Dental Services Advisory Committee Meeting Minutes

Date: Nov. 20, 2017

Minutes prepared by: Garrett/Vrklan/Maytan

Location: Mosquito Control

Meeting Topic: At the request of Commissioner Piper, the committee spent the meeting reviewing and

responding to last years’ dental legislative proposal. This proposal was supported by DHS and included in

Governor Dayton’s proposed budget, but which did not pass through the House and Senate. Dental Services

Advisory Committee (DSAC) members and guests were advised ahead of time the topic of the meeting, and a

worksheet to organize individual responses was distributed in advance.

DSAC Voting Members in Attendance

Name Organization

Mark Quilling Consumer

Carla McMorris Children’s Dental Services

Carl Ebert Community Dental Care

Leah Anderson PrimeWest

Michael Helgeson Apple Tree Dental

Dan Rose – today’s acting Chair Lakewood Health System

David Maki Dental Associates of MN

Colleen Brickle Normandale Community College

Michelle Storlie Diamond Dental

Jeff Ogden – via phone HealthPartners

Attendance of DHS and MDH staff

DHS: Jeff Schiff, Linda Maytan, Diogo Ries, Tracy Vrklan, Ellie Garrett, Jared Greupner

MDH: Prasida Khanal MPH BDS – State Oral Health Director – ex officio member

Attendance of the Public

Name Organization

Nicole Ferrian Delta Dental of Minnesota – government programs

Dave Klein HealthPartners

Robert Freeman HealthPartners

Deb Jacobi – via phone AppleTree Dental

Ken Bence MCH Advisory

Summer Abdalla Student – U of MN School of Public Health

Majda Hodzic MN Dental Association

Daniel Lightfoot MN Dental Association

Dick Diercks Park Dental

Mary Seieroe HCMC

Tara Erickson HCMC and AppleTree Dental

Issue 1: Administrative Simplification

Decision / Recommendation:

DSAC agrees that administrative simplification is necessary. There is a general consensus that medical and dental

claims ought to be integrated in order to serve recipients in a more holistic manner (e.g. integrating medical care

for diabetes with oral health care), just as care ought to be integrated. One suggestion is State-supported

uniform administrative billing standards and separately streamlined credentialing processes.

The committee acknowledges that the current administrative burden on small dental practices related to

credentialing, prior authorization, and submission of claims is too high. Reducing administrative burden

translates into fewer staff salaries, and therefore, reduction of overall operational costs.

Overall the DSAC was supportive of administrative simplification, but did not have a unified position on a

single dental administrator.

Issue 2: Rates Reform

Decision / Recommendation:

Poor reimbursement rate is not the only issue, but it is an important one. Minimally, reimbursements must

cover the cost of care. It is noted by the group that MCO’s often pay higher than fee-for-service. Improving

access requires additional investment to increase the base rate.

Tandem with low rates is the issue of the limited benefit set stipulated in state law. This creates an ethical

dilemma for oral health providers who are not able to submit claims for needed services. For example,

periodontal scaling and root planing (D4341 and D4342) should be covered for all adults in any setting (not just

in ambulatory care, or for pregnant women). Periodontal maintenance, D4910, should also be covered. D4346,

full mouth scaling in presence of generalized moderate or severe gingival inflammation, is often completed, but

is currently a MHCP non-covered service.

DSAC is supportive of an increase in rates overall and an expansion of MHCP covered services to meet the

needs of MHCP recipients.

Issue 3: Payment Structure Reform

Decision / Recommendation:

Some Medicaid patients have complex medical and social needs and require more time than the “typical private

practice patient.” DSAC felt that reimbursement should take into consideration the challenges of serving these

patients. A standardized rate does not acknowledge complexity of patients. One consideration would be RVU

(relative value unit) payments to offset the increased appointment time required to properly care for patients

with complex medical or social service needs.

The dental industry standard is the use of CDT codes for billing. The committee supports a move to use ICD-10

codes (diagnostic + billing) on MHCP claims, which increases accountability. ICD-10 codes promote a more

effective quality program which benefits recipients, providers, and DHS. In some instances the move has been

made to ICD-10 coding for dental claims, but it is not widely practiced in the US.

