References
Bonito AJ, Gooch R. Modeling the Oral Health Needs of 12-13 Year Olds in the Baltimore MSA: Results from One ICS-II Study Site. Paper presented at American Public Health Assn Annual Meeting, November 12, 1992, Washington, DC.
Butler MA, Beale CL. Rural-urban continuum codes for metro and nonmetro counties. Staff Report No. AGES 9425. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture. 1993.
Call, RL. Effects of Poverty on Children's Dental Health. Pediatrician 16:200-206, 1989.
Damiano PC, Brown ER, Johnson JD, Scheetz JP. Factors Affecting Dentist Participation in a State Medicaid Program. Journal of Dental Education 54(11):638-643, 1990.
Damiano PC, Brown ER, Johnson JD, Scheetz JP. Access to Dental Care for California Medi-Cal Recipients: A Report to the Legislature. California Policy Seminar, Institute of Governmental Studies, Berkeley, July 1990.
Damiano PC, Momany ET. Factors affecting dentists' participation in Medicaid and the impact on access to care. The American Association for Dental Research Annual Meeting, March 1993. Journal of Dental Research, 72 (special issue):172, abstract number 548, 1993.
Iowa Department of Human Services. Medicaid Provider Manual, Dental Services, pg E.7a-c, Des Moines.
Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol 1993;12:49-52.
National Center for Health Statistics. Health, United States, 1994. Table 82: Dental visits and interval since last visit, according to selected patient characteristics: US 1964, 1983, 1989. Hyattsville, MD: Public Health Service, 1995.
National Institute of Dental Research: Oral health of United States children: the National Survey of Dental Caries in US School Children, 1986-87. NIH Publication No. 89-2247, Bethesda, MD, 1989.
Office of Technology Assessment. Children's Dental Services Under the Medicaid Program. Background Paper. Congress of the United States. Washington, DC, September 1990.
Perloff JD, Kletke PR, Neckerman KM. Physicians' decision to limit Medicaid participation: Determinants and policy implications. J Health Polit Policy Law 1987; 12:221.
Strayer M, Ibrahim M. Dental health among home bound elderly. J Dent Res 1991;70(special issue):510 abstract no. 1994.
Appendix a:
1995 Survey of Iowa Dentists and Survey Results
This survey is being conducted by researchers at the
Public Policy Center and the
College of Dentistry at the
University of Iowa.If you have any questions or comments, please contact:
Peter C. Damiano, DDS, MPH
Associate Professor and
Director, Health Policy Research ProgramPublic Policy Center
227 South Quadrangle
University of Iowa
Iowa City, IA 52242-1192(800) 710-8891
INSTRUCTIONS: In this questionnaire we will be asking about your participation in and attitudes toward the Title XIX (Medicaid) program. For each question, please circle or check the box next to the most appropriate response or write your response in the space provided.
In order for the results of this study to reflect the views of dentists in Iowa, it is important that we hear from you. However, if you come to a question you do not feel comfortable answering, feel free to skip to the next question. When you have completed the questionnaire, please fold it and return it in the enclosed postage-paid envelope.
Thank you.
If you practice in more than one location, please answer
the questions in this survey as they pertain to what
you consider your primary practice location.1. In what city is your primary practice located? ______________, _______
city state
2. How many years have you been practicing in your current location?
mean: 16
median: 15
range: 0.25 - 56
years3. What is your area of practice?
753 (84%) o 1. General Practice
18 (2%) o 2. Pediatric Dentistry
34 (4%) o 3. Oral Surgery
16 (2%) o 4. Endodontics
14 (2%) o 5. Periodontics
8 (1%) o 6. Prosthodontics52 (6%) o 7. Orthodontics
o 8. Other dental specialty
The following questions are about your experience with the Title XIX (Medicaid) program.
4. Do you currently accept new Title XIX patients in your practice?
o1. NO
342 (37%)Û
If you are not currently accepting new Title XIX patients, please answer a-c.
a. Have you ever treated Title XIX patients in the past?
21 (7%) o 1. I have never accepted Title XIX patients.
