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Assessing Patterns of Restorative and Preventive Care Among Children Enrolled in Medicaid, by Type of Dental Care Provider
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Assessing patterns of restorative and preventive care among children enrolled in Medicaid, by type of dental care provider L. Susan Taichman, RDH, MPH, PhD; Woosung Sohn, DDS, PhD, DrPH; Sungwoo Lim, MA, MS; Stephen Eklund, DDS, MHSA, DrPH; Amid Ismail, BDS, MPH, MBA, DrPH
ral health problems are more pronounced among children from low socioeconomic backgrounds. A recent national survey reported that children in families with incomes below the federal poverty guideline (FPG) have twice as many carious lesions as do higherincome children.1 Furthermore, children at greatest risk of developing problems resulting from tooth decay are least likely to receive regular preventive and comprehensive dental care in private dental offices.2,3 Although most states offer comprehensive dental care coverage to children through Medicaid and other programs such as the State Children’s Health Insurance Program (SCHIP), utilization of dental care is low among children enrolled in Medicaid.4 The surgeon general’s report showed that fewer than 20 percent of Medicaid-covered children had a dental visit within a one-year period.3 The consequences of low dental-service utilization by Medicaid participants are poor oral health and signifi-
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ABSTRACT Background. The authors investigate the relationship of preventive dental treatment to subsequent receipt of comprehensive treatment among Medicaid-enrolled children. Methods. The authors analyzed Medicaid dental claims data for 50,485 children residing in Wayne County, Mich. The study sample included children aged 5 through 12 years in 2002 who had been enrolled in Medicaid for at least one month and had had at least one dental visit each year from 2002 through 2005. The authors assessed dental care utilization and treatment patterns cross-sectionally for each year and longitudinally. Results. Among the Medicaid-enrolled children in 2002, 42 percent had had one or more dental visits during the year. At least 20 percent of the children with a dental visit in 2002 were treated by providers who billed Medicaid exclusively for diagnostic and preventive (DP) services. Children treated by DP care providers were less likely to receive restorative and/or surgical services than were children who were treated by dentists who provided a comprehensive mix of dental services. The logistic model showed that children who visited a DP-care provider were about 2.5 times less likely to receive restorative or surgical treatments than were children who visited comprehensive-care providers. Older children and African-American children were less likely to receive restorative and surgical treatments from both types of providers. Conclusions. The study results show that the type of provider is a significant determinant of whether children received comprehensive restorative and surgical services. The results suggest that current policies that support preventive care–only programs may achieve increased access to preventive care for Medicaid-enrolled children in Wayne County, but they do not provide access to adequate comprehensive dental care. Key Words. Medicaid; dental care for children; dental care utilization. JADA 2009;140(7):886-894.
Dr. Taichman is an assistant professor, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor. Dr. Sohn is an assistant professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, 1011 N. University Ave., Ann Arbor, Mich. 48109, e-mail “[email protected]”. Address reprint requests to Dr. Sohn. At the time this study was conducted, Mr. Lim was a senior analyst, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. He now is an epidemiologist, Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene. Dr. Eklund is a professor emeritus of dental public health, Department of Epidemiology, School of Public Health, and an adjunct professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. At the time this study was conducted, Dr. Ismail was a professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. He now is dean, Maurice H. Kornberg School of Dentistry at Temple University, Philadelphia.
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cant unmet dental needs.2,5 Barriers to receipt of dental care and issues of access to dental care are well-documented.6 Research has shown that children in low-income families have roughly 50 percent fewer preventive-care visits than do children in higherincome families.7 Some of the most frequently identified factors impeding access to dental care include limited availability of providers, inadequate program financing and reimbursement, administrative difficulties in qualifying for Medicaid, patients’ lack of knowledge regarding oral health, and cultural factors.8 In recent years, the federal government, state and local governments and nongovernmental agencies have emphasized increasing dental visits—especially those in which preventive services are provided—among low-income children.3,9 State and local agencies have expanded preventive care services through programs such as SCHIP and Head Start.10,11 Several studies have shown that preventive dental care, including prophylaxis, fluoride treatments and placement of sealants, is effective in reducing dental diseases.12-14 In addition, studies have reported that access to preventive care is associated with obtaining comprehensive dental treatment. Lee and Horan15 found that children in a managed Medicaid program in Connecticut who received preventive dental care were eight times more likely to receive additional dental treatments than were those who did not receive preventive care. However, among the children in the study sample, only 20 percent who received preventive care also received comprehensive treatment. The percentage was even lower among African-American children (14 percent). Results of national and state surveys continue to report unmet needs, even among children who receive Medicaid services.16,17 Investigators in a study of Medicaid programs in Alabama and Georgia reported that 90 percent of the children who had had any dental visit received preventive care, but only about 50 percent of the children received comprehensive dental care.18 Robison and colleagues19 examined data from a statewide survey of schoolchildren in North Carolina who were enrolled in Medicaid and reported that 43 percent of primary or permanent teeth needing treatment received no treatment. Factors related to the limited utilization of services among children with Medicaid coverage include the duration of eligibility within a given year, race/ethnicity,
the child’s age, parents’ educational levels, geographic availability of dental care providers, the dentist’s skill in treating young children and racial discrimination.20,21 Programs that emphasize preventive care, such as school-based clinics and mobile dental vans, have received the support of many states in hopes of increasing access to preventive care among Medicaid enrollees and other low-income children.22-24 Although some programs have reported success,25,26 other reports27,28 have raised concerns regarding the programs’ lack of comprehensive dental care. In particular, the children who received preventive-care services did not receive needed restorative and surgical treatments owing to the lack of continuity of care or duplication of diagnostic services, leading to reduced payments.27,28 The aim of this study was to evaluate the effect of preventive dental care services on subsequent receipt of comprehensive dental treatment among Medicaid-enrolled children in Wayne County, Mich. SUBJECTS AND METHODS
Data. In this study, we used dental claims data (with patients’ identification concealed) for the years 2002 through 2005 for children enrolled in Medicaid and their dental care providers in Wayne County, Mich. Located in southeast Michigan, Wayne County has more than 2 million residents, with a large Medicaid population. Detroit is the major city in Wayne County, and 81.6 percent of its 951,270 residents are black, according to the 2000 U.S. Census.29 Our rationale for choosing Wayne County was the high density of low-income children with access-to-care challenges. We conducted this analysis by using information in a database about Medicaid claims maintained by the Medical Service Administration within the Michigan Department of Community Health (MDCH). Before providing us with the data set, the MDCH concealed private information, checked the data set for completeness and created unique identification numbers that could ABBREVIATION KEY. CDT: Current Dental Terminology. DP: Diagnostic and preventive. FPG: Federal poverty guideline. GEEs: Generalized estimating equations. MDCH: Michigan Department of Community Health. SCHIP: State Children’s Health Insurance Program. JADA, Vol. 140
