Chapter
3:
Dentists' Participation in, and Attitudes Toward, the Iowa Title XIX Program
Dentists' participation in Title XIX is one of the critical supply-side factors affecting recipients' access to dental services in Iowa. Title XIX participation, however, can take a number of forms, each providing a different level of access. Some dentists accept all the new Title XIX patients who approach their practice. Others selectively limit their new Title XIX patients (e.g. they might accept only patients from a group home or only patients referred from other dentists). Some dentists have Title XIX patients in their practice but aren't accepting new ones while others have nothing to do with the program, providing virtually no access for Title XIX recipients other than charity care.
Previous studies have found that a combination of factors affect dentists' decisions regarding whether or not to participate in the Title XIX program. These factors include demographic characteristics of the dentist, their attitudes toward the Title XIX program and toward Title XIX patients (Office of Technology Assessment 1990; Damiano, Brown, Johnson and Scheetz 1990a; Damiano, Brown, Johnson and Scheetz 1990b, Damiano and Momany 1993). In this report, we focus on factors that affect whether a dentist is accepting all new Title XIX patients in their practice. These dentists are considered 'full' participants in the Title XIX program. Dentists who do not accept all new Title XIX patients are considered 'limited' participants, which is similar to a definition developed by Perloff for evaluating physician participation in Title XIX (Perloff 1987). Our definition of dentists who have placed limits on their Title XIX participation is more broad than Perloff's and includes dentists who currently accept some new Title XIX patients, those who have some Title XIX patients in their practice, and those who do not accept new Title XIX patients. All of these dentists have limited their Title XIX participation and thus access for recipients, and it is impossible to accurately determine the extent of the barriers to access they have established. While differences may exist between the three types of dentists classified as limiting their participation, we believe this definition best evaluates differences between the most active Title XIX dentists and the less active providers.
To evaluate the participation of dentists in the Iowa Title XIX program and the factors that affect their participation, a written questionnaire was mailed to all full-time (over 30 hours per week on the licensure database) actively practicing dentists in Iowa (N=1,233). Dentists were selected from the list of all licensed dentists in Iowa obtained from the Iowa Board of Dental Examiners. Each dentist was mailed a questionnaire and cover letter in October 1995. Two weeks later, all dentists were mailed a postcard reminder. Approximately three weeks after the postcard, a second questionnaire and cover letter were mailed to nonresponding dentists. Nine hundred and thirty-seven dentists responded to the survey for a response rate of 76 percent.
Nonresponse bias tests were conducted to determine if the dentists who responded to the questionnaire differed from those who did not. No difference was found between respondents and nonrespondents regarding their sex, race, specialty or urban/rural location ( c 2 p>0.05). Older dentists were significantly less likely to have responded to the survey (T-test, p<0.05).
To determine the factors affecting the participation of Iowa dentists in the Title XIX program, dentists who accept all Title XIX patients in their practice (full participants) were compared with dentists who do not accept all new Title XIX patients (limited participants) regarding: 1) satisfaction with the Title XIX program; 2) attitudes toward treating low-income patients; 3) perceptions of how the Title XIX program compares with private insurance on issues such as paperwork and speed of payment; and 4) perceptions of which problems with the Title XIX program affect their practice the most. Chi-square statistical tests were used to determine whether full participants were significantly different from limited participants for each demographic factor and attitudinal item in the questionnaire. The responses were considered significantly different if p<0.05.
A logistic regression analysis was then completed to determine which of these factors were the most important factors related to a dentist being a full or limited Title XIX participant. With this analysis, the relative importance of the dentists' concerns about fees can be evaluated with the other non-economic issues (e.g. attitudes about the Title XIX program and patients, area of practice, urban/rural location) as they relate to their Title XIX participation.
Description of Dentists and Their Title XIX Participation
A description of the dentists who responded to the survey is presented in Table 3-1. In addition, the table shows the difference in Title XIX participation by the characteristic of the dentist: area of practice, age, type of practice, sex and urban/rural location. The nine level urban/rural variable used in these analyses was developed by the US Department of Agriculture to more precisely define rural areas ( Butler and Beale, 1993 ) . Full participation varied significantly by area of practice (oral surgeons were the most likely to be full participants), sex (men were more likely than women to be full participants), and urban/rural location (dentists in towns of 20,000 or less were more likely to be full participants).
