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	Preface - Acknowledgements - Table of Contents - Figure & Table List - Summary Preface In September 1995, the Iowa Prevention of Disabilities Policy Council contracted with Dr. Michael Kanellis and others at the University of Iowa College of Dentistry to educate dentists and physicians in Iowa about the oral health component of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program and to develop an EPSDT dental registry listing dentists in the state who are willing to accept into their practice children as young as one year of age who are enrolled in Title XIX. The need for this project arose when a number of physicians across the state reported problems finding dentists who were willing to accept referrals of children enrolled in Title XIX following their EPSDT screening examinations. As the project progressed, it became evident that there were three main reasons dentists were unwilling to accept children as young as one year of age enrolled in Title XIX: some dentists were not interested in treating children, (especially those under age 3), some were unconvinced of the need to examine children at one year of age, and many were not accepting any new Title XIX patients in their practice. This project, as a result, was expanded beyond the EPSDT registry to include: 1) the education of Iowa dentists and physicians about the oral health component of the EPSDT "Care for Kids" program and the importance of early dental examinations; 2) an evaluation of the utilization of dental services by children age five and under enrolled in Title XIX; 3) a study of the participation of Iowa dentists in the Title XIX program and factors affecting their participation; 4) a comparison of fees reimbursed by the Title XIX program to the average fees of Iowa private practice dentists; and 5) the development of a list of policy options for improving the Title XIX dental program. Throughout this report the term 'Title XIX' is used to represent the Medicaid program that was created as 'Title XIX' of the Social Security Act. Because most practicing dentists in Iowa more commonly refer to the Medicaid program as Title XIX, we have used this terminology throughout this report. This project was conducted by faculty and staff researchers at both the University of Iowa College of Dentistry and the Public Policy Center. Partial funding for this project was provided by the Iowa Department of Human Services and the Iowa Prevention of Disabilities Policy Council. Acknowledgments The authors would like to thank Ms. Kay DeGarmo, Coordinator of the Iowa Prevention of Disabilities Policy Council; Dr. Alfred Healy, Director of the Division of Developmental Disabilities, Department of Pediatrics; the members of the Iowa Prevention of Disabilities Policy Council; and Mr. Don Herman, Division Administrator, Division of Medical Services, and Ms. Sally Nadolsky, EPSDT Coordinator, Iowa Department of Human Services. Without their support this project could not have been conducted. Their recognition of the importance of access to oral health care for Title XIX recipients is greatly appreciated. The authors would also like to acknowledge Ms. Ann Kahler at the University of Iowa Hospital School Dentistry Department who has done an excellent job administering the EPSDT dental registry. The Iowa dentists who filled out the survey are also to be commended for their efforts in completing one more piece of paperwork, as is Mr. Robert Harpster of the Iowa Dental Association for his helpful comments on both the draft of the survey instrument and the final report. Thanks go to Mr. Dean Drevlow of the Professional Economics Bureau, who supplied information on the fee schedules of over 240 Iowa dentists, and to the Iowa dentists themselves, who sent us their fee schedules for use in the comparison of Title XIX fees to private practice fees. Drs. Chuck Blackburn, Bruce Anderson, Chad Stevenson, and Tad Mabry, former and current dental officers with the US Public Health Service, Indian Health Service (IHS), responded promptly to our request for information regarding the IHS levels of care. A number of individuals contributed time and effort critically reviewing a draft of this final report. Their comments were extremely helpful in making this a better report. Outside reviewers include Dr. William Maurer, Dental Director, Iowa Department of Public Health; Dr. Edward Schor, Medical Director, Iowa Department of Public Health; Dr. Robert Isman, California Department of Health Services; Dr. Joe Barsetti, pediatric dentist, Des Moines, IA; and Ms. Kay Leeper, Community Health Consultant, Iowa University Affiliated Program. University of Iowa colleagues include Drs. Doug Wakefield and Elizabeth Swanson, Associate Vice-Presidents for Health Sciences; Dr. Stacey Cyphert, Assistant to the Vice-President for Statewide Health Affairs and chair of the Iowa Medicaid Advisory Council; Dr. Art Nowak, Department of Pediatric Dentistry; and Dr. John Warren, Department of Preventive and Community Dentistry. We owe special thanks to our University of Iowa colleagues at the Public Policy Center and the College of Dentistry. At the Public Policy Center Mr. Chris Sheets provided valuable research assistance, Ms. Anita Makuluni edited this report, Ms. Carolyn Goff provided administrative support, and the Director, Professor David Forkenbrock, placed the resources of the Center at our disposal for this project. Drs. David Johnsen and Jed Hand at the College of Dentistry provided advice andguidance throughout this project. Table of Contents PREFACE ...................................................................................................................................... ACKNOWLEDGMENTS ....................................................................................................................................... LIST OF FIGURES ....................................................................................................................................... LIST OF TABLES ....................................................................................................................................... EXECUTIVE SUMMARY ....................................................................................................................................... CHAPTER 1: THE EPSDT DENTAL REGISTRY AND DENTISTS' VIEWS ON TREATING YOUNG CHILDREN ....................................................................................................................................... Dental Screening of Children ....................................................................................................................................... EPSDT Dental Registry ....................................................................................................................................... Iowa Dentists' Treatment of Young Children ....................................................................................................................................... Summary ....................................................................................................................................... CHAPTER 2: UTILIZATION OF DENTAL SERVICES BY CHILDREN AGE 5 AND UNDER ENROLLED IN TITLE XIX ....................................................................................................................................... Operating Room-based Dental Care ....................................................................................................................................... Summary ....................................................................................................................................... CHAPTER 3: DENTISTS' PARTICIPATION IN AND ATTITUDES TOWARD THE IOWA TITLE XIX PROGRAM ....................................................................................................................................... Description of Dentists and Their Title XIX Participation ....................................................................................................................................... Dentists' Attitudes Toward the Title XIX Program ....................................................................................................................................... Satisfaction with the Title XIX program ....................................................................................................................................... Treatment of low-income patients ....................................................................................................................................... Problems with participating in Title XIX ....................................................................................................................................... Most important factors affecting Title XIX participation--Logistic regression analysis ....................................................................................................................................... Summary ....................................................................................................................................... CHAPTER 4: DENTAL SERVICES PROVIDED TO TITLE XIX RECIPIENTS AND AN EVALUATION OF TITLE XIX REIMBURSEMENT LEVELS ....................................................................................................................................... Summary ....................................................................................................................................... CHAPTER 5: POLICY OPTIONS FOR IMPROVING THE IOWA TITLE XIX DENTAL PROGRAM ....................................................................................................................................... Dentists' Suggestions for Change ....................................................................................................................................... Policy Options ....................................................................................................................................... Policy discussion of ways to improve access to dental care for very young children ....................................................................................................................................... Policy options for adults ....................................................................................................................................... Additional suggestions ....................................................................................................................................... REFERENCES ....................................................................................................................................... APPENDIX A: 1995 SURVEY OF IOWA DENTISTS AND SURVEY RESULTS ....................................................................................................................................... APPENDIX B: DENTISTS COMMENTS AND CATEGORIZATION OF COMMENTS FOR SURVEY QUESTION 10 ....................................................................................................................................... List of Figures 1-1Geographical distribution of dentists in the EPSDT dental registry 1-2 Recommended activities for EPSDT dental screening of infants and young children 3-1 Number of dentists who discontinued their acceptance of new Title XIX patients, by year acceptance was discontinued List of Tables 1-1 EPSDT oral health screening and referral schedule 1-2 Recommended age for first dental visit 1-3 Youngest age of patient dentists are willing to see 1-4 Iowa dentists' recommended intervals of routine dental exams for children under six years of age 2-1 Thirty-eight most common dental procedures used in analyses of dental utilization, by service category 2-2 Iowa Title XIX enrollment, by age, FY 1994 2-3 Length of eligibility, FY 1994 2-4 Children receiving any dental service, by age, FY 1994 2-5 Children receiving an initial or periodic exam, by age, FY 1994 2-6 Children receiving a prophylaxis, by age, FY 1994 2-7 Children receiving