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be used to track children throughout the period of was 4.5 per year, so a cutoff point of 100 proanalysis (2002-2005). We checked the data furcedures equates to roughly 20 patients per year. ther for errors and mismatches in dental proThe arbitrary cutoff point of 100 allowed us to cedure codes.30 exclude dental care providers who treated During the period of analysis, children younger Medicaid-enrolled patients on a limited basis. than 6 years whose family income was at or below Service patterns. We then grouped regular 185 percent of the FPG and children aged 6 Medicaid providers on the basis of the pattern of through 19 years in families with incomes at or services provided. We categorized dentists whose below 150 percent of the FPG were eligible for billed services consisted of diagnostic and prevenMedicaid benefits in Michigan.31 tive (DP) services for 99.9 percent or more of the Two of us (W.S., S.L.) analyzed the Medicaid total billed services (dental procedure codes claims data initially to obtain descriptive statisD0120-D199930) as DP care–only providers. We tics, including measures of dental care utilization, categorized dentists who provided restorative and the percentage of the population with a dental surgical treatments in addition to DP services as visit, and the number and type of procedures per comprehensive-care providers. We conducted this visit per child from 2002 through 2005. The Medgrouping each year from 2002 through 2005. icaid claims database also included children’s Children’s dental visits. We assigned chilages and race/ethnicity and dentist dren to one of two groups on the information (such as identification basis of their dental visits (that is, The number of number and location and address). the type of dentist they visited each Subjects. The study sample year). In a given year, if a child visdiagnostic and included children aged 5 through preventive procedures ited a DP-care provider at least one 12 years who were enrolled in time, we categorized him or her as a per patient was Medicaid at least one month per member of the DP group. Children significantly higher year and had had at least one in this group also may have had among diagnostic and visits with comprehensive-care dental visit each year from 2002 preventive–care through 2005. We limited our providers. We assigned children analysis to this age group because who visited only dentists who proproviders than it the data showed that few children vided a comprehensive mix of dental was among younger than 5 years received services in a given year to the comprehensive-care treatment in Wayne County, and comprehensive-care group. providers for the number of children receiving We used a unique identification all years. treatment decreased substantially number to follow up children who after 12 years of age. We then followed up the 2002 sample of 5- through 12-year-old children in 2003 through 2005 to determine their receipt of dental care. The Health Sciences Institutional Review Board of the University of Michigan, Ann Arbor, reviewed and approved this research. Type of dental care provider. The claims data allowed us to determine the number and type of dental services performed by each dental care provider in children enrolled in Medicaid. To identify dentists who routinely provided dental care services to Medicaid beneficiaries, we divided them into “regular” and “occasional” providers. In each year, we considered dentists who performed 100 or more procedures per year to be regular Medicaid providers, while those performing fewer than 100 procedures per year were considered occasional providers. The mean number of procedures performed per patient in our database 888
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had been enrolled in Medicaid at least one month each year. This allowed us to link claims records with people to determine the type of dental services they received per year during the four-year period, as well as the type of dentists who delivered the services. Thus, it was possible to track the treatment each child received even if he or she visited multiple dentists or dentists outside of Wayne County. Analysis. We reported preventive care and comprehensive care in terms of the proportion of all children enrolled in Medicaid in Wayne County who had had at least one dental visit in 2002. We did not adjust the proportions of children who received either type of care for the period of eligibility in a given year. We collected follow-up data for descriptive univariate statistics to describe the proportion of children in selected subgroups who received preventive dental care
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TABLE 1
Wayne County, Mich., dental care providers who participate in Medicaid. VARIABLE
2002
2003
2004
2005
DP * Care †
Comprehensive Care ‡
DP Care
Comprehensive Care
DP Care
Comprehensive Care
DP Care
Comprehensive Care
17
252
23
265
22
253
34
271
Mean (SD §) No. of Children Per Provider Per Year
645.6¶ (707.3)
202.3 (286.7)
583 (569.4)
355.6 (519)
599 (529.3)
386.7 (565.6)
486.3 (522.6)
362.5 (592)
Mean (SD) No. of DP Services Per Child
8.1 (0.04)¶
7.3 (0.02)
7.7 (0.06)¶
6.4 (0.03)
8.7 (0.1)¶
7.6 (0.04)
8.0 (0.1)¶
6.9 (0.04)
No. of Providers
* † ‡ § ¶
DP: Diagnostic and preventive. Dentists who provided DP services only (dental procedure codes D0120-D1999 [source: American Dental Association30]). Dentists who provided restorative and surgical treatment in addition to DP services. SD: Standard deviation. P < .05.
and more comprehensive treatment. We used bivariate analyses to investigate the relationship between receipt of preventive care and subsequent receipt of comprehensive care for 2003 through 2005. We then developed logistic regression models to examine the association between children’s receipt of restorative and/or surgical treatment and the types of providers they visited during the four-year study period. The primary outcome was receipt of restorative and/or surgical services. We categorized this outcome variable as “yes or no.” Independent variables were provider type (comprehensive or DP), age in years (continuous), sex (male or female) and race (white/black/other). To account for the correlation between observations made in the same child across time, we estimated the odds ratios (ORs) of receiving restorative and/or surgical treatment over time by using generalized estimating equations (GEEs). In addition, we included children’s ages and interaction between age and provider type in the models to test whether the effect of provider type on receiving restorative and/or surgical treatments varied across ages. We assumed statistical significance at P < .05. We conducted all statistical analyses with statistical software (SAS version 9.1, SAS Institute, Cary, N.C.). RESULTS
The study sample included 50,485 children aged 5 through 12 years who were enrolled in Medicaid at least one month during 2002 and had had at least one dental visit in that year. The majority of
children were black (74 percent) or white (20 percent), with an almost equal distribution of boys and girls. Of those enrolled in Medicaid in 2002, 42 percent had had a dental visit during the year. Of those with a dental visit in 2002, almost 82 percent were enrolled during the entire 12 months (data not tabulated). Table 1 shows a summary of regular dental care providers. Of the 536 dentists who provided dental care to children in Wayne County in 2002, 267 were eliminated from our analysis because they provided fewer than 100 dental procedures to Medicaid-enrolled patients. Of the 269 regular dentists identified in 2002, 17 (6.3 percent) were DP care providers exclusively, and 252 (93.7 percent) provided a mix of restorative, surgical and preventive services (that is, were comprehensivecare providers). In general, DP-care providers treated more children than did comprehensivecare providers. This difference was statistically significant in 2002 but was not statistically significant in 2003 through 2005. Furthermore, the number of DP procedures per patient was significantly higher among DP-care providers than it was among comprehensive-care providers for all years. The number of DP-care providers doubled during the four-year study period. Table 2 shows the pattern of dental services for children aged 5 through 12 years in 2002 through 2005. In 2002, about 20 percent of the children enrolled in Medicaid in Wayne County visited DP-care providers at least once; the remaining 80 percent visited only the comprehensive-care providers. The children treated by DP-care JADA, Vol. 140
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TABLE 2
Demographic distribution and receipt of dental care services among Medicaid-enrolled children in Wayne County, Mich., by provider type. VARIABLE
No. of Children
2002
2003
2004
2005
DP * Care †
Comprehensive Care ‡
DP Care
Comprehensive Care
DP Care
Comprehensive Care
DP Care
Comprehensive Care
10,437
40,048
4,850
22,359
2,594
14,019
1,781
9,314
Children Who Received Restorative Services, % (Dental Procedure Codes D2110-D2999 §)
10.8¶
33.8
14.7¶
34.7
17.7¶
38.2
17.1¶
35.6
Children Who Received Surgical Services, % (Dental Procedure Codes D7000-D7999 §)
5.4¶
17.3
8.6¶
18.9
9.0¶
19.2
8.8¶
17.1
Sex, % Male Female
46.5 53.5
50.5 49.5
46.3 53.7
49.8 50.2
45.5 54.5
49.6 50.4
45.7 54.3
49.3 50.7
Race, % White African-American Other
6.6 89.6 3.8
24.1 69.9 6.0
8.5 86.6 4.9
25.4 68.2 6.4
9.5 86.9 3.6
26.8 66.3 6.9
9.5 86.6 3.9
29.5 63.3 7.2
* DP: Diagnostic and preventive. † Dentists who provided DP services only (dental procedure codes D0120-D1999 [source: American Dental Association30]). Some children who visited DP-care providers also received treatment from other (comprehensive-care) providers. ‡ Dentists who provided restorative and surgical treatment in addition to DP services. § Source: American Dental Association.30 ¶ P < .05.