Table 3-1. Description of dentists and their participation in the Title XIX program
All respondents Dentists' characteristic Number (% of characteristic) Full participants Number (%) Limited participants Number (%) Area of Practice* General Practice 753 (84%) 336 (45%) 415 (55%) Pediatric Dentistry 18 (2%) 8 (44%) 10 (56%) Oral Surgery 34 (4%) 26 (77%) 8 (24%) Endodontics (root canals) 16 (2%) 1 (6%) 15 (94%) Periodontics (gums) 14 (2%) 1 (7%) 13 (93%) Prosthodontics (crowns, dentures) 8 (1%) 1 (13%) 7 (87%) Orthodontics (braces) 52 (6%) 13 (25%) 38 (75%) 895 (100%) Age (Mean=46; SD=10) 26-35 128 (14%) 50 (39%) 78 (61%) 36-45 387 (42%) 153 (40%) 228 (60%) 46-55 237 (26%) 104 (44%) 130 (56%) 56-65 135 (15%) 66 (50%) 67 (50%) 66-75 23 (3%) 7 (30%) 16 (70%) 76 and older 3 (0%) 0 (0%) 3 (100%) 913 (100%) Practice type Solo Practice 693 (76%) 286 (42%) 397 (58%) Partner 159 (17%) 68 (43%) 90 (57%) Associate buying practice 19 (2%) 11 (58%) 8 (42%) Associate not buying practice 30 (3%) 10 (33%) 20 (67%) Independent contractor 15 (2%) 7 (47%) 8 (53%) 916 (100%) Sex* Female 77 (8%) 23 (30%) 53 (70%) Male 835 (92%) 356 (43%) 469 (57%) 912 (100%) Urban/Rural* Metro > 250,000 246 (26%) 85 (35%) 159 (65%) Metro < 250,000 219 (23%) 79 (37%) 137 (63%) Urban near metro 56 (6%) 19 (34%) 37 (66%) Urban far from metro 89 (10% 30 (34%) 59 (66%) 2500-20,000, near metro 115 (12%) 63 (55%) 52 (45%) 2500-20,000, far from metro 170 (18%) 92 (55%) 74 (45%) Rural near metro 19 (2%) 14 (74%) 5 (26%) Rural far from metro 21 (2%) 11 (58%) 8 (42%) 935 (99%) * Characteristic is statistically significant: c 2 p<0.05.
Other indicators of Iowa dentists' Title XIX participation are shown in Table 3-2. The rate of dentists accepting all new Title XIX patients declined significantly between 1992 and 1995. Sixty-two percent of Iowa dentists reported in a 1992 survey that they were accepting all new Title XIX patients compared to 42 percent in 1995. (The 1992 study was conducted by several of the same researchers using similar methods and questions to gather the information as the 1995 survey, however only half of the dentists were surveyed, using a single mailing. The survey resulted in a 64 percent response rate, n=377). Thirty-six percent of dentists were not accepting any new Title XIX patients in their practice in 1995 compared to 21 percent in 1992. Twenty-two percent of dentists in 1995 had established some criteria for deciding which Title XIX patients they would accept in their practice (e.g. only referrals from dentists).
Table 3-2. Iowa dentists' participation in the Title XIX program
Level of participation of dentists Number (Percent) Number (Percent) Accepting all new Title XIX patients 214 (62%) 393 (42%) Accepting only some new Title XIX patients 56 (16%) 208 (22%) Accepting no new Title XIX patients 73 (21%) 342 (36%) On average, dentists reported that eight percent of the patients in their practices were covered by Title XIX in 1995 (SD=8.5 percent). The percentage of Title XIX patients varied significantly by whether the dentists were full or limited participants (Table 3-3).
