While increasing dentist participation in Medicaid can help increase the likelihood of children receiving restorative and preventive dental care, more changes are needed to increase the program’s effectiveness, according to a study of the Alabama and Georgia Medicaid programs.
"The number of Medicaid dentists . . . only had a moderate effect on children’s likelihood of receiving restorative and particularly preventive dental care," noted an issue brief from the Child Health Insurance Research Institute (CHIRI). "Clearly, factors other than the availability of participating dentists influence children’s dental care use in public insurance programs."
Based on analysis of data from the two states, the report said that states across the country should consider these policy implications:
1. Increasing early access to and use of preventive dental services is an important goal for children’s public insurance programs.
2. Providing comprehensive dental benefits in public insurance programs permits children with dental disease to get treatment and not forgo vital dental care.
3. Implementing multipronged strategies that capitalize on where children and their families seek care should be pursued, particularly for underserved populations.
The CHIRI researchers found that less than 40% of Medicaid-enrolled children in the two study states received dental care during the study period; about half of the children who had dental care received intensive services such as emergency and restorative care, while almost all received preventive care; children who received medical care were more likely to receive dental care than those who received no medical care; and the number of dentists participating in Medicaid had some effect on the likelihood of children receiving dental care.
Data analyzed were from 1999 in Alabama and 1997 in Georgia, before efforts in either state to increase dentist participation in Medicaid. Less than 25% of Alabama Medicaid children, age 3 or older and enrolled at least six months, and 39% of comparable Georgia Medicaid children, received dental care during the study period. The researchers say those rates are typical for Medicaid programs across the country at that time.
"Preschoolers and adolescents received less dental care than elementary school children. . . . Overall, children with special health care needs received more dental care than other children enrolled in Medicaid. Minority children were slightly less likely to receive dental care than white children," the report said.
In Alabama and Georgia, nearly one-third of children enrolled in Medicaid who received medical care also received dental care. In contrast, children who did not receive medical care were much less likely to have received dental care (3% in Alabama and 23% in Georgia).
Increasing dentist participation in Medicaid often is cited as one of the ways to improve access to dental care, and some support for this proposition was found in Alabama and Georgia. Medicaid-enrolled children who lived in counties with the greatest number of Medicaid dentists per enrollee were 24% more likely to receive restorative dental care than their counterparts living in counties with the fewest Medicaid dentists per enrollee. The likelihood of receiving preventive dental care was also related to Medicaid dentist participation, but less strongly. Compared to children living in counties with an average number of Medicaid dentists per enrollee, children living in counties with more dentists were more likely to receive preventive dental care, but the converse was not always true. Thus, in some counties with a below average number of Medicaid dentists per enrollee, the likelihood of receiving preventive dental care was still better than in average counties.
Need for care not at issue
The researchers said there no longer is a question of whether children need early comprehensive dental care. Rather, dental and pediatric organizations recommend that low-income children visit a dentist after the first tooth erupts or by 12 months of age, for a range of interventions designed to prevent oral disease. Also, the U.S. Department of Health and Human Services (HHS) has released a five-step action strategy to improve oral health for all Americans.
The researchers explained that Alabama and Georgia Medicaid programs of the late 1990s are illustrative of the nation’s problems with dental care access for children in public insurance programs. Data from the national Medicaid Expenditure Panel Survey showed that nearly 75% of children with Medicaid coverage received no dental services in a year, even though they are entitled to dental care under Medicaid. The Alabama and Georgia programs were more effective at serving some populations than others. Children who had more contact with the health care system were more likely to receive dental care. But even though they fared better than children who did not use medical care, the majority of children who used medical care still did not receive any dental services. Preschool, adolescent, and minority children were less likely to receive dental care than others.
One factor that seems to help increase provision of dental services is Medicaid participation in medical care. CHIRI said that if every child who had a medical visit also had a dental visit, 61% of Alabama Medicaid children and 78% of Georgia Medicaid children would have received dental care. "States can take advantage of the fact that medical providers see more children than dentists to increase the proportion of children who receive dental care," the report asserted.
The Alabama Medicaid program implemented a dental initiative in October 2000 to recruit and retain dental providers and educate Medicaid families about the importance of preventive dental care. Under that initiative, dentists typically are reimbursed at 100% of regular Blue Cross Blue Shield rates.
The Georgia Medicaid program implemented its Take Five initiative in October 2000 to encourage dental providers to serve at least five children enrolled in Medicaid per year. Medicaid reimbursement fees for the 56 most-used dental services were significantly increased in July 2000 and received a 3.5% increase in July 2002.
Don Schneider, a Florida dentist and consultant to the American Dental Association, has conducted a survey of state actions to improve dental access for the association. "Far and wide, the major stumbling block to making progress in access to dental services in Medicaid is reimbursement. Most states are paying dentists at about the 10th percentile compared to the private sector," he says.