Some DSAC members were in support of sustaining Critical Access (CAD) (however it should be noted that some

vocal members benefit from the current program). Some DSAC members supported methodologies that

rewarded patient volume. An additional payment stratification for patient complexity is endorsed by some

members.

Dental home, where providers are supported to maintain oral health rather than payment for procedures and

preventive care was endorsed by group members.

Methodologies are supported to create a reimbursement structure which acknowledge patient complexity

and dental home / patient centered care.

Summary:

The group is enthusiastic about the possibility of real change, however the current and past impasses are on-

going. One voting member said, “We have been talking about this for at least 15 years – it’s the same

conversation”.

The overall feedback from DSAC is:

1. Administrative Simplification

2. Improve the benefit set

3. Increase Reimbursement

4. Reimbursement to reflect patient complexity and to support for a Dental Home model consistent with

some of our advanced value based purchasing models.

One voting member proposed an external, neutral mediator to facilitate meaningful progress on these issues. It

is agreed that the current system is not working, and that the existing impasses between stakeholders need a

new approach for working solutions.

Next Step: This will be submitted in memo format to Commissioner Piper for her review.

Next Meeting:

Date: March 19, 2018

Time: 1:00 p.m.

Location: TBD

Additional Meeting Notes

1. DHS Update / Schiff

Fluoride varnish application for 0 – 5 year olds at Child and Teen Check Up visits has been changed from

“recommended” to “required”.

Opioid Prescribing Guidelines from the Opioid Prescribing Work Group (OPWG) are being released

12/01/2017. Minnesota has lower opioid prescribing rates overall vs. other states, however a lot of

variation exists. Included in this is the rate of opioid naïve patients moving to dependence in MN.

2. SOHLI Update / Khanal and Maytan

Attended the first in-person conference with our SOHLI Cohort in Philadelphia Nov. 13-15. The project is

pressing ahead with work towards a state-wide Fluoride Varnish Registry. The SOHLI faculty will be on

site at DHS and MDH Feb. 13-14, 2018.

3. MDH Update / Khanal

The OABSS results are available, and MDH Commissioner Ehlinger has been briefed. A press release is

being discussed.

Prasida, and Dana Farley, presented on the opioid crisis in MN on Nov. 3 at the Delta Dental WITS

Symposium.

September DSAC meeting minutes

09.20.17

1:00-3:00 p.m.

Mosquito Control Building

Members present: Daniel Rose, David Maki, Louann Goodnough, Prasida Khanal, Leah Anderson,

Michael Helgeson

DHS: Jeff Schiff, Linda Maytan, Redwan Hamza, Tracy Vrklan

Guests: Erianna Reyelts (Children’s Dental Services), Michelle Conley, Nicole Ferrian (Delta Dental), Jared

Greupner (DHS/DCT Dental Clinics), Majda Hodzic (MN Dental Association), Robert Freeman (Health

Partners), Denise Haliburton, Dick Diercks (Park Dental)

Welcome and Introductions:

Dr. Maytan called the meeting to order. Minutes from the previous meeting were not approved as a

quorum was not present; the decision is made to post the March 2017 minutes. Members have had

opportunity to electronically comment. Sheila Riggs was announced as the new chair of DSAC. She is

unable to be present today. Since no issues are being called to vote, it was decided to have the meeting.

Introduction of Prasida Khanal, who presented information on her background and her position at MDH

(State Oral Health Director). Linda and Prasida were congratulated on their appointments to the SOHLI

leadership institute / CHCS.

Update from MDH:

Prasida spoke about the fluoride varnish policy change on the Child and Teen Check-Up which was

jointly accomplished via MDH and HDS partnership. This change reflects the state’s commitment to early

childhood caries prevention (EDDPI). The possibility of a fluoride varnish registry is being explored.

DHS Update:

Dr. Schiff provided an update about the Opioid workgroup. A report will be developed and shared with

providers showing how often Opioids are prescribed. The PMP will demonstrate prescribing outliers. Jeff

touched on the policy decision for C & TC mandatory FV application for 0 – 5 year olds. It is not known

how this will impact dental utilization rates. Linda mentioned the need to develop a dental registry,

possibly modeled after the MIIC, to capture all the places individuals receive FV application.

