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.     

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.     

Factors affecting dentist participation in a state Medicaid program

Provider participation is one factor affecting access to care for Medicaid recipients. There is evidence that providers are increasingly limiting their acceptance of Medicaid patients. Reasons cited for physicians and dentists not participating in Medicaid include low reimbursement rates, excessive paperwork, denial of reimbursement, and bureaucratic complexities. Telephone interviews were conducted with 92 dentists in California to determine factors affecting their decisions to participate in the California Medicaid (Medi-Cal) program. Low fees, denial of payment, and broken appointments by patients were identified as the three most important problems with the program. Non-participating dentists were more concerned about broken appointments, and complicated paperwork while less likely to believe the complexity of the program had recently decreased. Participating dentists were more concerned about the lack of services covered by Medi-Cal. The fact that participating and non-participating dentist have similar concerns about most aspects of the program may indicate that dentists who currently participate in Medi-Cal may become non-participants if problems with the program are not addressed.     

Reimbursement rates and policies for primary molar pit-and-fissure sealants across state Medicaid programs

BackgroundLittle is known about Medicaid policies regarding reimbursement for placement of sealants on primary molars. The authors identified Medicaid programs that reimbursed dentists for placing primary molar sealants and hypothesized that these programs had higher reimbursement rates than did state programs that did not reimburse for primary molar sealants.MethodsThe authors obtained Medicaid reimbursement data from online fee schedules and determined whether each state Medicaid program reimbursed for primary molar sealants (no or yes). The outcome measure was the reimbursement rate for permanent tooth sealants (calculated in 2012 U.S. dollars). The authors compared mean reimbursement rates by using the t test (α = .05).ResultsSeventeen Medicaid programs reimbursed dentists for placing primary molar sealants (34 percent), and the mean reimbursement rate was $27.57 (range, $16.00 [Maine] to $49.68 [Alaska]). All 50 programs reimbursed dentists for placement of sealants on permanent teeth. The mean reimbursement for permanent tooth sealants was significantly higher in programs that reimbursed for primary molar sealants than in programs that did not ($28.51 and $23.67, respectively; P = .03).ConclusionsMost state Medicaid programs do not reimburse dentists for placing sealants on primary molars, but programs that do so have significantly higher reimbursement rates.Practical ImplicationsMedicaid reimbursement rates are related to dentists' participation in Medicaid and children's dental care use. Reimbursement for placement of sealants on primary molars is a proxy for Medicaid program generosity.     

Comparison of Medicaid and Non-Medicaid Dental Providers

A statewide mail survey of a stratified sample of 640 Michigan general dentists was conducted in 1983, with a response rate of 41 percent, n = 261. An analysis was performed to compare Medicaid and non-Medicaid providers. About half of all respondents reported that they were not seeing any Medicaid patients (Group 1); 29 percent reported that less than 10 percent of their patients were Medicaid-eligible (Group 2), and 22 percent reported that 10 percent or more of their patients were Medicaid-eligible (Group 3). Significant differences existed among the three groups for age of respondent, length of time in practice, and number of new patients seen each month. Respondents with greater percentages of Medicaid patients in their practices were more likely to be in group practice. Stratification of respondents by location suggested that rural providers were more likely than urban respondents to have some Medicaid patients in their practices. Over 40 percent of respondents from all groups reported themselves as being not busy enough. In 1984, more than one million persons in Michigan were eligible for Medicaid dental benefits, but only one-fourth of these individuals were recipients of dental care. Factors that may limit dentists' participation in the Medicaid program, despite the presence of a large eligible population and self-reported lack of business, are discussed.     

