Children's Access to Dental Care in Connecticut's Medicaid Managed Care Program

Objective: To describe dental care utilization and access problems in Connecticut's Medicaid managed care program, using quantitative and qualitative research methods. Methods: Using Medicaid managed care enrollment and encounter data from Connecticut, utilization rates for preventive care and treatment services are determined for 87,181 children who were continuously enrolled in Medicaid managed care for 1 year in 1996–97. Sociodemographic and enrollment factors associated with utilization are identified using bivariate and multivariate methods. Dental providers and practices where children received services are described. Qualitative methods are used to characterize problems experienced by families seeking dental care during the study period. Results: Only 30.5% of children continuously enrolled in Medicaid managed care for 1 year received any preventive dental services; 17.8% received any treatment services. Children who received preventive care were eight times more likely to have received treatment services. Utilization was higher among (a) younger children, (b) children who lived in Hartford and in other counties served by public dental clinics, and (c) children enrolled in health plans that did not subcontract for administration of dental services. Just 5% of providers, primarily those in public dental clinics, performed 50% of the services. Families whose children needed care encountered significant administrative and logistical problems when trying to find willing providers and obtain appointments. Conclusions: Access to dental care is a problem for children in Connecticut's Medicaid managed care program. Several features of managed care have negatively affected access. Public dental clinics served many children across the state and contributed to higher utilization of preventive care and treatment services among children living in Hartford.     

Improving Children's Access to Oral Health Services: The Oral Health Initiative

Although major improvements have been made in oral health during the 20th century, many children in minority groups, from families with low-income, and with special health care needs still do not receive the oral health services that they need. To address the problem, the Health Resources and Services Administration (HRSA), working with the Health Care Financing Administration (HCFA), has launched the Oral Health Initiative. The initiative seeks to strengthen oral health service-delivery systems, enhance collaboration among federal agencies, and provide states with the resources needed to improve the oral health of hard-to-reach children. HRSA's activities include enhancing programs, services, and training, such as expanding the number of direct-service dental programs; establishing or enhancing graduate training programs in pediatric and general dentistry and in dental public health; and funding training programs in dentistry to train dental public health leaders.     

Indiana Children's Special Health Care Services Program: Impact of Administrative Changes on Health Care Utilization, Access to Care, and Unmet Needs

In this study we assessed the impact of administrative changes occurring in 1993 on the Indiana Children's Special Health Care Services program. Responses from a 1994-1995 survey were compared with a 199 1 survey. Unmet needs declined in 6 categories: primary medical care, hospital services, home nursing care, physical therapy, occupational therapy, and special equipment. Unmet needs remained the same in 6 categories: specialty care, speech therapy, respite care, parent support, child support, and sibling support. Unmet needs increased in 5 categories: dental care, mental health, transportation, housing modifications, and child and day care. Although program changes improved the health care needs of clients in many areas, additional efforts are still needed.     

Public Finance Policy Strategies to Increase Access to Preconception Care

Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. Millions of women of childbearing age (15–44) lack adequate health coverage (i.e., uninsured or underinsured), and others live in medically underserved areas. Service delivery fragmentation and lack of professional guidelines are additional barriers. This paper reviews barriers and opportunities for financing preconception care, based on a review and analysis of state and federal policies. We describe states’ experiences with and opportunities to improve health coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children's Health Insurance Program (SCHIP). The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.     

Dental Therapists: Improving Access to Oral Health Care for Underserved Children

Disparities in dental health care that characterize poor populations are well known. Children suffer disproportionately and most severely from dental diseases. Many countries have school-based dental therapist programs to meet children’s primary oral health care needs.Although dental therapists in the United States face opposition from national and state dental associations, many state governments are considering funding the training and deployment of dental therapists to care for underserved populations. Dental therapists care for American Indians/Alaska Natives in Alaska, and Minnesota became the first state to legislate dental therapist training.Children should receive priority preference; therefore, the most effective and economical utilization of dental therapists will be as salaried employees in school-based programs, beginning in underserved rural areas and inner cities.The 2000 report of the surgeon general Oral Health in America noted,