Social determinants of Health were briefly discussed.

Redwan discussed dental changes that came out of the last legislative special session. There is a 23.8 %

increase in FFS rates for dental. There is a rate increase to 54 % for MCRE recipients effective 01/01/18.

CA payments for MCRE were reduced to 20% effective 07/01/17. Rule 101 requirements were removed

for non-metro providers. Discussion followed about how this might impact access, and how to measure

it? Representatives from health plans said they are in the process of marketing this information to their

providers. Redwan discussed the letter from CMS to DHS regarding the low dental utilization rates in

MN. DHS was given 90 days to respond before CMS decides what to do with our federal funding. DHS

responded that there will be an effort to work with dental communities in metro and non-metro

locations to have discussions regarding dental access. It is hoped that dental issues will be addressed in

the next legislative session.

Review of DSAC statutory language:

Linda read the statutory language for DSAC.

Direction of DSAC:

DSAC is statutorily required to advise the DHS Commissioner. The direction of the Committee for the

2017-18 session is:

1. Advise / give feedback to the Commissioner about the failed legislative proposal from last

session.

2. Act as advisors on the upcoming State Oral Health Plan update.

State Oral Health Plan:

The group reviewed the Minnesota Oral Health Plan’s executive summary. There was a discussion

regarding the plans’ sustainability, prevention and education, Health Care Integration of Medical and

Dental and surveillance. The group recommends that there be more collaboration between MDH and

DHS to accomplish this plan. DSAC will be part of the workgroup with DHS and MDH to develop a new

state plan. DSAC will be involved in discussions about what measurable outcomes the plan should have.

A comment was made to also involve the MN Oral Health Coalition in this discussion. Linda and Prasida

acknowledge that Nancy Franke Wilson (ED of MOHC) is already aware of this pending project and has

given verbal support for review. The group discussed the possibility of more grant funding to do this.

Data sharing agreements between MDH and DHS are in place; a more robust agreement may or may not

be required. It may be useful to determine what substantive information is available regarding other

states and their oral health plans, particularly around sustainability. The group is interested in working

towards making the Oral Health Unit at MDH a sustainable unit, not dependent solely on grant funding.

Q/A and additional business: None

Meeting adjourned at 3:45.

Next Meeting: Nov 20, 2017 at 1 pm, Mosquito Control.

March DSAC meeting minutes

03.20.17

1:00-3:00 p.m.

Mosquito Control Building

Members present:

DHS: Jeff Schiff, Linda Maytan, Redwan Hamza, Tracy Vrklan

Members Present: Paul Walker, Louann Goodnough, Tom Green, Sheila Fuchs, Craig Amundson, Carl

Ebert, David Maki, Jeanne Edevold Larson, Sheila Riggs, Daniel Rose, Leah Anderson, Michael Helgeson,

Merry Jo Thoele, Michelle Storlie

Guests:

Mary Seieroe (HCMC), Daniel Lightfoot (MDA), Majda Hodzic (MDA), Michele Grose (SCHA), Patty

Graham (HealthPartners), Dick Diercks (Park Dental), Heidi Oliver, (UCare), Dave Klein (HealthPartners) -

presenter, Jeff Ogden (HealthPartners), Nicole Ferrian (Delta Dental), Deborah Jacobi (Apple Tree

Dental), Sarah Wovcha (Children’s Dental Services), Kathy Albrecht (Medica) - presenter, Jamie

Galbreath (UCare) – presenter, Michelle Scearcy (HealthPartners).

I and II. Welcome and Introductions:

Dr. Amundson called the meeting to order. The February Proposed meeting minutes were amended,

then accepted with the noted changes.

III. DHS Update: Jeff Schiff MD MBA

Opioid Work Group / current projects:

10.6 million dollars was allocated to the group. It is used to place 80% emphasis on treatment

and 20% on prevention and prescribing practice improvements. There is a study being released regarding

prescribing practices for opioids. Legislation for oral health prescribing recommendations will

recommend that dentists (and optometrists) limit prescribing Opioids to four days.

