ACCESS TO DENTAL CARE FOR LOW INCOME CHILDREN IN … to Dental... · Access to Dental Care for Low-Income Children in Illinois, December 2000 - 4 - • Total dental claims expenditures

Gayle R. ByckHollis J. Russinof

Judith A. Cooksey

December 2000

ACCESS TO DENTALCARE FOR LOW-INCOME CHILDREN INILLINOIS

CONTENTS

Executive Summary 3Introduction 6Background 7

Children’s Oral Health and Dental Care 7The Dental Workforce 9Illinois Medicaid Dental Program 12

The Illinois Study of Access to Dental Care for Medicaid Enrolled Children 13Illinois Dental Workforce 15Children’s Utilization of Dental Care 20Dentists Participation in the Medicaid Program 25Projecting Dentist Capacity 28Summary of Findings 33

Policy Initiatives by Midwestern States to Increase Access to Dental Care 35Problems 36Initiatives 37Summary of Findings 43

Study Limitations 45Policy Recommendations 46References 50Appendices 53

This report was prepared by:Gayle R. Byck, PhD, Hollis J. Russinof, MUPP, and Judith A. Cooksey, MD, MPH

We would like to acknowledge the research assistance of Terri Febbraro, LouiseMartinez and Catherine McClure.

Illinois Center for Health Workforce StudiesUniversity of Illinois at Chicago850 West Jackson Boulevard, Suite 400Chicago, Illinois 60607www.uic.edu/sph/ichws

December 2000Funding was provided by the Health Resources and Services Administration, Bureau ofHealth Professions and Bureau of Primary Health Care, and in collaboration with theIllinois Primary Health Care Association

http://www.uic.edu/sph/ichws

Access to Dental Care for Low-Income Children in Illinois, December 2000 - 3 -

EXECUTIVE SUMMARY

While children’s oral health has improved over the past forty years, many children haveinadequate dental care. In the last several years, national attention has focused on the problem oflimited access to dental care for low-income children. The causes of low access to dental careare complex. The lack of dentists willing to provide care to children with Medicaid has beencalled the most significant barrier to dental care. Most states are taking steps to expand dentists’participation, with the expectation that this will increase the number of children treated.

This situation prompted the Illinois Center for Health Workforce Studies (Center) at theUniversity of Illinois at Chicago (UIC) to conduct a study of access to dental care for Illinoislow-income children. This study was a collaborative effort of the Center and the Illinois PrimaryHealth Care Association (IPHCA). Data were obtained from the American Dental Association,the Illinois Department of Public Aid, (IDPA) and Doral Dental Services of Illinois (Doral).Funding for the study was provided by the Bureau of Health Professions and the Bureau ofPrimary Health Care of the Health Resources and Services Administration.

The study was conducted as three components:• a description of the supply, distribution, and characteristics of Illinois dentists, using

ADA data.• an analysis of Medicaid children’s dental services for the 12-month period of March 1999

through February 2000; data for this analysis were provided by IDPA and Doral. Thisanalysis describes the dental care expenditures and dental care utilized by childrenenrolled in the Illinois Medicaid program (this includes all children enrolled throughMedicaid and the State CHIP program, KidCare). The dentists’ participation in Medicaid,through enrollment numbers and care provided, is also described. Since one of theoriginal study goals was to assess the capacity of Illinois dentists to provide care toMedicaid children, this component concludes with three scenarios that estimate thenumbers of participating dentists needed to provide care to various target numbers ofchildren.

• an analysis of steps taken by Illinois and six surrounding states to address the problems oflow access to dental care for children with Medicaid.

The findings of this study demonstrate relatively low utilization rates for dental care amongIllinois children with Medicaid and limited levels of Medicaid participation by Illinois dentists.The data are presented for Illinois as well as for seven regions of the state. The key findings aresummarized here:

• Statewide, 33% (271,152) of children enrolled in Medicaid or KidCare utilized dentalcare during the year. Illinois children in the 4-5 and 6-12 year-old age groups had thehighest proportion visiting a dentist in the year (about 50%). The very young children(under three years of age) and adolescents had lower utilization rates. While 38% ofenrolled children in Cook County visited a dentist, the remainder of the State was below30%.


• Total dental claims expenditures were $29.17 million; the average expenditure per userwas $108.

• 34% (2034) of active general and pediatric dentists were enrolled in Medicaid. Ofenrolled dentists, 25% did not participate at all during the year, 39% submitted 1-100services, 28% submitted 101-999 services, and 8% submitted 1,000 services or more.

• The population-to-dentist ratios can be interpreted to mean, at the state level, that at 57%utilization by Medicaid/KidCare enrolled children, each of the 2,034 enrolled dentistswould need to treat 229 children, or each of the 1,537 participating dentists would need totreat 304 children; at two visits per child per year, these numbers would representsubstantial percentages of a dental practice’s visits. Currently, only 165 dentists providedat least 1,000 services during the year (treating an estimated 185 children at an average of5.4 services per dental service user).

• The regional variation in both Medicaid children’s utilization and enrollment andparticipation of dentists underscores the importance of examining access and workforceissues at small geographic levels.

• All seven states have undertaken a number of recent initiatives to address the problem ofaccess to oral health care for Medicaid-enrolled children. Each state has formallyacknowledged the problem through the formation of an advisory committee or task force.The most common changes in state programs and policies focused on increasing privatepractice dentist participation. However, in spite of the numerous and varied measurestaken by these states, all seven states reported on-going problems with access to oralhealth care for low-income children.

Based on our study and on discussions with groups in Illinois, the following recommendationswere made; they are discussed in greater detail in the report:

• Policy Recommendation 1: More dentists should be recruited to enroll in the Medicaidprogram. Efforts should be made to increase the number of children treated by currentlyenrolled dentists. This recommendation includes discussion of: adequate reimbursementrates; outreach to enroll new dentists in Medicaid; increasing participation levels ofcurrently participating dentists

• Policy Recommendation 2: Consider options to increase the dentist supply in under-served areas of Illinois.

• Policy Recommendation 3. Explore the feasibility of maintaining or expanding thecapacity of dental clinics known as safety net providers, such as community healthcenters, local health departments and others.

• Policy Recommendation 4. Encourage the integration of oral health care with primaryhealth care.

• Policy Recommendation 5. Enhance dental school training to include population-basedstudies of oral and dental disease among the high-risk groups, the problems with accessto dental care, and public health dentistry. Expose dental students to community basedprivate practices and safety net clinics where high-risk children are receiving care.

• Policy Recommendation 6. Expand the role of dental hygienists in the care of Medicaidchildren.


• Policy Recommendation 7. Establish a statewide oral health surveillance system.• Policy Recommendation 8. Expand community based preventive programs.

This study provides detailed information on the status of children’s dental services – utilizationand provider participation - in the Illinois Medicaid program during the study year. It alsoprovides scenarios for projecting the capacity of dentists to treat Medicaid enrolled childrenunder various scenarios. It is hoped that the information presented here will contribute to aclearer understanding of access to dental care for low-income Illinois children as well as todental workforce supply and planning. Further research on the role of safety net dental clinics inexpanding access to dental care for low-income children, and on the characteristics of dentistswho participate in the Medicaid program, would add to our understanding of how to addressproblems with access to dental care for low-income children.


INTRODUCTION

Children’s oral health has improved over the past forty years, due to fluoridation, improved oralhygiene, better nutrition, and access to oral health care services. However, oral problems relatedto dental caries or cavities (painful teeth, missing teeth and poor appearance, impairments inchewing and nutritional limits) and other oral conditions affect the health and well-being ofchildren and lead to missed school days and ongoing dental problems. While oral health careservices are an important component of comprehensive primary care services, many childrenhave inadequate dental care. In the mid-1990s, only one in five children with Medicaid receiveddental care in a year. In Illinois, only 27% of children with Medicaid received dental care in1998 (Holland, 1999).

In the last several years, national attention has focused on the problem of limited access to oralhealth care for low-income children. The Surgeon General’s Report on Oral Health in Americahas called oral health disease a “hidden epidemic” (US DHHS, 2000). The Healthy People 2010Program, a national public health agenda, has identified several targets to increase access todental care and to reduce the rates of decay and untreated caries.

The causes of low access to dental care are complex and include problems within the Medicaidprogram (payments, billing, client eligibility, services covered); limited participation by dentists;a limited number and limited capacity of public facilities offering oral health care services; and avariety of barriers facing children and their families that range from beliefs and attitudes aboutdental care to transportation problems. The lack of dentists willing to provide care to childrenwith Medicaid has been called the most significant barrier to dental care. Most states are takingsteps to expand dentists’ participation, with the expectation that this will increase the number ofchildren treated (GAO, 2000a).

This situation prompted the Illinois Center for Health Workforce Studies (Center) at theUniversity of Illinois at Chicago (UIC) to conduct a study of access to dental care for Illinoislow-income children. The purpose of the study was to assess the capacity of Illinois dentists’ tomeet the dental care needs of low-income children of Illinois, specifically those covered byMedicaid and KidCare, the State Children’s Health Insurance (CHIP) program. This study was acollaborative effort of the Center and the Illinois Primary Health Care Association (IPHCA) andwas conducted from November 1999 through September 2000. This report summarizes thefindings of the study and concludes with recommendations. An Advisory Committee assistedwith the study and reviewed this Report. Funding for the study was provided by the Bureau ofHealth Professions and the Bureau of Primary Health Care of the Health Resources and ServicesAdministration.

The study was conducted as three components. The first describes the supply and distribution ofdentists in Illinois. The second describes dental expenditures and children’s utilization of dentalcare and the participation of dentists in the Illinois Medicaid program. The findings from theseanalyses are presented for seven regions of the State to allow comparisons across regions of theState. The third component assessed the perspective of seven Midwestern states, includingIllinois, on their views of the problems contributing to low access and the steps being taken toaddress the problems.


We are grateful to each of the organizations that supplied the data used in this study, specificallythe American Dental Association, the Illinois Department of Public Aid, and Doral DentalServices of Illinois. We also acknowledge the contributions and time given by the intervieweesfrom the seven states who shared information, reports, and background materials.

BACKGROUND: CHILDREN’S ORAL HEALTH STATUS AND DENTAL CARE

Children’s Oral and Dental Health StatusNational population surveys have noted a decline over time in the number of children with dentalcaries and the numbers of teeth with decay. The percent of children ages 6 to 11 years withdental caries in permanent teeth declined from 56% in 1971 to 23% in 1987; the percent ofadolescents, ages 12 to 17 year, with caries declined from 90% to 71%. These rates havecontinued to decline, but some population subgroups have had persistent higher rates of dentalcaries and untreated caries. About 25% of children (principally low-income) have untreatedcaries, and these children have about 80% of the total population estimates of untreated caries inpermanent teeth (GAO, 2000b; US DHHS, 2000). Further analyses of national survey data thatinclude socioeconomic characteristics of children have shown significant effects of ethnicity andpoverty on untreated dental caries. The most recent national examination survey (NHANES III,1988-1994) found higher caries rates among Blacks, Mexican Americans, and low-incomechildren (Vargas, 1998). These data show significant income effects, with higher rates ofuntreated caries among lower income groups.

Data on Illinois children’s caries rates were collected during a statewide oral health survey ofschool-aged children conducted in 1993-94 (IDPH, 1996). This was the first and onlycomprehensive statewide oral health survey ever conducted in Illinois. This study found that54% of children had caries in primary or permanent teeth. Twenty-three percent of children hadcaries in permanent teeth (16% of children 6 to 8 years of age, and 57% of children 13 to 14years of age). Untreated caries (in either permanent or primary teeth) were more common inyounger children, with 38% of children 6 to 8 years of age with untreated caries, and 30% ofthose 15 years of age. Higher caries rates were noted for Black and Hispanic children comparedto white children.

Children’s Dental CareRoutine dental care for children includes diagnostic exams, preventive services (prophylaxis,applications of fluoride, sealants, and oral health education) and restorative care (filling cariousteeth). National household survey data on dental care utilization, defined as any visit in a year,have shown substantially lower utilization rates for several population subgroups with onlylimited changes over the twenty year period of 1977 to 1996 (Table 1). Dental visit rates forchildren under six years of age have increased only from 14% to 21%; older children’sutilization has been relatively stable at about fifty percent (Moeller, 1996; Edelstein, 2000).Utilization rates for Hispanics and Blacks are lower than Whites and dental visit rates haveremained lower among low-income children. Of note is the declining number of visits per useracross each time period.


1977 1987 1996Under 6 years 14% (2.2) 20% (1.7) 21% (1.6)6 to 18 years 51% (3.6) 51% (3.2) 52% (2.9)White 44% (3.3) 47% (2.9) 49% (2.9)Black 23% (2.5) 26% (2.4) 27%Hispanic 30% (3.2) 26% (2.5) 39%Poor 28% (3.2) 24% (2.5) ---Low income 32% (3.2) 30% (2.7) 30% (2.1)High income 53% (3.4) 56% (3.0) 60% (3.1)Source: Edelstein, Manski, and Moeller, 2000; Moeller and Levy, 1996.

Table 1: Use of Dental Services, Percent of Children with any Visit in a Year, Mean Number of Visits by Users (parentheses) by age, Race and Family Income, 1977, 1987, 1996

In 1996, only 43% of all children visited a dentist in the year. The total visits for children wereestimated at 87 million total visits, or 2.7 visits per child using services. In contrast, only about25% of children with Medicaid visited a dentist in a year. Studies show that children who hadpreventive medical visits are more likely to have had dental visits (Milgrom, 1998). Nationaldata indicate that the proportion of children who have a medical visit in past year is much higherthan the proportion who have a dental visit (74% vs. 43%; Table 2). Of those who had anambulatory medical visit, the average number of visits was 4.2. Even among publicly insuredchildren, 71% of these children had an ambulatory medical visit in the past year, and averaged 4visits per year. The disparity between medical and dental visits for younger children is mostnotable.

Table 2: Use of Medical and Dental Care by Children Under Age 18: United States, 1996

Population Characteristic

Percent with at least 1 ambulatory medical

care visit

Mean number of ambulatory medical

care visits

Percent with at least 1 dental care visit

Mean number of dental care visits

Total Children 74.2 4.2 42.7 2.7Age Under 6 85.1 4.4 21.5 1.6 6-12 69.8 3.6 54.8 2.5 13-17 67.1 4.6 51.2 3.7Health Insurance Any private 79.2 4.5 n/a n/a Public only 70.9 4.1 n/a n/a Uninsured 57.8 3.0 n/a n/a

Source: Krauss, Machlin, and Kass, 1996.


Public Health Objectives For Oral Health and Access to Dental CareHealthy People 2010 includes oral health objectives for the nation to reach by the year 2010(Healthy People 2010). Several of these are relevant to this study and are presented below withbaseline measures and target for each objectives. Note that these objectives are set for the entirepopulation and the low-income population generally starts from a baseline that is significantlybelow that of the general population.