providers received only DP treatment. However, some children received additional restorative or surgical treatment from other dentists (that is, comprehensive-care providers). In 2002, 10.8 percent of the children who visited DP-care providers underwent restorative procedures performed by other dentists. In comparison, 33.8 percent of the children who visited comprehensive-care providers underwent restorative procedures. This pattern continued in 2003 though 2005. Children who visited DP-care providers at least once were less than one-half as likely to receive restorative or surgical services as were those who visited comprehensive-care providers. We found significant differences in the sex and race of children who received care from the two types of providers. More girls than boys and more black children than those of other races received treatment from DP-care providers during the years tracked. Table 3 presents the outcome of the GEE models used to investigate the association 890
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between children’s receipt of restorative and/or surgical treatment and provider type. After adjusting for confounders such as age, sex and race, we found that children who visited DP-care providers were 2.5 times less likely (OR = 0.44) to have received restorative or surgical treatment than were those who visited comprehensive-care providers. Along with provider type, children’s age and race were significant determinants in receiving restorative and/or surgical treatment. We found no significant interactions between any of these variables in the model for restorative and/or surgical treatment. The figure (page 892) illustrates the proportion of children who received restorative care according to the type of dental provider they visited each year. The rate of receipt of restorative services fluctuated significantly—depending on the type of provider—when we followed up the same children across the four-year period. Because we followed up the same children in each pattern shown in the figure, it is unlikely
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that the restorative or surgical treatment needs of a group of children changed dramatically from year to year. Therefore, the study results suggest that the level of restorative and/or surgical treatment received was determined by the type of provider rather than by the child’s treatment needs or selfselection for follow-up care. DISCUSSION
TABLE 3
Logistic regression models of receipt* of restorative and surgical treatment across a four-year period among children aged 5 through 12 years at baseline. VARIABLE
RECEIPT OF RESTORATIVE TREATMENT† (n = 11,095) Odds Ratio
Sex Male (reference) Female
Standard Error
RECEIPT OF SURGICAL TREATMENT‡ (n = 11,095)
P Value
Odds Ratio
Standard Error
P Value
—§
—
—
—
—
—
0.96
0.02
.08
1.00
0.03
0.96
Race White (reference)
—
—
—
—
—
—
African-American
0.63
0.02
< .001
0.45
0.01
< .001
Other
1.15
0.06
.005
0.79
0.04
< .001
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Although the state of Baseline (2002) 0.97 0.006 < .001 0.92 0.006 < .001 Michigan offers compreAge, Years hensive Medicaid dental Provider Type coverage to all enrolled Comprehensive care¶ — — — — — — children, the results of this (reference) DP# care** 0.44 0.01 < .001 0.52 0.02 < .001 study show that access to comprehensive care was * The authors did not adjust receipt of treatment for the length of eligibility. † Restorative services are defined as dental procedure codes D2110-D2999 (source: American Dental not experienced univerAssociation30). sally by children enrolled ‡ Surgical services are defined as dental procedure codes D7000-D7999 (source: American Dental Association30). in the program. Children § Reference (odds ratio =1). who were treated by DP¶ Dentists who provided restorative and surgical treatment in addition to diagnostic and preventive services. care providers were less # DP: Diagnostic and preventive. likely to receive restorative ** Dentists who provided only diagnostic and preventive services. and surgical services than were those treated by dentists who billed MedicThe majority of DP-care providers in our study aid for a comprehensive mix of services. We found were associated with for-profit mobile dental that the type of provider was one of the most sigvans. Our results also support previous findings nificant determinants of whether children that older and minority children were less likely enrolled in Medicaid received restorative and/or to receive comprehensive care than were their surgical services. To our knowledge, this is the younger and white counterparts.21 first study in which investigators used Medicaid Access to care. Whether Medicaid-enrolled claims data to support the findings of previous children need preventive services is not disputed. studies suggesting a failure to receive comprehenPreventive-care dental services, including prophysive care among Medicaid-enrolled children laxis, fluoride treatments and placement of receiving treatment from dentists who provided a sealants, are effective in reducing dental limited scope of services.27,28 diseases.14,32-34 However, the percentage of chilOur findings suggest that a caveat is wardren who receive preventive care is low. Lee and ranted with regard to the common belief that Horan15 and Dasanayake and colleagues21 access to preventive services is the key to a child’s reported that low-income minority children were receiving comprehensive dental care.15,18 In fact, it one-half as likely to access preventive-care dental may depend on the way that the preventive care services as were their higher-income counterparts is organized and delivered. In this study, provider despite being at greater risk. Moreover, although type was a significant determinant of the level of the DP-care providers in our study may have comprehensive care that children enrolled in increased children’s access to preventive-care Medicaid received. We found that those who visservices, obtaining comprehensive care for these ited DP-care providers were 2.5 times less likely children appears to remain a significant problem. to receive comprehensive treatment than were One might argue that the provision of DP servthose who visited comprehensive-care providers. ices is better than providing no dental services at JADA, Vol. 140
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CHILDREN WITH RESTORATIVE TREATMENT (%)
focus on providing DP services may fail to establish 45 formal referral linkages to ■ 40 ■ ■ those who provide compre● ■ hensive dental services.28 35 ▲ ▲ ❉ ● ● Parents may assume that 30 ▲ because their children were ❉ ◆ DDCD treated by DP-care pro25 ◆ ❉ CDCD viders, no need exists to ▲ CCCD ● 20 ❉ DCCC seek comprehensive care ● ❉ ■ CCCC ▲ 15 from other dentists. ◆ ◆ Another barrier to ◆ 10 receiving follow-up care 5 may be the limited ability of comprehensive-care 0 2002 2003 2004 2005 providers to receive payYEAR ment from Medicaid for DP services for which another Figure. Patterns of receipt of restorative treatment, according to provider type, among children provider had submitted a aged 5 though 12 years (in 2002) enrolled continuously in Medicaid from 2002 through 2005. D: claim earlier in the year. Children who received care from diagnostic and preventive (DP)–care providers only. C: Children For example, under who received care from comprehensive-care providers. DDCD indicates that children in this group visited DP-care providers in 2002, DP-care providers in 2003, comprehensive-care providers in 2004 Michigan Medicaid law, and DP-care providers in 2005. CDCD indicates that children visited comprehensive-care providers in one child can receive two 2002, DP-care providers in 2003, comprehensive-care providers in 2004 and DP-care providers in 2005. CCCD indicates that children visited comprehensive-care providers in 2002, 2003 and 2004 and dental examinations, two DP-care providers in 2005. DCCC indicates that children visited DP-care providers in 2002 and prophylaxes, two fluoride comprehensive-care providers in 2003, 2004 and 2005. CCCC indicates that children visited applications and one set of comprehensive-care providers in 2002, 2003, 2004 and 2005. bitewing radiographs per year.35 Any duplication in billing of these services all to these underserved children. However, our results suggest that simply providing DP services beyond the allowance for a given year results in to these high-risk children does not ensure that denied payment for the service and reduced reimthey will receive needed comprehensive care and bursement for the comprehensive-care provider. actually may limit their opportunity to access These limitations make some dentists less apt to such treatment. treat children who have Medicaid coverage. The differences in the rates of restorative and No information is available from the claims surgical care between the two groups of children data regarding which children needed treatment may have resulted from self-selection (that is, in addition to the preventive care received. If the children with treatment needs chose to visit compreventive care services administered by DP-care