Dentists' participation and children's use of services in the Indiana dental Medicaid program and SCHIP: assessing the impact of increased fees and administrative changes

BACKGROUND: The authors conducted a study to evaluate whether administrative changes, including higher fee schedules for dental services in the Indiana dental Medicaid program and the State Children's Health Insurance Program (SCHIP), were associated with improved dentist participation and utilization of dental services by children. METHODS: The authors evaluated dentists' participation and children's use of services for the two years before fees were increased to 100 percent of the 75th percentile of usual and customary fees, compared with two years after the increase. They obtained administrative data from the Indiana Department of Family and Social Services Administration and the Indiana Department of Public Health to determine participation rates and service use. RESULTS: The number of dentists seeing a Medicaid-enrolled child increased from 770 in fiscal year (FY) 1997 to 1,096 in FY 2000. The number of Medicaid-enrolled children with any dental visit increased from 68,717 (18 percent) to 147,878 (32 percent), with little difference between children enrolled through the Medicaid-SCHIP and traditional Medicaid programs by FY 2000. The mean number of visits per child per year and the mean number of procedures per child per year remained relatively constant. The cost per enrolled child increased from dollars 1.70 to dollars 6.70 per month, while the cost per child with a visit increased from dollars 9 to dollars 21 per month. CONCLUSION: The increase in fees and changes in administration of the Indiana dental Medicaid program were positively associated with improved dentist participation and children's use of dental services. PRACTICE IMPLICATIONS: Changes beyond increasing fees to 100 percent of the 75th percentile may be needed if Medicaid-enrolled children are to have access to dental care commensurate with their lower oral health status and greater need for services. Sustained fee increases also are important. As of 2003, no increase in dental fees had occurred in the Indiana Medicaid program since the increase in FY 1998.     

Dental safety net capacity: An innovative use of existing data to measure dentists’ clinical engagement in state Medicaid programs

Background

The demand for dentists available for state Medicaid populations has long outpaced the supply of such providers. To help understand the workforce dynamics, this study sought to develop a novel approach to measuring dentists’ relative contribution to the dental safety net and, using this new measurement, identify demographic and practice characteristics predictive of dentists’ willingness to participate in Indiana's Medicaid program.

Methods

We examined Medicaid claims data for 1,023 Indiana dentists. We fit generalized ordered logistic regression models to measure dentists’ level of clinical engagement with Medicaid. Using a partial proportional odds specification model, we estimated proportional adjusted odds ratios for covariates and separate estimates for each contrast of nonproportional covariates.

Results

Though 75% of Medicaid‐enrolled dentists were active providers, only 27% of them had 800 or more claims during fiscal year 2015. As has been shown in previous studies, our findings from the proportional odds model reinforced certain demographic and practice characteristics to be predictive of dentists’ participation in state Medicaid programs.

Conclusions

In addition to confirming predictive factors for Medicaid enrollment, this study validated the clinical engagement measure as a reliable method to assess the level of Medicaid participation. Prior studies have been limited by self‐reported data and variations in Medicaid claims reporting.

Practical implications

Our findings have implications for state Medicaid policymakers by enabling access to data regarding dental providers’ level of participation in Medicaid in addition to identifying factors predictive of such participation. This information will inform Medicaid program plans and provider recruitment efforts.     

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.     

Texas dentists' attitudes toward the Dental Medicaid program

PURPOSE: The purpose of this study was to report the attitudes of Texas dentists toward the Dental Medicaid program. METHODS: A self-administered survey was mailed to all pediatric dentists and a random sample of general dentists. RESULTS: Surveys from 347 (69%) of 500 dentists (171 of 295 general dentists [58%] and 169 of 205 pediatric dentists [82%]) were returned. 57% of pediatric dentists and 29% of general dentists (P<.0001) treated at least 1 Medicaid patient in the past year. The major areas of dissatisfaction were: (1) broken appointments; (2) low reimbursement levels; and (3) patient noncompliance. This mirrors results from studies in Iowa, Louisiana, Ohio, Washington, and California. Both pediatric and general practitioners identified the following barriers to core for the Medicaid population: (1) low dental IQ; (2) few providers; and (3) no transportation. CONCLUSIONS: The major areas of dissatisfaction included both programmatic and patient-related factors. Attributes of the system (eg, lower reimbursement levels) are more modifiable than attributes of the patient population (eg, patient noncompliance and low dental IQ). Underfunding of dental Medicaid is endemic to all states studied in the literature. Providers, legislators, and government programs should target the programmatic problems with future efforts and funding.     