Impact on MN coverage with the proposed American Health Care Act: Minnesota has a larger benefit

sent than most states. The cost to keep that benefit set the same by 2030 would cost 35.8 billion dollars.

We will most likely lose federal funding. Right now, funding for Medicaid is matched at 50% using

Federal Dollars. MinnesotaCare gets federal funding as a basic health plan. A cost analysis being done

should be available this week. Dr. Schiff will send the report to all.

IV. SNBC project update:

The MCO’s gave project updates on the SNBC project and its progress.

Kathy Albrecht, the MCO lead, presented on progress the2017 SNBC Dental Access Improvement and

Evaluation Project has made. The group and its subgroups have been meeting since 2016. A report

detailing their proposals is due to DHS next month. An overview of the SNBC patient population was

given. It explained that most enrollees in SNBC have at least five chronic conditions.

The project has three goals:

Improve the number of annual dental visits for the SNBC population, from 46% to 60%.

Improve dental Access

Reduce the use of the ED for non-traumatic dental visits. Plan is to assist members in finding a

dental home, as the ED is not the correct location of care for dental services.

The group sent provider and member surveys in 12/2016. These surveys queried members

about their access to a dentist. The surveys asked providers what the challenges to providers are

for those serving those with special needs. A question was asked if the CAHPS dental survey is

still being used. Linda M. will check on this.

Answer: These two survey tools were meant to measure the program, not health plan level,

information. The true CAHPS survey measures health plan level satisfaction.

The Minnesota Department of Human Services 2017 CAHPS® 2.0 Dental, and Dental Non-user

survey project. The goal of this project is to establish baseline satisfaction and access

information for the managed care enrollees in Special Needs Basic Care (SNBC).

The survey instrument(s) selected for the 2017 DHS CAHPS® Dental project is the CAHPS® 2.0

Dental Survey. The CAHPS Dental questionnaire was designed by the Agency for Healthcare

Research and Quality (AHRQ) and asks adult enrollees in dental plans about their experiences

with the plan, the dentists, and their staff. DHS developed a modified version of the CAHPS

Dental Plan questionnaire as well as a questionnaire to survey Non-users of dental services.

The dental sample design includes sampling cells: dental services User cells consisting of SNBC

Metro/Non-metro; and dental services Non-user cells consisting of SNBC Metro/Non-metro.

De-duplication is done on the samples to ensure that only one person per household is surveyed

and no person is surveyed more than once.

Data collection started January 2017 and ended March 2017. Survey design uses a four-wave

mail plus telephone follow-up protocol. The survey vendor’s goal is to collect three hundred

completed questionnaires/interviews in each of the survey cells. Results of the survey

responses will be presented in a summary report expected to be published in June 2017.

This group has three primary Interventions for SNBC recipients:

1. Case Management (required by DHS). This will focus on outreach to members by a Care

Coordinator to offer assistance. It will be incorporated into the Medical Care Coordinator

benefits.

A question was posed regarding the number of people using care coordination now. No data regarding

this at this time. It varies by MCO.

A comment was made that there should be more collaborative efforts between MCO’s and DHS.

There was discussion regarding Group homes and the difficulty providers have trying to arrange services

for those with special needs. Is this being tracked? Right now it is not. This is not in the scope of this

project but will be noted for further discussion. At this time MCO’s do not provide money for group

home services. Those are FFS.

A comment was made about the mixing of “Utilization” and “access”.

2. Mentoring – required by DHS. There is an expert panel working to identify access barriers

and how to care for those with special needs when they come in to the dentist. This part of

the project will last for 3-5 years. The focus will be on recruiting more providers that want

training serving those with special needs. This will involve more surveys. A question was

posed about funding for educational materials. Money is not provided at this time.