What amounts to “a silent epidemic” of oral diseases is affecting our most vulnerable citizens—poor children, the elderly and many members of racial and ethnic minority groups.^1(p1)

This persistent epidemic has not been alleviated by continuation of the present dental care delivery system. A significant factor contributing to the inability of children to obtain adequate dental care is the shortage of accessible dentists.2 Expansion of the dental workforce to include dental therapists offers the potential for improvement.More than 14 000 dental therapists practice in more than 54 countries throughout the world, including New Zealand, which originated the concept; Australia; Canada; the United Kingdom; and, most recently, the United States, in Alaska and Minnesota.3–5 High school graduates are trained in a 2-year program to provide preventive and restorative dental care, usually for children. In some countries training is being extended to 3 years to incorporate both dental therapy and dental hygiene, and to provide treatment of adults as well as children.6,7Dental therapist programs have been studied extensively in a number of countries, and the quality of care, which includes preventive and restorative treatment for more than 90% of school-aged children through high school, has been consistently documented to equal care provided by dentists.8–10 School-based dental therapists are salaried public health workers, and the overall cost of providing care to children in schools is thus significantly lower than the cost of private dental care.11     

Step On It! Impact of a Workplace New York City Taxi Driver Health Intervention to Increase Necessary Health Care Access

Objectives. We describe the impact of the Step On It! intervention to link taxi drivers, particularly South Asians, to health insurance enrollment and navigate them into care when necessary.Methods. Step On It! was a worksite initiative held for 5 consecutive days from September 28 to October 2, 2011, at John F. Kennedy International Airport in New York City. Data collected included sociodemographics, employment, health care access and use, height, weight, blood pressure, and random plasma glucose. Participants were given their results, counseled by a medical professional, and invited to participate in free workshops provided by partner organizations.Results. Of the 466 drivers participated, 52% were uninsured, and 49% did not have a primary care provider. Of 384 drivers who had blood pressure, glucose, or both measured, 242 (63%) required urgent or regular follow-up. Of the 77 (32%) requiring urgent follow-up, 50 (65%) sought medical care at least once, of whom 13 (26%) received a new diagnosis. Of the 165 (68%) requiring regular follow-up, 68 (41%) sought medical care at least once, of whom 5 (7%) received a new diagnosis.Conclusions. This study provides encouraging results about the potential impact of an easy-to-deliver, easily scalable workplace intervention with a large, vulnerable population.New York City alone has more than 50 000 yellow taxi drivers and a similar number of livery drivers.1 A large majority, 94%, are immigrants, mainly originating from India, Bangladesh, Pakistan, Haiti, and West African countries.1 Taxi drivers are often at greater risk for cardiovascular disease (CVD) and associated risk factors than the general population.2,3 Studies looking exclusively at taxi drivers have found a correlation between the occupation and myocardial infarctions, multivessel disease, obesity, insulin resistance, high blood pressure, high triglycerides, and high low-density lipoproteins.3 By nature of their occupation, drivers have a sedentary lifestyle.4,5 Sedentariness in the general population has been linked to a higher CVD mortality rate, secondary to coronary heart disease, sudden heart failure, hypertension, and diabetes.6–11 Environmental exposures are also to blame for high CVD and lung cancer risk for taxi drivers. Exposure to particulate matter, which is often found at high levels in closed vehicles, has been linked to lower heart rate variability, a predictor of CVD, and to lung cancer.12–14Other factors, such as high stress, poor working conditions, long hours, unstable income, unhealthy diet, significant concern about personal safety on the job, and institutional and organizational barriers further contribute to poorer health among taxi drivers.5,15–17 Several reports and studies on the working and living conditions of taxi drivers have been released in California; Chicago, Illinois; and New York City and described similar health profiles for this population.5,15,16 In New York City, drivers typically work 10- to 12-hour shifts 6 days a week.4,16,18 Studies have also shown that a major systems-level obstacle for taxi drivers is lack of adequate health care; 60% of taxi drivers were found to be uninsured in a Chicago study19 and 52% in a New York City study.20 The occupation-related barriers to care experienced by this largely immigrant community are further exacerbated by literacy and language barriers, financial pressures, family obligations, and cultural values.4,19,21 South Asian taxi drivers, the largest group of yellow taxi drivers in New York City, potentially face a double burden for CVD because of both the nature of their occupation and the increased CVD risk associated with South Asian ethnicity.22–27Several studies have demonstrated the successful use of occupation-based interventions to effect lifestyle changes.17,28–31 A literature review of dietary promotion programs in the workplace demonstrated that, with industry cooperation and use of a social–ecological model of intervention, worksite interventions can have gradual and favorable results.17 In one social–ecological study, changes to workplace cafeteria food service in conjunction with behavioral interventions for workers resulted in a significant increase in fruit and vegetable consumption among participants.17 Support from workplace management was crucial for the success of this program.17 Although a paucity of data exist on interventions specifically for US taxi drivers, a number of European studies have had good results for exercise and diet interventions for taxi and other drivers.29–31 A British pilot study used a peer video to encourage drivers to make healthy lifestyle changes over a 1-year study period, resulting in 73% of participating drivers reporting a significant lifestyle change, with greater physical activity, positive diet changes, and more time spent on family activities.29 Another British study used a peer education model for CVD risk education. Peer “health champions” disseminated information about free screenings and medical referrals; more than 66% of those who received medical appointments at screenings subsequently attended them.30 In Sweden, a healthy eating workplace intervention conducted at rest stops resulted in improved nutritional balance in meal choices among truck drivers.31 The results of these studies suggest that the workplace can be an effective setting for taxi driver health interventions in the United States.28The Immigrant Health and Cancer Disparities Service (IHCD) at Memorial Sloan-Kettering Cancer Center designed and implemented a taxi driver workplace health intervention, Step On It!, in 2011 at the John F. Kennedy (JFK) International Airport yellow cab holding lot in New York City. The Step On It! intervention incorporates specific components addressing drivers’ barriers to care, including

