Determinants of general dentists' decisions to accept capitation payment: a conceptual model and empirical estimates

Abstract – Background: Shifts in payment options for dental care over several decades have resulted in more dental expenditures being paid through health maintenance organizations (HMOs), preferred provider organizations (PPOs), and capitation arrangements. Patients’ and employers’ choices to participate in these arrangements is determined in part by dentists’ willingness to participate in plans, and plan choices may be influenced by patient satisfaction, self‐reported oral health, and/or quality or cost of care. Objectives: This study examined determinants of dentists’ decisions to accept capitation payment for services. Research Design: Cross‐sectional mail survey in December 2006. Subjects: 1605 general dentists in Oregon. Measures: Questions addressed dentists’ perceptions of the importance of control over various practice parameters, willingness to accept capitation payment, employment or ownership status within the practice, and practice characteristics. Results: Capitation was accepted by 22.6% of the respondent dentists (n = 729). Reported average fees (2007 dollars) ranged from $60 (initial oral examination) to approximately $800 (porcelain crowns). The likelihood of accepting capitation payment was related to the number of dentists in the practice, but surprisingly owner‐dentists were no less likely than employee‐dentists (associates) to accept capitation. As expected, dentists’ usual and customary fees were negatively associated with accepting capitation. In contrast, measures of dentists’ importance of control were not related to decisions about capitation. Longer average appointment delays were related to acceptance of capitation, but the effects were small. Conclusions: Dentists’ behavior regarding payment acceptance is generally consistent with microeconomic theory of provider behavior. Study findings should inform practitioners, plan managers, and researchers in examining dentist payment decisions.     

Rural versus urban analysis of dental procedures provided to Virginia Medicaid recipients

PURPOSE: The purpose of this study was to report the distribution of procedures provided to Virginia Medicaid children by 3 types of dental providers in rural and urban areas. METHODS: Medicaid claims filed for dental patients less than 21 years old were obtained and analyzed for fiscal years 1994-1995. Dental providers were categorized according to their practice type: (1) general practice (GP); (2) pediatric (PD); and (3) public health (PH) dentists. Each type of practice was categorized as practicing in a metropolitan, urban, rural, or completely rural location and evaluated for percentages of preventive, diagnostic, and corrective services provided. RESULTS: Rural areas had a higher percentage of significant providers than did metropolitan or urban areas. General dentists performed more diagnostic and preventive but fewer corrective procedures than pediatric dentists. Pediatric dentists and general dentists in completely rural areas performed more corrective procedures than their counterparts in metropolitan or urban areas. CONCLUSIONS: General, pediatric, and public health dentists in metropolitan and urban areas perform slightly more diagnostic services and fewer corrective services than practitioners in more rural areas.     

Dental case management: increasing access to oral health care for families and children with low incomes

BACKGROUND: Medicaid beneficiaries have lower rates of dental visits and higher rates of dental disease compared with the rest of the population. Beneficiaries ascribe their low use of services to difficulties finding dentists who treat patients with Medicaid. Dentists cite low reimbursement rates, excessive paperwork, and patients' not keeping appointments and poor oral health literacy as reasons for not accepting patients with Medicaid. The authors pilot-tested the effectiveness of a dental case management program (DCMP) in increasing dentists' participation in Medicaid and Medicaid beneficiaries' use of services. METHODS: A dental case manager recruits dentists to participate in the Medicaid program, arranges training in billing procedures, resolves billing and payment problems, educates clients about the use of dental services and keeping appointments, links clients to dental offices, identifies potential barriers to care and helps clients obtain transportation to appointments. The authors evaluated the levels of participation of dentists in the DCMP in Medicaid and Medicaid beneficiaries' use of services. RESULTS: Dentists accepting new Medicaid patients increased from two to 28, with 145 dental visits a month provided to Medicaid beneficiaries. The percentage of Medicaid beneficiaries receiving dental services increased from 9 to 41 percent after the DCMP was implemented. CONCLUSIONS: The authors found that the DCMP was effective in increasing Medicaid beneficiaries' use of services, increasing dentists' participation in Medicaid, minimizing administrative burdens related to Medicaid participation, and increasing oral health literacy and treatment compliance among clients with low incomes.     