Purely in terms of economics, Mr. Schneider tells State Health Watch, it’s expected that only a small percentage of dentists would not see Medicaid fees as a losing proposition. He cites examples of Michigan and Tennessee in which a dramatic increase in reimbursement rates has led to an equally dramatic increase in services, access, and kids getting care. "Two things are needed to help solve the problem," Mr. Schneider says. "An increase in reimbursements to a market level and making the Medicaid program as dentist-friendly as possible."
In Michigan, he tells State Health Watch, Medicaid recipients were given a Delta Dental card. He says that giving administration of the program to that company gave the recipients access to the full Delta network of participating dentists who were paid the same rates for the care they provided.
Mr. Schneider is frank to concede his doubts about whether Medicaid children will ever access dental care at a rate equal to that for more affluent children. "I’d love to see it get to 50%," he says. "With the Medicaid population, there can be other issues such as transportation, translation, and care management. If you take the stigma out of the program with private administration, in theory there shouldn’t be any difference."
In a related matter, U.S. Senate Democratic leader Tom Daschle (D-SD) recently said steps must be taken to resolve a dentist shortage in South Dakota. "I have heard horror stories from South Dakotans who were forced to travel more than 100 miles for a simple dental procedure." He said incentives are needed for dentists to practice in underserved areas and called for more scholarships for dental training; creation of a business loan program to help new dentists purchase practices; grants to states from HHS to improve access, increase the number of dentists in rural areas, and buy equipment; and grants to expand dental programs in community health centers.
Mr. Daschle said improving access for children also is critical, and can be accomplished through increasing funding for pediatric dental residencies and providing grants for states to improve dental services for children covered by Medicaid and SCHIP.
Meanwhile, HHS is promoting its National Call to Action to Promote Oral Health aimed at improving oral health and preventing disease for all Americans. "This action strategy serves as a model of how the nation’s health can be improved when we work together to achieve common goals," said HHS Secretary Tommy Thompson. "Oral health is integral to overall health. It’s critical that we all work together to improve the nation’s oral health, especially among children."
Surgeon General Richard Carmona said the action plan is needed in response to a 2000 report, "Oral Health in America," which indicated that "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. That report’s message was that oral health is essential to general health and well-being, and can be achieved. However, a number of barriers hinder the ability of some Americans from attaining optimal oral health."
The Office of the Surgeon General reached out to a number of professional and advocacy organizations to assist in developing and promoting the Call to Action.
Carmona said the vision of the Call to Action is "to advance the general health and well-being of all Americans by creating critical partnerships at all levels of society to engage in programs to promote oral health and prevent disease." Goals of the effort are to promote oral health, improve quality of life, and eliminate oral health disparities. Five actions were drawn from the vision and goals.
1. Change perceptions of oral health. For too long, the document said, the perception that oral health is in some way less important than and separate from general health has been deeply ingrained in American consciousness. Activities to overcome these attitudes and beliefs can start at the grass-roots level and lead to a coordinated national movement to increase oral health literacy. Stakeholders are encouraged to work together to change perceptions of the general public, policy-makers, and health providers.
2. Overcome barriers by replicating effective programs and proven efforts. While the effectiveness of preventive interventions such as community water fluoridation and school-based dental sealants applied to children at risk have been persuasively demonstrated, very few states have implemented both measures to meet their health objectives. There is a need to identify and reduce disease and disability, improve oral health access, and enhance health promotion and health literacy.
3. Build a science base and accelerate science transfer. Biomedical and behavioral research into the causes and pathological processes of diseases can lead to interventions that will improve prevention, diagnosis, and treatment. The Call to Action said that too many people outside the oral health community are uninformed about, misinformed about, or simply not interested in oral health. Such lack of understanding and indifference may explain why community water fluoridation and school-based dental sealant programs fall short of full implementation, even though the scientific evidence of their effectiveness has been known for some time.
4. Increase oral health work force diversity, capacity, and flexibility. Carmona’s report said that the patient pool of any health care provider tends to mirror the provider’s own racial and ethnic background. As such, the provider can play a catalytic role as a community spokesperson addressing key health problems and service needs. While the number of women engaged in the health professions is increasing, the number of underrepresented racial and ethnic minorities is decreasing and remains limited. The report called for implementation strategies to change the racial and ethnic composition of the work force to meet patient and community needs, ensure a sufficient workforce pool to meet health care needs, and secure an adequate and flexible work force.
5. Increase collaborations. According to the report, the private sector and public sector each has unique characteristics and strengths and linking the two sectors can result in a creative synergy that capitalizes on the talents and resources of each partner. Efforts are needed within each sector to increase the capacity for program development, for building partnerships, and for leveraging programs.