Michigan Medicaid's Healthy Kids Dental program: an assessment of the first 12 months

BACKGROUND: In 2000, Michigan's Medicaid dental program initiated Healthy Kids Dental, or HKD, a demonstration program offering dental coverage to Medicaid-enrolled children in selected counties. The program was administered through a private dental carrier at private reimbursement levels. The authors undertook a study to determine the effect of these changes. METHODS: The authors obtained enrollment and utilization data for four groups: children covered in the first 12 months of HKD in 22 counties, children with private dental coverage in the same 22 counties in the same 12 months, Medicaid-enrolled children in the same 22 counties for 12 prior months, and Medicaid-enrolled children in 46 counties who were not included in the HKD program at any time. The authors compared access to care, dentists' participation, treatment patterns, patient travel distances and program cost. RESULTS: Under HKD, dental care utilization increased 31.4 percent overall and 39 percent among children continuously enrolled for 12 months, compared with the previous year under Medicaid. Dentists' participation increased substantially, and the distance traveled by patients for appointments was cut in half. Costs were 2.5 times higher, attributable to more children's receiving care, the mix of services shifting to more comprehensive care and payment at customary reimbursement levels. CONCLUSIONS: By increasing reimbursement levels and streamlining administration, the HKD demonstration program has shown that substantial improvements can be made to dental access for the Medicaid-enrolled population. PRACTICE IMPLICATIONS: The findings of this assessment suggest that appropriate attention to administration and payment levels can rapidly improve access for Medicaid-enrolled patients using existing dental personnel. By cooperating with state officials to design a program that addresses multiple issues, dental providers can help create a Medicaid dental program that is attractive to both providers and patients.     

Dental visits to hospital emergency departments by adults receiving Medicaid: assessing their use

BACKGROUND: Pain from toothaches represents a significant problem. People lacking access to private dental services may use hospital emergency departments, or EDs. In 1993, Maryland eliminated Medicaid reimbursement to dentists for adult emergency services. METHODS: The authors used the change in Medicaid policy that eliminated dentist reimbursement to establish two study periods. Data tapes describing patients' use of EDs were obtained from the Maryland Medicaid Management Information System. A total of 3,639 people visited EDs for dental problems sometime during the four-year study period. RESULTS: After controlling for age, race and sex, the authors found that the rate of ED claims was 12 percent higher in the postchange period than in the prechange period. Comparisons between periods show significant rate increases during the postchange period for men, whites, African-Americans and patients aged 21 through 44 years and 45 through 64 years. CONCLUSIONS: The change in Medicaid policy that eliminated dentist reimbursement and participation in the program appears to have increased the use of EDs for the treatment of dental problems. Practice Implications. Many EDs lack dental services and are not capable of providing definitive treatment. When definitive treatment is not provided, this pattern of care may be repeated if patients are forced to return for treatment.     

Third-party reimbursement and use of fluoride varnish in adults among general dentists in Washington State

BACKGROUND: Studies have indicated that a minority of dentists regularly use fluoride varnish to control caries. To increase the use of this new technology, Washington Dental Service, or WDS, began reimbursing dentists for providing fluoride varnish in January 1996. The aim of the authors' study was to determine whether reimbursement increased dentists' use of fluoride varnish. METHODS: In the fall of 1995, the authors asked a random sample of 532 general dentists in Washington state to complete a mail questionnaire on their use of caries control services. The survey was conducted before the institution of payment for fluoride varnish use, and dentists were unaware that fluoride varnish use would be a paid service in January 1996. In the fall of 1997 the same dentists were asked to complete a second questionnaire on the same topic. RESULTS: About 32 percent of dentists used fluoride varnish regularly before WDS started reimbursement for the service. Two years after reimbursement began, about 44 percent of dentists regularly used fluoride varnish (P = .004). Dentists' rates of use of other caries-control services (chlorhexidine rinses for caries control and adult pit-and-fissure sealants) did not change. Dentists' reasons for not using fluoride varnish included lack of awareness, lack of convincing evidence of a favorable cost:benefit ratio, patients' rejection of the service and low caries risk among adult patients. CONCLUSIONS: After fluoride varnish became a covered benefit, the use of fluoride varnish among general dentists increased after two years, but a majority of dentists still had not adopted the technology. The increase in use may be due to reimbursement, as well as other factors. PRACTICE IMPLICATIONS: Reimbursement by itself cannot increase dentists' use of caries control services.     