Table 3: Selected Health People 2010 Oral Health Objectives

Target 2010 Baseline

Reduce the number of children with dental caries in primary or permanent teeth 2-4 yrs: 11% 2-4 yrs: 18%6-8 yrs: 42% 6-8 yrs: 52%15 yrs: 51% 15 yrs: 61%

Reduce the number of children with untreated caries 2-4 yrs: 9% 2-4 yrs: 16%

6-8 yrs: 21% 6-8 yrs: 29%15 yrs: 15% 15 yrs: 20%

Increase the number of children with sealants on their molars 8 yrs: 50% 8 yrs: 23%14 yrs: 50% 14 yrs: 15%

Increase the number of children and adults who use the oral health care system each year 83% 65% ( > 2yrs age, 1997)Increase the proportion of the population served by water systems with optimally fluoridated water 75% 62% (1992)Increase the number of children (<200% of FPL) receiving any preventive dental services 57% 20% (1996)Increase the number of local health departments and community health centers with oral health services 75% 34% (1997)

THE DENTAL WORKFORCE

The American Dental Association (ADA) maintains datasets that allow for several types ofanalyses of dentists in the United States, irrespective of whether they are members of the ADA.In 1996 there were 154,900 active dentists in the US, when adjusted to the total population, thisyields a dentist-to-population ratio of 58 dentists to 100,000 population (US DHHS, 1999). Theoverall supply of dentists is predicted to grow somewhat slower than the population over the nexttwenty years, due to reduced dental school graduates. Due to concerns in the 1980s about apotential oversupply of dentists, and a declining dental school applicant pool, dental schoolsreduced their enrollments and several dental schools closed. At the national level, graduatesdeclined from 5,700 in 1983 to 3,900 in the mid-1990s. Two of the four Illinois dental schoolshave closed (Loyola and Northwestern). In Illinois, the total graduates declined from over 400per year in the mid-1980s to about 110 in 2001.

Dental care is largely a private practice model, with solo practitioners accounting for about two-thirds of dental practices, and smaller numbers of dentists in two and three person practices.Almost 93% of dentists who are professionally active are in private practice; others are dentalschool faculty, or employed by the armed services, government, other health organizations, or in


training (ADA, 2000a). In 1998, 14% of all active dentists were women (ADA, 2000a). The agedistribution of dentists included 14% under 35 years of age, and 25% at 55 years and older.

Eighty-one percent of dentists practice as general dentists with the remaining classified in theeight specialties of dentistry1. Pediatric dentists constitute about three percent of all dentists andthey provide both specialty dental care to children with complex medical, dental andpsychosocial needs, and basic dental care to healthy children. The geographic distribution ofpediatric dentists is largely in metropolitan and suburban areas, with fewer than five percentpracticing in rural areas (Erickson, 1997). There are limited data on the portion of children’sdental care that is provided by pediatric dentists, however due to their numbers, general dentistsare considered to be the major provider of dental care for children. Because of the reluctance ofsome general dentists to treat the very young or preschool aged child, pediatric dentists mayprovide care to a larger number of the very young children.

The 1998 ADA surveys of dentists in private practice reported an average of 47.6 weeks workedper year, with 36.9 hours per week in the office, and 33.4 hours per week in direct patient care(ADA, 2000a). This yields an average work year of about 1,590 patient care hours. Dentists’productivity, in terms of visits per year, varies substantially with the use of dental hygienists,with 2,640 visits per year for dentists without hygienists and 3,740 for dentists with hygienists.Productivity also varies by age, with full-time dentists 55 years and older treating fewer patientsper year (2,331 visits, excluding dental hygienist appointments) compared to 2,811 visits fordentists younger than 35 years, and 2,674 and 2,784 patient visits per year for dentists age 35-44and 45-54, respectively (ADA, 2000a).

There are approximately 100,000 active dental hygienists in the United States. The majority ofdental hygienists are employed by general practice dentists. Of students enrolled in dentalhygiene schools in 1997-1998, 97% were women and 12% were minorities (ADA, 2000b).

Dental hygiene focuses on health promotion and disease prevention. Dental hygiene servicesfocus on oral health education and dental prophylaxis, as well as applying dental sealants andfluoride treatments (ADHA, 2000). Thirty-five states have laws for varying forms of generalsupervision, which means that a dentist must authorize the procedures a dental hygienistperforms, but the dentist does not need to be physically present while the hygienist is treating thepatients. Proponents of general supervision believe it expands access to preventive services forunder-served populations by allowing dental hygienists to practice without a dentist physicallypresent in such locations as public health facilities, schools, nursing homes, hospitals, andprisons (ADHA, 2000).

Several states have experimented with expanded functions and less restrictive supervisionrequirements for registered dental hygienists to increase access to dental care for Medicaidpopulations. Under an EPSDT Exception to Policy, registered dental hygienists in Iowa canprovide clinical services, including sealants and fluoride varnishes, in designated maternal andchild health settings. These agencies can bill the state Medicaid program and be reimbursed forservices performed by hygienists in their employment. Connecticut has a program which allows 1 In October 1999, the ADA recognized Oral & Maxillofacial Radiology as a ninth dental specialty; however, nodata were available on the number of dental radiologists.


dental hygienists in public health settings to provide certain preventive services to Medicaidchildren without the direct supervision of a dentist (Tobler, 1999). California, Oregon, andWashington State allow for direct reimbursement from Medicaid to dental hygienists (ADHA,1999).

Dentists’ Participation in Care of Medicaid ChildrenA 1998 ADA survey found that 61% of dentists reported not treating any patients who werecovered by public assistance in their practices. State level studies of dentists’ participation inMedicaid programs over almost twenty years describe a fairly consistent picture of a modestnumbers of dentists enrolled in programs, with fewer dentists actually treating any children, andeven fewer dentists treating a large volume of children. Michigan researchers surveyed dentistsin 1983 and found that almost 50% of dentists were treating no Medicaid patients (children andadults); 29% reported that less than 10% of their patients were Medicaid; and 22% reported thatmore than 10% of their patients were Medicaid (Lang, 1986).

Surveys of dentists in California and Connecticut identified low Medicaid payment rates as themost important reason cited by dentists who limit their participation in Medicaid, followed bybilling and administrative burdens, poor patient compliance with keeping appointments, andlimited services covered (Damiano, 1990, Nainar, 1996). Studies of the relationship between feeincreases and dentists’ participation in state Medicaid programs have shown complex responses.When Medicaid fees were raised in Connecticut to 80% of the UCR rate (from about 35%),surveyed dentists (identified as pediatric and general dentists interested in treating children)reported a mixed response (Nainer, 1997). About half of the responding dentists indicated theywere accepting new Medicaid children, others commented that the fee increases would not affecttheir practices.

A recent survey of state Medicaid directors conducted by the U.S. General Accounting Office(GAO) found that 40 states had increased fees to attract more dentists to their programs. Resultsof these efforts were mixed with 14 states reporting increases in dentist participation or dentalutilization (generally, less than 3% increase in dental utilization); 15 states reported no changesin dentist participation or dental utilization; and 11 states could not yet assess an effect (GAO,2000a). This study found that the states with lower fees tended to have less effect on attractingmore dentists. This report also used the measure of treating 100 patients (children or adults) asan indication of substantial participation by dentists and based this on an ADA survey of dentistsin private practice where 100 represented about ten percent of the average patients treated in ayear.

There are some data available on dentists’ willingness to take Medicaid patients based ondentists’ demographic characteristics. Several studies have shown that older dentists and/ordentists in practice longer are less likely to accept Medicaid patients (Lang, 1986; Mayer, 2000;Milgrom & Riedy, 1998; Venezie, 1993). One study found that women dentists were less likelyto participate in Medicaid compared to men dentists (Mayer, 2000). Two studies found pediatricdentists more likely than general dentists to treat higher numbers of Medicaid patients (Venezie,1997; Mayer, 2000). One study found that minority dentists were 2.7 times more likely toparticipate in Medicaid than white dentists were (Mayer, 2000). This finding is consistent with


studies of physician’s behavior; minority pediatricians were reported as more likely to treat moreminority and poor patients than non-minority pediatricians (Brotherton, 2000; Xu, 1997).

There are no comprehensive data available on the role of traditional safety-net providers inproviding dental care for low-income children. For medical care, the term “safety net’ is used todescribe the providers that serve individuals lacking health insurance or the ability to paymedical costs out-of-pocket. Often these medical care providers receive public subsidies andcharge patients on a sliding fee schedule based on family income. Safety-net medical providersinclude public hospitals, community health centers, local health departments, and teachinghospitals.

Safety-net dental providers may include any of the above groups offering dental care, as well asdental school clinics and a limited number of other voluntary providers. This group of dentalcare providers is significant in that the dentists practicing in safety-net clinics may have arelatively large volume of their practice committed to low-income children. It has beenestimated that about one third of community health centers and local health departments hadsome type of oral health program in 1997. According to a recent study, in 1998, 385 of thenation’s 686 community health centers reported either providing dental services to at least 1,000patients or having at least one half FTE dentist working at the health center (GAO, 2000a). Asurvey of state Medicaid dental programs conducted in 1999, reported that when asked toindicate the reliance of states on safety net providers for Medicaid dental care, 31 states reportedeither great reliance (6 states) or some reliance (25 states) (APHSA, 2000).

THE ILLINOIS MEDICAID DENTAL PROGRAM

In March 1999, the Illinois Department of Public Aid (IDPA) entered into a three-year contractwith Doral Dental Services of Illinois (Doral) to operate the Medicaid/KidCare dental program.The three-year contract budgets $108 million over three years, with $19 million foradministrative costs and $89 million for dental claims payments. This contract places Doral atrisk only for administrative costs and the State at risk for claims costs. This is a change in therisk assignment that is considered positive toward increasing access to care, in that it removes thenegative financial risk of increased utilization from the contractor.

From 1984 through February 1999, the Illinois Medicaid dental program had been operatedunder contract with Delta Dental. Under this contract, Delta assumed risk for contracting andclaims; they received capitated payments per enrolled child from IDPA. Dentists were paidthrough discounted fee for service. Throughout this period, children’s dental services werecontinuously covered, although adult services were eliminated from 1995 through 1997. InSeptember 1999, the Illinois Auditor General reported on a management audit of the contractwith Delta Dental. For the period of 1996 through 1998, the report noted several problems,including relatively high administrative payments, declining children’s utilization rates, anddeclining numbers of dentists providing care (Holland, 1999).

In July 1998, there was a significant increase in dental fees for common procedures, whichhelped place Illinois fees at about a midrange compared to other states (previously Illinois fees


had been in the very low range; rates were also increased in July 1999. A 1999 national study ofMedicaid dental fees for fifteen common procedures reported that Illinois fees were in the 34%to 72% range of average fees for the region (GAO, 2000a). Estimates of current Medicaid feesare about 55 to 60% of the UCR (usual, customary and reasonable) fees.

As seen in Table 4, the number of children (and the percent of the total enrolled) receiving dentalcare declined slightly from 1996 to 1997, with a marked decline in1998 (Holland, 1999). Thistable shows the dental expenditures over the three years. However, the expenditures include alarge administrative cost; for example in 1998, dental claims accounted for only $17.7 million,while administrative costs totaled $11.5 million. The 1998 dental claims paid per user was $82(using the $17.7 million claims paid).

The number of enrolled dentists also declined from 1996 through 1998, from 3,791 to 3,311. In1998, only 1,524 of the 3,311 (46%) of enrolled dentists billed and received payment for care.The distribution of services provided by dentists, measured as dental procedures paid for in theyear, showed that 443 dentists had 1- 12 procedures; 414 dentists had 13 - 199 procedures; 403dentists had 100 - 999 procedures; and 264 dentists had 1,000 to 10,000 or more procedures(Holland, 1999).

Table 4: Illinois Medicaid dental program, children enrolled and receiving care, dentists enrolled, and dental expenditures, 1996 - 1998

1996 1997 1998

Children enrolled 851,985 819,118 793,132Children receiving dental care 280,746 271.746 216,423Percent children with dental care 33% 33% 27%Dentists enrolled 3,791 3,476 3,311Total dental expenditures $ 26.6 million $ 30.2 million $ 29.2 millionSource: Holland WG, 1999.

The Illinois Study of Access to Dental Care forMEDICAID ENROLLED CHILDREN

Study OverviewThe study was conducted between November 1999 and September 2000. The three studycomponents are summarized in this report beginning with a description of the supply,distribution, and characteristics of Illinois dentists, using ADA data. Next, the study examinesMedicaid children’s dental services for the 12-month period of March 1999 through February2000; data for this analysis were provided by IDPA and Doral. This analysis describes the dentalcare expenditures and dental care utilized by children enrolled in the Illinois Medicaid program(this includes all children enrolled through the State CHIP program, KidCare). The dentists’participation in Medicaid, through enrollment numbers and care provided, is also described.Since one of the original study goals was to assess the capacity of Illinois dentists to provide careto Medicaid children, this component concludes with three scenarios that estimate the number ofparticipating dentists needed to provide care to various target numbers of children. The thirdstudy component presents an analysis of steps taken by Illinois and six surrounding states to


address the problems of low access to dental care for children with Medicaid. The discussion ofpolicy recommendations draws on the findings from all three study components.

A project advisory group of key dental groups, policymakers, and other stakeholders wasconvened to provide oversight and guidance for this study. Members included representativesfrom the Illinois Primary Health Care Association (IPHCA), the Illinois State Dental Society(ISDS), the Illinois Society of Pediatric Dentistry (ISPD), the Illinois Dental HygienistsAssociation (ADHA), the Illinois Department of Public Health (IDPH) Division of Oral Health,the regional HRSA office, the Illinois Department of Public Aid (IDPA), Doral Dental Services,representatives from the state’s two dental schools (Southern Illinois University and theUniversity of Illinois at Chicago), and a representative from the child health advocacycommunity. A complete list of members is included in Appendix A. Two meetings were heldwith the advisory group; in February 2000 to review the project work plan; and in September2000 to review the project progress, and preliminary data analysis. Advisory group members alsoprovided guidance outside the meetings through personal communications. In addition, theadvisory group members received a draft of the final project report and were given theopportunity to provide clarifications and comments.

Study MethodsAn abbreviated version of the data sources and methods is presented here; Appendix B describesthe data sources and methodology in further detail. The following data were obtained:demographic and professional characteristics of Illinois dentists (members and non-members)from the ADA; Medicaid/KidCare children’s enrollment and utilization and dentist enrollmentand participation data from IDPA and Doral; county population data from the U.S. CensusBureau; and zip code-county matching information from the U.S. Postal Service.

Data from IDPA/Doral were provided at the county level. We aggregated the county data intoregions to allow for comparisons across Illinois. The seven regions used by the IDPH Divisionof Oral Health were used in this study (see map, Appendix C).

Table 5 shows general population information for the seven Illinois regions. These sevenregions range in population from over five million residents in Cook County, to slightly morethan one half million residents in the Marion region. The number of counties included in theregions varies from one county (Cook) to 27 counties in the Marion region. The Collar Countiesrefers to the eight counties that surround Chicago/Cook County. Of the 3.2 million children inIllinois, approximately one-quarter are enrolled in Medicaid/KidCare; the percentage of childrenwho are enrolled in Medicaid/KidCare varies from 10% in the Collar Counties to 35% in CookCounty.