prehensive-care providers). The differences also providers were much more effective than those may suggest, to a lesser degree, that DP services administered by the comprehensive-care were effective and the children did not need addiproviders, we would have expected to find a tional treatment. On the other hand, our results decrease in the need for restorative services in may suggest that children who visited DP-care subsequent years. We found, instead, a fluctuaproviders did not receive additional needed treattion in the need for restorative care year by year ment because of the lack of referral, lack of comaccording to the type of provider from whom the pliance or depletion of Medicaid resources. children received care. Access to additional treatment may have been As shown in the figure, whenever a group of affected by a number of factors. We cannot deterchildren received treatment from DP-care mine from the claims data the extent to which the providers, they received little restorative care low level of follow-up comprehensive care was the during that year. However, their receipt of result of a child’s parent not seeking dental care restorative services increased in the following because of a lack of available dental care proyear if they received care from comprehensiveviders or because no other treatment was needed. care dentists. This finding may indicate that However, it has been suggested that dentists who comprehensive-care dentists overtreat patients 892
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rather than that DP-care providers undertreat patients. However, on the basis of the generally high treatment needs of low-income children,36 this finding likely suggests that many children may not have received needed follow-up treatment when they received care from DP-care providers. Study limitations. Our analysis shows that state Medicaid dental claims data can be useful in better understanding important issues such as the types of services children enrolled in Medicaid receive. The strengths of this study include the longitudinal design, the large number of children, data from actual dental visits and data with good detail about the services each child received. However, this analysis was restricted to a single county in a single state, and the findings may apply only to children insured through Medicaid. Another potential weakness of this analysis is the inclusion of children who were eligible for coverage for only a brief period, which may have inflated the rates for DP services. However, although the lack of eligibility might have reduced children’s opportunity to receive restorative services, it does not fully explain the significant fluctuation in the restorative service rate that we observed. Our data show that, although a large number of children received preventive care services, only a small proportion of children who were treated by DP-care providers received restorative and/or surgical care by other dentists. However, we cannot determine whether this treatment was provided as a result of referrals from DP-care providers. We captured only the services provided by dentists on the basis of their Medicaid claims. Although not likely, it is possible that these children received restorative and/or surgical services from dental care providers who did not participate in the Medicaid program. From a public policy standpoint, the treatment care patterns found in these analyses call for careful examination of the availability of comprehensive care in addition to preventive care for children enrolled in Medicaid. The results of this study suggest that although strategies must be developed to encourage use of preventive dental services among children enrolled in Medicaid, further steps must be taken to ensure that children who need comprehensive dental services receive them. Strategies for improvement. Governmental agencies have made recommendations to improve
the delivery of preventive dental care for children in public insurance programs3,37 by using alternative service approaches, such as for-profit mobile dental vans and school-based/school-linked programs. However, if large numbers of school-aged children are receiving preventive services through these programs and continue to have unmet treatment needs, additional strategies are warranted. These may include establishing clear guidelines to ensure that necessary comprehensive treatment accompanies preventive services and/or establishing pragmatic referral networks among dental care providers and the preventivecare programs. CONCLUSIONS
Given the limitations of this analysis based on claims data, we found that the type of provider, rather than the treatment need, was a significant determinant of whether children enrolled in Medicaid received comprehensive restorative and surgical dental services. The results suggest that current programs and policies that support DP care only may have increased access to these services for children enrolled in Medicaid in Wayne County, but they do not provide adequate access to needed comprehensive dental care. Continued focus on mechanisms and strategies to ensure receipt of comprehensive care for this high-risk group of children is required. ■ Disclosure. None of the authors reported any disclosures. This study was supported by grant U-54 DE 14261 from the National Institute of Dental and Craniofacial Research; the University of Michigan, Ann Arbor; and the Delta Dental Fund of Michigan. 1. Beltran-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis: United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005;54(3):1-43. 2. U.S. General Accounting Office. Oral health: dental disease is a chronic problem among low-income populations. Washington: U.S. General Accounting Office; 2000. Publication GAO/HEHS 00-72. 3. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 4. U.S. General Accounting Office. Oral health: factors contributing to low use of dental services by low-income populations. Washington: U.S. General Accounting Office; 2000. Publication GAO/HEHS-00-149. 5. U.S. Department of Health and Human Services, Office of Inspector General. Children’s dental services under Medicaid: access and utilization. Washington: U.S. Department of Health and Human Services; 1996. Publication OEI-09-93-00240. 6. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think. Am J Public Health 2002;92(1):53-58. 7. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2002;2(2 suppl):141-147. 8. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA 2000;284(20):2625-2631. 9. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington: U.S. Department of Health and Human
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Services; 2000. “www.healthypeople.gov/Document/tableofcontents. htm#under”. Accessed June 3, 2009. 10. Kenney G. The impacts of the State Children’s Health Insurance Program on children who enroll: findings from ten states. Health Serv Res 2007;42(4):1520-1543. 11. Wang H, Norton EC, Rozier RG. Effects of the State Children’s Health Insurance Program on access to dental care and use of dental services. Health Serv Res 2007;42(4):1544-1563. 12. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Makela M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2004;(3):CD001830. 13. Centers for Disease Control and Prevention. Fluoridation of drinking water to prevent dental caries. MMWR Morb Mortal Wkly Rep 1999;48(41):933-940. “www.cdc.gov/mmwr/PDF/wk/mm4841.pdf”. Accessed May 26, 2009. 14. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics 2004;114(4):418-423. 15. Lee MA, Horan SA. Children’s access to dental care in Connecticut’s Medicaid managed care program. Matern Child Health J 2001;5(1):43-51. 16. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000;105 (4 part 2):989-997. 17. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. JADA 1998; 129(9):1229-1238. 18. VanLandeghem K, Bronstein J, Brach C. Children’s dental care access in Medicaid: the role of medical care use and dentist participation. CHIRI Issue Brief 2. Rockville, Md.: Agency for Healthcare Research and Quality; 2003. AHRQ publication 03-0032. 19. Robison VA, Rozier RG, Weintraub JA. A longitudinal study of schoolchildren’s experience in the North Carolina Dental Medicaid Program, 1984 through 1992. Am J Public Health 1998;88(11):1669-1673. 20. Kenney GM, McFeeters JR, Yee JY. Preventive dental care and unmet dental needs among low-income children. Am J Public Health 2005;95(8):1360-1366. 21. Dasanayake AP, Li Y, Wadhawan S, Kirk K, Bronstein J, Childers NK. Disparities in dental service utilization among Alabama Medicaid children. Community Dent Oral Epidemiol 2002;30(5): 369-376. 22. Bureau of Dental Health, New York State Department of Health. Planning and implementing a school-based health center dental program: guidance in applying to provide dental health services in a school in New York State. March 2007. “www.health.state.ny.us/prevention/ dental/docs/sbhc_guidance_providers.pdf”. Accessed June 1, 2009. 23. Jackson DM, Jahnke LR, Kerber L, Nyer G, Siemens K, Clark C. Creating a successful school-based mobile dental program. J Sch Health 2007;77(1):1-6.