Characteristics of dentists participating in capitation and Preferred Provider Organization dental plans

BACKGROUND: In 1998, the American Dental Association Survey Center conducted a telephone and mail survey of U.S. dentists in private practice in an effort to determine the extent of dentists' participation in capitation and preferred provider organization, or PPO, dental plans and the characteristics of dentists who participate in those plans. METHODS: An initial telephone screening survey of a random sample of 11,550 dentists in private practice was conducted to identify dentists who participated in PPO or capitation dental plans. Dentists who participated in either of these plan types then were asked to complete a mail survey on their plan participation. RESULTS: The majority of dentists participating in either type of dental plan reported having never left a dental plan. Dentists who belonged to more than one PPO or capitation plan reported that a larger percentage of their patients were enrolled in these plans and that more of their practice's gross income came from the plans. Participation in PPO and capitation plans has had a positive impact on the practices of many of the responding dentists, particularly with regard to expanding their patient base. CONCLUSIONS: The authors found that the majority of dentists participating in PPO dental plans found it to be a positive experience overall. Dentists participating in capitation plans were less satisfied; more than 50 percent of capitation plan participants reported some level of dissatisfaction with the plans. The majority of dentists participating in a PPO plan expected to renew participation when their current contract expired; a much smaller percentage (though still a majority) of responding capitation-plan participants indicated the same. PRACTICE IMPLICATIONS: Responding dentists' overall indication of satisfaction with their current PPO plan participation probably indicates further growth for these dental plans. On the other hand, capitation plan participants seem much less satisfied with their plans. PPO plans, therefore, seem much more likely to be the type of plan that dentists will choose in the future.     

The influence of practice type, region, and age on treatment recommendations for primary teeth.

The purpose of this study was to investigate dentists' treatment recommendations for interproximal surfaces of primary molars based on the type of practitioner (general dentist or pediatric dentist), geographic location, and age of practitioner. Simulated cases, which included histories and pictures of bite-wing radiographs, were mailed to a random sample of 2000 general dentists and 1000 pediatric dentists. Dentists were asked to select their treatment recommendations for eight cases involving the interproximal surface of a specified primary molar. The return rate was 42% (1245) overall, with 36% (723) from general dentists and 52% (522) from pediatric dentists. An amalgam restoration was recommended most often for these eight cases. Dentists in the age 60+ category and pediatric dentists were more likely to recommend treatment for smaller interproximal lesions. Composite resins were recommended infrequently; however, dentists in the 60+ age category and dentists in the Northeast and Southwest were somewhat more likely to recommend composite resin than younger dentists, or dentists in other geographic locations. Dentists in the 40-49 age range, pediatric dentists, and dentists in the Southwest were the most likely to recommend stainless steel crowns. These simulated cases demonstrate differences and similarities in the treatment recommendations for interproximal lesions on primary molars based on age, practice type, and region.     

General dentists' referral of children younger than age 3 to pediatric dentists

PURPOSE: The purpose of this study was to assess which variables are associated with Iowa general dentists' referral of children younger than age 3 to pediatric dentists. METHODS: A survey was mailed to all Iowa general dentists (N=1,089). Respondents were asked how likely (never, sometimes, often, always) they were to refer children younger than age 3 to pediatric dentists in the past 12 months. Associations between referral patterns with practice, dentists,' and patients' characteristics were determined. RESULTS: The adjusted response rate was 65%. Nearly 50% of all dentists reported often or always referring children younger than age 3. Dentists who referred were more likely to be males and to have been in practice longer. Dentists who perceived that they had not received adequate exposure to preschool children younger than age 3 in dental school were more likely to refer. Dentists with smaller percentages of children within their practices were more likely to refer. Dentists most often referred children who were uncooperative, had severe decay, or had special needs. CONCLUSIONS: About one half of Iowa's general dentists refer children younger than age 3 to a pediatric dentist. Initiatives need to be undertaken to address dentists' reluctance to care for young children.     