1. health insurance enrollment education and enrollment assistance to address lack of health insurance;
2. referrals to low-cost or free health clinics and hospitals to address financial barriers to obtaining health insurance;
3. referrals to culturally and linguistically appropriate care to address language and cultural barriers;
4. events held during work hours, providing a window of opportunity, and assistance with finding clinics with flexible hours, to address drivers’ long work hours; and
5. onsite health screening and counseling with triage to urgent or regular follow-up to address lack of knowledge related to current health status and need for care.

After drivers were assessed for health care access and utilization, medical history, and CVD risk factors; screened for hypertension and elevated random plasma glucose; and measured for body mass index (BMI), Step On It! used a health care access navigation and case management intervention to link drivers to health insurance enrollment and navigate them into care when necessary. We describe the impact of this intervention on the primary outcome of interest, drivers’ engagement in needed medical care.     

The Rural Dental Health Program: The Long-Range Effect of a School-Based Enriched Dental Health Program on Children's Oral Health*

ABSTRACT: In November 1985, 406 children ages 15 to 19 were clinically examined, answered survey questions covering dental attitudes and behaviors, and were tested to determine their dental knowledge. This group included 56 percent of the 725 first through third graders who participated in the Rural Dental Health Program beginning in the fall of 1975. The Rural Dental Health Program was a study designed, in part, to measure the effect of a school-based dental health program on the oral health of children in a rural, underserved Pennsylvania county. Measures taken on 406 children, six and one-half years after the educational program ended were used to test for its possible long-term impact on oral health. Evidence obtained from analysis of covariance supports the hypothesis that dental health education had a positive effect on children's oral health.     