262 (93%) o 2. I accepted Title XIX patients for ________ years , then stopped accepting new Title XIX patients in the year 19 ____.
b. In the past year, how seriously have you considered starting to accept new Title XIX patients?
Not seriously Moderately seriously Very seriously
1 2 3 4 5
279 (92%) 12 (4%) 8 (3%) 0 (0%) 4 (1%)c. If Title XIX fees were brought to a level closer to usual and customary, would you consider participating in the program?
83 (27%) o 1. NO, I would not consider accepting new Title XIX patients under any condition
68 (22%) o 2. YES
154 (51%) o 3. YES, but only if other changes were made as well
o2. YES
583 (63%)Û
If you are currently accepting new Title XIX patients, please answer a and b.
a. Do you have any criteria for selecting Title XIX patients into your practice?
393 (65%) o 1. NO, I accept all new Title XIX patients.
o 2. YES, in our office we accept (please check all that apply):
64 (15%) o 1. A set number of new Title XIX patients
119 (29%) o 2. Our own patients who go on Title XIX
74 (18%) o 3. Referrals from other dentists/physicians
66 (16%) o 4. Children
26 (6%) o 5. Patients from our county
65 (16%) o 6. Otherb. How seriously have you considered stopping your acceptance of new Title XIX patients in the past year?
Not seriously Moderately seriously Very seriously
1 2 3 4 5
120 (22%) 70 (13%) 140 (25%) 86 (16%) 137(25%)5. About what percentage of your current patients are covered by Title XIX?
mean: 8.37%
median: 5.0%
range: 0 - 60%
6. Please read the following statements about the Title XIX (Medicaid) program and circle the number which indicates the degree to which you disagree or agree with these statements.
7. For the next set of questions, please compare the Title XIX (Medicaid) program to the private insurance carriers with which you interact. For each question, circle the number (1 to 5) that most closely reflects your experience with the Title XIX program. a. How complicated is Title XIX paperwork compared to the paperwork for private insurers?
Strongly disagree
(1)
Disagree
(2)Neither agree nor disagree
(3)
Agree
(4)
Strongly agree
(5)a. It is difficult to provide comprehensive treatment to Title XIX patients. ..................................
2%
10%
16%
39%
33%b. The Title XIX program has been getting less complicated in the last few years ......................... 19% 28% 33% 19% 2% c. Title XIX patients make other patients feel uncomfortable in the office ....................................... 11% 35% 38% 13% 3% d. Without the Title XIX program, low income patients would not be able to get adequate dental care .................................................. 4% 11% 18% 49% 18% e. I am concerned about having the only practice in the area that accepts Title XIX patients 9% 20% 34% 22% 15% f. The Title XIX program respects my professional judgment concerning patient care ___ 21% 29% 24% 24% 3% g. Oral health problems of Title XIX patients are more severe than those of other patients 1% 12% 24% 46% 16% h. Dentists can have an impact on the policies of the Title XIX program .......................................... 23% 32% 23% 18% 5% i. Low income patients are more difficult to treat than others 3% 21% 30% 35% 11% j. Dentists have an ethical obligation to treat Title XIX patients 15% 19% 27% 33% 7% k. Changes in the Title XIX program are communicated effectively to my office ...................... 8% 22% 29% 39% 2% l. I am more likely to be sued if I treat Title XIX patients .............................................................. 5% 32% 49% 9% 4% b. How promptly does the Title XIX program pay dentists compared to the speed of payment by private insurers?
Much less complicated Less complicated About the same More complicated Much more complicated 1 2 3 4 5 0% 2% 36% 40% 22% c. How much of a hindrance are Title XIX prior approval requirements compared to the requirements of private insurers?
Much less promptly Less promptly About the same More promptly Much more promptly 1 2 3 4 5 27% 42% 31% 1% 0% d. How do the fees reimbursed by Title XIX compare to the fees reimbursed by private insurers?
Much less of a hindrance Less of a hindrance About the same More of a hindrance Much more of a hindrance 1 2 3 4 5 0% 4% 39% 38% 18%
Pays much less Pays
lessPays about
the samePays more Pays much more 1 2 3 4 5 86% 13% 1% 0% 0% e. How easy is it to find a dental specialist who will accept a Title XIX referral, as compared to the referral of a privately insured patient?