{Question about follow up surveys that focus on the issues and barriers providers actually have when

providing services to the special needs population. The group said yes. They hope to focus on this. A

possible survey to Care Coordinators was discussed.}

3. Tele dentistry – required by DHS. This involves looking at technology involved and how to

make access to tele dentistry work for providers. A question was asked about how the

money is reimbursed to providers. It goes to the dentist that gave the treatment

recommendation. A goal of this project is to establish virtual dental homes. More questions

were raised regarding the cost for house calls and the request to have better

reimbursement for things.

_____________________________________________________________________________________

V. SNBC Q & A:

A question was posed as to why DHS does not have special reimbursement rates for those serving the

special needs population. It was explained that this is outside the project scope.

Other questions and comments were made regarding the Olmstead Project and the intersection with

SNBC. The SNBC project does work to address issues identified in Olmstead, and the activities of the

project are used in Olmstead reporting.

More questions were raised about Olmstead. There is no money associated with it. It is up to the

legislature to decide. A concern was raised regarding the funding. If the money is not available, how can

we hope to improve access? A further comment was made regarding a bill for dental grants; perhaps

this money can be used to support those efforts.

A question was asked about legislation to have one or more vendors provide dental coverage. The

answer is not known at this time. Comments were made suggesting if dental services are carved out,

you may lose care coordination from the MCO’s.

A question was asked regarding the number of dental visits to the E.R. for SNBC population.

Answer: For calendar year 2015, 1.65% SNBC enrollees had an ED visit for a non-traumatic dental issue.

For the same year, 29.79% of SNBC enrollees who went to the ED for non-traumatic dental issues had a

follow up dental office visit within 15 days of the ED visit. The 2016 data will be available in the 3rd

quarter of Calendar Year 2017.

A question was posed regarding outreach by MCO’s. This should be done by the Care Coordinator.

Answer: There is no data source across all MCO’s and the amount of outreach varies with each MCO.

____________________________________________________________________________________

VI. New business: No new business.

VII. Final Remarks: Merry Jo’s pending retirement and the accomplishments she has made

to DSAC were acknowledged. All stood to applaud her.

VIII. Adjourn: Motion was made to adjourn at 2:45 pm.

Next DSAC Meeting: June 19th, 1 – 3 pm at Mosquito Control

(Note: This meeting was cancelled. The next meeting will be on 9-18-17 at Mosquito Control.)

February DSAC Meeting Minutes

02.06.17

1:00-3:00 p.m.

Room 2370 Andersen Building

Members Present:

DHS: Julie Marquardt, Jeff Schiff, Redwan Hamza, Tracy Vrklan, Linda Maytan

Members Present: David Maki, DDS MBA, Tom Green (Family Advocate), Leah Anderson (Prime West),

LouAnn Goodnough (MetroState), Sheila Riggs (U of MN), Carl Ebert (Community Dental Care), Michelle

Storlie (Advanced Dental Therapist), Sheila Fuchs (Delta Dental), Michael Helgeson (Apple Tree Dental),

Carla McMorris

Guests: Amy Koch, Majda Hodzic (MDA), Daniel Lightfoot (MDA), Dick Diercks (Park Dental), Robert

Freeman, Jeff Ogden (Health Partners), David Klein (Health Partners), Jared Greupner (DHS/DCT), Sarah

Wovcha (Children’s Dental), Mary Seieroe (HCMC)

Dr. Mike Helgeson, AppleTree, acted as Chair in the absence of Dr. Amundson.

Welcome and Introductions:

Meeting called to order by Dr. Helgeson at 1:05 pm. A motion was made to approve today’s agenda.

Explanation of the Governor’s proposed budget:

Julie Marquardt (DHS purchasing) attended the meeting to give an update on the Governor’s proposed

budget and how it affects dental rates, structure and administration. DHS recognizes that changes need

to occur in order for increased access to happen. DHS has reviewed OLA audits, and gotten input from

the dental committee in regards to the budget proposal.

The proposal has three components:

1. Administrative Simplification. DHS has proposed using up to 2 vendor(s) to carve out dental

payments FFS. These vendors will bid on the contract and DHS will decide which vendor to use.

Other states have used models similar to this successfully. Vendors need to have a plan in place

that will take into consideration access for Medicaid enrollees.