Improving utilization of preventive dental services by Medicaids-enrolled children: focus on the parents

The Access to Baby and Child Dentistry (ABCD) program was implemented in Washington State in 1995 to increase utilization of dental services for children enrolled in Medicaid. The program has increased utilization of services; nevertheless, only 54 percent of Medicaid-enrolled children in ABCD who received care were given a topical fluoride treatment. To gain a better understanding of why children may not be receiving topical fluoride treatment, we interviewed parents. Focus group research found strong parental support for preventive services. Parents were willing to take their children to regular dental visits, but lack of knowledge of benefits was common. This lack of knowledge translated into a failure to fully utilize the topical fluoride benefits. We recommend that the program continue to encourage participation of dentists, regularly update information about program benefits for both dentists and parents, and enhance the visibility of the program in the community.     

The dentist's role in access to dental care by Medicaid recipients

This study uses a decision analytic approach to assess the dentist's role in access to care by Medicaid recipients. The question of whether a private dentist, when given the choice, will schedule a Medicaid or non-Medicaid patient is examined. The model considers factors frequently reported to influence dentist's decisions over whether to accept Medicaid recipients into their practices. Factors include reimbursement rates, probability of broken appointments, and likelihood of reimbursement. The model permits calculation of the expected benefits in dollars for comparable treatment of Medicaid and non-Medicaid patients. Under a variety of conditions, it is shown that the strategy to schedule a non-Medicaid patient dominates alternative strategies in which Medicaid recipients are scheduled. Policy implications of these results are discussed.     

Dental therapists in general dental practices: an economic evaluation

Dental access disparities are well documented and have been recognized as a national problem. Their major cause is the lack of reasonable Medicaid reimbursement rates for the underserved. Specifically, Medicaid reimbursement rates for children average 40 percent below market rates. In addition, most state Medicaid programs do not cover adults. To address these issues, advocates of better oral health for the underserved are considering support for a new allied provider-a dental therapist- capable of providing services at a lower cost per service and in low-income and rural areas. Using a standard economic analysis, this study estimated the potential cost, price, utilization, and dentist's income effects of dental therapists employed in general dental practices. The analysis is based on national general dental practice data and the broadest scope of responsibility for dental therapists that their advocates have advanced, including the ability to provide restorations and extractions to adults and children, training for three years, and minimum supervision. Assuming dental therapists provide restorative, extraction, and pulpal services to patients of all ages and dental hygienists continue to deliver all hygiene services, the mean reduction in a general practice costs ranges between 1.57 and 2.36 percent. For dental therapists treating children only, the range is 0.31 to 0.47 percent. The effects on price and utilization are even smaller. In addition, the effects on most dentists' gross income, hours of work, and net income are negative. The estimated economic impact of dental therapists in the United States on private dental practice is very limited; therefore, the demand for dental therapists by private practices also would probably be very limited.     

The impact of dental Medicaid reform on dental care provider activity and market penetration of dental support organizations

BackgroundMedicaid state dental programs have experienced changes related to provider practice settings with the increased growth of dental support organizations (DSOs). The authors conducted this study to assess the impact of state Medicaid reform on the dental practice environment by examining provider activity and practice setting.MethodsThis was a retrospective cohort study of more than 13 million dental claims in the Virginia Medicaid program. It included children and dental care providers in the Virginia dental Medicaid program at some time during a 9-year period (fiscal years 2003-2011). The independent variable was the provider practice setting: private practice, DSO, and safety-net practice. The outcomes included annual measures of claims, patients, and payments per provider. The outcomes were examined over 3 phases of the study period: prereform (2003-2005), implementation phase (2006-2008), and postreform maturation (2009-2011).ResultsProvider activity increased after dental program reform, with private-practice providers delivering most of the dental care in the Medicaid program. There was a significant penetration of DSO providers in number of providers, claims per provider, and patients per provider (P < .001). Regression results found that providers in DSO settings had an increased number of patients and claims compared with private-practice providers.ConclusionsMedicaid reform has resulted in a significant increase in provider participation and growth of DSO-affiliated providers.Practical ImplicationsAreas of the state with more dense population had a higher penetrance of dentists practicing in DSO settings providing dental services to children enrolled in Medicaid.