Table 5: Illinois Regions: Counties, Population, and Medicaid Enrolled Children

Illinois ChampaignCook

CountyEdwards-

ville Marion Peoria RockfordCollar

Counties

Number of counties in region 102 16 1 17 27 24 9 8

Total Populationa 12,128,370 786,896 5,192,326 1,056,015 565,357 1,067,864 628,004 2,831,908

Population Under 18a 3,181,338 190,495 1,345,897 276,075 138,598 269,118 161,410 799,745

Estimated percent of child population enrolled in Medicaidb

24.7% 21.8% 34.5% 24.9% 29.5% 21.8% 18.7% 10.1%

Source: a U.S. Census Bureau, 2000. b Number of Medicaid/KidCare enrolled children as of September 1, 1999, from the Illinois Department of Public Aid.

The calculation of percent of child population enrolled in Medicaid/KidCare is based on enrolled children age 0-18 and child population age 0-17.

THE ILLINOIS DENTAL WORKFORCE

The dental workforce of Illinois will be presented with a description of all active patient careIllinois dentists, followed by a more detailed discussion of active patient care dentists practicingas general dentists and pediatric dentists. This is followed by a description of Illinois dentalhygienists and dental clinics that are safety net providers for dental care, that is, public or privateclinics that receive financial subsidies or have other means to offer dental care at a discountedcost to their patients.

Illinois Dentists: All SpecialtiesIn February 2000, there were 7,096 active patient care dentists in Illinois (Table 6). Thisdefinition includes all dentists in private practice, full-time and part-time, hospital staff dentists,and dental school faculty also in practice2. Also in Table 6 are the total population figures forIllinois and the regions. When adjusted to the population, the Illinois dentist-to-population ratiowas 59 active dentists to 100,000 population, similar to the national average. However, withinthe State, the ratio varies from a high of 67 and 68 in Cook County and the Collar Countiesregions, to a low of 31 in the Marion region. Cook County and Collar Counties account for 76%of all active patient care dentists in the state and 65% of the population.

Table 6 also displays the population to dentist ratios for the State and regions. These estimatesshow the potential supply of dentists available to residents of the State. The ratio for all residentsis 2,001 persons per one dentist. These ratios vary by region, with higher population-to-dentistratios for the areas with a lower supply of dentists (Marion, Peoria and Champaign regions). TheCook County and Collar county regions have lower population-to-dentist ratios, reflecting ahigher supply of dentists.

2 It is not clear from the data whether some dentists in these categories also provide dental care in safety netfacilities.


Table 7 shows the specialty distribution of dentists by Illinois regions. Approximately 83%(5,921) were general practitioners and 2% (140) were pediatric dentists, the two specialties mostrelevant to this analysis. The proportion of dentists in each region who are general practitionersis fairly constant except in Marion, where 91% of dentists are in general practice and there wereno pediatric dentists. Very few dentists specialize in dental public health.

Table 6: Illinois Dentists and Dentists to Population Ratios, All Regions


CountyEdwards-


CountiesDentists (all specialties) 7,096 328 3,469 475 172 427 303 1,922Population per dentist (all specialties) 1,709 2,399 1,497 2,223 3,287 2,501 2,073 1,473

Dentist to 100,000 pop. 59 42 67 45 30 40 48 68

General & pediatric dentists 6,061 274 2,997 407 157 367 262 1,597Pop. per gen/ped dentist 2,001 2,872 1,733 2,595 3,601 2,910 2,397 1,773Gen/ped dentists to 100,000 population 50 35 58 39 28 34 42 56

Total Population 12,128,370 786,896 5,192,326 1,056,015 565,357 1,067,864 628,004 2,831,908Source: Dentist data from American Dental Association Masterfile, February 2000. Population Data from U.S. Census Bureau, 2000.

Table 7: Illinois Active Dentists* by Specialty**, by Region

Total IL Champaign Cook

County Edwards-

ville Marion Peoria Rockford Collar

Counties% % % % % % % %

General Practice 83 81 85 84 91 85 85 80

Oral Surgery 4 5 3 4 3 4 4 4

Endodontics 2 0.9 2 2 0.6 1 2 2

Orthodontics 5 6 4 5 5 6 5 7

Pediatric Dentistry 2 2 2 2 0 1 2 3

Periodontics 3 3 3 2 0 2 2 3

Prosthodontics 1 0.6 1 0.6 0.6 1 1 1

Oral Pathology 0.1 0 0.2 0 0 0 0 0.2

Dental Public Health 0.1 0.3 0.1 0.4 0 0 0 0.1

Total*** 100 100 100 100 100 100 100 100

Total Dentist Count 7,096 328 3,469 475 175 427 303 1,922Source: American Dental Association, February 2000.*Active Dentist includes private practice >30 hours, private practice < 30 hours, hospital staff dentist, and PT faculty/PT practice.** In October 1999 a ninth specialty was added - Oral & Maxillofacial Radiology - although no data were available for this specialty.*** Percentages do not add up to 100% due to rounding.


Dentists in General Dentistry and Pediatric DentistryThe remainder of this report, where we use the term dentist, we are referring to Illinois dentiststhat are active patient care dentists in either general dentistry or pediatric dentistry. We havechosen to focus on these dentists since they are considered the primary care dentists available tochildren. Several any other dental specialties are important for children’s dental care(orthodontists, oral surgeons, and endodontists), however they are not included in this analysis.

Gender. Statewide, 83% of the dentists were men and 17% were women (Table 8). In CookCounty, a larger proportion of active dentists were women (21%), while in all five downstateregions, the proportion of women dentists was much lower (5% to 12%).

Race/Ethnicity. Only 72% of dentists reported on their race/ethnicity to the ADA. Given thislimitation, 85% of these Illinois dentists were white, 9% were Asian American, 3% were AfricanAmerican, and 3% were Hispanic. Both Cook County and Collar Counties have a higherproportion of Asian American dentists (12% and 10%), while only Cook County has a higherproportion (5%) of African American dentists.

Table 8: Gender and Race/Ethnicity of Illinois Active Dentists*, by Region

Total IL ChampaignCook

CountyEdwards-


Counties% % % % % % % %

Men 83 90 79 88 95 94 89 83

Women 17 10 21 12 5 6 11 17Total 100 100 100 100 100 100 100 100

Asian American 9 2 12 4 1 3 5 10

African American 3 1 5 2 0 0.4 1 1

Hispanic 3 0 4 0.3 0 3 1 3

White 85 97 79 94 99 94 93 87

Total 100 100 100 100 100 100 100 100Source: American Dental Association, February 2000.*Active Dentist includes private practice >30 hours, private practice < 30 hours, hospital staff dentist, and PT faculty/PT practice.

Age. In Illinois, the mean age of dentists was 49 years. It should be noted that while 7% ofdentists were younger than 35 years of age, the majority of the dentists with unknown agegraduated from dental school in 1993 or later; including these 1993-1999 graduates in theyounger than age 35 group would increase that percentage to 11%. Twenty five percent ofdentists were 55 years of age or older (Table 9). The percentage of older dentists is even higherin three downstate regions (Champaign-30%, Marion-29%, Peoria-31%). Based on the totaldentist counts for these three regions, these regions together have about 300 dentists in the agerange (55 years and greater) that could be expected to retire over the next decade.


Table 9: Age of Illinois Active Dentists*, by Region

Total IL Champaign Cook

County Edwardsville Marion Peoria RockfordCollar

Counties % % % % % % % %

Less than 35 yrs. 7 8 7 9 6 5 4 7

35-44 yrs. 32 25 33 30 24 24 32 35

45-54 yrs. 32 35 30 34 38 38 39 33

55-64 yrs. 14 16 13 15 17 15 11 14

65 or older 11 14 12 11 12 16 11 7Unknown Age 4 2 5 3 3 3 2 3Source: American Dental Association, February 2000.*Active Patient Care includes private practice >30 hours, private practice < 30 hours, hospital staff dentist, and PT faculty/PT practice.

Dental School Attended. About 80% of Illinois dentists attended dental school in Illinois (Table10). Forty-four percent of these dentists attended the University of Illinois at Chicago (UIC),31% attended Loyola, 16% attended Northwestern, and 9% attended SIU. While only 9% weregraduates of SIU, they accounted for substantial proportions of active dentists in the downstateregions (Edwardsville 66%, Marion 43%, Champaign-28%). Both Northwestern and Loyolahave closed their dental schools.

Table 10: Location of Dental School Attended by Illinois Active Dentist* by Region and Illinois School Attended

Total IL ChampaignCook


Counties% % % % % % % %

Illinois School 79 73 80 73 69 79 79 83

Non-IL, US School 20 27 20 27 31 21 21 17

Total 100 100 100 100 100 100 100 100Illinois

UIC 44 41 45 24 43 52 45 45

SIU 9 28 2 66 43 19 9 2

Northwestern 16 13 18 3 5 9 19 16

Loyola 31 19 35 7 9 20 27 37

Total 100 100 100 100 100 100 100 100Source: American Dental Association, February 2000.*Active Dentist includes private practice >30 hours, private practice < 30 hours, hospital staff dentist, and PT faculty/PT practice.UIC=University of Illinois at Chicago; SIU=Southern Illinois University.


Commentary on the Characteristics of Illinois Active Dentists in General and Pediatric PracticeWhile the statewide ratio of dentists is at the national mean, several areas of the state have muchlower ratios and the metropolitan Chicago area has a much higher ratio. This maldistribution iscommon among health professionals and reflects a variety of factors such as concentration oftraining in metropolitan areas (three of the four dental schools); and other professional andpersonal preferences for practicing and living.

With about one third of dentists in three regions approaching retirement age, there may bedifficulty in maintaining an adequate overall supply of dentists in these areas. The number ofnew dentists graduating from Illinois dental schools will be much lower than in the recent past;competition for the new graduates will likely favor metropolitan areas over rural areas andsmaller towns. Thus, these areas are at risk of a continued dentist undersupply over the nextdecade.

In addition to the age distribution of Illinois dentists, the data on where these dentists attendeddental school foreshadow future supply problems. Thirty-seven percent of current Illinoisdentists (47% of Illinois dentists who attended dental school in Illinois) are graduates ofNorthwestern and Loyola, both of which have closed. There is no mechanism in place to replacethis significant source of dentists in Illinois.

Illinois has a slightly higher percent of women dentists than the national average of 14%; and thewomen dentists are more highly concentrated in the greater Chicago metropolitan area. Thedistribution of professional women in metropolitan areas has been seen with other professions(e.g. medicine). Since women dentists may be more likely to work fewer hours per year, thismay yield a slightly lower work capacity on average for women dentists.

Illinois Dental HygienistsIn Illinois, under the Dental Practice Act, dental hygienists are allowed to work under directsupervision of a licensed dentist, which means that a dentist must authorize the service and bephysically present in the office or approve the work before the patient leaves the office. Detaileddata and counts of dental hygienists are not as readily available as are the data for dentists.There is no national survey or census of hygienists. The State licensure data, maintained by theIllinois Department of Professional Regulation (IDPR) can list the number of hygienists whomaintain an active license (includes hygienists currently not working but still licensed), but thiscount does not reflect the number in active practice, their full-time or part-time work status, andmay include hygienists from out of state. According to IDPR reports, at the end of fiscal year1998, there were 5,431 registered dental hygienists with active licenses.

Another source of data on employed hygienists is the U.S. Bureau of Labor Statistics (BLS),which surveys employers and provides counts of various occupations and work settings. In1998, the BLS reported there were 6,280 dental hygienists in Illinois. However, BLS does notidentify unique employed hygienists, so that hygienists working for two employers would becounted twice.


Safety Net Dental ClinicsThe Illinois Department of Public Health has collected information on dental clinics that servepatients with limited ability to pay for services; these 72 clinics represent the current “safety net”dental clinics in Illinois. The organizations sponsoring these clinics include 24 local healthdepartments; three townships; nine community health centers; five school based clinics; fivehospital clinics; eight clinics at dental hygiene schools; three clinics at dental schools; and tworeferral clinics. Thirteen private not-for-profit organizations also offered clinics. These includedcommunity centers, Salvation Army, Boys & Girls Club, Catholic Charities, and others. Elevennew clinics are proposed to open and offer dental care. The map in Appendix D, from the IDPH,shows the location of all current and proposed safety net dental clinics in Illinois.

The range of services offered by these clinics varies depending on staffing and other resources.Many clinics offer only diagnostic (exams) and preventive care services (cleanings, fluoride andsealants). Others offer restorative care including filling cavities. The dental school clinics offer afull range of dental services, including complex services, and treat large numbers of Medicaidchildren. Several of the community health centers, local health department and school-basedclinics can bill for their dental services through the cost-based reimbursement plan of Medicaidknown as FQHC (Federally Qualified Health Centers). The FQHC payment (known as theencounter rate) includes all dental procedures provided in a single visit; the encounter rate variesby individual community health center and is capped at $62.31. The amount of care provided bythese clinics can be tracked through the Medicaid FQHC payments. In 1999, these clinicsaccounted for 3.3% of all Medicaid dental payments and 1.2% of all services. In Illinois, theschool-based dental programs bill through the EPSDT (Early Periodic Screening PreventionTreatment) fees that pay at the rate of preventive services.

CHILDREN’S UTILIZATION OF DENTAL CARE

This section will describe the children enrolled in the Medicaid and KidCare programs in Illinoisas of September 1999. The number and proportion of enrolled children receiving dental servicesfor the entire twelve-month period of March 1999 through February 2000 will be described forthe State as a whole and by region. The number of and expenditures for dental procedures willbe described for Illinois only.

Medicaid/KidCare EnrollmentAs of September 1, 1999 (the midpoint of this study) there were 818,269 children andadolescents under 21 years of age enrolled in the Medicaid program. These children account for25% of the Illinois child population (Table 5). Enrollment counts by region are shown for thefollowing age groups: 0-3 years, 4 to 5 years, 6 to 12 years, 13 to 18 years, and 19 and 20 years(Table 11).


Table 11: Medicaid/KidCare Enrollment in Illinois, by Age Group and Region, 9/1/99



Counties

Total Enrollees 818,269 43,607 482,142 71,983 42,799 61,524 31,782 84,432

Age 0-3 234,871 12,601 136,125 18,512 11,374 17,438 9,715 29,106

Age 4-5 100,993 5,325 60,829 8,575 4,843 7,313 3,671 10,437

Age 6-12 289,148 15,162 173,437 26,103 15,261 21,418 10,729 27,038

Age 13-18 161,157 8,532 94,505 15,683 9,419 12,487 6,083 14,448

Age 19-20 32,100 1,987 17,246 3,110 1,902 2,868 1,584 3,403Source: Illinois Department of Public Aid, 2000.

Sociodemographic characteristics of Medicaid/KidCare enrolled children. IDPA provided racialbreakdowns of children enrolled in Medicaid (729,768) and KidCare (75,127) as of December 1,1999 (IDPA, 2000). Of these children, 30% were White, 48% were African-American, 19% wereHispanic, 2% were Asian, and 1% were other races.

Utilization of dental care by Medicaid/KidCare enrollees.Table 12 lists the number and percentage of children enrolled in Medicaid/KidCare who receivedany dental care services in Illinois during the year. Statewide, 33% of enrollees received at leastone dental service. Children in Cook County had a higher utilization rate (38%) than any otherregion. All other regions were below 30%, with the lowest utilization in the Collar Counties, atonly 23%.