Dentists' participation in capitation and preferred provider organization dental plans

BACKGROUND: In 1998, the American Dental Association Survey Center conducted a telephone and mail survey of U.S dentists in private practice in an effort to determine the extent of dentists' participation in capitation and preferred provider organization, or PPO, dental plans and the characteristics of dentists who participate in those plans. METHODS: An initial phone screening survey was conducted with a random sample of 11,550 dentists in private practice. Dentists who indicated that they participated in capitation or PPO dental plans received a follow-up mail survey asking specific questions concerning these two types of dental plans. RESULTS: Almost one-half of responding dentists indicated that they participated in either capitation or PPO dental plans. However, far more dentists reported participating in PPO dental plans than in capitation dental plans. The majority of participating dentists' patients were reported to be fee-for-service patients. CONCLUSIONS: Dentists' participation in PPO dental plans generally increased from that indicated in previous surveys, though participation in capitation plans declined. There was some regional and demographic variation in participation in these dental plans, but such differences were not large. Pricing and concerns about quality of care continue to be the primary concerns of nonparticipating dentists. PRACTICE IMPLICATIONS: Dentists reporting participation in PPO dental plans are becoming more common, but such plans still do not cover the majority of participating dentists' patients. A large percentage of nonparticipating dentists cite pricing and concerns about quality care as reasons for not joining these plans.     

How did we get here? Where are we going? Hopes and gaps in access to oral health care

This article reviews the history and future good of acceptance ethics and helps frame the publication of papers presented at the workshop on Professional Promises: Hopes and Gaps in Access to Oral Health Care. Discovery and development of Universal Patient Acceptance (UPA), a practical application of acceptance ethics, is key to systematizing access to oral health; UPA expands partnerships among professional volunteerism, culture, and economic structures. A Veterans' Administration health services preventive dentistry research project and a West Virginia school children's preventive dental program raised awareness of acceptance. A state insurance crisis revealed an underlying systems ethics problem that was not purely legal, political, educational, economic, or scientific in nature. Key players were identified for dialogue, and questions were ranked. UPA was articulated and proposed as a unique, practical, and positive professional promise. The experience involved PEDNET, a dental ethics education group. An intensive applied dental ethics course for practicing dentists was developed; it attracted the American College of Dentists (ACD) and American Dental Association (ADA). Annual ACD LeaderSkills helped expand continuing education of ethics; several dental ethics summits were initiated. Concepts like discourse, adequate care, and viewing organizations as both persons and machines motivated further exploration of acceptance. Separating acceptance from diagnosis, treatment, and payment improves discourse on the various philosophical notions and practical applications that dominate each area.     

Procedures provided to Medicaid recipients by pediatric, general and public health dentists in the commonwealth of Virginia: fiscal years 1994 and 1995.

PURPOSE: The purpose of this study was to report any differences found among the mean percentages of procedures performed by three types of dental providers for each type of service performed. The study focused on the types of services provided by dentists to Medicaid children in Virginia. METHODS: Medicaid claims field for dental patients younger than age 21 were obtained and analyzed for fiscal years 1994 and 1995. Dental providers were categorized according to their practice: general practice (GP), pediatric dentist (PD) and public health dentist (PH). Each type of practitioner (GP, PD, and PH) was evaluated for percentages of diagnostic, preventive, and corrective services provided to their Medicaid patients. The preventive category was subdivided into preventive services (scaling, prophy, fluoride and oral hygiene instruction) and sealant services. RESULTS: For each type of service, the mean percentages of procedures performed were compared among the three types of dental providers. The evaluation of the diagnostic procedure variable resulted in the finding that GP practitioners performed a significantly greater percentage of diagnostic procedures to their Medicaid patients than do PD and PH dentists (p < 0.0001). The percentage of preventive procedures performed by PD and GP dentists was not significantly different but was significantly lower than those performed by PH dentists (p < 0.0001). Finally, PD dentists performed a significantly greater percentage of corrective procedures than both GP and PH dentists (p > 0.0037). CONCLUSION: Differences were found among the mean percentages of procedures performed by the three types of dental providers for each type of service performed.     

Louisiana dentists' attitudes toward the dental Medicaid program.