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24. Albert DA, McManus JM, Mitchell DA. Models for delivering school-based dental care. J Sch Health 2005;75(5):157-161. 25. Melvin CS. A collaborative community-based oral care program for school-age children. Clin Nurse Spec 2006;20(1):18-22. 26. Redmond AR, Martin N. Provision of school-based preventive oral health services to Medicaid beneficiaries. Prev Chronic Dis 2006;3(1): A28. 27. Schneider D, Rossetti J, Crall J. Assuring comprehensive dental services in Medicaid and Head Start programs: planning and implementation considerations. National Oral Health Policy Center. Technical Issue Brief; 2007. “www.healthychild.ucla.edu/nohpc/ National%20Oral%20Health%20Policy%20Center/OralCenterPubs/ DentalServicesinMedicaidHeadStart.pdf”. Accessed June 1, 2009. 28. The Center for Health and Health Care in Schools. Florida’s mobile dental van experience: Medicaid-supported school-based dental care—a description from the Florida Medicaid Office. The Center for Health and Health Care in Schools. “www.healthinschools.org/static/ states/fldental.aspx”. Accessed May 26, 2009. 29. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau. The black population: 2000. Census 2000 Brief. “www.census.gov/prod/2001pubs/c2kbr01-5.pdf”. Accessed May 26, 2009. 30. American Dental Association. CDT-2006: Current Dental Terminology. 5th ed. Chicago: American Dental Association; 2005. 31. Tilly J, Ullman FC, Christenberry JC. Recent changes in health policy for low-income people in Michigan. Washington: Urban Institute; 2002. “www.urban.org/publications/310442.html”. Accessed May 26, 2009. 32. Edelstein BL, Bendor DB. Medicaid pediatric dental utilization and expenditure data. From the American Academy of Pediatrics Medicaid State Reports—FY 1995; 1998. “www.cdhp.org/CDHPPubs/ OtherPublications.asp?zoom_highlight=pediatric+dental+utilization”. Accessed May 26, 2009. 33. Weintraub JA, Stearns SC, Rozier RG, Huang CC. Treatment outcomes and costs of dental sealants among children enrolled in Medicaid. Am J Public Health 2001;91(11):1877-1881. 34. Dasanayake AP, Li Y, Kirk K, Bronstein J, Childers NK. Restorative cost savings related to dental sealants in Alabama Medicaid children. Pediatr Dent 2003;25(6):572-576. 35. Michigan Department of Community Health. Implementation of CDT-4 dental procedure codes; and revised chapter III—coverages and limitations. Medical Services Administration Bulletin. “www.michigan. gov/documents/Dental-03-01_72612_7.pdf”. Accessed May 26, 2009. 36. Michigan Department of Community Health. Count your smiles: 2005-2006. “www.mi.gov/documents/Basic_Screening_Survey_updated_ 3-16-06_164625_7.pdf”. Accessed May 26, 2009. 37. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness of school-based preventive dental care. Am J Public Health 1985;75(4):382-391.
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Assessing patterns of restorative and preventive care among children enrolled in Medicaid, by type of dental care provider L. Susan Taichman, RDH, MPH, PhD; Woosung Sohn, DDS, PhD, DrPH; Sungwoo Lim, MA, MS; Stephen Eklund, DDS, MHSA, DrPH; Amid Ismail, BDS, MPH, MBA, DrPH
ral health problems are more pronounced among children from low socioeconomic backgrounds. A recent national survey reported that children in families with incomes below the federal poverty guideline (FPG) have twice as many carious lesions as do higherincome children.1 Furthermore, children at greatest risk of developing problems resulting from tooth decay are least likely to receive regular preventive and comprehensive dental care in private dental offices.2,3 Although most states offer comprehensive dental care coverage to children through Medicaid and other programs such as the State Children’s Health Insurance Program (SCHIP), utilization of dental care is low among children enrolled in Medicaid.4 The surgeon general’s report showed that fewer than 20 percent of Medicaid-covered children had a dental visit within a one-year period.3 The consequences of low dental-service utilization by Medicaid participants are poor oral health and signifi-
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ABSTRACT Background. The authors investigate the relationship of preventive dental treatment to subsequent receipt of comprehensive treatment among Medicaid-enrolled children. Methods. The authors analyzed Medicaid dental claims data for 50,485 children residing in Wayne County, Mich. The study sample included children aged 5 through 12 years in 2002 who had been enrolled in Medicaid for at least one month and had had at least one dental visit each year from 2002 through 2005. The authors assessed dental care utilization and treatment patterns cross-sectionally for each year and longitudinally. Results. Among the Medicaid-enrolled children in 2002, 42 percent had had one or more dental visits during the year. At least 20 percent of the children with a dental visit in 2002 were treated by providers who billed Medicaid exclusively for diagnostic and preventive (DP) services. Children treated by DP care providers were less likely to receive restorative and/or surgical services than were children who were treated by dentists who provided a comprehensive mix of dental services. The logistic model showed that children who visited a DP-care provider were about 2.5 times less likely to receive restorative or surgical treatments than were children who visited comprehensive-care providers. Older children and African-American children were less likely to receive restorative and surgical treatments from both types of providers. Conclusions. The study results show that the type of provider is a significant determinant of whether children received comprehensive restorative and surgical services. The results suggest that current policies that support preventive care–only programs may achieve increased access to preventive care for Medicaid-enrolled children in Wayne County, but they do not provide access to adequate comprehensive dental care. Key Words. Medicaid; dental care for children; dental care utilization. JADA 2009;140(7):886-894.
Dr. Taichman is an assistant professor, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor. Dr. Sohn is an assistant professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, 1011 N. University Ave., Ann Arbor, Mich. 48109, e-mail “[email protected]”. Address reprint requests to Dr. Sohn. At the time this study was conducted, Mr. Lim was a senior analyst, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. He now is an epidemiologist, Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene. Dr. Eklund is a professor emeritus of dental public health, Department of Epidemiology, School of Public Health, and an adjunct professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. At the time this study was conducted, Dr. Ismail was a professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor. He now is dean, Maurice H. Kornberg School of Dentistry at Temple University, Philadelphia.