When utilization is examined by age groups, the statewide rate for very young children (0 to 3years of age) was the lowest, at only 13% of children (Tables 12 and 13). Higher proportions ofpre-school aged (4 and 5 year-olds) and school aged children (6 to 12 year olds) received dentalservices (51% and 47%, respectively); this pattern of proportionately higher use for these agegroups holds across regions. The adolescent and young adult age groups (ages 13 to 18 yearsand 19 and 20 years) had utilization rates of about 27%. Across all age groups, the Cook Countyutilization rates were the highest in the State; the Collar County rates were generally the lowest,and the rest of the State regions showed only limited variation.


Table 12: Illinois Medicaid/KidCare Children – Enrollees and Dental Service Users

Age Group Enrollees Users Users %

Age 0-3 234,871 29,292 13

Age 4-5 100,993 51,617 51

Age 6-12 289,148 137,073 47

Age 13-18 161,157 44,698 28

Age 19-20 32,100 8,472 26

Total Illinois 818,269 271,152 33Source: Illinois Department of Public Aid, 2000.

Table 13: Percentage of Enrolled Children Who Used Dental Services, by Region

ChampaignCook


Counties% % % % % % %

Total Enrollees 26 38 28 28 29 27 23

Age 0-3 8 15 11 9 10 9 9

Age 4-5 44 57 45 42 47 41 36

Age 6-12 38 53 39 39 41 41 34

Age 13-18 24 31 22 26 25 22 20

Age 19-20 20 30 23 27 23 22 19Source: Illinois Department of Public Aid, 2000.

Commentary on Medicaid Children’s Utilization of Dental CareThis utilization rate for Illinois Medicaid children is at about the mean for other states. In 1995,among the 27 state Medicaid programs reporting utilization data, the mean utilization rate was34% of Medicaid children utilizing at least one dental visit in a year, with state utilization ratesranging from 22% to 48% of children (GAO, 2000b). However, the Illinois rate does not farewell against the visit rates for all children or to Healthy People 2010 objectives.

Total Expenditures and Dental Procedures ProvidedExpenditures by Age Group. In 1999, $29.16 million dollars was spent on dental care forMedicaid enrollees under 21 years of age. The average expenditure per user was $108 per year,with the expenditures increasing with age of user, from $81 for the very young children (0-3years) to $145 for the 19 and 20 year olds (Table 14). The increases by age group reflect the mixof dental services used, with higher cost services (oral surgery and orthodontics), as well as a


higher proportion of restorative services, being more common in the older age groups (seebelow).

Table 14: Average Payment per Dental Services User

Age 0-3 Age 4-5 Age 6-12 Age 13-18 Age 19-20Total

EnrolleesTotal Dental Services Paid $2,369,221 $5,037,292 $14,252,951 $6,278,546 $1,231,349 $29,169,359

Number of Users 29,292 51,617 137,073 44,698 8,472 271,152

Payment/User $81 $98 $104 $140 $145 $108Source: Illinois Department of Public Aid, 2000.

Expenditures by Procedures Category Individual procedure codes were grouped into procedurecategories3 to examine the aggregate expenditures by procedure category. The list of procedurecodes paid and submitted were categorized by: (a) Diagnostic (exams, x-rays); (b) Preventive(prophylaxis, fluoride, space maintainers); (c) Restorative (fillings); (d) Restorative (crowns,inlays, onlays, veneers); (e) endodontic; (f) periodontic; (g) Removable prosthodontics; (h)Implants, fixed prosthodontics; (i) Oral surgery; (j) Orthodontics; (k) Miscellaneous (anesthesia,mouth guards, occlusal adjustments); (l) FQHC encounter fee; and (m) EPSDT (screenings,exams, fluoride, and prophylaxis - at school). The FQHC and EPSDT categories refer to settingswhere the services occurred, certain safety net dental clinics for FQHC, and school-basedsettings for EPSDT.

The total number of services provided in 1999 was over 1.4 million, with an average cost perprocedure of $19.86 (Table 15). Average expenditures for commonly performed procedurecategories were $12.34 for diagnostic services, $17.61 for preventive services, $38.12 forrestorative (filling cavities) services, and $28.81 for oral surgery services. The FQHC encounterfee was $52.46 (this is for a visit, which includes several procedures); and the EPSDT averagewas $10.71.

3 These categories were provided to us by the Illinois State Dental Society and are available from the Illinois Centerfor Health Workforce Studies by request.


Table 15: Total Expenditures and Number of Services by Procedure Category, Illinois Medicaid Children’s Dental Services

Procedure Category Total Expenditures Number of Services

Average Payment per Procedure

Diagnostic $5,333,740 430,873 $12.34Preventive $7,501,193 425,859 $17.61Restorative (fillings) $7,951,737 208,595 $38.12Restorative (other) $712,151 14,093 $50.53Endodontic $1,325,671 17,166 $77.23Periodontics $41,434 487 $85.08Removable prosthodontics $50,058 173 $289.35Implants, fixed prosthodontics $23,940 160 $149.63Oral surgery $1,637,302 56,821 $28.81Orthodontics* $413,414 n/a n/aMiscellaneous $186,601 8,553 $21.82FQHC Encounter Fee $961,638 18,330 $52.46EPSDT $3,020,812 282,017 $10.71TOTAL $29,159,690 1,468,133 $19.86Source: Illinois Department of Public Aid, 2000.* Orthodontics are most often billed by the case, in monthly installments over the course of treatment.

Total expenditures by procedure category, by age group. Spending by procedure categoryincluded 18% on diagnostic, 26% on preventive, and 30% on restorative care services (Table16). However, these estimates provide an incomplete picture of the total expenditures on theseservices since EPSDT includes diagnostic and preventive services, and FQHC includes a varietyof service types. Differences in types of services used by different age groups can also be seenin Table 16. For the children under 13 years of age, most of the services fell under thepreventive, diagnostic, restorative, and EPSDT categories. As age increased, restorative (fillings)accounted for a greater proportion of services, as did oral surgery for the oldest group ofadolescents.


Table 16: Percentage of Total Expenditures by Procedure Category, by Age GroupProcedure Category Age 0-3 Age 4-5 Age 6-12 Age 13-18 Age 19-20 Illinois Total

% % % % % %Diagnostic 26 20 17 17 20 18Preventive 33 26 27 24 11 26Restorative (All) 24 31 26 37 42 30Oral Surgery 4 4 6 5 14 6Orthodontics 0 0 1 4 1 1FQHC Encounter Fee 4 4 3 3 3 3EPSDT 3 8 16 3 0 10Other Procedures 6 7 4 7 10 6TOTAL 100 100 100 100 100 100Source: Illinois Department of Public Aid, 2000.

Average Number of Dental Procedures by Age GroupThe average number of procedures used per year per child user is shown in Table 17. Thisshows an increasing number of procedures by age group up to 18 years of age. The data showthat over the year period, children received on average 5.4 procedures. The data that wereobtained for this study do not allow for an estimation of the number of visits, nor the number ofprocedures per visit.

Table 17: Procedures per UserAge Group Enrollees Users Number of procedures Procedures/User

Age 0-3 234,871 29,292 114,968 3.9 Age 4-5 100,993 51,617 251,693 4.9 Age 6-12 289,148 137,073 781,944 5.7 Age 13-18 161,157 44,698 272,751 6.1 Age 19-20 32,100 8,472 46,777 5.5Total Illinois 818,269 271,152 1,468,133 5.4

Source: Illinois Department of Public Aid, 2000.

DENTIST PARTICIPATION IN THE MEDICAID PROGRAM

Dentists who wish to provide care and bill the Medicaid program must be enrolled as a Medicaiddental provider. This requires the dentist to complete an application and agree to the terms of theMedicaid program as administered by the dental intermediary. In 1999, when Doral became theIDPA dental intermediary, all dentists had to re-enroll; therefore, the counts of participatingdentists should be current in reflecting providers willing to participate in the Medicaid programas evidenced by their recent enrollment. Dentists’ participation was examined in terms ofenrollment and, more importantly, the level of services provided and billed during the year.


Dentists enrolled in the Medicaid ProgramIDPA data show that 34% (2,034 of 6,061) of active patient care general and pediatric Illinoisdentists were enrolled as Medicaid/KidCare providers on June 30, 2000 (Table 18)4. Theproportion of dentists enrolled by region ranged from 18% (281 of 1,597) in Collar Counties to61% (168 of 274) in Champaign. Higher enrollment may reflect greater outreach andrecruitment efforts by Doral or greater willingness of dentists in a certain area to treat Medicaidchildren.

Table 18 also shows that 497 dentists enrolled in Medicaid (24% of all enrolled dentists) had notsubmitted a claim for services during the year. Thus, 76% of enrolled dentists provided at leastone service in the year. A higher proportion of enrolled dentists provided care in the Marion andPeoria regions (82% of enrolled dentists).

Dentists Providing Services Through the Medicaid ProgramIn Illinois 1,537 dentists provided some service. The measure for service is any procedure billedand paid for by Medicaid. Thus service and procedure are used interchangeably. The level ofparticipation was assessed by examining the number of dentists who submitted (a) 1-100services/year, (b) 101-999 services/year, and (c) greater than 999 services/year. The proportionof active dentists who participated at these different levels was calculated as both a proportion ofenrolled dentists in Illinois and of all active dentists, enrolled and not enrolled, in Illinois (Table18). The data do not allow for an estimate of the number of free or pro bono care provided bydentists.

It should be noted that a single visit by a child might include more than one procedure. The datareceived do not allow us to estimate the number of dental visits per child nor does it provide thenumber of children receiving each level of care. However, the data do allow for an estimation ofthe number of children treated per dentist. We can estimate the number of children served byusing the average of 5.4 procedures per child per year. Thus, dentists with 0 to 100 procedureswould be estimated to have treated between one and 19 children; dentists with 101 and 999procedures would be estimated to have treated between 19 and 185 children; dentists with morethan 999 procedures would have treated more than 185 children.

However, this estimate has a serious limitation in that some children may receive only a singleprocedure and others may receive large numbers of procedures. Another way to estimate thenumber of children served per dentist is to take the total number of children utilizing care(271,152) and divide this by the number of dentists providing any service (1,537). This yields anestimate of 176 children per dentist; this estimate is a statewide average that does not reflect thereality that many dentists provide a low volume of services and a few dentists provide a highvolume of services.

4 As noted in the Data and Methods Appendix, there were 385 providers with more than one practice site.


Table 18: Medicaid Enrollment and Participation of Illinois Active and Enrolled Dentists



Counties

DENTISTS 1

Active dentists a 6,061 274 2,997 407 157 367 262 1,597 # Enrolled dentists 2 2,034 168 1,058 182 77 150 118 281 % of Active Dentists Enrolled 34% 61% 35% 45% 49% 41% 45% 18%Dentists with 0 services # Enrolled dentists 497 39 277 42 14 27 26 74 % Enrolled 24% 23% 26% 23% 18% 18% 22% 26%Dentists with 1-100 services b # Enrolled dentists 802 88 334 83 33 70 67 127 % Enrolled 39% 51% 32% 46% 43% 47% 57% 45% % Active dentists 13% 32% 11% 20% 21% 19% 26% 8%Dentists with 101-999 services b # Enrolled dentists 570 36 346 39 21 34 22 72 % Enrolled 28% 21% 33% 21% 27% 23% 19% 26% % Active dentists 9% 13% 12% 10% 13% 9% 8% 5%Dentists with >999 services b # Enrolled dentists 165 5 101 18 9 19 5 8 % Enrolled 8% 3% 10% 10% 12% 13% 4% 3% % Active dentists 3% 2% 3% 4% 6% 5% 2% 1%a American Dental Association, February 2000. Active patient care includes private practice <30 and >30 hours per week, hospital staff dentist, and PT faculty/PT private practice.b Illinois Department of Public Aid, 2000. For dates of service March 1, 1999 to February 29, 2000 - For Claims Paid Through June 30, 2000.

1 Active patient care general and pediatric dentists are unique dentists, while enrolled providers may practice at more than 1 site. There were 385 enrolled providers with multiple sites.2 This analysis includes only Illinois enrolled providers (out of state providers are excluded).

Participation levels as a proportion of enrolled dentists indicated that 39% of enrolled dentistssubmitted between 1-100 services during the year, 28% submitted 101-999 services during theyear, and 8% submitted at least 1000 services per year. Participation levels as a proportion ofactive dentists demonstrate much lower levels of participation. The number of active dentists isseen as the upper limit of dentists available to provide care to Medicaid/KidCare enrolledchildren; it is recognized, however, that an unknown number of these dentists would not bewilling to enroll in Medicaid under any circumstances, and an unknown number of the generaldentists may not feel comfortable treating children. Of all active dentists in Illinois, 13%submitted between 1-100 services during the year, 9% submitted 101-999 services during theyear, and 3% submitted at least 1000 services per year.

Using our estimates of number of children treated, these data can be summarized as follows: forevery ten dentists enrolled in Medicaid during the year,

• two dentists provided no care,• four dentists provided a small volume of care (1 to 99 procedures),


• three dentists provided a moderate level of care (100 to 999 procedures), and• one dentist provided a large volume of care (over 1,000 procedures).

High Volume Dentists Of the 165 dentists (8% of all active dentists) who submitted at least 1,000services during the year, from data not shown in the table found that 109 dentists submittedbetween 1,000-1,999 services, 51 submitted between 2,000-4,999 services, and 5 submitted5,000 or more services. Most of these high volume dentists were located in Cook County

Non-Illinois Dentists. Out-of-state dentists also received Medicaid reimbursement for dentalservices. Fifty-seven dentists in other states received reimbursement; 51 dentists were in statescontiguous to Illinois, with Iowa accounting for 21 dentists. Most of these dentists submittedbetween 1-100 services for IDPA reimbursement.

PROJECTING DENTIST CAPACITY

Population to Dentist RatiosAs noted earlier in the report, the statewide supply of all active dentists in Illinois is at thenational average of 58 dentists per 100,000 population. Other ratios of dentist-to-population canbe used to assess the dentist-to-population supply. For example, Illinois has 4.4 active patientcare pediatric dentists per 100,000 children, age less than 18. The pediatric dentists ratios areless commonly reported, although a 1993 estimate reported 4.4 private practice pediatric dentistsper 100,000 children <18 nationally, or 5.1 professionally active (private and non-privatepractice) pediatric dentists per 100,000 children <18 (Waldman, 1995).

The supply of dentists can also be examined by reversing this ratio and discussing the populationper active dentist. The national ratio of population to all active dentists would be estimated as1,724 persons per dentist in 1996. This ratio allows one to consider the relationship between adentist and an estimated potential population served.

While there is no standard for an adequate supply, the federal government does have criteria forareas considered to have a shortage of dentists. The existing total population-to-full-time-equivalent-dentist ratio standards for a geographic area to qualify as either a geographic orspecial population Dental Health Professional Shortage Area (DHPSA) is at least 5,000 personsto one dentist or 4,000 persons to one dentist, respectively. The American Academy of PediatricDentistry does not have any standards for child population-to-pediatric dentists. A recent GAOreport noted that there is no agreed upon minimum ratio for assessing supply of dentists (GAO,2000a).

