Pennsylvania Medicaid Approach

1
Pennsylvania Medicaid Approach

• Special Smiles Program

Paul R. Westerberg, D.D.S., M.B.A. Chief Dental
Officer Pennsylvania Dept. of Public Welfare
and Emilee Langer, M.P.H. Executive
Director Special Smiles, Ltd.
2
Milestones
1995 Pedodontic Residency established by
Pediatric Dental Associates at Episcopal
Hospital in Philadelphia 1997 Mandatory Managed
Care implemented in the Southeast Zone of
Health Choices 1999 First DPW sponsored dental
summit in Pennsylvania 2000 Proposal to
create a dedicated dental facility to treat
special needs patients proposed by Pediatric
Dental Associates
2
3
Medicaid Managed Care in Pennsylvania
4
Negotiation/Contracting Phase

• Required negotiations with the four Managed
  Care Organizations operating in SE Health
  Choices
• Global budgeting was proposed with capacity to
  be divided between MCOs according to market
  share
• Venture capital was provided by Pediatric
  Dental Associates
• Universal participation by MCOs required for
  operational status

4
5
Location of Special Smiles, Ltd.September 2001
6
Our Patients

• Individuals who require anesthesia to complete
  routine dental care
• Age 12 and older
• Intellectual disabilities
• Physical disabilities
• Maladaptive behaviors
• MR/MH dual diagnosis

7
Patient Demographics

• 68 community supported
• 18 intermediate care facilities for mental
  retardation (ICF/MR)
• 15 parent supported
• gt 50 severe to profound disabilities
• 20 non-MR patients

8
Patient Demographics by Age Group

• Established to serve adults with special needs
• Viable program for children ages 12-21
• Majority of patients at Special Smiles are 21-54
  (77)

9
What We Do

• Full mouth rehabilitation
• Comprehensive exam, prophylaxis, fluoride,
  sealants
• Full mouth x-ray
• Amalgam and composite fillings
• Endodontics
• Periodontal scaling and root planing
• Minor oral/periodontal surgery
• Excision and biopsy of lesions
• Gingivectomy/alveoloplasty
• Extractions
• 100 of care delivered under IV or general
  anesthesia

10
How It Works

• Two appointments
• Screening
• Lifetime medical and dental history
• Physical Exam from primary care physician
• Diagnostic lab tests as directed by anesthesia
  protocol
• Consent for dental treatment and anesthesia
• Full mouth rehabilitation

11
Outcomes

• Comprehensive cost-effective care
• Over 40,000 procedures completed
• 3,600 full mouth rehabilitations
• Education and outreach to 400 parents and agency
  personnel
• Reduced cancellation rate from 47 to 18 over 2
  years

12
Demystifying the ProcessLessons Learned

• Opportunity
• Relationships
• Perseverance

12
13
Opportunity

• Managed Care implementation
• Focus
• Flexibility
• Provider initiative
• Expertise
• Availability

13
14
Relationships

• State government (DPW)
• Advocacy organizations
• Ongoing contracts with Health Choice MCOs
• Americhoice of Pennsylvania
• Health Partners
• Keystone Mercy Health Plan
• ACCESS
• Established collaborative partnerships
• Philadelphia Coordinated Health Care
• Philadelphia Citizens for Children and Youth

15
Perseverance

• Concept development
• Implementation/ continuation
• Negotiation/contracting
• Administrative competencies
• Advocacy
• Continuous quality improvement

16
Future

• Sustainability
• Current model is dependent on continuing
  adult dental benefits under MA in Pennsylvania
• Expansion to children and elderly
• Replication Attempts
• 2004 - Request for Applications solicited to
  create a dedicated facility based on the Special
  Smiles model
• 2005 - Collaborative effort with PA Department
  of Health Primary Care Community Challenge
  Grants

16
17
Contact Information

• Paul R. Westerberg, D.D.S., M.B.A.
• PA Dept. of Public Welfare
• P.O. Box 2675
• Harrisburg, PA 17105
• 717-772-7395
• pwesterber_at_state.pa.us

• Emilee Langer, M.P.H.
• Special Smiles, Ltd.
• 100 E. Lehigh Ave
• Centennial Two
• Philadelphia, PA 19125
• 215-707-0580
• specialsmilesltd_at_msn.com

www.specialsmilesltd.com