Use of a Community Mobile Health Van to Increase Early Access to Prenatal Care

Objective: To examine whether the use of a community mobile health van (the Lucile Packard Childrens Hospital Women’s Health Van) in an underserved population allows for earlier access to prenatal care and increased rate of adequate prenatal care, as compared to prenatal care initiated in community clinics. Methods: We studied 108 patients who initiated prenatal care on the van and delivered their babies at our University Hospital from September 1999 to July 2004. One hundred and twenty-seven patients who initiated prenatal care in sites other than the Women’s Health Van, had the same city of residence and source of payment as the study group, and also delivered their babies at our hospital during the same time period, were selected as the comparison group. Gestational age at which prenatal care was initiated and the adequacy of prenatal care — as defined by Revised Graduated Index of Prenatal Care Utilization (RGINDEX) — were compared between cases and comparisons. Results: Underserved women utilizing the van services for prenatal care initiated care three weeks earlier than women using other services (10.2 ± 6.9 weeks vs. 13.2 ± 6.9 weeks, P = 0.001). In addition, the data showed that van patients and non-van patients were equally likely to receive adequate prenatal care as defined by R-GINDEX (P = 0.125). Conclusion: Women who initiated prenatal care on the Women’s Health Van achieved earlier access to prenatal care when compared to women initiating care at other community health clinics. None of the authors have financial conflicts of interest to disclose.     

Problems With Access to Dental Care for Medicaid-Insured Children: What Caregivers Think

OBJECTIVES: This study aimed to gain insight into the experiences, attitudes, and perceptions of a racially and ethnically diverse group of caregivers regarding barriers to dental care for their Medicaid-insured children. METHODS: Criterion-purposive sampling was used to select participants for 11 focus groups, which were conducted in North Carolina. Seventy-seven caregivers of diverse ethnic and racial backgrounds participated. Full recordings of sessions were obtained and transcribed. A comprehensive content review of all data, including line-by-line analysis, was conducted. RESULTS: Negative experiences with the dental care system discouraged many caregivers in the focus groups from obtaining dental services for their Medicaid-insured children. Searching for providers, arranging an appointment where choices were severely limited, and finding transportation left caregivers describing themselves as discouraged and exhausted. Caregivers who successfully negotiated these barriers felt that they encountered additional barriers in the dental care setting, including long waiting times and judgmental, disrespectful, and discriminatory behavior from staff and providers because of their race and public assistance status. CONCLUSIONS: Current proposals to solve the dental access problem probably will be insufficient until barriers identified by caregivers are addressed.     

Impact of a Japanese Incentivization Program to Increase End-of-Life Care Outside of Hospitals

ObjectivesTo analyze the association of an incentivization program to promote death outside of hospitals with changes in place of death.DesignA longitudinal observational study using national databases.Setting and ParticipantsParticipants comprised Japanese decedents (≥65 years) who had used long-term care insurance services and died between April 2007 and March 2014.MethodsUsing a database of Japanese long-term care insurance service claims, subjects were divided into community-dwelling and residential aged care (RAC) facility groups. Based on national death records, change in place of death after the Japanese government initiated incentivization program was observed using logistic regression.ResultsHospital deaths decreased by 8.7% over time, mainly due to an increase in RAC facility deaths. The incentivization program was more associated with decreased in-hospital deaths for older adults in RAC facilities than community-dwelling older adults.Conclusions and ImplicationsIn Japan, the proportion of in-hospital deaths of frail older adults decreased since the health services system introduced the incentivization program for end-of-life care outside of hospitals. The shift of place of death from hospitals to different locations was more prominent among residents of RAC facilities, where informal care from laymen was required less, than among community residents.     

Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics

PURPOSE Although vaccination of health care workers against influenza is widely recommended, vaccination uptake is low. Data on interventions to increase staff immunization in primary care are lacking. We examine the effect of a promotional and educational intervention program, not addressing vaccine availability, to raise the influenza vaccination rate among staff in primary care clinics.METHODS The study included all 344 staff members with direct patient contact (physicians, nurses, pharmacists, and administrative and ancillary staff) in 27 primary care community clinics in the Jerusalem area during the 2007–2008 influenza season. Thirteen clinics were randomly selected for an intervention that consisted of a lecture session given by a family physician, e-mail-distributed literature and reminders, and a key figure from the local staff who personally approached each staff member.RESULTS Influenza immunization rate was 52.8% (86 of 163) in the intervention group compared with 26.5% (48 of 181) in the control group (P<.001). When compared with the rate of immunization for the previous season, the absolute increase in immunization rate was 25.8% in the intervention clinics and 6.6% in the control clinics. Multivariate analysis showed a highly significant (P<.001) independent association between intervention and immunization, with an odds ratio of 3.51 (95% confidence interval, 2.03–6.09).CONCLUSION We have developed an effective intervention program to increase previously low vaccination rates among primary health care workers. This simple intervention could be reproduced easily in other clinics and organizations with an expected substantial increase in influenza immunization rates.     

