Integration of Care Committee Meeting Minutes April 15, 2020

Members Present: Danielle Beiling (Co-chair), Donald Powell (Co-chair), Annette Roque,  Randall Bruce, Paul Carr, Mitchell Caponi, Bettina Carroll (non-voting), Dorothy Farley, Billy Fields, Ronnie Fortunato, Janet Goldberg, Deborah Greene, Bill Gross, Christopher Joseph (phone) David Klotz, Peter Laqeur, John Schoepp, Claire Simon (phone), Brenda Starks-Ross, Joel Zive, Graham Harriman, Rose Chestnut, Mary Correa,

Members Absent: Lauren Benyola, Michael Ealy, 

DOHMH Staff: Jose Colon-Berdecia, Kimbirly Mack, Guadalupe Dominguez Plummer,  Giovanna Novoa,

Welcome/Introductions w Pronouns/Moment of Silence/

Review of the Meeting Packet/Review of the Minutes:

Ms. Lawrence opened introductions with pronouns and Ms. Chestnut led the moment of silence. The minutes were accepted. 

Public Comment/New Business            

None.

A Conversation with Oral Health Care Providers

(Please note that numbered, bold questions were on the agenda. Questions in italics were generated during the meeting. All answers are paraphrased and not direct quotes from providers/committee members)

1. What are the barriers that keep PLWH from accessing oral health care?
   1. What would help more people access and be retained in care?
   1. Have you seen any efforts that were successful in improving utilization?

Dr. Moy: Wait time can be difficult, finding providers that they like. Do walk in emergencies – have staff shortages. Length of time in field, familiarity with patients – they disclose that mental health issues and drug relapses cause dropouts in care. Important to be non-judgmental. Caring environment helps retain patients.

Dr. Taddeo: As PrEP usage has increased and new HIV infections goes down, partnerships have been fading – network of care not as strong. Lots of difficulties for patients to understand who accepts their insurance. Outreach is no longer funded- to help get clients with comorbidities, or mobility issues, into the sites.

Dr. Gonzalez: Very small space, limited chairs. Issues with high no-show rates. Created different scheduling tweaks – patients can walk in and be seen that day – keep 3-4 openings – and keep a list of patients that are nearby if the openings are not used by walk-ins. In dentistry every minute counts – a lot of re-educating our pts on what an appointment consists of – and help them understand that any lateness impacts work that can be done. Do a lot of work arounds with scheduling – i.e. schedule an x ray in advance, so that even if a patient is late for that, on time for actual appointment.

Dr. Tasca: Providers all talk to clients about importance of oral health and refer clients to the dentist. Years ago, pts were so overwhelmed with medical condition, only the most serious dental issues were addressed. The stabilization of HIV clients (wrt viral load) has increased the number of clients doing preventive care.

• What are common issues you see in this population? 
  • Is there adequate coverage for the scope of work needed?

Dr. Moy: Dry mouth, caries around the gum line. Patients with ADAP who have been my patients for a while have received oral care education, and come in 3-4 times a year for a cleaning – ADAP covers such services. Seeing bone loss, periodontal disease and caries

Dr. Tadeo: See a huge transition over the last few decades – not seeing the kind of oral health complications that I used to see- no swelling of gums, not as much bone loss. Issue I see is insurance, and keeping them on insurance. Whether its interim insurance, ADAP, Medicaid, managed care – that’s the biggest issue we see.

Dr. Tasca: Great increase in dental health. See early periodontal bone loss – try to do more cleanings to prevent this. Not seeing the kind of terrible issues I used to see. Getting people coverage is an issue – getting coverage for a root canal so people don’t lose the teeth. Financing for the dental care is a huge issue.

Dr. Gonzalez: Still see decay, periodontal disease – may not be HIV related, and just poor oral health education. Majority of clients are compliant. Try to work with clients – offer a sliding scale for things not covered by insurance so that patients have more access.

• Is there a significant need for more complex treatment?
  • How are more complex treatment plans achieved?
  • How much is reimbursed, if any, for implants? 

Dr. Taddeo: Referring patients out, especially ADAP patients, is difficult – many places won’t take them when it comes to specialists. Even hospitals won’t take them. So I can send them to Wyckoff, which is very far, but I cannot refer them to Woodhall, which is down the block. Not only do some health centers not take certain insurances, like ADAP – difficult hurdle getting them specialty care.

Dr. Moy: Totally agree – do most of the extractions at Sinai – because difficult for pts to get appointment with an oral surgeon. Medicaid and Medicaid managed care per hospital policy, can only refer to a dental school or some institutions, like the Institute for Family Health. If a pt needs a specialist for a bone graft or an implant – has to be the dental school or IFH, where there is a sliding school. Dental school has a sliding scale, and are used to doing pre-auths for care. Really hard for patients due to limited coverage that even the managed care plans have – asking them where to get treatment – and they don’t know. We try to do as much as possible in house. Difficult for pts to get around – transportation issues. Many of my pts are older – needing walkers or canes now.It matters who takes insurance – sending people all the way down to NYU.

What % of patients fall into donut hole of coverage?