Table 3-3. Acceptance of all new Title XIX patients by percent of Title XIX patients
and Title XIX self-reported reimbursements in FY 1995
All respondents Number (% of characteristic) Percent Title XIX in practice* 0 percent 71 (8%) 1 (1%) 70 (99%) 0.1-5 percent 379 (44%) 118 (31%) 261 (69%) 5.1-10 percent 214 (25%) 122 (57%) 92 (43%) 10.1-15 percent 73 (9%) 43 (59%) 30 (41%) 15.1-20 percent 65 (8%) 43 (66%) 22 (34%) 20.1-25 percent 17 (2%) 14 (82%) 3 (18%) Over 25 percent 37 (4%) 27 (73%) 10 (27%) 856 (100%) 368 (43%) 488 (57%) Self-reported Title XIX reimbursement FY 1995* $0 61 (12%) 1 (2%) 60 (98%) $1-$5,000 128 (24%) 40 (31%) 88 (69%) $5,001-$10,000 103 (19%) 46 (45%) 57 (55%) $10,001-$15,000 48 (9%) 26 (54%) 22 (46%) $15,001-$20,000 48 (9%) 30 (63%) 18 (37%) $20,001-$30,000 53 (10%) 31 (58%) 22 (42%) $30,001-$50,000 50 (9%) 33 (66%) 17 (34%) Over $50,000 39 (7%) 29 (74%) 10 (26%) Total 530 (100%) 236 (45%) 294 (55%) * Participation level is statistically significant: c 2 p<0.05.
Fourteen percent of the limited participants did not have any Title XIX patients in their practice. About two thirds (68 percent) of the limited participants had five percent or fewer Title XIX patients compared to one third for the full participants. Less than one in four (23 percent) dentists had more than ten percent Title XIX patients in their practice. The amount that dentists indicated they were reimbursed for care provided to Title XIX patients during 1995 is also shown in Table 3-3. Over half (55 percent) were reimbursed $10,000 or less for care provided to Title XIX patients.
Almost all of the dentists who said they are no longer accepting new Title XIX patients had accepted new Title XIX patients at some point in the past (93 percent). Almost two-thirds of the dentists (65 percent) who reported that they no longer accept new Title XIX patients, did so within the last three years (Figure 3-1). This may be a little misleading because dentists who have retired or left Iowa may have ended their participation in Title XIX in earlier years however most dentist currently in practice have ended their acceptance of new Title XIX patients in the past three to five years.
Figure 3-1. Number of dentists who discontinued their acceptance of new Title XIX patients,
by year acceptance was discontinuedOf those who do not accept any new Title XIX patients, only three percent indicated they had either moderately or very seriously considered accepting new Title XIX patients during the past year (Table 3-4). Almost one fourth of these dentists (22 percent) indicated, however, that if Title XIX allowed charges were increased to approach their usual and customary fees, they would reconsider accepting new Title XIX patients. About half (51 percent) indicated they would only consider accepting new Title XIX patients if fees were increased and other changes in the program were made as well. Twenty-seven percent indicated they would not consider accepting new Title XIX patients under any circumstances. Conversely, about two thirds of the dentists who are currently accepting new Title XIX patients indicated they had seriously considered changing their policy during 1995. One fourth reported they had very seriously considered discontinuing their acceptance of new Title XIX patients while another 41 percent had moderately seriously considered making this change.
Table 3-4. Dentists' consideration of future participation in Title XIX
Statement
(3)(4)
Very Seriously (5)
For those accepting new Title XIX patients:
How seriously have you considered stopping your acceptance of new Title XIX patients in the past year?120 (22%)
70 (13%)
140 (25%)
86 (16%)
137 (25%)
For those not accepting any new Title XIX patients:
How seriously have you considered starting to accept new Title XIX patients in the past year?279 (92%)
12 (4%)
8 (3%)
0 (0%)
4 (1%)
Reluctance to accept new Title XIX patients is due in part to how busy the dentists believed their practices to be. Although only one percent of all dentists reported that their practice was closed to all patients, dentists who felt busier were significantly more likely not to accept all new Title XIX patients (Table 3-5).
Table 3-5. Acceptance of all new Title XIX patients by dentists' perception
of how busy they are*
Full participants Busyness Practice limited--no new patients Too busy to treat all requesting appointments Provided care to all requesting it but felt overworked Provided care to all requesting it but did not feel overworked Not busy enough, would like more patients *Statistically significant differences: c 2 p<0.05.
If the need for a dental specialist arose, dentists indicated that it would be difficult to find a specialist who would accept this referral. Eighty-five percent of all dentists indicated that Title XIX patients were more difficult to refer to a dental specialist than patients with private insurance.