treatment services, by age, FY 1994 2-8 Cost by type of service for the 38 most common services, by age, FY 1994 2-9 Children age five and under enrolled in Title XIX receiving dental care in an operating room, by age, FY 1994 2-10 Difference between hospital and dentist charges and the allowed charges for operating room dental care for children age 5 and under enrolled in Title XIX, FY 1994 2-11 Operating room dental care broken out by hospital and dentist allowed charges for children age 5 and under enrolled in Title XIX, by age, FY 1994 2-12 Most common dental procedures provided in the operating room, FY 1994 3-1 Description of dentists and their participation in the Title XIX program 3-2 Iowa dentists' participation in the Title XIX program 3-3 Acceptance of all new Title XIX patients by percent of Title XIX patients and Title XIX self-reported reimbursements in FY 1995 3-4 Dentists' consideration of future participation in Title XIX 3-5 Acceptance of all new Title XIX patients by dentists' perception of how busy they are 3-6 Percentage of dentists agreeing or disagreeing with aspects of the Title XIX program 3-7 Percent of dentists agreeing or disagreeing with aspects of treating Title XIX patients 3-8 Percent of dentists reporting certain aspects of Title XIX as very important in their office 3-9 Factors significantly related to being a full participant in Title XIX as determined by logistic regression analysis 4-1 Number of procedures and Title XIX total allowed charges for selected dental procedures (FY 1994) 4-2 Comparison of average private practice fees with Title XIX reimbursement rates for the most common dental procedures 5-1 Dentists' preferences if changes are to occur in the Title XIX dental program 5-2 Estimated impact of increasing reimbursement for pediatric dental procedures to 75 percent of the average fee in Iowa 5-3 Potential impact of increasing reimbursement for adult dental procedures to 75 percent of the average fee in Iowa 5-4 US Public Health Service levels of dental care Executive Summary The purpose of this project was to assist the Iowa Department of Human Services (IDHS) in providing access to dental care for Title XIX recipients, evaluate aspects of Title XIX dental program in Iowa, and to develop a series of policy options for improving the program. The project arose from the concern of some Iowa physicians who reported difficulty locating dentists willing to accept the referral of Title XIX enrolled children (especially those as young as age one), following an EPSDT screening. This project began with the establishment of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Dental Registry, combined with a series of educational activities with Iowa physicians and dentists about the EPSDT Dental Registry and the importance of examining children as young as one year old. Further investigation evaluated the dental utilization of Title XIX enrolled children, the level of Iowa dentists' participation in the Title XIX program, a comparison of Title XIX reimbursement with average private practice fees in Iowa and the development of some options to improve the program. This report includes a detailed discussion of: • The EPSDT registry of Title XIX participating dentists and the education of Iowa dentists and physicians about the oral health component of the EPSDT "Care for Kids" program; To help identify dentists who would be willing to accept a Title XIX enrolled child as young as one year old, a statewide EPSDT dental registry was established. The EPSDT dental registry acts as a reference guide for social service agencies, physicians, dentists and other health care professionals attempting to identify dentists willing to provide EPSDT dental services to children as early as age one. Interested health care professionals can call the University of Iowa Department of Pediatric Dentistry, and receive the name of the closest dentist who has agreed to participate. Currently included in this registry are 189 dentists from 67 Iowa counties and four bordering states. Dentists were recruited to participate in the EPSDT dental registry and were educated about the need for children to receive a dental examination by age one in several ways. In March of 1995, a letter was sent to all dentists with a current Iowa Title XIX provider number requesting their permission to have their name placed in the EPSDT dental registry. Second, educational activities concerning the EPSDT program and the need to see children enrolled in Title XIX at one year of age were conducted around the state, including district dental meetings. During the summer of 1995, every dentist and physician in the state of Iowa received a copy of the EPSDT "Care for Kids" Newsletter, which focused on oral health care issues. In the October 1995 edition of the Iowa Dental Journal, an article appeared entitled "Care For Kids: Iowa's EPSDT Program". Both the Summer newsletter and the Iowa Dental Journal article included a list of recommended activities to be carried out at EPSDT dental screenings by the Iowa Department of Human services. • The utilization of dental services by Title XIX enrolled children age five and under During FY 1994, 14,889 children age 5 and under received dental services (31% of all enrolled children based on full-time equivalents (FTE)). The Title XIX allowed charges for this care during FY 1994 totaled $1,927,316 (allowed charges are the amount Title XIX would pay for a procedure without consideration of copayments, third party coverage, or patient costs prior to eligibility for the medically needy program). This was an average of $129 per child who received any dental care and includes hospital costs associated with treating some children in the operating room under general anesthesia. The allowed charges for the dentists' portion of this amount was $1,531,658 while the hospital portion was $395,658. The total allowed charges for the 317 children who received dental care in the hospital operating room was $559,348 ($143,690 of which was for the dentists' allowed charges) at an average of $1,701 per case. The