All of them – Medicaid must follow the manual. Dental implants to hold the dentures – it’s a tough process – very difficult, must get a lot of documentation. Pt with cancer in the jaw – huge surgery – struggling to find a place to make him dentures. Very delayed treatment. Limited in number of chairs on site – can only see so many patients, with no specialists on site – also limiting. Many places do not accept the patients insurance, because most private dentists don’t take them.

Dr. Gonzalez: Similar challenges – created a list of referral places. List of facilities throughout the 5 boroughs, the insurance they take and the specialties they offer. Try to work with the patients to make sure they are comfortable – try to do warm referrals, calling the site with patient to help the process. Columbia takes patients for many procedures. Set payment plans for patients – work with the patient to help make treatments accessible. For implants, etc, help patients with letters of support for implants or dentures. No pts thus far have been able to get implants through Medicaid.

Dr. Tasca: Finding places for specialty care that accept the insurances, is very difficult. Lots of referrals to dental schools at NYU and Columbia – takes a long time – things that would be done in one treatment take 3-4 visits. Getting an appointment is extremely difficult – their phone trees are hard to navigate. And even after all of that, they might not cover the treatment. Extremely difficult.

What can be done for implants if current coverage doesn’t work?

Dr. Tasca:  So far have not been successful in getting implants covered – bar is so high, its almost designed to prevent people from accessing the service. Access is not there to implants on a practical level.

What number of patients are in need of implants?

Dr. Taddeo: 60-70%. Even getting dentures approved is difficult – 8 points of contact, anything beyond, won’t be approved. Missing all molars, but have pre-molars, won’t get a denture – can be missing 12 teeth and won’t be approved. Getting dentures is a huge barrier – lots of paperwork. Then a lot of waiting. A patient with pain, in need of a root canal, has to wait an extensive amount of time, and can only be treated for pain, until the approval comes in. 

Dr. Moy: Unless pt is willing to pay out of pocket – cannot access it. Even at dental schools or another facility – no payment plans, must pay in full – will be charged at least $1800 per implant – and that’s without complications or bone grafting. The stringency of the criteria is very high. 

Dr. Gonzalez: No success in implant department, try to provide all the documentation – important that pts have realistic expectations – how long it will take. Negative experience come when people don’t know what they are in for. Patients referred to a prosthodontist for a full mouth reconstruction – took years – but now they couldn’t be happier – full cost would be $30-50,000. Was made affordable, but only because it was used as a teaching procedure. First guidelines released by Medicaid were very unclear around implants – guidelines are much more clear now. Still important to review expectations with patients.

Can an ENT do a bone graft under Medicaid to ensure coverage? Has anyone seen it work?

Mr. Carr noted that under Medicaid, can access coverage in this way according to Dr. Resnik of Grady Health Center. 

• Where are the gaps in coverage? 
  • If you had a wishlist for what was covered – what would it include?
  • What services are needed beyond what Medicaid is able to pay? 
  • Given the Ryan White Program’s payor of last resort requirement (meaning – we can only pay when no one else covers the service), how could Ryan White Part A funds help support the overall health outcomes for patients if used for oral health care?

Root canals, dentures, crowns – pretty much everything except cleanings, fillings and extractions. Dentures covered when pt still has a few teeth left – no 8 point of contact limit, asking people to chew with their pre-molars. 

• Coverage:
  • How many of your clients access other dental coverage than Medicaid?
  • How are undocumented persons getting oral health care? How is it funded?   
  • On average how much does it cost to serve the needs of one person’s oral health care needs in a year? 

Dr. Taddeo: Insurance is usually managed Medicaid: Healthplex, Dentaquest, some Signa. Last 9 months, United Healthcare – comparative plans that are in sync with secondary managed care.  

Dr. Moy: 60-70% are in Medicaid managed care, 15-20% straight Medicaid, another 20% is ADAP. Don’t take commercial insurance

Dr. Gonzalez: 70% Healthplex, Dentaquest. 25% uninsured. Medicaid group growing in number.

Dr. Tasca: Mostly Dentaquest and Healthplex, some Liberty. 

Why isn’t commercial insurance accepted?

Depends on facility – some do and some don’t. At Callen Lorde – no private insurance accepted because we don’t have the space. Focus is on patients with more limited resources and options. Same at Mount Sinai.

What percent are undocumented?

Has decreased. Used to get 1-2 people per week. Doing outreach to these communities – but they are not coming in, out of fear. Prior to 2016 approximately 5% – other providers agreed with this number.

• When, if ever, do you have waiting lists?

No one runs a waitlist

Is money from reimbursement enough to cover services?

Dr. Taddeo: No. Rates don’t cover anywhere near the cost. Bring in grants, and wrap around from Medicaid – helps pay for services. That’s what keeps providers afloat. Every CFO would get rid of dentistry – it’s a money loss. 

Dr. Tasca:  Dentistry has one of the highest overhead rates among medical practices – materials are very expensive. Relying on reimbursement rates would not keep pace – have to rely on grants.

Dr. Moy: Rates do not cover basic costs. 

Dr. Gonzalez – Costs $12 just to disinfect and set up the room for each patient. 

Public Comment

 None.