PURPOSE: This study was performed to determine factors associated with Louisiana dentists' participation in the Dental Medicaid Program. METHODS: Surveys were mailed to all pediatric and general dentists as reported by the Louisiana State Board of Licensing. A second mailing was made to non-respondents. RESULTS: Surveys from 956 of 1,926 dentists (50%) were returned. Of 607 general dentists and 40 pediatric dentists who treated dental Medicaid-enrolled children in the past year, 269 (44%) and 18 (45%), respectively, treated all Medicaid-enrolled children. Newly graduated dentists were more likely to be actively enrolled than their more established counterparts (chi 2 = 10.67; p = 0.01). Medicaid reimbursement levels were viewed as "much less" than private fees by 62%, "less" by 33% and "the same" by 4% of the respondents. Broken appointments were the most prevalent reported problem (80%), followed by low fees (61%), patient non-compliance (59%), unreasonable denial of payments (57%), slow payment (44%), and complicated paperwork (42%). With the exception of the perceived importance of Medicaid reimbursement levels, active and inactive general and pediatric dentists' perceptions of the importance of Medicaid issues were not significantly different. These findings indicated that significantly more Medicaid-active general dentists who allocated 10% of their office visits to Medicaid-eligible children felt that slow payment (p = 0.002) and complicated paperwork (p < 0.001) were more important problems than general dentists who allocated less time to Medicaid-eligible children. CONCLUSIONS: Louisiana dentists' sources of dissatisfaction with Medicaid are similar to those of dentists in other states. Some of the issues are programmatic and are within the power of the dental Medicaid director and state legislature to address. Patient-related issues such as frequent broken appointments may be addressed by assigning case managers to Medicaid beneficiaries.     

Professional monopoly, social covenant, and access to oral health care in the United States

Lack of access to oral care is a severe problem in the United States with over one-third of the population lacking dental insurance. In this group, 32 million people lack dental insurance and access to public dental services (Medicaid or Medicare), and 7 million of them need dental care. In some high-risk populations, such as Native Americans, two-thirds have unmet dental needs. Only 1 percent of Medicaid-eligible babies have a dental examination before twelve months of age. In this paper the social covenant of the dental profession is examined and suggestions made for improving access to care through improved efficiency. It is proposed that 1) private dentists should accept 5 percent per annum of their patients for indigent care funded by improved efficiency from utilizing allied dental providers (ADP) in new roles, and 2) ADP should have their own independent state boards. If dentists refuse to honor their social covenant, then ADP should be allowed to practice independently, breaking the professional monopoly.     

Ohio dental care providers' treatment of young children, 2002

BACKGROUND: Adequate access to dental care for young children--particularly those from low-income families--is a public concern. The authors conducted a survey of Ohio dental care providers to examine factors influencing their willingness to care for these children. METHODS: Random samples of Ohio general practitioner (GPs) dentists and pediatric dentists (PDs) and all Ohio safety-net dental clinics completed a mail survey regarding treatment of children aged 0 through 5 years. The authors categorized responses by provider type and further analyzed GPs' responses by years since graduation and geographic character. RESULTS: Few Ohio GPs (8 percent) recommended a first dental visit by 1 year of age. While 91 percent of GPs treated children aged 3 through 5 years, only 34 percent treated children aged 0 through 2 years, most often for emergency visits or examinations. Only 7 percent of all GPs and 29 percent of PDs accepted patients enrolled in Medicaid without limitations. CONCLUSIONS: Children's being young (0-2 years of age) and having Medicaid as a payment source made GPs substantially less likely to treat them. Children's being enrolled in Head Start made GPs somewhat more likely to treat them. PRACTICE IMPLICATIONS: New strategies for ensuring dental care access for young children from low-income families are necessary. Such strategies may take the form of interpeer advocacy, education, practice incentives or creation of coordinated GP and PD teams.     

Practices and opinions of pediatric and general dentists in Connecticut regarding the age 1 dental visit and dental care for children younger than 3 years old

PURPOSE: This study aimed to determine the percentage of general and pediatric dentists in Connecticut that were aware of, and practice, the current AAPD guidelines for the age one dental visit and to determine the services they provide to 0-2-yr-old patients. METHODS: A survey was mailed to Connecticut general and pediatric dentists seeking information on practice type, years in practice, training, ages of children seen, procedures performed and opinions regarding the age one dental visit. RESULTS: The response rate was 42% for general dentists and 84% for pediatric dentists, giving a sample of 113 and 60 dentists, respectively. All responding pediatric dentists reported seeing 0-2-yr-olds as compared to 42% of general dentists. Although not statistically significant, general dentists who were female or in practice less than 10 years were more likely to see 0-2-yr-olds. The majority of pediatric dentists reported performing all procedures surveyed, however, only just over half of general dentists provided topical fluoride or restorative care. Among pediatric dentists, 98% were aware of the AAPD guidelines and 92% agreed with them compared to 41% and 45% of general dentists respectively. CONCLUSIONS: Nearly all Connecticut pediatric dentists are caring for 0-2-yr-olds compared to 42% of Connecticut general dentists.     