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cant unmet dental needs.2,5 Barriers to receipt of dental care and issues of access to dental care are well-documented.6 Research has shown that children in low-income families have roughly 50 percent fewer preventive-care visits than do children in higherincome families.7 Some of the most frequently identified factors impeding access to dental care include limited availability of providers, inadequate program financing and reimbursement, administrative difficulties in qualifying for Medicaid, patients’ lack of knowledge regarding oral health, and cultural factors.8 In recent years, the federal government, state and local governments and nongovernmental agencies have emphasized increasing dental visits—especially those in which preventive services are provided—among low-income children.3,9 State and local agencies have expanded preventive care services through programs such as SCHIP and Head Start.10,11 Several studies have shown that preventive dental care, including prophylaxis, fluoride treatments and placement of sealants, is effective in reducing dental diseases.12-14 In addition, studies have reported that access to preventive care is associated with obtaining comprehensive dental treatment. Lee and Horan15 found that children in a managed Medicaid program in Connecticut who received preventive dental care were eight times more likely to receive additional dental treatments than were those who did not receive preventive care. However, among the children in the study sample, only 20 percent who received preventive care also received comprehensive treatment. The percentage was even lower among African-American children (14 percent). Results of national and state surveys continue to report unmet needs, even among children who receive Medicaid services.16,17 Investigators in a study of Medicaid programs in Alabama and Georgia reported that 90 percent of the children who had had any dental visit received preventive care, but only about 50 percent of the children received comprehensive dental care.18 Robison and colleagues19 examined data from a statewide survey of schoolchildren in North Carolina who were enrolled in Medicaid and reported that 43 percent of primary or permanent teeth needing treatment received no treatment. Factors related to the limited utilization of services among children with Medicaid coverage include the duration of eligibility within a given year, race/ethnicity,
the child’s age, parents’ educational levels, geographic availability of dental care providers, the dentist’s skill in treating young children and racial discrimination.20,21 Programs that emphasize preventive care, such as school-based clinics and mobile dental vans, have received the support of many states in hopes of increasing access to preventive care among Medicaid enrollees and other low-income children.22-24 Although some programs have reported success,25,26 other reports27,28 have raised concerns regarding the programs’ lack of comprehensive dental care. In particular, the children who received preventive-care services did not receive needed restorative and surgical treatments owing to the lack of continuity of care or duplication of diagnostic services, leading to reduced payments.27,28 The aim of this study was to evaluate the effect of preventive dental care services on subsequent receipt of comprehensive dental treatment among Medicaid-enrolled children in Wayne County, Mich. SUBJECTS AND METHODS
Data. In this study, we used dental claims data (with patients’ identification concealed) for the years 2002 through 2005 for children enrolled in Medicaid and their dental care providers in Wayne County, Mich. Located in southeast Michigan, Wayne County has more than 2 million residents, with a large Medicaid population. Detroit is the major city in Wayne County, and 81.6 percent of its 951,270 residents are black, according to the 2000 U.S. Census.29 Our rationale for choosing Wayne County was the high density of low-income children with access-to-care challenges. We conducted this analysis by using information in a database about Medicaid claims maintained by the Medical Service Administration within the Michigan Department of Community Health (MDCH). Before providing us with the data set, the MDCH concealed private information, checked the data set for completeness and created unique identification numbers that could ABBREVIATION KEY. CDT: Current Dental Terminology. DP: Diagnostic and preventive. FPG: Federal poverty guideline. GEEs: Generalized estimating equations. MDCH: Michigan Department of Community Health. SCHIP: State Children’s Health Insurance Program. JADA, Vol. 140
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be used to track children throughout the period of was 4.5 per year, so a cutoff point of 100 proanalysis (2002-2005). We checked the data furcedures equates to roughly 20 patients per year. ther for errors and mismatches in dental proThe arbitrary cutoff point of 100 allowed us to cedure codes.30 exclude dental care providers who treated During the period of analysis, children younger Medicaid-enrolled patients on a limited basis. than 6 years whose family income was at or below Service patterns. We then grouped regular 185 percent of the FPG and children aged 6 Medicaid providers on the basis of the pattern of through 19 years in families with incomes at or services provided. We categorized dentists whose below 150 percent of the FPG were eligible for billed services consisted of diagnostic and prevenMedicaid benefits in Michigan.31 tive (DP) services for 99.9 percent or more of the Two of us (W.S., S.L.) analyzed the Medicaid total billed services (dental procedure codes claims data initially to obtain descriptive statisD0120-D199930) as DP care–only providers. We tics, including measures of dental care utilization, categorized dentists who provided restorative and the percentage of the population with a dental surgical treatments in addition to DP services as visit, and the number and type of procedures per comprehensive-care providers. We conducted this visit per child from 2002 through 2005. The Medgrouping each year from 2002 through 2005. icaid claims database also included children’s Children’s dental visits. We assigned chilages and race/ethnicity and dentist dren to one of two groups on the information (such as identification basis of their dental visits (that is, The number of number and location and address). the type of dentist they visited each Subjects. The study sample year). In a given year, if a child visdiagnostic and included children aged 5 through preventive procedures ited a DP-care provider at least one 12 years who were enrolled in time, we categorized him or her as a per patient was Medicaid at least one month per member of the DP group. Children significantly higher year and had had at least one in this group also may have had among diagnostic and visits with comprehensive-care dental visit each year from 2002 preventive–care through 2005. We limited our providers. We assigned children analysis to this age group because who visited only dentists who proproviders than it the data showed that few children vided a comprehensive mix of dental was among younger than 5 years received services in a given year to the comprehensive-care treatment in Wayne County, and comprehensive-care group. providers for the number of children receiving We used a unique identification all years. treatment decreased substantially number to follow up children who after 12 years of age. We then followed up the 2002 sample of 5- through 12-year-old children in 2003 through 2005 to determine their receipt of dental care. The Health Sciences Institutional Review Board of the University of Michigan, Ann Arbor, reviewed and approved this research. Type of dental care provider. The claims data allowed us to determine the number and type of dental services performed by each dental care provider in children enrolled in Medicaid. To identify dentists who routinely provided dental care services to Medicaid beneficiaries, we divided them into “regular” and “occasional” providers. In each year, we considered dentists who performed 100 or more procedures per year to be regular Medicaid providers, while those performing fewer than 100 procedures per year were considered occasional providers. The mean number of procedures performed per patient in our database 888
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had been enrolled in Medicaid at least one month each year. This allowed us to link claims records with people to determine the type of dental services they received per year during the four-year period, as well as the type of dentists who delivered the services. Thus, it was possible to track the treatment each child received even if he or she visited multiple dentists or dentists outside of Wayne County. Analysis. We reported preventive care and comprehensive care in terms of the proportion of all children enrolled in Medicaid in Wayne County who had had at least one dental visit in 2002. We did not adjust the proportions of children who received either type of care for the period of eligibility in a given year. We collected follow-up data for descriptive univariate statistics to describe the proportion of children in selected subgroups who received preventive dental care
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TABLE 1
Wayne County, Mich., dental care providers who participate in Medicaid. VARIABLE
2002
2003
2004
2005
DP * Care †
Comprehensive Care ‡
DP Care
Comprehensive Care
DP Care
Comprehensive Care
DP Care
Comprehensive Care
17
252
23
265
22
253
34
271
Mean (SD §) No. of Children Per Provider Per Year
645.6¶ (707.3)
202.3 (286.7)
583 (569.4)
355.6 (519)
599 (529.3)
386.7 (565.6)
486.3 (522.6)
362.5 (592)
Mean (SD) No. of DP Services Per Child
8.1 (0.04)¶
7.3 (0.02)
7.7 (0.06)¶
6.4 (0.03)
8.7 (0.1)¶
7.6 (0.04)
8.0 (0.1)¶
6.9 (0.04)
No. of Providers
* † ‡ § ¶
DP: Diagnostic and preventive. Dentists who provided DP services only (dental procedure codes D0120-D1999 [source: American Dental Association30]). Dentists who provided restorative and surgical treatment in addition to DP services. SD: Standard deviation. P < .05.
