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.     

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.     

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.     

Dentists' ranking of Medicaid reimbursement rates as a measure of their pediatric Medicaid participation

The objective of the study was to determine the usefulness of dentists' ranking of Medicaid reimbursement rates as a measure of their participation in the Medicaid program for children. Data were obtained from two mail-in questionnaire surveys of Connecticut dentists, before and after an increase in Medicaid reimbursement rates for children. Dentists ranked acceptability of Medicaid reimbursement rates on a seven-point index, while their participation in the Medicaid program was assessed by whether they acknowledged treating Medicaid children and were currently accepting new Medicaid children into their practices. There was a significant difference (p < 0.0001) in the dentists' ranking of Medicaid reimbursement rates following the rate increase indicating that the index was responsive. Acceptance of new Medicaid children into dental practices was a better measure of active participation in the Medicaid program. Following the increase in Medicaid reimbursement rates, dentists ranking it as acceptable/equivocal were more likely (p < 0.02) to accept new Medicaid children into their practices. In conclusion, the index of dentists' ranking of Medicaid reimbursement rates was a responsive and valid measure of their participation in the Medicaid program.     

Method of payment for children's dental services by practice type and geographic location.

The purpose of this project was to evaluate practice type and geographical differences in methods of payment accepted for children's dental services. A survey was mailed to 2000 general dentists and 1000 pediatric dentists randomly selected to provide representation from the 50 United States. Dentists were asked to specify the type of practice and the state in which they primarily practice. The survey included Medicaid, dental insurance, preferred provider organizations (PPO), and self-payment as payment options. Dentists were asked to indicate whether they never, occasionally, or frequently accepted each option of payment for children's dental services. Responses were received from 1245 (42%) dentists, including 723 general dentists and 522 pediatric dentists. Chi-square statistical analysis revealed significant practice type and regional differences in the acceptance of Medicaid for payment. Pediatric dentists accept Medicaid more frequently than general dentists (P < 0.001). Most dentists accept dental insurance and self-payment, while few indicate involvement with a PPO. The study revealed significant practice type differences only in the acceptance of Medicaid as payment for children's dental services. On a geographic basis, there were significant differences in the acceptance of Medicaid and dental insurance.     

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.     

Access to dental care in Alabama for children with special needs: parents' perspectives

BACKGROUND: Access to dental care and delivery of quality dental health services are important for children with special needs. The authors surveyed parents of children with special needs in Alabama to determine their perceptions of access and barriers to dental care for their children. METHODS: The authors sent a questionnaire to 2,057 parents of children aged 3 to 13 years with special needs--cleft lip and/or palate; cerebral palsy, or CP; spina bifida; or epilepsy/seizure disorders--who were listed in a database provided by Children Rehabilitation Services of Alabama. The authors conducted univariate and multivariate analyses to calculate odds ratios and 95 percent confidence intervals. RESULTS: The overall response rate was 38 percent (N = 714). Eighty-five percent of respondents reported that their children had received some form of routine dental care. However, 35 percent of respondents reported they had had problems finding dentists willing to treat their children. Among those with problems, significant barriers to dental care included their children's having Medicaid insurance, poor oral health or CP, as well as a shortage of dentists with training in the care of children with special needs. CONCLUSIONS AND PRACTICE IMPLICATIONS: While the majority of respondents said their children had access to dental care, one-third said their children had problems receiving this care. Many of these problems can be ameliorated. Increasing providers' participation in the Medicaid program and improving their knowledge about, empathy for and training in the care of children with special needs is essential in improving access to dental care for this population.     

Caries risk assessment practices among Texas pediatric dentists

PURPOSE: The purpose of this study was to determine current caries risk assessment (CRA) practices of Texas pediatric dentists. METHODS: A 20-question survey was sent to all 204 active members of the Texas Academy of Pediatric Dentistry. The mailing list was obtained from the Texas Academy of Pediatric Dentistry roster. RESULTS: The response rate was 62% (127/204). Eighty-three percent of respondents reported that parents are receptive to education about caries risk factors. Socioeconomic status was unrelated to receptivity. Ninety-three percent of respondents reported that they are actively involved in CRA. Thirty-eight percent of those responding reported performing CRAs on greater than 76% of their patients; 9% reported no CRA use. Forty percent of respondents reported that they assess caries risk but do not document the caries risk status. Seventy percent of respondents reported a desire for more CRA education. No significant differences were found between: (1) year o fgraduation; (2) practice type; or (3) payer sources received and CRA practices. CONCLUSIONS: A need exists for more comprehensive caries risk assessment practices and increased documentation of caries risk status by Texas pediatric dentists. The continuing education of dental professionals in caries risk assessment is essential.     

Appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in eastern Iowa

PURPOSE: The purpose of this prospective study was to assess the appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in three Eastern Iowa practices. METHODS: During the month of October 1998, a tally was kept of all patient appointments at a private pediatric dental office, a public health dental clinic, and a university-based pediatric dentistry clinic. Patients were categorized as either Medicaid or non-Medicaid. Appointment behavior categories were defined as: On time; Failure; Late-notice Cancellation (less than 24 hours notice); and Tardy (greater than 10 minutes). The data was entered in SPSS and analyzed using the chi square statistic. Statistical significance was P < 0.05. RESULTS: A total of 1,406 appointments were recorded for all three sites. Overall, patients on Iowa Medicaid had higher appointment failure, late-notice cancellation, and tardiness rates than non-Medicaid patients at all three clinics. However, these differences were only statistically significant for the private office and the university-based clinic. Failed appointment rates for Medicaid patients were much higher at the private office (38%) than at the other two sites. CONCLUSION: Consistent with anecdotal reports from dentists, Medicaid patients had higher rates of broken appointments than did non-Medicaid patients, particularly in a private practice setting.     

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.     

Materials used to restore class II lesions in primary molars: a survey of California pediatric dentists

PURPOSE: The purpose of this study was to determine which materials were most commonly used by pediatric dentists in California to restore Class II lesions in the primary dentition. METHODS: A questionnaire consisting of 18 multiple-choice questions was mailed to all 440 active members of the California Society of Pediatric Dentistry (CSPD). The questions related to the practitioners' material of choice for restoring Class II lesions in primary molars. RESULTS: A 66% response rate was received. For 57% of the respondents, amalgam was the material of choice for restoration of Class II lesions in primary molars. Twenty-nine percent selected composite, 5% glass ionomer, 6% compomer, and 1% (1 practitioner) stainless steel crowns. Sixty-eight percent responded that amalgam has historically proven to be a safe, reliable, and affordable material. The main reasons cited for using composite resin were "patient preference" (86%) and "better esthetics" (78%). Most practitioners used either a single-step (fifth-generation) or 2-step (fourth-generation) bonding agent (53% and 35%, respectively). When using a nonamalgam restorative material, 49% of practitioners used a traditional Class II amalgam preparation. The role of dental literature in treatment decision-making was not significantly related to the restorative material used. CONCLUSIONS: While amalgam was the most common material used for Class II restorations, nonamalgam materials were significantly popular among California pediatric dentists.     

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.     

Opinions of practitioners and program directors concerning accreditation standards for postdoctoral pediatric dentistry training programs.

PURPOSE: This study was performed to assess opinions of program directors and practitioners about the importance and necessary numbers of experiences required by current accreditation standards for training of pediatric dentists. METHODS: A 32-item questionnaire was sent to all program directors of ADA-accredited postdoctoral pediatric dentistry training programs and to a random sample of 10% of the fellow/active membership of the American Academy of Pediatric Dentistry. RESULTS: An overall response rate of 56% was obtained from the single mailing. Practitioners and program directors differed significantly (P < or = 0.05) only in their opinions about the number of submucosal and intravenous sedation cases required for proficiency of eight experiences surveyed. The two groups differed significantly in 3 of 12 areas in terms of importance attributed for practice of contemporary pediatric dentistry: initiating and completing a research paper, biostatistics/epidemiology, and practice management. Program directors had little difficulty obtaining required experiences, and program dependence on Medicaid did not negatively affect quality of education. CONCLUSION: Practitioners and program directors agreed on the importance of most experiences and activities required by current accreditation standards.     

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.     