Table 19 presents various ways of examining the supply of Illinois dentists available to treatchildren enrolled in Medicaid. The first section of this table shows that the number of enrolledMedicaid children per enrolled dentists is 402 children. This varies by region, with Marion andCook County having high numbers of Medicaid children to enrolled dentists (556 and 456children) and Champaign and Rockford having low numbers of children to dentists (260 and 269children). Another way to look at these same data is to reverse the ratio and look at the numberof dentists available to a standard number of children such as 1,000. From this perspective, there


are 1.8 and 2.2 active dentists per 1,000 children in the Marion and Cook County regions,respectively. Note that in Table 6, for the general population, Cook County had the highestdentist-to-population ratios and Marion region had the lowest. However, when examining theMedicaid child population, Cook County falls to just above Marion for dentist to enrolledchildren ratios. Part of the explanation may be found in Table 18, which shows that Marion hasa higher proportion of enrolled dentists and of participating dentists than Cook County.

The next set of rows in Table 19 show the same ratios but include only participating dentistsand enrolled children. The number of Medicaid children using dental care per participatingdentist are seen to range from about 90 children per dentist (Champaign, Rockford, and CollarCounties regions) to around 200 children (Cook County and Marion region). With the statewideaverage of 176 children users per participating dentist, there would have to be a threefoldincrease in the number of children seen by each participating dentist in order for all enrolledchildren to receive dental care (to 532 children per participating dentist).

If all enrolled dentists were actively treating children, the 2,034 enrolled dentists would onaverage have to treat 402 children to have all children receive care. These averages do notreflect the reality that most dentists treat very small numbers of children and others treat muchlarger numbers. The dentist participation data presented above show that 570 dentists provide amoderate to substantial volume of care (100 to 999 procedures); and only 165 dentists providelarge to very large volumes of care (1,000 or more procedures). For purposes of comparison, arecent GAO report defined “substantial participation” as seeing at least 100 Medicaid patients ina year (GAO, 2000a). In most states, less than 25% of dentists met this definition. In Illinois, itappears that about 12% of dentists come near this level of participation.

Children Ratios, All Regions

Illinois Champaign Cook County

Edwards-ville Marion Peoria Rockford Collar

Counties

Medicaid enrolled gen/peds dentist 2,034 168 1,058 182 77 150 118 281

Medicaid children to enrolled dentist

402 260 456 396 556 410 269 300

Medicaid enrolled dentist to 1000 children 2.5 3.9 2.2 2.5 1.8 2.4 3.7 3.3

Medicaid participating dentists 1,537 129 781 140 63 123 92 207

Medicaid children to participating dentist

532 338 617 514 679 500 345 408

Medicaid participating dentist to 1000 children 1.9 3.0 1.6 1.9 1.5 2.0 2.9 2.5

Medicaid children users to participating dentists 176 91 233 144 190 145 89 92

Medicaid children 818,269 43,607 482,142 71,983 42,799 61,524 31,782 84,432

Medicaid children users 271,152 11,763 182,223 20,111 11,945 17,799 8,197 19,114Source: Illinois Department of Public Aid, 2000. Calculations based upon these data.

Table 19: Illinois Medicaid Enrolled and Participating Dentists, and Dentists to Medicaid


Projecting Dentist Capacity Required to Serve Medicaid ChildrenThe scenarios shown in Table 20 present another approach for analyzing the required dentistcapacity needed to treat larger volumes of Medicaid children. The output from this analysis isthe number of children that would have to be accepted by dentists under these scenarios.

The assumptions for all scenarios are as follows: 1) the number of children enrolled inMedicaid/KidCare is held constant at the 1999 count (818,269 children); and 2) the total numberof Illinois active dentists (general and pediatric dentistry) is held constant (6,061 dentists, with50% of all active dentists equaling 3,030 dentists); the number of Medicaid enrolled dentists isheld constant (2,034 dentists), and the number of participating dentists, i.e. those who treated atleast one child, is held constant (1,537 dentists).

The scenarios vary by the number of children targeted to receive at least one dental visit per yearwith the following levels: 1) current level of 33% of Illinois Medicaid enrolled children whoreceived at least one dental service (271,152 children); 2) 57% of children, based on the HealthyPeople 2010 objective of low-income children receiving preventive dental care (466,413children); and 3) 83% of children, based on the Healthy People 2010 target of the number ofchildren and adults using the oral health care system each year (679,163). Recognizing that thetarget of 83% utilization – while an established national goal - is extremely ambitious, we willfocus our discussion below on the 57% target for the low-income population.

It is unlikely that many children under two years of age would see a dentist, therebyoverestimating the number of children in these scenarios. However, the American Academy ofPediatric Dentistry does recommend that all children have an oral health care visit by age one.Also, the number of children enrolled in Medicaid/KidCare has increased since September 1999due to intensive outreach and enrollment efforts, which would underestimate the number ofchildren per dentist.

The scenarios vary by the dentist group (general and pediatric dentists only) assumed available toprovide care and include:

• Scenario A: all currently participating dentists (1,537dentists) accept the childrentargeted to receive care, (three levels of care 33%, 57%, 83% of children);

• Scenario B: all currently enrolled dentists (2,034 dentists) accept children targeted toreceive care, (all three levels of children);

• Scenario C; 50% of all active Illinois dentists (3,030 dentists) accept children targeted toreceive care, (all three levels of children).

For simplicity, the percentages of current users and of enrolled and participating dentists in thecalculations for each region are based on the Illinois average.

These scenarios show the number of children that each dentist in that scenario would need toserve. For example, under scenario A for all participating dentists, at the current Medicaid childutilization rate of 33%, each dentist would need to treat 176 children. The expectation would bethat all needed care would be provided. To estimate the impact on the dentist’s practice, at twovisits per year per child, this would total 352 Medicaid visits (with several procedures per visit).The average number of visits provided by a dentist per year as reported by the ADA is 2,640 for


dentists without a dental hygienist, and 3,740 for dentists with a dental hygienist (ADA, 2000a).Thus, these children’s visits would take up between 13% and 9% of the dentist’s total scheduledvisits.

Still using scenario A, if the percentage of children treated were to increase to 57%, then eachparticipating dentist would need to treat 304 children (608 visits), accounting for between 16%and 23% of all scheduled visits. These are higher percentages of a dental practice than mostdentists are willing to devote to Medicaid patients. This demonstrates that if the number ofdentists participating in Medicaid is not substantially increased, and barring major increases inthe public sector capacity, a greater number of children cannot be served.

Under scenarios B and C, assuming more dentists treat Medicaid children, the number ofchildren per dentist, and the corresponding percentage of practice visits, would decline. Evenassuming that the number of available dentists almost doubles from 1,537 (currentlyparticipating) to 3,030 (50% of active dentists), and assuming the 57% utilization goal isreached, that amounts to 154 children (308 visits) per dentist, or between 12% and 8% of allscheduled visits.

One can also estimate the expenditure increase that would be required to meet the target of 57%of enrolled children (466,413 children) obtaining dental services. This estimate will use the 1999average expenditure per child per year of $108. If 57% of enrolled children received dental care,the number of new children receiving services would be 195,261 (466,413 - 271,152 currentusers), which at $108 per child yields an additional cost of $21.1 million, for a total cost of $50.3million (466,413 x $108). The most likely way to achieve this target is for incrementalexpansion of services over several years. For example, the Healthy People 2010 allows ten yearsto meet this goal. Since Illinois starts at a higher baseline (33%) than the 20% Healthy Peoplebaseline, it should take less than ten years to achieve this goal. It should also be noted that the$50 million figure represents less than 5% of the $1.1 billion dollars spent on all Medicaidservices for children in FY98 (Tang, 1999).


Table 20: Number of Medicaid Children Treated per Dentist under Three Scenarios (children treated based on current utilization and Healthy People 2010 objectives)

Illinois Champaign Cook County Edwardsville Marion Peoria RockfordCollar

Counties

Scenario A: Varying utilization* of enrolled children to all participating dentists; 25% of active dentists; 1537 IL dentists83% enrolled children 442 281 512 427 564 415 281 33957% enrolled children 304 193 352 293 387 285 193 232Current users (33% of enrolled children) 176 91 233 144 190 145 87 92

Scenario B: Varying utilization* of enrolled children to all enrolled dentists; 34% of active dentists; 2034 IL dentists83% enrolled children 334 212 379 328 461 340 224 24957% enrolled children 229 145 260 225 317 234 154 171Current users (33% of enrolled children) 133 69 172 111 155 119 70 68

Scenario C: Varying utilization* of enrolled children to 50% of active dentists; 3030 IL dentists83% enrolled children 224 264 267 294 453 279 201 8857% enrolled children 154 181 183 202 311 191 138 60Current users (33% of enrolled children) 89 105 106 117 180 111 80 35

* These utilization figures are based on the following Healthy People 2010 Objectives: -Increase the number of children and adults who use the oral health care system to 83%.- Increase the number of children (<200% of FPL) receiving any preventive dental services to 57%.- 33% is the actual utilization rate for Illinois Medicaid enrolled children during the period 3/99-2/00.


SUMMARY OF FINDINGS ON ACCESS TO DENTAL CARE IN ILLINOIS

Comparisons across Time: 1996-1999In 1999, 33% of children with Medicaid, over 271,100 children, utilized dental care in the year.This rate is similar to the Illinois experience in 1996 and 1997 and increased from reported ratesin 1998 (when 27% of children utilized dental care). Despite some fluctuations in enrollmentnumbers, the number of children receiving care in 1999 was very close to the number receivingcare in both 1996 and 1997, and was an increase from 1998 (216,400).

Dentist enrollment in Medicaid was lower in 1999, 2,034 dentists, than in the three prior years,which had over 3,300 dentists enrolled with Delta Dental. The ISDS notes that Delta’s list ofenrolled dentists was out-of-date and included many dentists who were deceased or retired. Thisdrop may also reflect the requirement that dentists re-enroll with Doral, giving nonparticipatingdentists the opportunity to drop their enrollment. Of note is the consistent number of dentistswho provided care in 1998 under Delta (1,524 dentists) and in 1999 under Doral (1,537 dentists).

Total dental claims expenditures in 1999 were $29.17 million, higher than the reported dentalclaims payments in 1998 ($17.7 million of the total expenditures of $29.2 million, with theremaining $11.5 million as administrative costs). The 1999 average expenditure per user was$108.

Enrollment and UtilizationA positive finding is that 76% of enrolled dentists submitted at least one service forreimbursement during the year. Studies have indicated that it is easier to encourage alreadyparticipating Medicaid dentists to increase their level of participation than it is to encourage non-participants to join. However, participation at more substantial levels is much lower. Only 36%of enrolled dentists provided at 100 or more services/year and only 8% of enrolled dentistsparticipated at 1,000 or more services/year. A dentist who submitted 1,000 services forreimbursement, performed an average of 20 services/week.

Consistent with national data, Illinois children in the 4 to 12 year old ages had the highestproportion visiting a dentist in the year (about 50%). The very young children (under threeyears of age) and adolescents had lower utilization rates. While 38% of Medicaid-enrolledchildren in Cook County visited a dentist, the remainder of the State was below 30%. Theoverall lower dentist supply in the downstate regions may contribute to lower utilization rates inthose areas.

The population-to-dentist ratios can be interpreted to mean, at the state level, that at 57%utilization by Medicaid/KidCare enrolled children, each of the 2034 enrolled dentists would needto treat 229 children or each of the 1537 participating dentists would need to treat 304 children;at two visits per child per year, these numbers would represent substantial percentages of a dentalpractice’s visits. Currently, only 165 dentists provided at least 1000 services during the year, ortreated at least 185 children at an average of 5.4 services per dental service user. The costs ofexpanding dental care can be estimated by multiplying the per user average cost by the numberof new children receiving care.


Regional VariationRegional variations were seen in the supply of all dentists (all specialties) and in the supply ofgeneral and pediatric dentists, after adjusting to the population size. The Cook County and theCollar County regions had a higher supply of dentists; the Marion region, had very low supply,with the Peoria and Champaign regions also low.

Regional variation existed in the proportion of general and pediatric dentists who were enrolledand participated in Medicaid. Only 18% of active dentists in the Collar Counties enrolled inMedicaid compared to 61% in Champaign. However, about the same proportion, approximatelythree-fourths of enrolled dentists in both of those regions participated at any level, althoughslightly more of the participants in the Collar Counties were moderate participants (101-999services) than in Champaign. Marion and Peoria had the highest proportions (12% and 13%,respectively) of enrolled participants who participated at the highest level (>999 services).

The results from the scenarios of the number of Medicaid children treated per dentist also variedby region. If utilization were increased to 57% and the number of participating dentists (1,537)stayed constant, the number of children per dentist would range from 193 in the Champaign andRockford regions to 352 in Cook County and 387 in Marion. At 57% utilization and achieving50% participation of all active dentists (3,030 statewide), the number of children per dentistwould range from 60 in the Collar Counties to 311 in Marion.

The regional variation in both Medicaid children’s utilization and enrollment and participation ofdentists underscores the importance of examining access and workforce issues at smallgeographic levels.


POLICY INITIATIVES BY MIDWESTERN STATESTO INCREASE ACCESS TO DENTAL CARE

The seven-state policy assessment was designed to capture a regional perspective on access todental care services for low-income children by surveying key informants in states adjacent toIllinois. States selected for interviews included Illinois, Indiana, Missouri, Kentucky, Iowa,Wisconsin, and Michigan. Key informants playing a primary role in oral health service, policy,or program administration were selected. Because a special focus of this study is the strategiesstates have employed to expand capacity of community health centers to provide dental services,representatives of the primary care association in each state were also surveyed.

State public health dental directors, state public aid dental personnel, and representatives oforganized dentistry (state dental associations) were identified by review of State and TerritorialDental Director directories and on-line dental and primary care association sources.

Structured interviews were conducted using a 12-14-question interview guide5. Three differentquestionnaires were developed to capture a description of the problem of access to dental carefor low-income children and information on the measures put in place to address it. Onequestionnaire was used for both departments of public aid and state dental associations, whowere asked to provide a brief history of their state’s Medicaid and CHIP dental programs andactions taken to increase access for children. A second questionnaire asked public health dentaldirectors to describe the objectives and activities of their departments, the nature of dentalservices offered by local health departments and any efforts underway to increase access at thecommunity level. A third questionnaire was employed to learn how primary care associationmember health centers increase capacity and the problems they encounter in doing so. Allrespondents were asked to share any pertinent reports, analyses or evaluations of administrativeor programmatic changes to dental programs in their states.

The survey instruments were pilot-tested with representatives from Illinois and Michigan. InMarch 2000 letters were sent to the remaining potential interviewees describing the researcheffort and asking for their participation in a 20-30 minute telephone interview. Interviews werescheduled in advance and conducted by a trained research associate. In almost all instances, anadditional staff member was present to take notes and verify interviewer accuracy.

Interviews were conducted from February to July 2000. A total of 26 of 28 key informantinterviews (93%) were completed in seven states. Non-respondents included one department ofpublic health and one primary care association.

Responses from each interview were written up in narrative format corresponding to thestructure of the survey instrument. An analysis was performed by extracting responses,organizing them by theme, and grouping them to obtain an enumeration of 1) issues contributingto the problem of access for low-income children and 2) a state-by-state tally of the measuresundertaken to address access to dental care. Written documentation received from keyinformants, ranging from formal reports to legislative bodies to brochure style program

5 The interview guides are available from the Center upon request.


descriptions, was analyzed only for measures to improve oral health and access to dental servicesfor low-income children. Problem identification is described in the narrative below.