and more comprehensive treatment. We used bivariate analyses to investigate the relationship between receipt of preventive care and subsequent receipt of comprehensive care for 2003 through 2005. We then developed logistic regression models to examine the association between children’s receipt of restorative and/or surgical treatment and the types of providers they visited during the four-year study period. The primary outcome was receipt of restorative and/or surgical services. We categorized this outcome variable as “yes or no.” Independent variables were provider type (comprehensive or DP), age in years (continuous), sex (male or female) and race (white/black/other). To account for the correlation between observations made in the same child across time, we estimated the odds ratios (ORs) of receiving restorative and/or surgical treatment over time by using generalized estimating equations (GEEs). In addition, we included children’s ages and interaction between age and provider type in the models to test whether the effect of provider type on receiving restorative and/or surgical treatments varied across ages. We assumed statistical significance at P < .05. We conducted all statistical analyses with statistical software (SAS version 9.1, SAS Institute, Cary, N.C.). RESULTS
The study sample included 50,485 children aged 5 through 12 years who were enrolled in Medicaid at least one month during 2002 and had had at least one dental visit in that year. The majority of
children were black (74 percent) or white (20 percent), with an almost equal distribution of boys and girls. Of those enrolled in Medicaid in 2002, 42 percent had had a dental visit during the year. Of those with a dental visit in 2002, almost 82 percent were enrolled during the entire 12 months (data not tabulated). Table 1 shows a summary of regular dental care providers. Of the 536 dentists who provided dental care to children in Wayne County in 2002, 267 were eliminated from our analysis because they provided fewer than 100 dental procedures to Medicaid-enrolled patients. Of the 269 regular dentists identified in 2002, 17 (6.3 percent) were DP care providers exclusively, and 252 (93.7 percent) provided a mix of restorative, surgical and preventive services (that is, were comprehensivecare providers). In general, DP-care providers treated more children than did comprehensivecare providers. This difference was statistically significant in 2002 but was not statistically significant in 2003 through 2005. Furthermore, the number of DP procedures per patient was significantly higher among DP-care providers than it was among comprehensive-care providers for all years. The number of DP-care providers doubled during the four-year study period. Table 2 shows the pattern of dental services for children aged 5 through 12 years in 2002 through 2005. In 2002, about 20 percent of the children enrolled in Medicaid in Wayne County visited DP-care providers at least once; the remaining 80 percent visited only the comprehensive-care providers. The children treated by DP-care JADA, Vol. 140
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TABLE 2
Demographic distribution and receipt of dental care services among Medicaid-enrolled children in Wayne County, Mich., by provider type. VARIABLE
No. of Children
2002
2003
2004
2005
DP * Care †
Comprehensive Care ‡
DP Care
Comprehensive Care
DP Care
Comprehensive Care
DP Care
Comprehensive Care
10,437
40,048
4,850
22,359
2,594
14,019
1,781
9,314
Children Who Received Restorative Services, % (Dental Procedure Codes D2110-D2999 §)
10.8¶
33.8
14.7¶
34.7
17.7¶
38.2
17.1¶
35.6
Children Who Received Surgical Services, % (Dental Procedure Codes D7000-D7999 §)
5.4¶
17.3
8.6¶
18.9
9.0¶
19.2
8.8¶
17.1
Sex, % Male Female
46.5 53.5
50.5 49.5
46.3 53.7
49.8 50.2
45.5 54.5
49.6 50.4
45.7 54.3
49.3 50.7
Race, % White African-American Other
6.6 89.6 3.8
24.1 69.9 6.0
8.5 86.6 4.9
25.4 68.2 6.4
9.5 86.9 3.6
26.8 66.3 6.9
9.5 86.6 3.9
29.5 63.3 7.2
* DP: Diagnostic and preventive. † Dentists who provided DP services only (dental procedure codes D0120-D1999 [source: American Dental Association30]). Some children who visited DP-care providers also received treatment from other (comprehensive-care) providers. ‡ Dentists who provided restorative and surgical treatment in addition to DP services. § Source: American Dental Association.30 ¶ P < .05.
providers received only DP treatment. However, some children received additional restorative or surgical treatment from other dentists (that is, comprehensive-care providers). In 2002, 10.8 percent of the children who visited DP-care providers underwent restorative procedures performed by other dentists. In comparison, 33.8 percent of the children who visited comprehensive-care providers underwent restorative procedures. This pattern continued in 2003 though 2005. Children who visited DP-care providers at least once were less than one-half as likely to receive restorative or surgical services as were those who visited comprehensive-care providers. We found significant differences in the sex and race of children who received care from the two types of providers. More girls than boys and more black children than those of other races received treatment from DP-care providers during the years tracked. Table 3 presents the outcome of the GEE models used to investigate the association 890
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between children’s receipt of restorative and/or surgical treatment and provider type. After adjusting for confounders such as age, sex and race, we found that children who visited DP-care providers were 2.5 times less likely (OR = 0.44) to have received restorative or surgical treatment than were those who visited comprehensive-care providers. Along with provider type, children’s age and race were significant determinants in receiving restorative and/or surgical treatment. We found no significant interactions between any of these variables in the model for restorative and/or surgical treatment. The figure (page 892) illustrates the proportion of children who received restorative care according to the type of dental provider they visited each year. The rate of receipt of restorative services fluctuated significantly—depending on the type of provider—when we followed up the same children across the four-year period. Because we followed up the same children in each pattern shown in the figure, it is unlikely
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that the restorative or surgical treatment needs of a group of children changed dramatically from year to year. Therefore, the study results suggest that the level of restorative and/or surgical treatment received was determined by the type of provider rather than by the child’s treatment needs or selfselection for follow-up care. DISCUSSION
TABLE 3
Logistic regression models of receipt* of restorative and surgical treatment across a four-year period among children aged 5 through 12 years at baseline. VARIABLE
RECEIPT OF RESTORATIVE TREATMENT† (n = 11,095) Odds Ratio
Sex Male (reference) Female
Standard Error
RECEIPT OF SURGICAL TREATMENT‡ (n = 11,095)
P Value
Odds Ratio
Standard Error
P Value
—§
—
—
—
—
—
0.96
0.02
.08
1.00
0.03
0.96
Race White (reference)
—
—
—
—
—
—
African-American
0.63
0.02
< .001
0.45
0.01
< .001
Other
1.15
0.06
.005
0.79
0.04
< .001
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Although the state of Baseline (2002) 0.97 0.006 < .001 0.92 0.006 < .001 Michigan offers compreAge, Years hensive Medicaid dental Provider Type coverage to all enrolled Comprehensive care¶ — — — — — — children, the results of this (reference) DP# care** 0.44 0.01 < .001 0.52 0.02 < .001 study show that access to comprehensive care was * The authors did not adjust receipt of treatment for the length of eligibility. † Restorative services are defined as dental procedure codes D2110-D2999 (source: American Dental not experienced univerAssociation30). sally by children enrolled ‡ Surgical services are defined as dental procedure codes D7000-D7999 (source: American Dental Association30). in the program. Children § Reference (odds ratio =1). who were treated by DP¶ Dentists who provided restorative and surgical treatment in addition to diagnostic and preventive services. care providers were less # DP: Diagnostic and preventive. likely to receive restorative ** Dentists who provided only diagnostic and preventive services. and surgical services than were those treated by dentists who billed MedicThe majority of DP-care providers in our study aid for a comprehensive mix of services. We found were associated with for-profit mobile dental that the type of provider was one of the most sigvans. Our results also support previous findings nificant determinants of whether children that older and minority children were less likely enrolled in Medicaid received restorative and/or to receive comprehensive care than were their surgical services. To our knowledge, this is the younger and white counterparts.21 first study in which investigators used Medicaid Access to care. Whether Medicaid-enrolled claims data to support the findings of previous children need preventive services is not disputed. studies suggesting a failure to receive comprehenPreventive-care dental services, including prophysive care among Medicaid-enrolled children laxis, fluoride treatments and placement of receiving treatment from dentists who provided a sealants, are effective in reducing dental limited scope of services.27,28 diseases.14,32-34 However, the percentage of chilOur findings suggest that a caveat is wardren who receive preventive care is low. Lee and ranted with regard to the common belief that Horan15 and Dasanayake and colleagues21 access to preventive services is the key to a child’s reported that low-income minority children were receiving comprehensive dental care.15,18 In fact, it one-half as likely to access preventive-care dental may depend on the way that the preventive care services as were their higher-income counterparts is organized and delivered. In this study, provider despite being at greater risk. Moreover, although type was a significant determinant of the level of the DP-care providers in our study may have comprehensive care that children enrolled in increased children’s access to preventive-care Medicaid received. We found that those who visservices, obtaining comprehensive care for these ited DP-care providers were 2.5 times less likely children appears to remain a significant problem. to receive comprehensive treatment than were One might argue that the provision of DP servthose who visited comprehensive-care providers. ices is better than providing no dental services at JADA, Vol. 140