Much
easier
EasierAbout
the sameMore
difficultMuch more difficult 1 2 3 4 5 0% 0% 14% 43% 43% f. How comprehensive are the services covered by Title XIX as compared to private insurance?
8. The following is a list of commonly reported problems with Title XIX programs. Please indicate how important you considered each problem to be when deciding how much to participate in Title XIX.
Much less comprehensive Less comprehensive About
the sameMore comprehensive Much more comprehensive
1 2 3 4 5 28% 50% 20% 2% 1%
Not important (1) (2) Moderately important (3)
Very important (5)
a. Complicated paperwork .................. 13% 23% b. Low fees ......................................... 2% 16% c. Need for prior approval ................... 13% 25% d. Intermittent eligibility of Title XIX patients .................................................. 7% 28% e. Denial of payment ........................... 5% 26% f. Broken appointments ....................... 2% 12% g. Slow payment ................................. 9% 30% h. Collection of copayments ................ 17% 20% i. Patient non-compliance ................... 3% 27% j. Frequently changing Title XIX regulations ............................................. 11% 28% k. Not enough other practices in the area accepting Title XIX patients .......... 16% 17%
9. Which three of these problems (a-k) do you consider to be the most important for your office (with "1" indicating the most important).
(34%)
(29%)
(11%)
10. Like many programs, Title XIX is currently under review for ways to reduce their costs. If it were to become necessary, which of the following options do you feel would be the three best ways for Title XIX to reduce costs? Please rank your first three choices from 1 to 3.
see Table 5-1 or Appendix B
for resultsa. Eliminate all dental coverage for Title XIX recipients
b. Eliminate all dental coverage for adults
c. Reduce the number of dental services covered for adults
d. Reduce the number of dental services covered for children and adults
e. Eliminate coverage of orthodontic services
f. Reduce the reimbursement rates for selected dental procedures
g. Other:
h. Other:The following questions are related to the treatment of children in your practice.
(Responses for General Practitioners and Pediatric Dentists only)
11. In your practice, do you treat children under the age of 14?
2% o 1. NO
98% o 2. YES
12. What is the youngest age of patients you are willing to accept into your practice?
mean: 2.6
median: 2.5
range: 0 - 18
years
13. At what age do you believe children should make their first visit to the dentist?
mean: 2.5
median: 2.7
range: 0 - 5
years14. How often do you believe children under the age of six need to be seen for routine dental exams?
23% o 1. Yearly
70% o 2. Every six months
0% o 3. Every three months
4% o 4. Other
3% o 5. Six to 12 months
15. In your practice, how often do you place sealants on children under the age of 14?
2% o 1. Routinely on all deciduous and permanent molars
40% o 2. Routinely but only on all permanent molars
42% o 3. On selected children (e.g., high caries rate or deep pits and fissures)
5% o 4. Rarely or never
12% o 5. Not applicable (specialist or don't see patients under 14 years old)
16. How likely are you to place sealants on children (under the age of 14) who are on Title XIX?
3% o 1. More likely than on my other patients
68% o 2. About the same as on my other patients
15% o 3. Less likely than on my other patients
14% o 4. Not applicable (specialist or don't see patients under 14 years old)
17. Are you familiar with the Iowa Title XIX EPSDT program?
69% o 1. NO
16% o 2. YES
15% o 3. YES, only because I received a recent brochure about the program
18. In the past year, approximately how many children on Title XIX
under the age of 14 have been referred to your practice by physicians?mean 4
median 0
range 0 - 200
We would like to ask some basic questions to identify how different practice attributes
generally relate to Iowa dentists' impressions of the Title XIX (Medicaid) program.19. How would you best describe your practice during the past 12 months?
