Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents.

BACKGROUND: We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation. METHODS: Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, "average marginal effects") on dental care utilization and costs to Medicaid, controlling for patient and county characteristics. RESULTS: Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service: (1) Expected number of diagnostic services per patient-quarter increased by .009 units; (2) Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06; (3) Total expected cost per patient-quarter for all services increased by $0.64. These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions. CONCLUSION: The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Estimating determinants of dentist productivity: new evidence.

OBJECTIVE: Productivity (output per unit of input) is a major driver of dental service capacity. This study uses 2006-2007 data to update available knowledge on dentist productivity. METHODS: In 2006-2007, the authors surveyed 1,604 Oregon general dentists regarding-hours worked, practice size, payment and patient mix, prices, dentist visits, and dentist characteristics. Effects of practice inputs and other independent variables on productivity were estimated by multiple regression and path analysis. RESULTS: The survey response rate was 55.2 percent. Dentists responding to the productivity-related questions were similar to dentists in the overall sampling frame and nationwide. Visits per week are significantly positively related to dentist hours worked, number of assistants, hygienists, and number of operatories. Dentist ownership status, years of experience, and percentage of Medicaid patients are significantly positively related to practice output. The contributions of dentist chairside time and assistants to additional output are smaller for owners, but the number of additional dentist visits enabled by more hygienists is larger for owners. CONCLUSION: As in earlier studies of dental productivity, the key determinant of dentist output is the dentist's own chairside time. The incremental contributions of dentist time, auxiliaries, and operatories to production of dentist visits have not changed substantially over the past three decades. Future studies should focus on ultimate measures of output--oral health--and should develop more precise measures of the practice's actual utilization of auxiliaries and their skill and use of technology.

Pay-for-performance incentive program in a large dental group practice.

BACKGROUND: Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS: The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS: The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS: This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS: Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

Federally Qualified Health Center Substitution of Local Health Department Services.

INTRODUCTION: Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. METHODS: Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. RESULTS: There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. CONCLUSIONS: LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.

Dentists' perceptions of barriers to providing dental care to pregnant women.

PURPOSE: The purpose of the study was to understand US dentists' attitudes, knowledge, and practices regarding dental care for pregnant women and to determine the impact of recent papers on oral health and pregnancy and guidelines disseminated widely. METHODS: In 2006 and 2007, the investigators conducted a mailed survey of all 1,604 general dentists in Oregon; 55.2% responded). Structural equation modeling was used to estimate associations between dentists' attitudes toward providing care to pregnant women, dentists' knowledge about the safety of dental procedures, and dentists' current practice patterns. RESULTS: Dentist's perceived barriers have the strongest direct effect on current practice and might be the most important factor deterring dentists from providing care to pregnant patients. Five attitudes (perceived barriers) were associated with providing less dental services: time, economic, skills, dental staff resistance, and peer pressure. The final model shows a good fit with a chi-square of 38.286 (p = .12; n = 772; df = 52) and a Bentler-Bonett normed fit index of .98 and a comparative fit index of .993. The root mean square error of approximation is .02. CONCLUSION: Findings suggest that attitudes are significant determinants of accurate knowledge and current practice. Multidimensional approaches are needed to increase access to dental care and protect the oral health of women during pregnancy. Despite current clinical recommendations to deliver all necessary care to pregnant patients during the first, second, and third trimesters, dentists' knowledge of the appropriateness of procedures continues to lag the state of the art in dental science.

Medicaid reforms in Oregon and suboptimal utilization of dental care by women of childbearing age.

BACKGROUND: The authors conducted a study of dental services used by women of childbearing age who were enrolled in Medicaid in Oregon during the early 2000s, a period of reform during which health care coverage was expanded. They compared claims for pregnant women, women who were not pregnant and had children and women who were not pregnant and did not have children. They also compared differences in claims between those for women enrolled in managed care and those for women enrolled in fee-for-service plans. METHODS: The authors computed the proportion of women for whom a dental claim was submitted in six-month spans for 2000, 2001, 2002 (before reform) and 2005 (after reform). RESULTS: Before and after reforms, the mean utilization rate for pregnant women, adjusted for the proportion of the period covered, decreased from 0.36 (standard deviation [SD] = 0.025) to 0.22 (SD = 0.028). Among women who were not pregnant and had children, the average adjusted rates decreased from 0.49 (SD = 0.201) to 0.21 (SD = 0.078). The pattern was similar among women who had no dependent children: rates decreased from 0.50 (SD = 0.028) to 0.19 (SD = 0.078). Most of the claims were for diagnostic services. The authors found no differences between women enrolled in managed care and those enrolled in fee-for-service plans. CONCLUSION: Contrary to their intention, health care reforms in Oregon were detrimental to the vulnerable populations that Medicaid is intended to serve. CLINICAL IMPLICATIONS: Dental care is important for maternal and child health. However, utilization is unlikely to improve without changes in Medicaid and the dental care delivery system.