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CHILDREN WITH RESTORATIVE TREATMENT (%)
focus on providing DP services may fail to establish 45 formal referral linkages to ■ 40 ■ ■ those who provide compre● ■ hensive dental services.28 35 ▲ ▲ ❉ ● ● Parents may assume that 30 ▲ because their children were ❉ ◆ DDCD treated by DP-care pro25 ◆ ❉ CDCD viders, no need exists to ▲ CCCD ● 20 ❉ DCCC seek comprehensive care ● ❉ ■ CCCC ▲ 15 from other dentists. ◆ ◆ Another barrier to ◆ 10 receiving follow-up care 5 may be the limited ability of comprehensive-care 0 2002 2003 2004 2005 providers to receive payYEAR ment from Medicaid for DP services for which another Figure. Patterns of receipt of restorative treatment, according to provider type, among children provider had submitted a aged 5 though 12 years (in 2002) enrolled continuously in Medicaid from 2002 through 2005. D: claim earlier in the year. Children who received care from diagnostic and preventive (DP)–care providers only. C: Children For example, under who received care from comprehensive-care providers. DDCD indicates that children in this group visited DP-care providers in 2002, DP-care providers in 2003, comprehensive-care providers in 2004 Michigan Medicaid law, and DP-care providers in 2005. CDCD indicates that children visited comprehensive-care providers in one child can receive two 2002, DP-care providers in 2003, comprehensive-care providers in 2004 and DP-care providers in 2005. CCCD indicates that children visited comprehensive-care providers in 2002, 2003 and 2004 and dental examinations, two DP-care providers in 2005. DCCC indicates that children visited DP-care providers in 2002 and prophylaxes, two fluoride comprehensive-care providers in 2003, 2004 and 2005. CCCC indicates that children visited applications and one set of comprehensive-care providers in 2002, 2003, 2004 and 2005. bitewing radiographs per year.35 Any duplication in billing of these services all to these underserved children. However, our results suggest that simply providing DP services beyond the allowance for a given year results in to these high-risk children does not ensure that denied payment for the service and reduced reimthey will receive needed comprehensive care and bursement for the comprehensive-care provider. actually may limit their opportunity to access These limitations make some dentists less apt to such treatment. treat children who have Medicaid coverage. The differences in the rates of restorative and No information is available from the claims surgical care between the two groups of children data regarding which children needed treatment may have resulted from self-selection (that is, in addition to the preventive care received. If the children with treatment needs chose to visit compreventive care services administered by DP-care prehensive-care providers). The differences also providers were much more effective than those may suggest, to a lesser degree, that DP services administered by the comprehensive-care were effective and the children did not need addiproviders, we would have expected to find a tional treatment. On the other hand, our results decrease in the need for restorative services in may suggest that children who visited DP-care subsequent years. We found, instead, a fluctuaproviders did not receive additional needed treattion in the need for restorative care year by year ment because of the lack of referral, lack of comaccording to the type of provider from whom the pliance or depletion of Medicaid resources. children received care. Access to additional treatment may have been As shown in the figure, whenever a group of affected by a number of factors. We cannot deterchildren received treatment from DP-care mine from the claims data the extent to which the providers, they received little restorative care low level of follow-up comprehensive care was the during that year. However, their receipt of result of a child’s parent not seeking dental care restorative services increased in the following because of a lack of available dental care proyear if they received care from comprehensiveviders or because no other treatment was needed. care dentists. This finding may indicate that However, it has been suggested that dentists who comprehensive-care dentists overtreat patients 892
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rather than that DP-care providers undertreat patients. However, on the basis of the generally high treatment needs of low-income children,36 this finding likely suggests that many children may not have received needed follow-up treatment when they received care from DP-care providers. Study limitations. Our analysis shows that state Medicaid dental claims data can be useful in better understanding important issues such as the types of services children enrolled in Medicaid receive. The strengths of this study include the longitudinal design, the large number of children, data from actual dental visits and data with good detail about the services each child received. However, this analysis was restricted to a single county in a single state, and the findings may apply only to children insured through Medicaid. Another potential weakness of this analysis is the inclusion of children who were eligible for coverage for only a brief period, which may have inflated the rates for DP services. However, although the lack of eligibility might have reduced children’s opportunity to receive restorative services, it does not fully explain the significant fluctuation in the restorative service rate that we observed. Our data show that, although a large number of children received preventive care services, only a small proportion of children who were treated by DP-care providers received restorative and/or surgical care by other dentists. However, we cannot determine whether this treatment was provided as a result of referrals from DP-care providers. We captured only the services provided by dentists on the basis of their Medicaid claims. Although not likely, it is possible that these children received restorative and/or surgical services from dental care providers who did not participate in the Medicaid program. From a public policy standpoint, the treatment care patterns found in these analyses call for careful examination of the availability of comprehensive care in addition to preventive care for children enrolled in Medicaid. The results of this study suggest that although strategies must be developed to encourage use of preventive dental services among children enrolled in Medicaid, further steps must be taken to ensure that children who need comprehensive dental services receive them. Strategies for improvement. Governmental agencies have made recommendations to improve
the delivery of preventive dental care for children in public insurance programs3,37 by using alternative service approaches, such as for-profit mobile dental vans and school-based/school-linked programs. However, if large numbers of school-aged children are receiving preventive services through these programs and continue to have unmet treatment needs, additional strategies are warranted. These may include establishing clear guidelines to ensure that necessary comprehensive treatment accompanies preventive services and/or establishing pragmatic referral networks among dental care providers and the preventivecare programs. CONCLUSIONS
Given the limitations of this analysis based on claims data, we found that the type of provider, rather than the treatment need, was a significant determinant of whether children enrolled in Medicaid received comprehensive restorative and surgical dental services. The results suggest that current programs and policies that support DP care only may have increased access to these services for children enrolled in Medicaid in Wayne County, but they do not provide adequate access to needed comprehensive dental care. Continued focus on mechanisms and strategies to ensure receipt of comprehensive care for this high-risk group of children is required. ■ Disclosure. None of the authors reported any disclosures. This study was supported by grant U-54 DE 14261 from the National Institute of Dental and Craniofacial Research; the University of Michigan, Ann Arbor; and the Delta Dental Fund of Michigan. 1. Beltran-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis: United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005;54(3):1-43. 2. U.S. General Accounting Office. Oral health: dental disease is a chronic problem among low-income populations. Washington: U.S. General Accounting Office; 2000. Publication GAO/HEHS 00-72. 3. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 4. U.S. General Accounting Office. Oral health: factors contributing to low use of dental services by low-income populations. Washington: U.S. General Accounting Office; 2000. Publication GAO/HEHS-00-149. 5. U.S. Department of Health and Human Services, Office of Inspector General. Children’s dental services under Medicaid: access and utilization. Washington: U.S. Department of Health and Human Services; 1996. Publication OEI-09-93-00240. 6. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what caregivers think. Am J Public Health 2002;92(1):53-58. 7. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2002;2(2 suppl):141-147. 8. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA 2000;284(20):2625-2631. 9. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington: U.S. Department of Health and Human
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