In August 2000 these findings were mailed to all 28 key informants (and, in some instances,additional parties who took part in the interview) with a letter asking them to verify accuracy andcorrect any misrepresentations. Responses were received from 16 of the 30 (53%) by therequested return date. A second request to those not responding was sent in mid-September 2000.An additional 7 responses were subsequently received.

The findings from this survey provide a description of how seven Midwestern states characterizethe oral health status of low-income children and barriers to dental care. Our survey alsodescribes the measures these states have put in place to improve access to care and oral health.

PROBLEMS IDENTIFIED BY STATES

The problems identified by survey participants echoed the well-documented findings of recentnational and academic assessments of children’s oral health needs (see Background). Thefindings of our interviews and analysis of documentation received are organized and enumeratedby common element or theme. The numbers in parenthesis represent the number of statesidentifying that topic or issue.

Poor oral health statusKey informants in several states reported that low-income children suffer disproportionatelyfrom poor oral health status, often presenting with severe and advanced dental disease andrequiring extensive treatment (3). In addition, respondents felt that the Medicaid program forEarly and Periodic Screening, Diagnosis and Treatment (EPSDT), which includes dental servicesfor Medicaid enrolled children aged 0-21, is under-utilized and that there is insufficientinfrastructure to receive children referred from an EPSDT screening for further care, especiallyto dental specialists (3). Finally, two states reported that too few public health programs focus onoral health and that local communities are extremely limited in their capacity to provide patienteducation and preventive care.

Barriers to careThe low participation rate of private practice dentists in Medicaid and CHIP programs wasreported to be a significant barrier to care. Reimbursement rates, typically well below both theoverhead and the usual, customary, and reasonable rate (UCR) charged by dentists, wereconsistently cited as a major cause of low participation (7). Respondents said that dentistsdescribed the Medicaid system as cumbersome and administratively difficult to work with,resulting in lost time and revenue (6). Key informants discussed problems such as high no-showrates among Medicaid patients as another disincentive for dentists to enroll (7), and felt thatdentists have a poor perception of, if not a prejudice against, Medicaid patients, viewing them asdisruptive and non-compliant (6). Others cited a general dislike/distrust among dentists of stateprograms as a reason for low participation (4).

Further barriers to access were reported to result from the undersupply and maldistribution ofdentists. States described severe problems in rural areas where there are few participating


dentists (especially specialists) and patients must travel great distances to find a dentist who willsee them, or in any area where patients lack transportation to get to appointments (4). Lack ofchild care and employment flexibility that would allow Medicaid recipients to take children toappointments during typical dentist office hours were also cited (3), as was the stigma associatedwith Medicaid and dealing with dentists who will not accept it (1). Finally, the increasingnumber of children covered by CHIP and expanded Medicaid programs, coupled with the pent-up demand for services, was expected to exacerbate the already limited availability of bothprivate providers and public dental facilities (3).

Informants described the capacity of public-sector dental clinics, i.e. community health centersor local public health departments offering dental services, as severely limited (3), many ofwhich maintain long waiting lists for dental appointments. Recruitment and retention of dentiststo these settings/geographic areas is difficult. Many federally qualified health centers must relyon the limited resources of the National Health Service Corps to recruit dentists to their settings(5). Respondents reported that local communities in their states had extremely limited funding tostart-up new dental clinics or assist existing facilities in maintaining or enhancing the servicescurrently being offered (3).

Finally, states identified an overall shortage of dentists in the workforce (5). Some attributed thisto recent dental school closures (2) and an insufficient number of new graduates to replace arapidly retiring dental workforce (3). Private practices are reported to be full with private-paypatients and dentists are able to build, and seen as preferring to build, comfortable practices fromamong these patients (3). Two respondents expressed concern over a lack of exposure in dentaltraining and support in practice for community health dentistry, which would prepare and sustainprofessionals who are interested in treating this population.

INITIATIVES

The following section describes measures undertaken by states to improve the oral health statusof low-income children and decrease barriers to dental care. These measures took place largelywithin the three years from 1997 to the time of the interviews in the spring and summer of 2000.Table 21 categorizes the findings on common measures undertaken by states to improve childoral health status, to decrease barriers to dental services, and to increase capacity of dentists toserve low-income children. Table 22 describes unique programs or efforts underway inindividual states.

Access to Dental Care for Low-Income Children in Illinois, December 2000 - 38 -Table 21: State Measures to Improve Oral Health Status and Access to Dental Care Services for Low-Income Children, 1997-2000

Initiatives Illinois Indiana Iowa1 Kentucky Michigan Missouri Wisconsin1.Advisory Committee, Task Force or Coalition on Access ✔ ✔ ✔ ✔ ✔ ✔ ✔

2. Oral Health Assessment & Planning Community-level oral health survey or needs assessment ✔ ✔ ✔ ✔ ✔ ✔ Child oral health screening ✔ ✔ ✔ ✔

Technical assistance to local communities to implementinterventions ✔ ✔ ✔ ✔ ✔ ✔ ✔

3. Prevention Community water fluoridation ✔ ✔ ✔ ✔ ✔ ✔ ✔ Community dental sealant program ✔ ✔ ✔ ✔ ✔ School fluoride mouthrinse programs ✔ ✔ ✔ ✔ ✔ ✔

4. Dental Coverage – CHIP/Medicaid Expansion ✔ ✔ ✔ ✔ ✔ ✔ ✔

5. Changes in Medicaid Program Administration New leadership in state Medicaid office ✔ ✔ ✔

Contracted with new external dental intermediary for state’s Medicaid program ✔

6. Improve Private Practice Provider ParticipationRaised reimbursement rates to dentists ✔ ✔ ✔ ✔ ✔ ✔ ✔Simplified program administration ✔ ✔ ✔ ✔ ✔ ✔ ✔Conducted outreach to dentists ✔ ✔ ✔ ✔ ✔ ✔ ✔

7. Improve Client Participation & UtilizationConducted outreach to clients ✔ ✔ ✔ ✔ ✔ ✔

8. Public Sector CapacityStart-up funds to local health departments, under-servedcommunities to establish dental clinics and increase capacity ofexisting facilities ✔ ✔ ✔ 3 ✔4 ✔ ✔

9. Practice Acts:Hygienists and/or pediatricians can apply some treatmentsindependent of DDS and obtain reimbursement from stateMedicaid program ✔2

1. Data missing: Unable to speak to Iowa Primary Care Association2. EPSDT Exception to Policy allows Maternal & Child Health Clinics in

some counties to bill for services performed by hygienists in their employ.3. No state funds available to licensed primary care or rural health care

centers, M/CHCs or FQHCs.4. FY 1999 $5 million in state funds allocated for competitive capacity

building grants to both public and private entities

Source: Year 2000 interviews with key informants in state public health dental offices, departments of public aid, state dental associations and primary care associations, conducted by the Illinois Centerfor Health Workforce Studies in collaboration with the Illinois Primary Health Care Association.


Table 22: State Specific Strategies to Improve Oral Health Status and Access to Dental CareServices for Low-Income Children, 1997-2000

Illinois Public-private partnerships conduct planning, access equipment and provide service at the local level.

The Illinois Department of Public Health, Division of Oral Health, assists communities in implementingschool-based dental sealant programs, providing preventive oral health care to children participating in thereduced meals program. The Division also makes funds available to communities wanting to conduct anOral Health Needs Assessment and Planning Program.

The Illinois Department of Public Aid established a grant program to fund clinic start-up costs. In order tobe eligible for funding, local areas must have completed an Oral Health Needs Assessment and PlanningProgram.

Indiana Statewide dental sealant campaign planned during upcoming year.

Iowa ABCD Program: Identifies barriers & seeks to ease them through building public infrastructure, providingstate-supported care coordination, and working with local dentists to provide a dental home for Medicaidrecipients.

Kentucky None reported.Michigan Healthy Kids Dental: FY 1999 demonstration project to provide Medicaid recipients in 22 counties (26%)

with private insurance look alike coverage to see if access to private practice dentists improves.

Missouri In collaboration with Missouri Primary Care Association, the Dental Association will hire a consultant toconduct focus group studies and town hall meetings with local residents, providers, legislators, etc. toidentify problems and solutions to access to oral health services.

Legislation pending that would allow hygienists to perform screenings in “public health” settings and wouldalso mandate oral hygiene curricula in accredited elementary schools.

Primo Grants give revenue assistance to dentists establishing practices in under-served areas.

Wisconsin Healthy Smiles for Wisconsin is a CDC-sponsored initiative to improve youth oral health through education,disease prevention and treatment resulting in a comprehensive plan for the state.

Under the same grant, the Back to School for Health Smiles initiative will link dental hygiene programs andlocal schools for education, prevention and treatment and will result in a statewide plan for collaboration.

The Seal a Smile statewide program encourages counties and cities to conduct sealant programs. It includesa “how to” manual, some state sealant funding and free sealant materials from Oral Health America. About22 communities are conducting sealant programs.

Source: Year 2000 interviews with key informants in state public health dental offices, departments of public aid, state dental associations andprimary care associations, conducted by the Illinois Center for Health Workforce Studies.


1. Advisory Committee, Task Force or Coalition on AccessAll seven states indicated that some form of coalition, task force or advisory committee had beenformed, either voluntarily or as charged by the state, to address the issue of access to dental care. Inseveral instances, both a task force and a coalition were present, sometimes working together. Onestate described its coalition as a public-private partnership, another as an advisory panel or committee,and two each used the terms “task force” and “coalition.” Groups could include representatives fromMedicaid, public health, organized dentistry, dental schools, dental hygienists, primary careassociations, private and public sector dentists, Head Start programs, Area Health Education Centers(AHECs), legislative bodies, adult and pediatric medicine, child advocacy and hospitals. These groupsserved to convene some or all of the entities responsible for programs or services to low-incomechildren; to communicate the issue among themselves and coordinate their disparate efforts; to publishreports to influence policy changes; to make recommendations to legislative bodies, state agencies orgovernors’ offices; to oversee the allocation of rate increases to dentists; to evaluate dental programs;to build support for interventions; and draw political attention and public awareness to the issue. In thecase of one state, three large-scale dental summits were held from 1998 – 2000 and regular meetingsbetween Medicaid staff and the dental association were also reported.

2. Oral Health Assessment & PlanningThe extent to which states were able to conduct child oral health screenings, surveys and/or oral healthneeds assessments varied widely, although all states provided some form of technical assistance tolocal communities to assist their efforts to improve access to dental services. Although these measureswere cited as improvements, only four states had undertaken screening of children for oral healthneeds, and five states had surveyed or otherwise conducted oral health assessments at the local level.Resources for these efforts were generally described as limited.

3. Enhanced Prevention EffortsWater fluoridation was the most widely cited form of prevention, provided by all states interviewed. Inlocal areas where water fluoridation was not possible, state public health agencies were sometimes ableto assist with funding for school fluoride mouthrinse programs.

Dental sealant programs, typically offered to school-age children identified by their eligibility forfree/reduced school lunch, were available to children in five states and were also identified byinformants as an effective but under-funded preventive measure.

4. Expand Children’s Coverage for Dental Services through CHIPEach of the seven states interviewed cited the federal Children’s Health Insurance Program (CHIP)among the measures that have helped improve access to dental services for low-income children.Either through the expansion of the state’s existing Medicaid benefits, by covering children under aseparate CHIP program, or through some combination of both, each state had increased eligibility forand/or coverage of dental services for low-income children.

5. Changes in Medicaid Program AdministrationThree states indicated that new leadership in the state Medicaid office led to improvements in theadministration of the dental program. In each instance, the change in personnel meant a newrecognition of the problem and subsequently a new approach or commitment to improving access to


dental care for low-income people. In Illinois, an Auditor General inquiry into the contract with a pastdental intermediary led to a new contractual design awarded to a new external intermediary.

6. Improving Private Practice Dentist ParticipationAll seven states reported making administrative changes to the Medicaid program that were designedto improve private practice dentist participation. First among these was an increase or series ofincreases in fees paid to dentists for a variety of services provided to Medicaid clients. For example,Wisconsin implemented rate increases of 5% annually from 1997 to 1999. Illinois increased rates onselect procedure codes an average of 56% in 1999, with $8.5 million going toward children’spreventive services. Most dramatically, in 1998, Indiana raised rates by an average of 119%.

In addition, states took measures to simplify enrollment, approval, billing and payment methods byreducing or eliminating prior authorizations for some services (6); moving to ADA uniform billingcodes (6), in some cases with electronic entry; and reducing the billing/payment cycle (3).Individually, states implemented further changes, for example allowing dentists to determine thenumber of patients referred to them by the Medicaid program; holding workshops on billing andpolicy; designating Medicaid staff to respond to dentist questions; simplifying the certification process;and revising handbooks and materials.

Most states implemented outreach or recruitment programs to inform dentists about the programmaticimprovements and encourage either first time or increased participation (6). In some instances, thestate’s dental intermediary conducted recruitment and outreach activities, while in others the statedental society did so. Collaborative efforts were also reported. The president of one state dental societyenrolled in the Medicaid program and used a recruitment mailing to encourage members to do thesame. One state’s recruitment plan was implemented in phases, targeting dentists who were alreadyenrolled but not billing the Medicaid program, attempting to increase the number of Medicaid clientsseen by lower volume dentists and, finally, recruiting dentists who were never enrolled. Another statecreated a campaign urging dentists to “Share the Care” by taking several Medicaid clients into theirpractices. This program also supplied dentists with a monthly newsletter and sent letters thanking themfor their participation.

7. Improving Client Participation and UtilizationEfforts to increase Medicaid enrollee participation and utilization were made by six of seven statesthrough outreach to Medicaid enrollees and their families. Most often this took the form of letters,brochures or pamphlets to clients outlining the importance of oral health; promoting preventive care;and stressing the need for early and regular visits, compliance, keeping scheduled appointments andoffice etiquette. At least four states reported the existence of toll-free numbers for referral of Medicaidclients to enrolled dentists, and these numbers were published in enrollment and promotional materialsand on recipient cards. One state reported having a very active Medicaid Member Services Council.Another paid the costs of transportation to dental visits.

8. Increasing Public Sector Capacity for Dental CareDental services offered by community health centers, federally qualified health centers, and localhealth departments varied from state to state, as did each state’s ability to increase capacity. (Dentalschool clinics, hospitals and community-based organizations were not included in this survey.) Moststates (6) made grant funds available to help local communities establish dental clinics; purchase


equipment; expand physical facilities; prolong hours of operation; increase the number of dentalchairs; or offer loan repayment as an enticement to recruit and retain dentists. In one state, Kentucky,no such grants were available to licensed primary care centers (their federally qualified health centers).In Michigan, one such competitive grant was awarded to a private entity supplying a mobile van tolow-income children in designated school settings, local health department clinics and Head Startprograms. At least one state reported that very few local health departments offered dental services.Illinois created a manual for local communities on how to access a wide variety of resources, includingdonated space and equipment, to establish dental services in local areas. In 1998, the IllinoisDepartment of Public Aid began making grants to local health departments to establish or expand“much needed” dental services.

9. Practice ActsDental hygienist practice acts vary by state, with some requiring little to no general or directsupervision by dentists for diagnostic and preventive services. Only one state in our study hadenhanced the practice act of dental hygienists and pediatricians to enable them to apply preventivetreatments independent of a general dentist and be reimbursed by the state Medicaid program (Iowa).A second state had such legislation pending.