Scottish dentists' preferences for remuneration and their opinions on the scope of General Dental Service treatment

A questionnaire was sent to a list of what was considered to be all dentists currently in practice in the General Dental Service (GDS) and Community Dental Service (CDS) in Scotland; 72% responded. The dentists were asked to indicate the general method by which they would prefer to be paid, given a choice of fee for item-of-service, salary or capitation. Opinion was split among the GDS respondents, between fee for item-of-service (34.9%), a salaried system of payment (32.6%), or a service based on differing remuneration systems for the dental care of adults and children (22.5%). Only 22.6% of GDS respondents said they would prefer a capitation system for the treatment of child patients. Most CDS respondents said they preferred to be salaried. Dentists in both services were asked if they felt there was a need to extend the range of treatment items which are currently permitted in the GDS; most felt that there was. About 80% of all respondents felt that there was a need to allow payment for various items of preventive dental care within the GDS. Almost a third of GDS respondents also mentioned various items of restorative dental treatment which they felt should be funded (a concern which fewer CDS respondents (6.7%) mentioned). Few respondents suggested any other additional types of treatment items.     

General dentists' perceptions of educational and treatment issues affecting access to care for children with special health care needs

This study analyzed a data subset of a national survey of general dentists conducted in 2001 to determine their overall care of children with special health care needs (CSHCN). In the survey, dentists were asked to respond to questions in the following areas: did they provide care for CSHCN (children with cerebral palsy, mental retardation, and those who are medically compromised); what were their perceptions of the training they received in dental school related to CSHCN; what was their interest in additional training for CSHCN; and what factors influenced their willingness to provide care for CSHCN? Only about 10 percent see CSHCN often or very often, and only one in four respondents had hands-on experience with these patients in dental school. Postgraduate education in general practice or advanced general dentistry residency had no effect on willingness to care for CSHCN. Older dentists, those accepting Medicaid for all children, and those practicing in small communities were more likely to see CSHCN. Dentists willing to see CSHCN also were more likely to perform procedures associated with special needs and underserved child populations including pharmacologic management and stainless steel crowns. Dentists with hands-on educational experiences in dental schools with CSHCN were less likely to consider such factors as level of disability and patient behavior as obstacles to care and were more likely to desire additional education in care of CSHCN.     

Network capitation practices: a new concept

The percentage of consumers in the U. S. covered by dental insurance has increased dramatically over the last 10 years. As dental insurance grows, it is becoming increasingly important to examine the context of dental care payment systems. At present, almost all insurance programs are geared toward the fee-for-service system, which reimburses dentists a fixed sum for each type of procedure. The exceptions to fee-for-service dental insurance plans are few. A capitation program for dental care, which reimburses dentists a fixed amount per enrolled patient regardless of services rendered, offers many advantages for both consumers and providers and should be available as an option. Network capitation represents a new approach to the payment of dental care. A network capitation program is being developed in the United States and will use an approach involving two contracts, one which will be used with an insurance company, and the second with a network of private practitioners. The insurance company will supply dental practices with dental patients and funds on a capitation basis. Patients will be given the choice of fee-for-service or capitation. Network capitation allows fee-for-service solo or group practitioners to incorporate capitation patients into their practice.     

Dentist participation in a public-private partnership to increase Medicaid participation and access for children from low income families

The purpose of this research is to solicit feedback from dental society members involved in a program (Access to Baby and Child Dentistry, ABCD) to provide care for children receiving Medicaid benefits, and to gain an understanding of dentist participation. We investigated whether general dentists who were participants in ABCD were more fully integrated into the dental society profession and community, and whether they demonstrated greater interest in children. Dentists were stratified regarding ABCD participation and randomly selected to be interviewed (N = 40). The majority thought it appropriate for general dentists to care for very young children. Participants found fewer problems in fee levels in Medicaid, but there was no difference in an index of fees between the groups. Participants were no more active in the dental society, and few differences existed between the groups regarding other aspects of personal or professional life. Dentists participating in ABCD to improve access had a good experience and have positive views of the program. This may encourage other nonspecialist colleagues to participate in programs for children.