2. Eliminate the CAD add-on payments. Give a rate increase across the board to all dentists. The

proposal will raise dental rates by 54 %. This will also help increase access.

3. Overall rate increase. This will take all add-ons and increase the base rates. This proposal does

not affect rates to FQHC’s and Community Clinics.

Q and A with Julie about the Governor’s Proposed budget

Q: How much money this will take from the Health Care Access fund?

This is a proposal, which has not been through the approval process yet. Attached, please find

the Governor’s Proposal and the pages regarding health care and the bill language (see Article 4, starts

on page 99). The budget proposes some reallocation of funds up to $25 million to account for this.

Q: What is the total amount the proposal will cost? This is unknown at this time.

Q: What if there is a reduction overall (no CAD, no increase in rates) if the proposed increase is not

approved?

The proposal is designed to be approved as a package with the goal of increasing dental access overall.

Q: Why will it take until 2019 to be implemented? The competitive bidding process takes time.

Q: If approved, will we see improved access? It will give providers a better system with administrative

simplicity. This will hopefully have providers more willing to participate in Medicaid and offer better

access to dental patients, especially children and those with special needs. It is hopeful that we will also

see an improvement in adult services, and better access in rural areas. This proposal does not include an

expansion to the adult benefit set.

Q: How does this intersect with the state Olmstead Plan? Olmstead planning is present in all policies.

For dental, the metric is to increase the number of annual dental visits per year for adult beneficiaries.

Q: How will the proposed new model affect MCO’s and FFS providers? Will there be disagreement

between providers? Julie answered that they all have to work together to develop relationships with

vendors with an effort to increase access. The money will be paid to the vendor to pay providers for

their services.

Q: Will credentialing be done at the DHS level? Yes

Q: Who assumes the risk in a single-payer system? DHS

Q How does this affect transportation and interpretative services? “It depends.” Not all the money will

come from the MCO and the money to provide those services may actually come from the county.

Coordination will need to occur.

Q: If the 54 % rate increase is approved, how will DHS ensure that the money is given back to dental

providers? All dental monies will be paid FFS and we are required to give money for the FFS rates for all

payments. There will be the same rate increase across the board.

Q: Will this affect Rule 101 providers? No, this will not change the requirements for Rule 101 providers.

Q: Will rates be different in terms of geographical location? No. The base rates will be the same for all

providers.

Q: With the base rate increases in fees will these rates be enough to attract more private providers?

The hope is that this will attract more private providers willing to accept Medicaid enrollees. MN has

looked at other states who have increased provider participation by increasing the reimbursement rates.

The rate increase corresponds to a demonstrable increase in providers. She further stated the goal is to

make the money be sustainable and have less administrative burden than there is now. It will streamline

payments and the administrative processes. Money will be to administer the program, not to take risks

on claims.

Q: Are there “incentives” in place for providers? No. There will be metrics regarding claims and access

when a vendor is approved by DHS. The goal is to monitor both rates and access. Collaboration amongst

vendors will likely be regionally based, not on a county by county basis. .

Q: Does this mean that services will be based on a hierarchy of need? Julie stressed that is access is the

challenge, not creating a hierarchy of needs. This proposal is a stepping stone, offering more money for

dental services for hard to reach populations. At this time there is not a different paradigm for

payment.

Comments were submitted by Jeanne Larson about the proposed governor’s budget as it pertains to

Northern Dental Access. These were read to the group in Jeanne’s absence at her request. A copy of

those comments may be requested from Jeanne.

A comment was made by Dr. Schiff that the proposal already has input from the dental community. He

said comments can still be sent in to Dr. Maytan

_____________________________________________________________________________________

A motion was made and carried to approve the November 21 minutes.

New members appointed to DSAC were introduced. (David Maki, Louann Goodnough, Leah Anderson)

Sheila Riggs passed out a flyer for a talk being held at the U of MN School of Dentistry on February 21st.

Other DHS updates:

Dr. Schiff commented on the Opioid work group and the progress being made. Additionally, he

commented that DHS will publish Race and Ethnic Group Dashboards.

Meeting adjourned at 2:35 p.m.