Dentists' Attitudes Toward the Title XIX Program
Dentists were presented with a series of statements about their satisfaction with the Title XIX program, the treatment of low-income Title XIX patients, a comparison of selected issues between Title XIX and private insurance, and their perceptions of problems with the Title XIX program. For the questions about the Title XIX program and Title XIX patients, dentists were to respond, on a scale of one to five, how strongly they agreed or disagreed with each statement. They were also given a series of commonly perceived problems with Title XIX, and were to rank the relative importance of each problem from "not important" to "very important" in their office.
Satisfaction with the Title XIX program
Table 3-6 shows the statements presented to dentists concerning their attitudes about the Title XIX program. On each of the five items, dentists who were full participants in Title XIX had significantly more positive views about the program than dentists who were limited participants ( c 2 test, p<0.05). Full participants viewed the program significantly more positively concerning their ability to provide comprehensive treatment, improvements in the complexity of the program, the program's respect for their professional judgment, their ability to impact the Title XIX program, and how well programmatic changes are communicated with their office.
Similarly more positive views were found when comparing aspects of the Title XIX program relative to private dental insurance. Although they did not necessarily view these issues positively, full participants viewed Title XIX paperwork, speed of payment, prior approval requirements, and comprehensiveness of services significantly more favorably than limited participants ( c 2 p<0.05). For example, significantly more limited participants (68 percent to 54 percent) thought Title XIX paperwork was either more or much more complicated than the paperwork for private insurance. Forty-three percent of full participants thought the paperwork was about the same compared to 31 percent of limited participants. Less than two percent of all dentists thought Title XIX paperwork was less complicated than private insurance. More limited participants than full participants believed they were paid less promptly by Title XIX (76 percent to 59 percent). Among both full and limited participants, 77 percent believed Title XIX services were generally less comprehensive than private insurance, although they differed on the degree. Thirty-two percent of limited participants believed they were much less comprehensive compared to 22 percent of full participants.
Table 3-6. Percentage of dentists agreeing or disagreeing
with aspects of the Title XIX program
It is difficult to provide comprehensive treatment to Title XIX patients.* Full
Limited1%
2%13%
8%19%
13%44%
36%23%
41%The Title XIX program has been getting less complicated in the last few years.* Full
Limited13%
24%30%
26%34%
31%21%
17%2%
2%The Title XIX program respects my professional judgment concerning patient care.* Full
Limited16%
24%29%
29%22%
25%30%
29%3%
3%Dentists can have an impact on the policies of the Title XIX program.* Full
Limited18%
28%33%
31%24%
23%20%
15%6%
3%Changes in the Title XIX program are communicated effectively to my office.* Full
Limited6%
9%20%
24%22%
35%49%
31%3%
1%*Statistically significant differences: c 2 p<0.05.
The only programmatic issue on which there was no significant difference was how Title XIX fees compared to fees paid by private insurance. Compared to private insurance, 99 percent of all dentists thought Title XIX reimbursed less, with 85 percent of both groups reporting that it was much less than what they are paid by private insurance.
Treatment of low-income patients
Issues relating to the treatment of low-income patients can be an important factor determining the dentist's satisfaction and willingness to participate in Title XIX. Therefore, when evaluating satisfaction with the program, it is important to distinguish between the dentists' attitudes toward the Title XIX program and their attitudes toward treatment of low-income patients. The attitudes of dentists toward the treatment of low-income patients was evaluated using a similar set of statements as those used to obtain their perceptions of the Title XIX program.
The responses of full participants were significantly different from the responses of limited participants on five of the seven statements concerning low-income patients ( c 2 p<0.05, Table 3-7). The largest difference was regarding the ethical obligation to treat Title XIX patients. Sixty-one percent of full participants agreed that dentists have an ethical obligation to treat Title XIX patients compared to 26 percent of limited participants. For limited participants, this attitude could be a factor affecting their level of participation or could have changed following their decision to no longer accept new Title XIX recipients. There was general agreement from over half of both groups that the Title XIX program is important for access to dental care for low-income patients. Eighty-one percent of full participants and 57 percent of limited participants agreed that without the Title XIX program, low-income patients would not be able to get adequate dental care.
