DENTAL SAFETY NET

TOP ABSTRACT DENTAL SAFETY NET MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
A few studies have examined the size and capacity of the dental safety net at the national level² (H.B., R. Weaver, unpublished data, 2004). Although the safety net plays an important role in providing care to low-income and other disadvantaged groups, it has limited capacity relative to the size of the underserved population. One weakness of these studies is that their estimates of the size and capacity of the safety net are based on "order-of-magnitude guesses" rather than on the primary collection of data at the state level.

One study examined the capacity of the dental safety net in Illinois. Byck and colleagues³ recently surveyed all Illinois dental safety-net clinics, and they reported a total of 95 federally qualified health centers (FQHCs), community health centers (CHCs), local health departments, private not-for-profit clinics, schools of dentistry and dental hygiene clinics, and school-based clinics. In 2000, these clinics provided a mean of 3,150 patient visits per clinic, for a total of 300,000 patient visits per year. Assuming a mean of 2.2 visits per patient, the 95 clinics treated about 136,363 patients. These authors also reported the results from 57 clinics representing the three largest identified groups of community-based clinics.⁴

In this report, we describe the dental safety net in Connecticut and examine the capacity and efficiency of this system to provide care to the noninstitutionalized underserved population in the state.

	MATERIALS AND METHODS

TOP ABSTRACT DENTAL SAFETY NET MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
In 2003, we gathered information to describe the Medicaid and State Children’s Health Insurance Program (SCHIP) in terms of enrolled members, utilization rates and reimbursement rates to dentists. We obtained these data from the Connecticut Department of Social Services, which is responsible for running the Medicaid and SCHIP programs.

We identified safety-net providers in the state from a comprehensive list compiled and continuously updated by the Connecticut Department of Public Health. We verified and augmented this list by examining Medicaid dental claims data for the year 2000–2001 and identified public- and voluntary-sector delivery sites and providers.

To establish the capacity and structure of the state’s safety net, we surveyed all facilities by telephone, written survey or both to obtain data regarding the number of full-time equivalent (FTE) dentists, hygienists, dental assistants and other staff members, as well as the number of dental operatories. FQHCs, CHCs and the state dental school also provided detailed output data regarding the number of patient visits and patients treated annually in their facilities. We combined the data from the FQHCs and CHCs.

Medicaid fees in Connecticut are in the bottom first to seventh percentiles compared with other New England states.

To compare the productivity (that is, mean number of patient visits per year per dentist) of safety-net dentists with that of private practitioners, we first examined the mean number of allied health personnel and operatories per dentist in private general practices and in Connecticut safety-net clinics. We obtained the data for the former from the 2002 Survey of Dental Practice conducted by the American Dental Association.⁵ We then adjusted the dental output of a dentist in private practice on the basis of the known output elasticities (that is, the percentage change in output over the percentage change in input) of allied health staff (.54) and operatories (.17) in private practices.⁶ This calculation gives the output of private practices if they were configured the same way that safety-net clinics are configured.

We also estimated the percentage of Medicaid-enrolled children served by safety-net clinics versus private dental offices. We used Medicaid dental claims for children enrolled continuously for the year 2000–2001 to identify the two provider types. As part of this analysis, we also compared the mix of services provided to children. We conducted the latter analysis to assess the comparability of the output from safety-net clinics with that from private practices that treat the underserved.

	RESULTS

TOP ABSTRACT DENTAL SAFETY NET MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Underserved patients and the Medicaid system. The disadvantaged population in Connecticut consists of two groups: Healthcare for UninSured Kids and Youths (HUSKY A) and SCHIP (HUSKY B). HUSKY A is composed of children in families with incomes at or below 185 percent of the federal poverty guidelines and families with incomes at or below 150 percent of the federal poverty guidelines. HUSKY B is composed of children in families with incomes above 185 percent of the federal poverty guidelines. Children in families with incomes between 185 and 235 percent of the federal poverty guidelines incur no premiums; those in families with incomes between 235 and 300 percent of the federal poverty guidelines incur modest premiums; and those in families with incomes higher than 300 percent of the federal poverty guidelines incur group premium rates negotiated by the state.⁷

In fiscal year (FY) 2001, 229,150 people, aged 0 to 21 years were enrolled in HUSKY A and 11,460 were enrolled in HUSKY B, for a total of 240,610 people.⁷

Approximately 29 percent of the Medicaid- and SCHIP-eligible population (aged 0 to 21 years) visited a dentist one or more times in FY 2001. Three hundred twelve private practitioners and 111 dentists working in safety-net facilities provided these services. These dentists represent 14.5 percent and 5.1 percent, respectively, of the total number of practicing dentists (N = 2,159) in the state (T.B., H.B., L. Brown, M.L., D.H., unpublished data, 2003).