State-specific initiativesThe following are descriptions of unique initiatives undertaken by individual states as described bothby key informants and in documentation provided by them.

Illinois described a number of local collaborations designed to establish or expand oral health facilitiesfor under-served populations or dental Health Provider Shortage Areas. Public and private agenciescollaborate on the local level for service provision (a few county health departments partner with statedental school and dental hygiene schools) and to recruit and bring services to the area. In addition,strategic planning, project implementation and advocacy to improve statewide coordination and accessto oral health care is conducted by the IFLOSS Coalition, a public-private partnership.

Iowa’s ABCD program (Access to Baby and Child Dentistry), modeled on the Spokane, Washingtonprogram, employs care coordinators in one rural (nine-county service area) and one urban area of thestate to help low-income families establish a dental home and achieve maintenance level care.Coordinators provide patient education; help families locate a Medicaid-enrolled dentist and scheduleand keep regular and referral appointments; assist with day care and transportation; provide follow-upand monitoring; and refer families to other community services. Care coordinators act as a bridgebetween low-income children and both public and private dental resources. In this way they contributeto the oral health infrastructure of the state by identifying all dentists in their designated areas, creatingrelationships with them and acting as liaison between dentists, patients and responsible publicagencies. Two additional areas are projected for state fiscal year 2001.

Michigan created Healthy Kids Dental, a private insurance look-alike demonstration project in 22counties for Medicaid beneficiaries. (Funds have been appropriated to expand demonstration to 15additional counties in FY 2001.) Healthy Kids Dental automatically enrolls Medicaid beneficiariesunder age 21 in those counties and provides them with private insurance cards. Modeled on it’s ownsuccessful MI-CHILD CHIP program, dentists are reimbursed at competitive rates using a private


insurance compatible system (ADA codes and standard claim forms). Patients have no co-payment andthere is no annual maximum coverage per child. The demonstration project targets participation byprivate practice dentists.

Missouri created a coalition, including the Missouri Dental Association and Primary Care Association,that will hire a consultant to conduct focus group studies and town hall meetings to identify problems,educate all participants, and determine solutions for access to care from which a program will be built.Participants will include Medicaid-enrolled families, local residents and dentists, and legislativerepresentatives. In a separate initiative, the University of Missouri Kansas City School of Dentistryhas created a manpower task force and many of the stake holders (MDA, PCA, MO Coalition for OralHealth) are members.

Missouri also has legislation pending that would allow dental hygienists to practice in public healthsettings serving Medicaid children without a dentist’s supervision. Hygienists would be able to providecleaning, sealant, fluoride and oral hygiene instructions. The Dental Board has not yet determinedwhat constitutes a “public health setting.” This bill would also allow pediatricians to apply fluoride andwould mandate oral hygiene curricula in all accredited elementary schools.

The Missouri Department of Health will appropriate $1 million for PRIMO Grants. These are five-yearcontracts of $100,000 to dentists who agree to establish their practices in under-served areas for aminimum five-year period. Dentists receive $50,000 the first year, $30,000 the second year and$20,000 the third year. After year three, it is expected that the practice will be self-sustaining so nomoney is provided to augment practice revenues.

Wisconsin has been awarded a Centers for Disease Control and Prevention (CDC) grant that will allowa coalition in the state to create a plan to address access to oral health education, prevention andtreatment services by working with schools and communities. Specifically, this initiative will seek toestablish a youth oral health surveillance and data collection system; make dental sealants available(Seal a Smile); and provide oral health education to school-aged children. In addition, through theBack to School for Healthy Smiles initiative, dental hygiene education programs in the state willcollaborate to share strategies and create a plan for promoting partnerships between themselves and thestate’s elementary schools to create school-based and school-linked education, prevention and servicedelivery programs with the goal of improving the oral health of Wisconsin children.

SUMMARY OF FINDINGS FROM STATE INITIATIVES

All seven states have undertaken a number of recent initiatives to address the problem of access to oralhealth care for Medicaid-enrolled children. Each state has formally acknowledged the problem throughthe formation of an advisory committee or task force. The most common changes in state programsand policies focused on increasing private practice dentist participation. Some of these initiatives arediscussed in more detail below. However, in spite of the numerous and varied measures taken by thesestates, all seven states reported on-going problems with access to oral health care for low-incomechildren.


Private practice dentist participation. Our survey found that states consistently addressed issues thateffected private practice dentist participation in their Medicaid programs. All seven states had raisedreimbursement rates to dentists, simplified the processes for enrollment, approval and billing, andconducted outreach to dentists with information on these improvements, either to improve existingrelationships or recruit new dentists. At least one state said provider participation increased as a resultof rate increases (Indiana), while another said that during five consecutive years of rate increases,provider participation had actually declined (Wisconsin). A study of North Carolina Medicaidreimbursement rate increases failed to demonstrate an increase in access to dental services for thatstate’s Medicaid population (Mayer, 2000). State respondents felt that these were necessary steps tokeep and recruit dentists, but respondent(s) in at least one state (Michigan) believed that somepercentage of dentists would always decline to participate, under any circumstances (Michigansurvey).

A further limitation of this measure is that it does not benefit populations in areas where there simplyare no dentists or where the few dentists who do practice in the area do not participate in the Medicaidprogram. For example, three Illinois counties, all in the Marion region, have no active dentists at alland eleven additional counties have no dentists who are enrolled in Medicaid. As a baseline, increasedenrollment and participation by dentists is crucial but it will address only a portion of the problem.

State advisory committees. Another consistent finding was the existence in every state of a coalition,task force or advisory committee on access to care for low-income families. These groups represent acollective acknowledgement of the problem, an awareness shared by the government, policy,advocacy, and professional communities, and reflect the level of concern for and multi-faceted natureof the problem of prevention and treatment of oral health disease among low-income populations. Thework of such groups is intended, in part, to address the splintered nature of policy development andservice delivery but it is not clear how much of their efforts has translated into more coordination ofcare or to what extent the authority exists to implement substantive change in policy or access to dentalcare.

Issues not addressed by these initiatives Finally, although the seven states we surveyed described acomprehensive list of measures to improve access, issues were identified that remain unaffected bythese initiatives.• Inadequate overall supply of dentists. The question of an adequate number of dentists to serve all

populations was raised by informants in five states. For some states, dental school closures havereduced the number of graduates entering the workforce.

• Potential benefits of exposing dental students to community practice. Respondents were notroutinely aware of possible efforts in their states to expose dental students to the principles ofcommunity-oriented dentistry or to opportunities to practice in low-income communities, althoughsuch curricular changes were deemed by many to be necessary and appropriate.

• Dominance of the private practice dental care model. Due to the entrepreneurial nature of dentalpractice, dentists are perceived as having the discretion to build their practices with the clients oftheir choice. Absent any intervention, respondents felt that the dental profession would continue toproduce large numbers of independent, private practitioners working in small business settings andcultivating a clientele that allows them to build a viable business.


STUDY LIMITATIONS

There were several important limitations to this study. The first was simply the fact that this detailedlook at the Illinois Medicaid dental care experience was the first of its kind in Illinois. While we couldrefer to the study done by the Illinois Auditor General that provided helpful comparison data from1996 through 1998, their information was not presented at the detail (e.g. regional levels) of our study.Thus, we have very few ways to assess whether our findings fully present an accurate portrayal ofutilization and participation in Illinois Medicaid dental care. The data we received were provided ascounty level counts, not individual records for either children or dentists. We could not perform anytests on the quality of the data; we simply used it as presented to us. Common problems with Medicaiddata, such as inadequate reporting of all dental services, duplicate reporting of services, inaccuracies indentist assignments for services, changes in addresses of recipients, and other issues could not beassessed. This argues strongly for the continued study of the Illinois experience and the use of data atthe record level, which would allow for better assessment of data reliability and more detailed analysis.

Another study limitation was our inability to merge the data from the ADA (demographic and practicecharacteristics of dentists) with the IDPA/Doral data on participation in Medicaid. This would havebeen useful in studying the characteristics of dentists who participated in Medicaid. Data fromIDPA/Doral were provided in services/procedures, rather than visits, preventing us from discussingparticipation in terms of patient visits per dentist. Also, data from safety net dental clinics were notavailable by site; dentists at these sites bill under their own provider ID number. These dentists maysplit their time among multiple private offices and safety net clinics, making it impossible todifferentiate what and how many services where provided at each location. An understanding of therole safety net dental clinics play in the overall provision of dental services to low-income childrenwould be useful. Also, understanding the differences in provision of dental services by private andpublic sector providers, as well as an examination of what makes those settings and patient interactionssuccessful, is necessary to develop models for expanding capacity of dental providers.

The study component that consisted of interviews with key informants from seven states was limited tothe information provided by the interviewee and supplemented with reports and other written materialssent to us. The interviewees were selected from four organizations (public health dental program,Medicaid dental program, state dental society, and association representing the community healthcenters.) and presented their perspectives. Missing from this list of stakeholders are the dentalhygienists and the patients/consumers or advocates for children enrolled in Medicaid and CHIP.


POLICY RECOMMENDATIONS

The findings of this study demonstrate relatively low utilization rates for dental care among Illinoischildren with Medicaid and limited levels of Medicaid participation by Illinois dentists. Since itappears that expanding Illinois dentists’ capacity for care of sufficiently large numbers of Medicaidchildren will be at best an incremental process, other options to deliver care should be explored. Thereare significant barriers for the strategies to increase dentists’ participation; for example, if there are nodentists located in a particular area, then increasing the Medicaid reimbursement rate is not going toincrease participation in that area. Studies of dentists have shown that there are substantial proportionsof dentists who will not participate in Medicaid regardless of reimbursement rates. If communityhealth centers cannot recruit enough dentists to operate a dental clinic, then having space andequipment for a dental clinic will not enable their clients to receive dental care. Several areas ofIllinois with low dentist volumes may not have enough dentists to serve the insured and private paypopulation, much less the Medicaid and uninsured populations. In addition, the findings frominterviews with key informants in Illinois and surrounding states indicated that a variety of initiativeshave been tried by most or all states to address these issues, yet every state still reported problems withaccess to dental care for their Medicaid and low-income populations.

These findings raise several questions. Have these state initiatives not had sufficient time to generatean impact? Are the initiatives too limited in their scope? Are there sufficient financial resources forexpansion of state Medicaid dental programs? Is a multifaceted approach with a combination ofcoordinated initiatives needed for change to occur? Must more outreach be directed at the families andconsumers of care? Or is there a need for new initiatives, new solutions, to the persistent problem oflow access to dental care for low-income children?

Based on our study and on discussions with groups in Illinois, the following recommendations arepresented. Since our study did not address problems affecting access from the perspective of familiesand children in the Medicaid program, we can offer only limited recommendations. However, westrongly encourage the State to continue to work with groups addressing these issues such as theIllinois IFLOSS coalition. Our study did not assess the financial consequences of expanding servicesto children, nor options for targeted dental fee increases, although these are important issues forconsideration.

Recommendation 1: More dentists should be recruited to enroll in the Medicaid program. Effortsshould be made to increase the number of children treated by currently enrolled dentists.a. Adequate reimbursement rates. The literature, our key informant interviews, and discussionswith dentists and other experts all indicate that without adequate reimbursement, as well as simplifiedbilling and administration, dentists will not increase their levels of Medicaid participation. Currently,the dental fees paid by Medicaid are estimated at 55-60% of the UCR rate, many groups indicate thatfees nearer 70 to 75% of UCR may be needed to attract dentists. However, even with theseimprovements, studies show that dentists’ increases in participation may be modest. While adequatereimbursement and simplified billing and administration are crucial, addressing these issues may becalled a necessary, but not sufficient, policy solution.

b. Outreach to enroll new dentists in Medicaid Targeted efforts should be continued to reach moredentists and their office staff to inform them about positive changes with Doral as the Medicaid dental


intermediary, such as current fees, simplified billing, and shortened payment cycles. Dentists whoalready participate in Medicaid could validate these improvements. Information on the number ofdentists enrolled in their area could be provided as a way to allay concerns about being the onlyMedicaid dentist in the area and, consequently, being overwhelmed with Medicaid patients. Asubstantial number of eligible children are enrolled under the CHIP program and dentists should beaware that this population differs from the Medicaid population (Byck, 2000) and they may behavemore like private pay or privately insured dental patients in terms of keeping appointments andcomplying with treatment.

Research shows that older, more established dentists are less likely to participate in Medicaid.Outreach efforts can be designed to target dentists with the greatest likelihood of participation.Conversely, outreach conducted to dentists who seem less likely to participate can still be undertaken,but new strategies are needed to increase the effectiveness of these efforts.

c. Increase participation levels of currently participating dentists Outreach efforts should also bedirected at enrolled dentists with the goal of increasing their participation and asking about problemswith the program. Perhaps innovative incentives or awards could be developed for dentists with greaterservice volumes; of course, this would need to be balanced by concerns of encouraging “Medicaidmills” for children’s dental care.

Policy Recommendation 2: Consider options to increase the dentist supply in under-served areas ofIllinois.For several regions of Illinois, the dentist supply, based on ADA data, is quite low, notably the Marionregion, and to a lesser extent Peoria and Champaign regions. The markedly reduced output of newgraduates from Illinois dental schools will make it difficult for these communities to recruit newdentists. This situation should be further assessed and key groups should review findings of this andother studies. At a minimum this review should include the dental schools, the Illinois State DentalSociety, the regional dental societies, Doral and IDPA, as well as other groups that are communitystakeholders, such as businesses, and educational institutions. These discussions may requireconsideration of expanding dental school enrollments to produce more Illinois dentists. Also,consideration should be given to efforts to increase the diversity of providers since minority providersmay be more likely to treat a minority and under-served populations.

Other options include the development of State loan forgiveness programs for dentists willing topractice in under-served areas or those willing to provide care to a certain level of Medicaid patients.For example, the State of Maryland recently offered a loan assistance repayment plan for dentists whocommit to treat Medicaid patients as at least 30% of their practice patient load.

Policy Recommendation 3. Explore the feasibility of maintaining or expanding the capacity ofdental clinics known as safety net providers, such as dental school clinics, community healthcenters, local health departments and others.While our study had only limited information on the dental services provided by these clinics, theyrepresent places where dental services are now provided and where high-risk children are found(schools, community health centers, local health departments, community centers, and dental trainingsites). The Illinois Department of Public Health is collecting information on these sites and this is an


important first step. Further assessment of the issues these clinics encounter in recruiting staff,equipping their sites, receiving payments for services, all need to be considered.

Other states are exploring ways to increase dental care capacity in these sites and this experience maybe useful to Illinois. Healthy People 2010 sets a target of increasing to 75% the proportion of localhealth departments and community health centers that have an oral health component. More start-upfunds and grants to existing and new safety net providers are needed, as are incentives to improve thesuccess of recruiting and retaining dentists. In addition, greater use of existing facilities may bepossible. For example, many community colleges have dental hygiene and dental technician programsand accompanying clinical facilities. It may be possible to use these facilities outside of class time,which would alleviate the barrier relating to expensive equipment and facilities.

Policy Recommendation 4. Encourage the integration of oral health care with primary health care.Several reports have recommended a stronger link between oral health care and primary medical care.Studies have shown that children who had preventive medical visits are more likely to have had dentalvisits. National data also indicate that the proportion of children who had a medical visit in past year ismuch higher than the proportion who had a dental visit (74% vs. 43%). Thus, children who may notsee a dentist in one or more years may see a medical care provider; this is particularly true for childrenunder three years of age.