For the other statements, although there was a statistically significant difference in their responses, it is not clear that there is a practical difference between the attitudes of full and limited participants. About one third of all dentists were concerned about having the only practice in their area that accepts Title XIX patients. Between 40 and 50 percent of all respondents disagreed that Title XIX patients make other patients uncomfortable in their office. While about fifteen percent of all dentists believed that they would be more likely to be sued if they treat Title XIX patients.
There were no statistically significant differences in the dentists' attitudes about the oral health status of low-income patients or the level of difficulty treating them. Almost two thirds of all dentists (63 percent) agreed that the oral health problems of Title XIX patients are more severe than other patients. About half of all dentists, (47 percent), indicated that low-income patients are more difficult to treat than other patients.
Table 3-7. Percent of dentists agreeing or disagreeing with
aspects of treating Title XIX patients*Statistically significant differences: c 2 p<0.05.
Title XIX Participation Title XIX patients make private patients feel uncomfortable in the office.* Full
Limited
10%
32%
42%
14%
3%Without the Title XIX program, low-income patients would not be able to get adequate dental care.* Full
Limited
5%
13%
25%
46%
11%I am concerned about having the only practice in the area that accepts Title XIX patients.* Full
Limited
9%
17%
38%
19%
17%Dentists have an ethical obligation to treat Title XIX patients.* Full
Limited
21%
23%
30%
22%
4%I am more likely to be sued if I treat Title XIX patients.* Full
Limited
5%
28%
53%
11%
4%Oral health problems of Title XIX patients are more severe than those of other patients. Full
Limited
1%
12%
27%
46%
15%Low-income patients are more difficult to treat than others. Full
Limited
4%
20%
31%
35%
11%Problems with participating in Title XIX
A combination of program and patient issues were evaluated together by asking dentists how important each of these Title XIX program and patient issues were in their practice. The percentage of full and limited Title XIX participants reporting each problem to be very important (a five on a scale of one to five) is reported in Table 3-8. The relative importance of each item was evaluated by asking dentists to indicate which of these were the first, second and third most important issues in their practice. Each first response was given a score of three points, a second was two points and a third was one point. The number of points for each issue were then added together and the total point score for each item was used to determine the relative rank or importance of the issue compared to the other issues.
Table 3-8. Percent of dentists reporting certain aspects of
Title XIX as very important in their office
Problem Percent 'very important' Rank Percent 'very important' Rank Percent 'very important' Rank Low fees 66% 1 78% 1 73% 1 Broken appointments 78% 2 86% 2 82% 2 Patient noncompliance 46% 3 61% 3 54% 3 Denial of payment 47% 4 56% 4 52% 4 Complicated paperwork 16% 6 31% 5 25% 5 Intermittent eligibility 39% 5 42% 6 41% 6 Slow payment 24% 8 40% 7 33% 7 Only practice accepting 16% 7 23% 8 20% 8 Need for prior approval 13% 9 21% 9 17% 9 Frequently changing regulations 16% 10 24% 10 20% 10 Collection of copayments 15% 11 23% 11 19% 11 Low fees and broken appointments were the two most important issues to both groups of dentists. Low fees received the highest rank score for both groups but a higher percentage of dentists (82 percent to 73 percent) indicated that broken appointments were a very important issue in their practice. It is important to note that two out of the three most important issues were patient issues (broken appointments and patient noncompliance) which are more difficult than program related issues for the Title XIX program to address.
Most important factors affecting Title XIX participation--Logistic regression analysis
To determine which factors were the most strongly associated with a dentists' participation in Title XIX, a logistic regression analysis was performed. This method of analysis allows for a combination of issues to be considered together to determine which are most highly associated with a dentist's participation in Title XIX. The measure of participation used in this analysis (the dependent variable) was whether dentists were full or limited participants. The factors associated with full or limited participation that were evaluated included the demographic characteristics of the dentists, their attitudes toward the Title XIX program and Title XIX patients and characteristics of the dental delivery system in their area such as the dentist to population ratio in the dentist's county.