Reexamining the Effects of Family Structure on Children's Access to Care: The Single-Father Family

Objective. To examine the effects of family structure, focusing on the single-father family, on children's access to medical care.
Data Source. The 1999 and 2002 rounds of the National Survey of America's Families (NSAF) including 62,193 children ages 0–17 years.
Study Design. We employ a nationally representative sample of children residing in two-parent families, single-mother families, and single-father families. Multivariate logistic regression is used to examine the relationship between family structure and measures of access to care. We estimate stratified models on children below 200 percent of the federal poverty threshold and those above.
Data Collection/Extraction Method. We combine data from the Focal Child and Adult Pair modules of the 1999 and 2002 waves of the NSAF.
Principal Findings. Children who reside in single-father families exhibit poorer access to health care than children in other family structures. The stratified models suggest that, unlike residing in a single-mother family, the effects of residence in a single-father family do not vary by poverty status.
Conclusions. Children in single-father families may be more vulnerable to health shocks than their peers in other family structures.     

Increased Children's Access to Fluoride Varnish Treatment by Involving Medical Care Providers: Effect of a Medicaid Policy Change

Background. In 2004, the State of Wisconsin introduced a change to their Medicaid Policy allowing medical care providers to be reimbursed for fluoride varnish treatment provided to Medicaid enrolled children.
Objective. To determine the extent by which a state-level policy change impacted access to fluoride varnish treatment (FVT) for Medicaid enrolled children.
Data Source. The Electronic Data Systems of Medicaid Evaluation and Decision Support database for Wisconsin from 2002 to 2006.
Study Design. We analyzed Wisconsin Medicaid claims for FVT for children between the ages of 1 and 6 years, comparing rates in the prepolicy period (2002–2003) to the period (2004–2006) following the policy change.
Principal Findings. Medicaid claims for FVT in 2002–2003 totaled 3,631. Following the policy change, claims for FVT increased to 28,303, with 38.0 percent submitted by medical care providers. FVT rates increased for children of both sexes and all ages, rising from 1.4 per 1,000 person-years of enrollment in 2002–2003 to 6.6 per 1,000 person-years in 2004–2006. Overall, 48.6 percent of the increase in FVT was attributable to medical care providers. The largest increase was seen in children 1–2 years of age, among whom medical care providers were responsible for 83.5 percent of the increase.
Conclusions. A state-level Medicaid policy change was followed by both a significant involvement of medical care providers and an overall increase in FVT. Children between the ages of 1 and 2 years appear to benefit the most from the involvement of medical care providers.     

Access to Care Outcomes: A Telephone Interview Study of a Suburban Safety Net Program for the Uninsured

Access DuPage (AD) currently provides primary care for about 14,000 low income, uninsured residents of suburban DuPage County, IL, an area with a very limited healthcare safety net infrastructure. A telephone interview survey evaluated health care utilization, satisfaction, and health status outcomes and compared recent enrollees to individuals in the program for at least 1 year. Sequential new AD enrollees (n = 158) were asked about the previous year when uninsured, while randomly selected established AD enrollees (n = 135) were asked the same questions about the previous year when actively enrolled in AD. Established enrollees reported being more likely to get ‘any kind of tests or treatment’ (96.3 vs. 46.2 %, p < 0.0001), fewer cost (78.5 vs. 21.3 %, p < 0.0001) and transportation barriers to care, more preventive and mental health services, and better self-management care. However, established enrollees also reported 14 % greater use of hospital inpatient and 9 % greater use of emergency room care, as well as continued difficulty in accessing needed specialty and dental care services. Despite more (diagnosed) conditions, established enrollees were over 2.5 times more likely to report good to excellent health status and over three times more likely to rate their satisfaction with health care as good to excellent. Findings illustrate the substantial benefits of assuring access to care for the uninsured, but do not reflect immediate savings from reduced hospital utilization. Access to care programs will be an important tool to address the needs of the 30 million people who will continue to be uninsured in the United States.