One reason for the overall low utilization rates is the low Medicaid reimbursement rates. Medicaid fees in Connecticut are in the bottom first to seventh percentiles compared with other New England states.⁸

Safety-net clinics. Table 1 shows the different types of safety-net clinics in Connecticut and the mean FTE staffing for each clinic type. Community health centers (both FQHCs and CHCs) represent the largest component of the safety-net system in terms of dental chairs (106) and FTE dentists (35). These community clinics also employ the largest number of hygienists (17) and assistants (44), both absolutely and relative to the number of FTE dentists.

About 27 public schools have a dental facility in which dental services—mainly screening and preventive—are provided to children. Only six school districts provided comprehensive dental care. Eleven dental hygienists, four FTE dentists and five FTE dental assistants staffed these clinics in 2003.

Twenty pediatric dentistry and 18 advanced education in general dentistry (AEGD) residents and fellows from The University of Connecticut School of Dental Medicine, Farmington, deliver dental care in safety-net clinics in the community or in the dental school. These 38 residents and fellows have access to 38 chairs, but only two hygienists and 14 assistants are available to provide care. Dental students also provide dental care to underserved patients, but they were not included in our analysis because they are not licensed dentists. Likewise, we did not include specialty residents in this study, because many of their patients are not underserved.

In total, the safety-net system in Connecticut had 221 dental chairs and employed 111 FTE dentists or dental residents, 38 hygienists and 95 dental assistants in 2003.

Visits and patients per clinic. Table 2 presents the number of patient visits and patients treated per dentist in CHCs and the dental school AEGD and pediatric dentistry residency programs (combined) and, for comparison purposes, the number of visits and patients treated per private independent practitioner nationally.

To assess differences in productivity between safety-net dentists and dentists in private practice, we examined the current structure of the safety-net system and private practices nationally with respect to dental chairs, hygienists and assistants. We found that the safety-net dental clinics employed 34.3 percent fewer allied health staff members and used 48.6 percent fewer operatories per dentist than did private practices.

The number of patient visits per private practitioner, when adjusted to reflect the number of operatories and allied health personnel per dentist in safety-net clinics, was estimated to be 2,072 (Table 2). Thus, with the same number of operatories and allied health personnel as safety-net clinics, private practices were only slightly more productive (1.4 percent) than CHCs with regard to the number of patient visits per dentist. The larger difference (8.0 percent) between private practitioners and AEGD and pediatric residency programs may reflect the educational component of these programs.

If we assume that the entire safety-net system in Connecticut had the same output capacity per dentist as did CHCs, the 111 FTE dentists providing care in safety-net clinics could treat about 67,932 patients annually. This represents about 28.2 percent of the people currently enrolled in the HUSKY A and B programs. This does not include most adults covered by public dental insurance and the thousands of adults and children who are underserved but not eligible for, or not enrolled in, Medicaid or SCHIP.

To determine the actual contribution of the safety-net system to the care of underserved children in Connecticut, we analyzed Medicaid and SCHIP claims from 100,000 children who were continuously enrolled in these programs in 2000–2001. Table 3 shows that 67 to 72 percent of these children received care in the offices of private practitioners and 28 to 33 percent received care in safety-net clinics.

View this table: [in this window] [in a new window]   TABLE 3 PREVENTIVE AND RESTORATIVE SERVICES PROVIDED TO CHILDREN ENROLLED IN MEDICAID AND SCHIP* BY SAFETY-NET CLINICS AND PRIVATE PRACTICES IN CONNECTICUT.