This represents an opportunity to reach children and their parents to discuss oral and dental health.The dental community could work with children’s primary health care providers – pediatricians, familypractice physicians, nurse practitioners – and their representative organizations (e.g., AmericanAcademy of Pediatrics) to address the problem of children’s oral and dental health. This is particularlyimportant for high-risk children (low-income or minority children), the groups least likely to see adentist and at higher risk for having untreated dental caries. Primary medical care providers need tolearn more about the importance of oral health, how to talk to parents about their children’s oral healthneeds, and how to perform basic oral health screenings. They could be encouraged to include oralhealth in well-child visits. In addition, they should have information for Medicaid and uninsuredchildren on where to obtain dental care in their community.

Policy Recommendation 5. Enhance dental school training to include population-based studies oforal and dental disease among the high-risk groups, the problems with access to dental care, andpublic health dentistry. Expose students to community based private practices and safety net clinicswhere high-risk children are receiving care.Dental schools could broaden their curriculum to include more information on public health dentistry,issues regarding access to dental care, and varied utilization patterns of different population groups.Through both classroom and offsite experiences, dental students could be exposed to successful privatedental practices with a large number of Medicaid patients, as well as to safety net clinics (e.g.,community health centers, hospital outpatient clinics) – practices and clinics that are outside thetraditional model of private practice dentistry. The intent of this exposure during dental school is tofoster a greater awareness of dental access problems and of successful practice model that provideaccess to care.

Policy Recommendation 6. Expand the role of dental hygienists in the care of Medicaid children.Dental hygienists are an important component of the dental workforce in Illinois and their expandedrole in the care of Medicaid children should be seriously considered and tested.


Over one quarter of Medicaid dental expenditures and a larger percent of all procedures were forpreventive care services (cleanings, fluoride, sealants). Hygienists are trained to provide theseservices. Hygienists are also trained to counsel children and their families on oral health and dentalself-care. Dentists who employ a hygienist have a substantially larger capacity to provide services.

The State could consider testing programs which expand dental hygienists’ provision of certainservices (e.g. cleanings, fluoride, sealants, and screening exams. If properly designed, this wouldallow for the testing of conditions that would enable under-served children to have access to preventivedental care – and possibly reduce dental problems in the future and thus prove cost-effective. Accessto dental providers is a critical barrier to oral health care; access could potentially be improved byexpanding the use of dental hygienists.

Policy Recommendation 7. Establish a statewide oral health surveillance system.Currently, in Illinois as well as nationally, there are limited data available to inform healthprofessionals, policy makers, health advocates, and others about the oral health needs of a population.There are a few states that have regular surveillance activities in place to assess oral health status ofchildren, thus, providing a picture of oral health status (i.e., caries experience) over time. At least onestate (North Carolina) collects data on workforce characteristics of dentists and dental hygienists aspart of the licensure renewal process.

A comprehensive oral health surveillance system will enable Illinois to collect and analyze oral healthdata in order to monitor the oral health status of the population and subgroups, identify needs, makedecisions, influence policy makers, secure program resources, and evaluate programmatic success inimproving oral health. The oral health surveillance system could have the capacity to assess oralhealth workforce capacity and characteristics, oral disease burden, population trends, oral health status,health behaviors related to adverse oral health, and dental insurance coverage.

Policy Recommendation 8. Expand community based preventive programs.Prevention of oral disease is key in decreasing the demand for services among low-income children.School based oral health education programs, community based sealant programs, and programs thatraise awareness and educate low-income families about the importance of oral health care andinfluence their behavior in seeking oral health care for their children should be developed and orexpanded.


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Appendix A

Illinois Center for Health Workforce StudiesDental Advisory Group – Members & Invited Guests

Diann Bomkamp, RDH, BSDHADHA District VIII TrusteeAmerican Dental Hygienists' Association

Ann Boyle, DMDAssociate DeanSchool of Dental MedicineSouthern Illinois University

Gerald Ciebien, DDS, MPHChairman, Access to Care CommitteeChicago Dental Society

Shelly DuncanVice PresidentCommunity Health ServicesIllinois Primary Health Care Association

Patrick Ferrillo, Jr., DDSDean, School of Dental MedicineSouthern Illinois University

Robyn Gabel, MSPH, MJDExecutive DirectorIllinois Maternal & Child Health Coalition

Steve Geiermann, DDSRegional Dental ConsultantBureau of Primary Health CareHealth Resources and Services Administration

Julie Janssen, RDH, MAPublic Service AdministratorDivision of Oral HealthIllinois Department of Public Health

Greg JohnsonDirectorProfessional ServicesIllinois State Dental Society

Lewis Lampiris, DDS, MPHChief, Division of Oral HealthIllinois Department of Public Health

Ann LattigSenior Public Service AdministratorBureau of Comprehensive Health ServicesIllinois Department of Public Aid

Pat LawManagerBureau of Comprehensive Health ServicesIllinois Department of Public Aid

Henry Lotsof, DDSVice PresidentDoral Dental Services of Illinois

Tim LynchManagerGovernmental AffairsAmerican Dental Hygienists Association

Laura Neumann, DDS, MPHGroup Associate Executive Director,Professional ServicesAmerican Dental Association

Matt PowersAdministratorDivision of Medical ProgramsIllinois Department of Public Aid

Indru Punwani, DDS, MSDHead, Pediatric DentistryUniversity of Illinois at Chicago

Mark Rosenberg, MD, FAAPPresident, Illinois ChapterAmerican Academy of Pediatrics


Mary Catherine RingChief, Center for Rural HealthIllinois Department of Public Health

Maria L.S. Simon, DDS, MSPresident, Illinois Society of Pediatric DentistryPediatric & Adolescent Dental Associates

Dave SpinnerManagerMedical Assistance Dental ProgramIllinois Department of Public Aid

Rodney Vergotine, DDSUndergraduate Clinic DirectorCollege of DentistryUniversity of Illinois

Debra WhitmerPresidentIllinois Dental Hygienists' Association

StaffGayle Byck, PhDSenior Research SpecialistIllinois Center for Health Workforce StudiesUniversity of Illinois at Chicago

Judith Cooksey, MD, MPHDirectorIllinois Center for Health Workforce StudiesUniversity of Illinois at Chicago

Julie Mansour, MBAAnalystIllinois Center for Health Workforce StudiesUniversity of Illinois at Chicago

Hollis Russinof, MUPPCenter Manager & Policy AnalystIllinois Center for Health Workforce StudiesUniversity of Illinois at Chicago


Appendix B: Data Sources and Methods

This appendix describes the data sources for the first two study components: (1) describing the supplyand distribution of Illinois dentists; and (2) describing dental expenditures, children’s utilization of dentalservices, and dentists participation in the Medicaid program. In addition, some comments on themethodology are provided; further details on methodology are available from the Center upon request.The methods for the study component which assessed the problems and strategies in seven Midwesternstates are described in that section of the report.

Data Sources

Sociodemographic data on Illinois dentists

A data set of all Illinois dentists was obtained from the American Dental Association (ADA) in February2000. This data set included both ADA members and non-members. The data set included: addressinformation including zip code, birth date, gender, race, year of graduation from dental school, dentalschool attended, specialty, and occupation type (e.g., private practice >30 hours per week, hospital dentist,etc.). The only information with a large proportion of missing values was race (28% missing for activedentists).

Zip codes matched to counties

A data set from the United States Postal Service (USPS) was purchased which listed all zip codes andtheir corresponding county and state (USPS, 2000). The Illinois zip codes and counties were extractedand merged with the ADA file to add county information for each dentist. It should be noted that an exactzip code to county match was not feasible as some zip codes cross county lines, and zip code boundariesdo change. It is believed that this limitation does not have a significant impact on the study results.

County population estimates

Population data, total and children <18, for each county was obtained from the Population EstimatesProgram, Population Division, U.S. Census Bureau. (CO-99-13) Population Estimates for Counties byAge Group: July 1, 1999. Internet release data: August 30, 2000.

Dentist enrollment and participation in Medicaid; and Medicaid/KidCare enrollee utilization ofdental care

Data on dentist enrollment and participation in Medicaid, Medicaid/KidCare enrollee utilization of dentalcare, and procedures performed were provided by the Illinois Department of Public Aid (IDPA) and DoralDental Services (Doral), the state’s Medicaid dental intermediary. Except for Medicaid/KidCareenrollment and provider enrollment, all data were for services provided from March 1, 1999 throughFebruary 29, 2000, for claims paid through June 30, 2000. Medicaid/KidCare enrollment figures were asof September 1, 1999 (the midpoint of the claims data provided). The list of enrolled providers was datedJune 30, 2000. Table B-1 below shows a list of all data files received from IDPA.


The enrollee-level data were provided by county (often by zip code for Cook County), and for thefollowing age groups: 0-3 years, 4-5 years, 6-12 years, 13-18 years, and 19-20 years. The Cook countyzip code data were aggregated for this report to provide estimates for the entire county.

IDPA/Doral provided a count of dentists in each county who submitted services, grouped by 1-100services, 101-999 services, 1000-1999 services, 2000-4999 services, and 5000 or more services; this is themeasure of participation used in this study. A service is any procedure billed to and paid for by Medicaid.Thus, service and procedure are used interchangeably.

Procedure-level data were provided statewide for the abovementioned age groups, and were aggregatedinto the following categories, as provided by the Illinois State Dental Society: (a) Diagnostic (exams, x-rays); (b) Preventive (prophylaxis, fluoride, space maintainers); (c) Restorative (fillings); (d) Restorative(crowns, inlays, onlays, veneers); (e) endodontic; (f) periodontic; (g) Removable prosthodontics; (h)Implants, fixed prosthodontics; (i) Oral surgery; (j) Orthodontics; (k) Miscellaneous (anesthesia, mouthguards, occlusal adjustments); (l) FQHC encounter fee; and (m) EPSDT. The latter two categories werenot on the ISDS list, but were clearly designated on the IDPA data.

A conference call was held in September 2000 prior to the second advisory group meeting withrepresentatives of IDPA, IDPH Division of Oral Health, and ISDS to review the data analysis and clarifyquestions. This call clarified the following points of interest:

• data relevant to utilization were for individual services rather than visits or claims (a visit orclaim usually consists of more than one service). This limits the ability to discuss how manyMedicaid patient visits occurred, for example, in a county or per dentist;

• an individual provider with multiple locations is listed more than once in the list of enrolledproviders. Since, for our study, each site needs to be counted, this overestimates the number ofparticipating dentists in our analysis. Analysis of the list indicated that 385 (19%) of the 2,078Illinois provider identification numbers were listed more than once; of these, 278 (72%) hadonly 2 practice sites, and 199 (72%) of this group had both practice sites in the same county.Many of the multiple sites were all in Cook County. Table B-2 shows the breakdown ofnumber and location of practice sites for these 385 providers;

• the procedure-level data should be grouped by category, e.g., preventive, diagnostic,restorative, etc, as noted above.


Table B-1: Data Files Received from IDPA on July 10, 2000(Unless noted, data is for service provided 3/1/99-2/29/00, for claims paid through 6/30/00)

1. Total Claims Paid- by county (except zip codes for Cook )- by age group

2. Percentage of all Medicaid claims that are dental- by county (except zip codes for Cook )- by age group

3. Number of Unique Medicaid Enrollees Receiving Dental Services- by county (except zip codes for Cook )- by age group

4. Average Number of Visits per Patient- by county (except zip codes for Cook )- by age group

5. Proportion of Medicaid Enrolled Children Receiving Dental Services- by county (Cook and Other includes out of state and unknown)- by age group

6. Medicaid Enrollees as of 9/1/99 (includes KidCare enrollees)- by county (except zip codes for Cook )- by age group

7. Count of Participating Providers as of 6/30/00- by county (Cook=non-Chicago, Cook(Chicago)=Chicago), State (non-Illinois)

8. Average Number of Services Submitted per Provider Submitting Services- by county (Cook=non-Chicago, Cook(Chicago)=Chicago), State (non-Illinois)

9. Distribution of Services Submitted by Providers- by county/state- claims: 1-100, 101-999, 1000-1999, 2000-4999, 5000+)

10. Mean Dollars Paid Per Encounter- by county (except zip codes for Cook )- by age group

11. Total Services Paid by Procedure Code- by age group

12. Total Number of Services Submitted for Each Procedure-by age group

13. Dental Provider Children's Fee Schedule- code, allowed amount

14. Enrolled Providers by Zip Code , as of June 30, 2000- provider ID, zip code


Table B-2: County Information about Providers with Multiple Sites

Numberof sites

Number ofproviders

All same county All different county Other

2 278 (72%) 199 79 NA3 75 (19%) 31 6 38 – 2 of 3 same4 18 (5%) 4 41 5 – 2 same, other 2 different

4 – 3 of 4 same1 – 2 same, 2 same

5 7 (2%) 3 0 2 – 2 same, 2 same, 1 different1 – 3 of 5 same1 – 2 same, other all different

6 6 (2%) 1 0 3 – 5 of 6 same2 – 2 same, 2 same, others different

7 1 (0%) 0 0 1 – 5 same, 2 sameTOTAL 385 (100%) 238 (62%) 89 (23%) 58 (15%)

1 3 of these 4 provider ID numbers had the same 4 counties: Iroquois, Livingston, Logan, McLean

Notes on Methodology

• It was not possible to merge the ADA and IDPA data files, so sociodemographic characteristics ofMedicaid providers could not be studied.

• Active patient care general practice and pediatric dentists were defined from ADA data as dentistswhose specialties were listed as “general practice” or “pedodontics” and who were employed as : (1)private practice >30 hours/week; (2) private practice <30 hours/week; (3) hospital staff dentist; or (4)part-time faculty/part-time dentist6. This subset of dentists was selected since they are the most likelyproviders of dental care services to low-income children. In addition, as explained below, the ADAdata set is believed to be most useful and reliable for private practice dentists as opposed to dentistswho work in government or public health settings.

• There was some discussion as to how dentists who work at safety net sites (i.e., community healthcenters) would be classified in the ADA occupation codes. Personal communication with advisoryboard members revealed that these types of dentists would probably identify themselves as “otherfederal services – VA, public health” or “other health organization staff”. There were 144 general and1 pediatric dentists who were listed as “other federal services”, and 242 general and 3 pediatricdentists who were listed as “other organization staff”. An attempt was made to determine the practicesite of these 390 dentists. However, only 71 of these dentists had office addresses listed, as opposed tohome addresses, in the ADA data file, and it was difficult to determine their practice type.

6 Excluded occupation codes: full time faculty; armed forces-army, navy, air force, marines; other federal services-VA, publichealth; state or local government; graduate student/resident; other non-dental student; other health organization staff; not inpractice-seeking employment; no longer in practice (retired); and other occupation.


Appendix C

Illinois Department of Public Health Division of Oral Health Regions

Rockford

Peoria

Champ

Edwardsville

Marion

Chicago /Cook

s
CollarCountie
aign


Appendix D

Documents

ACCESS TO DENTAL CARE FOR LOW INCOME CHILDREN IN … to Dental... · Access to Dental Care for Low-Income Children in Illinois, December 2000 - 4 - • Total dental claims expenditures