For many of the attitudinal questions, scales were created by averaging the responses of questions that pertained to similar aspects of the program. For example, there were six questions pertaining to the administration of the Title XIX program. Dentists responses to these items were averaged together to get one measure of how they feel about the program administration of Title XIX. Topic areas were considered appropriate to combine together if individual dentists responded consistently to the questions concerning the topic as indicated by the Chronbach test of internal reliability (alpha statistic). Scale scores were included in the analysis if they had an alpha greater than 0.6. Scale scores were found to be sufficiently reliable for two different aspects of the program and were included in the regression analysis: attitudes toward program administration, and toward Title XIX patients. The other scales lacked sufficient reliability for inclusion in the regression (Title XIX fees, speed of payment, paperwork, and how concerned they were with being the only practice in their area accepting Title XIX patients).
The results of this analysis are presented in Table 3-9. The items most significantly associated with being a full versus a limited participant were two demographic characteristics (location and area of practice) and three attitudinal issues (attitude scale toward the Title XIX program, how busy they felt in their practice, and their belief that there is an ethical obligation to treat Title XIX patients).
Items that were included in the regression but were not significantly related to being a full participant were: Urban/rural areas other than those listed in Table 2-9 (mostly more urban areas except for towns fewer than 2500 not adjacent to a metro area), the age of the dentist, the dentist to population ratio in the county, the dentist's attitude toward Title XIX patients (scale score), the dentist's attitude about Title XIX fees compared to private insurance fees, how important a problem low fees were in the office, the dentist's feeling that the Title XIX program respects their professional judgment, the role of the dentist in the practice (e.g. solo owner, partner, associate), or their area of practice other than oral surgeon and orthodontist.
Table 3-9. Factors significantly related to being a full participant in Title XIX
as determined by logistic regression analysis
Attitude toward Title XIX administration (scale score)* 0.54 (.384-.753) Dentists have an ethical obligation to treat Title XIX patients* 0.56 (.484-.653) How busy they felt in their practice* 1.65 (1.361-1.989) Urban/rural variables compared with counties in metro areas of 250,000 to 1 million in population: Urban population of 2,500- 19,999, adjacent to a metro area* 2.95 (1.617-5.368) Urban population of 2,500- 19,999, not adjacent to a metro area* 2.45 (1.447-4.140) Completely rural or fewer than 2,500 urban population, adjacent to a metro area* 6.30 (1.544- 25.710) Completely rural or fewer than 2,500 urban population, not adjacent to a metro area 2.67 (.872-8.178) Area of practice, compared to General Practice Oral surgery* 8.59 (3.266-22.602) Orthodontics* 0.37
(.164-.824)
*Statistically significant, p<0.05.
Confidence intervals that do not include 1.0 indicate a significant difference between
those who do and those who do not accept all new Title XIX patients.The odds ratios for the significant variables indicate the likelihood that dentists with those characteristics or attitudes have of being a full participant in the program. For example, dentists with a more negative attitude toward the administration of the program were about half as likely to be full participants as dentists with a more positive view of the administration of the program. Dentists who felt less busy were 65 percent more likely than dentists who felt busier to accept all new Title XIX patients. Those who did not believe there was an ethical obligation to treat Title XIX patients were 44 percent less likely to be full participants. Dentists in urban areas, 2500-19,999 adjacent to metro areas were almost three times more likely to be full participants than dentists in cities of 250,000 to 1 million; dentists in urban areas, 2500-19,999 not adjacent to metro areas were almost two and a half times more likely; those in rural areas less than 2500 but adjacent to metro areas were 6.3 times more likely be full participants. By area of practice, oral surgeons were 8.6 times more likely to be full participants than general dentists while orthodontists were only one-third as likely.
Summary
Dentists' participation in Title XIX declined significantly between 1992 and 1995. Forty-two percent of all Iowa dentists are now full participants in the program. The two most important problems with the program for Iowa dentists were low fees and broken appointments. Patient noncompliance was the third most important issue. While fees were considered a problem, it was non-economic factors that were significantly associated with whether a dentist was a full participant in the program. These included their area of practice, being located in a town under 20,000 (except very rural areas under 2500), having a more positive view toward the program administration of Title XIX, feeling less busy in their practice, and indicating a belief that dentists have an ethical obligation to treat Title XIX patients.
