can it accommodate other disabilities requiring wheelchair lifts or other specialized equipment.
Instead, disabled patients languish on waiting lists for years at the few places that can see them — usually dental schools. When they get an appointment, it’s frequently a financial hardship requiring time off of work for caregivers, long drives from remote areas of the state, overnight hotel stays and out-of-pocket surgical fees.
...
Without a centralized database, the number of patients that need special dental care is hard to quantify. Approximately 1.3 million children, or 15% of all children, in the state have chronic physical, developmental or behavioral conditions — although of course not all of those require special dentistry. The Department of Developmental Services also serves an estimated 330,000 individuals with disabilities. And California’s growing aging population includes 690,000 seniors with Alzheimer’s disease.
But, according to the dental association, there are only 14 dental schools and surgery centers that can handle these special needs patients. Some hospitals give dentists admitting privileges to perform surgery, but they say it’s often difficult to book operating time. ...
One of the primary reasons it’s so difficult to find a dentist is that most don’t accept Medi-Cal, the state health plan for its poorest residents, which a majority of people with disabilities rely on. In 2021, about 36% of active licensed dentists in the state accepted Medi-Cal. That number has grown by about 10% since 2017, when the state increased reimbursement rates. However, the number of Medi-Cal enrollees has also grown, reaching 14 million in the past two years.
Last month, the National Council on Disability issued a report titled "Medicaid Oral Health Coverage for Adults with Intellectual & Developmental Disabilities – A Fiscal Analysis."FULL REPORT (
PDF)
FULL REPORT (
DOC)
SCOPE AND PURPOSE: In its preliminary research into how to improve the oral health of people with intellectual and developmental disabilities (I/DD), NCD examined:
- The relationship between states’ Medicaid dental benefits and the receipt of basic dental care among adults with I/DD;
- The relationship between state waiver programs and receipt of dental care;
- The estimated cost and potential savings of implementing basic dental Medicaid benefits in states that do not currently offer it;
- The role of coordination between developmental disability (DD) agencies and Medicaid agencies for improving access to dental care; and
- Promising Medicaid-funded state and private strategies for expanding dental care for adults with I/DD.
NCD's ongoing policy focus on health equity led NCD to pursue an examination of the dental care experiences specific to individuals with I/DD under Medicaid. This initial report is part of ongoing related research into how to incentivize oral health providers to participate in Medicaid. A future study will examine why providers choose not to participate in Medicaid programs and waivers that facilitate the treatment of patients with I/DD and the potential incentives that could rectify that problem.
KEY FINDINGS: Of the nearly 7.3 million adults with I/DD in America, nearly 4.5 million rely on Medicaid for health coverage. NCD found that Medicaid does not uniformly provide adults with I/DD dental coverage and twelve states do not provide basic dental benefits aside from limited waiver programs in seven of them. This often times results in adults with I/DD in those states foregoing preventative and routine dental care and seeking emergency dental care at much higher cost, and/or developing chronic health conditions. Existing research shows dental health is the predicate for general health and general health is the predicate for positive employment, education, and community living outcome, yet adults with I/DD ages eighteen years and older experience poorer oral health and significant barriers to obtaining oral health care, relative to adults without I/DD. Poor oral health not only often leads to chronic disease, it also increases the likelihood of experiencing poor physical health.
NCD’s study estimates federal and state governments combined would realize a ROI of approximately $7.7 million beyond recovering the initial cost, annually, and the share of that ROI for those twelve states would total close to $3 million, annually. NCD estimates an overall modest return on investment for providing basic dental coverage for adults with I/DD in those states that provide emergency-only or no coverage ranging from an increased cost of $60,358 in Nevada to as much savings as $829,803 in Maryland – with costs likely offset by eliminating costly trips to the emergency room.
KEY RECOMMENDATIONS:
- States should add dental benefits for adults with I/DD to their 1915(c) and 1915(i) waivers or 1115 demonstrations and refer to those states that currently extend dental coverage to adults with I/DD as a model. States should consider available data about and evaluations of these waiver programs to prioritize the types of dental services and target populations to include in their own waivers. States can use available data as guidance to maximize access to key, cost-effective dental services while balancing available funding.
- States should fund programs that address the additional barriers to obtaining oral health care through Medicaid, including incentivizing the dental workforce to attract providers with expertise in treating adults with I/DD through continuing education programs, implementing programs that improve daily oral care provided by caregivers, and improving education and support for good oral hygiene for adults with I/DD. Additionally, states should address transportation barriers and coordinate services between DD agencies and Medicaid providers.
- The U.S. Department of Health and Human Services, through the Administration on Community Living, should conduct additional research to offer policy insights and recommendations that would reduce the need for the receipt of dental care in the OR and to improve access to the OR for people with I/DD.
The Politics of Autism discusses health care, and explains that autism services can be complicated, creating difficulties for autistic people and their families.
David Tuller of Kaiser Health News at The Washington Post:
People with autism, cerebral palsy and other developmental disorders face enormous barriers to adequate and timely dental care — on top of their other challenges. Many dentists either avoid treating these patients or lack the skills needed to do so. Some patients with developmental disabilities are unable to endure even regular dental exams or cleanings without general anesthesia.
But most dentists don’t offer it and getting insurance to cover it for routine dental work is often a struggle.
Because it is difficult for them to get treatment, people with developmental disorders suffer “a high burden of dental disease,” according to a 2012 study of more than 4,700 patients published in the Journal of the American Dental Association. Thirty-two percent of the patients studied suffered from untreated cavities and 80 percent from serious gum infections.
“Many individuals with developmental disabilities cannot personally maintain their own dental hygiene,” according to a September study by the California Legislative Analyst’s Office (LAO). “Often, they need extra appointments or special accommodations that dentists are unable or unwilling to provide.”
In many cases, patients need these extra appointments to help them get accustomed to the environment of a dental office, including the equipment, procedures and personnel. This can help minimize their anxiety and reduce the need for deep sedation or general anesthesia.
But sometimes there is no alternative to anesthesia.