Early orthodontic treatment as a means to increase access for children enrolled in Medicaid in Washington state

BACKGROUND: The authors assessed the likelihood that interceptive orthodontic Medicaid programs would increase access to care for Washington children. METHODS: The authors surveyed 210 Washington state orthodontists, including questions on demographics, attitudes toward early treatment, use of innovations and perceptions of Medicaid. Respondents were either Medicaid participants or nonparticipants. RESULTS: Fifty of 159 respondents were Medicaid participants. Most respondents perceived early orthodontic treatment as beneficial. Medicaid participants were more willing to participate in Medicaid early-treatment programs, had slightly fewer patients in the "other insurance" category, provided more discounted fees, received more Medicaid inquiries, practiced in rural areas with lower household incomes, reported feeling overworked and experienced fewer Medicaid problems. The principal problem reported with the Medicaid system was low fee reimbursement. CONCLUSIONS: Programs offering early orthodontic treatment could increase access. Important barriers would be low fees and unfamiliarity with Medicaid. PRACTICE IMPLICATIONS: Medicaid should design programs aimed at early treatment with reasonable reimbursement and an educational component.     

Sealant use and placement techniques among pediatric dentists.

BACKGROUND: Pit and fissure sealant use varies widely among dentists. The authors conducted a survey to determine the current variations and patterns of sealant placement among pediatric dentists. METHODS: The authors mailed a 20-question survey to American Academy of Pediatric Dentistry members from six states, who represented one-third (1,210) of the membership, as well as to all 52 pediatric dentistry departments in U.S. dental schools. The authors examined selection criteria, placement techniques, evaluation methodologies, and the one- and three-year estimated success and reapplication rates of sealant placement. RESULTS: The response rates were 70 percent for practitioners and 90 percent for dental schools. Approximately 80 percent of respondents said they sealed caries-free and questionable carious surfaces. Only 20 percent of the respondents said they sealed incipient carious surfaces; none said they would seal overt caries. Surface preparation was used always or sometimes by 87 percent of the respondents. The estimated one- and three-year sealant retention rates were 89 percent and 78 percent, respectively, for practitioners and 83 percent and 71 percent, respectively, for dental schools. CONCLUSIONS: The survey demonstrated wide variations in selection criteria, placement techniques and evaluation methodologies, yet showed remarkable similarities between practitioners and dental schools. The reported retention rates were consistent with those reported in the literature. PRACTICE IMPLICATIONS: The survey results suggested that pediatric dentists were searching for evidence-based selection criteria and a technique protocol for sealant placement that improved clinical success. The wide technique variations reported were likely a result of training diversity, diagnostic uncertainty, technique and material sensitivity, and an attempt to improve the success rate.     

Practice patterns of board-certified pediatric dentists: frequency and method of cleaning children's teeth

PURPOSE: The purpose of this study was to assess the periodicity of the recall examination and frequency and most often used technique for cleaning children's teeth. The resulting data were compared to current scientific evidence and recommendations to determine the appropriateness of practices by board-certified pediatric dentists. METHODS: A 28-item questionnaire was mailed to the 1,034 members of the College of Diplomates of the American Board of Pediatric Dentistry residing in the United States. This report describes data pertaining to recall appointment periodicity, frequency and method of cleaning children's teeth, use of auxiliaries in prophylaxis, and instruction in oral hygiene. RESULTS: Six hundred twenty-nine surveys were returned, tabulated, and analyzed. Only 1% of dentists did not have an active recall program, 95% used a 6-month recall interval, and the remaining 5% had an interval ranging from 3 to 18 months. Hygienists were employed in 62% of pediatric dentistry practices. Pumice/rubber cup prophylaxis was employed routinely at recall by 67% of respondents; 24% reported the use of toothbrush and dental floss for cleaning; the other 9% reported no routine method for prophylaxis. The average fee for a pumice/rubber cup prophylaxis was dollar 42.55, and dollar 40.31 for a toothbrush prophylaxis. One hundred percent of pediatric dentists reported providing oral hygiene instruction for their patients. The instruction was directed to both parent and child in 97% of practices, child only in 2% of practices, and the parent only in 1% of practices. CONCLUSIONS: Recall intervals were not based on specific criteria related to individual patient needs. The majority of pediatric dentists employed the pumice/rubber cup prophylaxis method for cleaning children's teeth.