	DISCUSSION

TOP ABSTRACT DENTAL SAFETY NET MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
This study of dental safety-net clinics in Connecticut suggests that CHCs, hospital clinics and dental school clinics are the largest component of the safety-net system in terms of numbers of dental chairs, FTE dentists and allied health personnel. An examination of the safety-net system at the national level also showed that these three organizations accounted for most of the system’s capacity (H.B., R. Weaver, unpublished data, 2004).

These clinics play a critical role in caring for the underserved population. Many patients from low-income families do not have the resources to pay for dental care out of pocket, and for those covered by public insurance, access to care is limited because relatively few private-sector dentists in Connecticut (14.5 percent) participate in the Medicaid and SCHIP programs. This is not surprising in light of the fact that Medicaid reimbursement fees are below the seventh percentile for the region.

In addition, because low-income patients often come from single-parent families and use public transportation, it is difficult and expensive for them to travel outside their immediate neighborhoods to receive dental care. Thus, safety-net clinics represent a critical resource for low-income communities.

However, relative to the total number of under-served patients, safety-net clinics have limited capacity and are able to treat only a small percentage of the targeted population (that is, about 29 percent of enrolled children). This lack of capacity is made more acute by the current staffing patterns of safety-net clinics; specifically, they employ relatively few dental hygienists and assistants. This is a problem because a large percentage of children—and to a lesser extent adults—needs only diagnostic and preventive services. For example, according to the Third National Health and Nutrition Examination Survey, about 50 percent of children from lower-income families have untreated carious teeth.⁹ Because of a lack of hygienists, safety-net system dentists appear to spend considerable time providing preventive services.

Likewise, Hillman and colleagues¹⁰ found that dentists are far more productive when they work with full-time dental assistants. In Connecticut, assistants are in short supply, and many safety-net dentists work without this important resource.

Clearly, greater use of dental hygienists and assistants would have a significant impact on the capacity of safety-net clinics to provide care to underserved people. If safety-net clinics had the same allied health staffing levels as those of private practices, we estimate that the output of the safety-net clinics in Connecticut would increase by at least 80 percent, a substantial expansion over the present system.

Interestingly, the ratio of dentists to allied health care personnel in Connecticut is similar to that in Illinois safety-net clinics.^3,4 This suggests that the understaffing of hygienists and assistants in the two states may be related to the funding of safety-net clinics.

The similar number of patient visits per dentist in private dental practices and safety-net clinics (with the same operatory and staffing configurations) was an unexpected finding, because private practitioners are paid on a fee-for-service basis, while most safety-net clinic dentists are salaried. Hillman and colleagues¹⁰ and Stearns and colleagues¹¹ reported that physicians paid on a fee-for-service basis see more patients and produce more services per unit of time than do salaried physicians. Use of a different output measure (for example, dollar value of services) might show a difference in productivity between private practitioners and safety-net dentists. This issue merits further investigation.

With a limited safety-net system, it is no surprise that the great majority of underserved patients obtain dental care from private practitioners. In this study, 69 percent of children enrolled in Medicaid who obtained care did so in private offices. As we noted above, this high percentage is all the more remarkable because Connecticut Medicaid dental reimbursement fees are so low.

	CONCLUSION

TOP ABSTRACT DENTAL SAFETY NET MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
This study examined the dental safety net in Connecticut and found that CHCs, hospital dental residency programs, public schools and the dental school AEGD and pediatric dentistry residency programs are the primary providers of care, employing about 111 dentists. The system uses fewer operatories and allied dental staff members per dentist than do private practitioners, and it generates fewer visits per dentist. However, when we adjusted the number of patient visits per private practitioner to reflect the number of operatories and allied health personnel per dentist in safety-net clinics, the number of visits per dentist was almost the same.

As an upper-boundary estimate, the safety-net system has the capacity to care for about 67,932 patients per year; this is 28.2 percent of the patients enrolled in public dental insurance plans in Connecticut. An examination of Medicaid claims for the year 2000–2001 revealed that most enrolled children (69 percent) obtained their dental care from private practitioners. The dental safety-net system is an important community resource for providing care to the underserved population, and greater use of allied dental personnel could substantially improve the capacity of the system.