dental office-based care totaled $1,387,968 in allowed charges for an average of $93 per child treated. Therefore, the operating room-based dental care that was provided to two percent of Title XIX enrolled children age five and under who received a dental service in FY 1994 accounted for 29 percent of all allowed charges for dental services to this group of children. If the allowed charges for anesthesia, pre-operative and post-operative care were included, the percentage of all allowed charges used by children receiving dental care in an operating room would be even higher. Excluding hospital allowed charges, dental care for Title XIX enrolled children treated in the operating room accounted for almost 10 percent of all dollars spent on dentists' services. Average costs for operating room dental care increased with age, probably as a result of older children having more severe oral health problems at the time of their visit. Two-year-olds were the most likely to have received dental care in the operating room. This is due, at least in part, to inappropriate use of the baby bottle (e.g., sleeping with the bottle). • Attitudes and participation of Iowa dentists in the Title XIX program and factors affecting their participation; To evaluate the attitudes and the lack of participation of Iowa dentists concerning the Title XIX program and their attitudes about treating children, a written questionnaire was mailed to all full-time, actively practicing dentists in Iowa (N=1,233) in October 1995. Eleven percent of responding dentists thought that children should be seen by age one, 35 percent thought children should be seen by age two or less and 84 percent believed that children should visit a dentist by age three or less. Twenty-six percent of dentists reported they were willing to accept patients as young as one year of age, increasing to half of the responding dentists at two years of age. Over 80 percent were willing to see three-year-olds. Dentists' participation in Title XIX declined significantly between 1992 and 1995. Forty-two percent of all Iowa dentists reported accepting all new Title XIX patients in 1995 compared to 62 percent in 1992. Thirty-six percent of dentists were not accepting any new Title XIX patients in their practice in 1995 compared to 21 percent in 1992. On average, eight percent of the patients in an Iowa dentist's practice in 1995 were covered by Title XIX. 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. About two thirds of the dentists who are currently accepting new Title XIX patients indicated they had seriously considered changing their policy during 1995. The two most important problems Iowa dentists indicated about the program 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 accepting all new Title XIX patients. These included their area of practice (oral surgeons were more likely to accept all new Title XIX patients, while orthodontists were less likely), practice location in a town under 20,000 (except very rural areas under 2500), having a more positive view toward the administration of Title XIX program, feeling less busy in their practice, and indicating a belief that dentists have an ethical obligation to treat Title XIX patients. • Fees reimbursed by the Title XIX program compared to fees of Iowa private practice dentists Allowed charges for all Title XIX dental services during FY 1994 totaled $20,251,528. Title XIX fees averaged 62 percent of the average private practice dental fees in Iowa; some of the more common and desirable procedures (exams, routine fillings) had among the lowest allowed charges compared to average private practice fees. If fees were uniformly increased to 75 percent of the average fees in Iowa (assuming no increase in utilization), the cost to the Title XIX program for a select group of procedures for children is estimated to be $700,000, while for adult services it is estimated to be $450,000. • Policy options for improving the Title XIX dental program In the written survey, dentists rank ordered a series of options for possible changes if the budget for the Title XIX program needed to be reduced. The dentists' top three choices were: the elimination of orthodontic coverage (a 34 percent), selective reduction in services for adults (27 percent score), and the elimination of adult coverage (11 percent score). The potential policy options developed from the comments of the dentists includes: For children... Policy option 1: Increase reimbursement levels for dentists who provide routine care including EPSDT screenings to young children Policy option 2: Develop alternative methods of providing dental screenings, education and referrals to Title XIX enrolled children under age 3. Policy option 3: Establish and monitor an indicator of the effectiveness of the Title XIX dental program For adults... Policy option 1: Retain current benefit package for adults but increase fees closer to dentists' UCR fees Policy option 2: Provide only selective dental services for adults Policy option 3: Provide only emergency services for adults Policy option 4: Eliminate all adult dental services Policy option 5: Provide dental care to only certain Title XIX-enrolled populations Policy option 6: Establish a managed dental care plan Policy option 7: Implement a yearly maximum dollar amount of coverage Policy option 8: Increase recipient copayments Listed below are additional suggestions, including those made by dentists in the survey to improve the efficiency of the program and reduce the perceived hassles associated with participating in the Title XIX dental program. • Use a standard claims billing form such as the one developed by the American Dental Association along with the ADA standard list of procedure codes. • Improve the program's relationship with dentists. • Establish a dental advisory committee for the Title XIX program • Accept electronic submissions of dental claims. • Establish a way to reduce the number of broken dental appointments. • Reduce mailings concerning administrative changes to the Title XIX program that do not include dental issues.