11% o 1. Too busy to treat all requesting appointments
51% o 2. Provided care to all requesting it, but felt overworked
24% o 3. Provided care to all requesting it, but did not feel overworked
12% o 4. Not busy enough, would have liked more patients
1% o 5. Practice limited, no new patients taken
20. In your practice, how many dentists practice
over 30 weeks/year (including yourself) ?mean 1.7
median 1.0
range 1 - 95dentists
21. How would you describe your role in your primary practice?
76% o 1. Solo practice (owner)
17% o 2. Partner
2% o 3. Associate buying into the practice
2% o 4. Associate not buying into the practice
2% o 5. Independent contractor
22. Please check your category of personal NET practice income (excluding investment or nonpractice income).
3% o 1. under $30,000
13% o 2. $30,000 - $59,999
24% o 3. $60,000 - $89,999
24% o 4. $90,000 - $119,999
15% o 5. $120,000 - $149,999
8% o 6. $150,000 - $179,999
14% o 7. over $180,000
Finally, we would like to ask a few questions about hygienists and computer usage in your office as well as give you an opportunity to make additional comments.
23. How many full- or part-time hygienists
do you employ in your practice?full-time
mean 0.7
median 0
range 0 - 11part-time
mean 0.8
median 0
range 0 - 6
24. For each hygienist, how many hours per week do they work in your practice?
Hygienist #1 (hours per week)
Hygienist #2 (hours per week)
Hygienist #3 (hours per week)
Hygienist #4 (hours per week)
Hygienist #5 (hours per week)
Hygienist #6 (hours per week)
25. Do you currently have one or more computers in your office?
346 (38%)
o 1. NO
570 (62%)
o 2. YES
Û
a. If yes, are you currently submitting any of the following insurance claims electronically (directly from a computer)?
183 (20%) o 1. Delta Dental
9 (1%) o 2. Other commercial insurers
26. Approximately how much were you reimbursed by Title XIX
for dental services in 1994?mean $18,944
median $10,000
range $0 - $300,00027. Please indicate below who completed this questionnaire (check all appropriate responses).
o 1. Dentist
o 2. Hygienist/Assistant
o 3. Office staff
o 4. Other (specify)
28. We are interested in any comments you may have about the Title XIX program.
Thank you for completing this questionnaire.
Please return it in the enclosed postage-paid envelope.
Appendix B:
Dentists Comments and Categorization of Comments for Survey Question 10
These are a summary of the comments dentists made to items g. and h. (Other) in question 10 of the survey:
10. Like many programs, Title XIX is currently under review for ways to reduce their costs. If it were to become necessary, which of the following options do you feel would be the three best ways for Title XIX to reduce costs? Please rank your first three choices from 1 to 3.
a. Eliminate all dental coverage for Title XIX recipients
b. Eliminate all dental coverage for adults
c. Reduce the number of dental services covered for adults
d. Reduce the number of dental services covered for children and adults
Eliminate coverage of orthodontic services
f. Reduce the reimbursement rates for selected dental procedures
g. Other:
h. Other:Dentists Responses:
Reduce Administrative costs
Reduce paperwork
Reduce staff
Reduce unnecessary mailings
Electronic claims submission
Accept ADA forms
Become more efficient
Eliminate consultant reviews
Change program administration from Unysis
Eliminate monthly eligibility
Hire competent help
Change eligibility
Tighten eligibility
Restrict eligibility to recipients with healthy behaviors
Eliminate nursing home patient eligibility
Increase compliance
Stress preventive services
Encourage patient responsibility and home care
Tie eligibility to patient compliance
Payment changes
Increase copayments
Set yearly maximum per patient
Stop lifetime coverage
Evaluate hospitalization policy for mentally retarded
Dentists should donate time to free clinics
Increase reimbursements to decrease fraud
Create a yearly tax credit rather than fee for service
Create a tiered fee system
Payment changes (continued)
No second billing to Title XIX
Require preauthorization of crowns
Only see Title XIX patients in public health clinics or the Dental School
Reduce frequency of exams, cleanings
Capitate payment
Eliminate transportation
Reduce Fraud
Police recipients
Police providers
No cuts
No cuts/medical cuts only
Recodes
Eliminate adult orthodontic coverage-- recoded as 10c
Dentists suggestions that were not specific ways to reduce costs
Establish a broken appointment policy
Trust dentists
Faster reimbursement
Approve replacement of posterior teeth
Make patients appreciative
Educate patients about costs
Study cost issue
Require education for parents
