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J Am Dent Assoc, Vol 137, No 1, 86-94.
© 2006 American Dental Association |
TRENDS |
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS, MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. The authors surveyed 210 Washington state orthodontists, including questions on demographics, attitudes toward early treatment, use of innovations and perceptions of Medicaid. Respondents were either Medicaid participants or nonparticipants.
Results. Fifty of 159 respondents were Medicaid participants. Most respondents perceived early orthodontic treatment as beneficial. Medicaid participants were more willing to participate in Medicaid early-treatment programs, had slightly fewer patients in the "other insurance" category, provided more discounted fees, received more Medicaid inquiries, practiced in rural areas with lower household incomes, reported feeling overworked and experienced fewer Medicaid problems. The principal problem reported with the Medicaid system was low fee reimbursement.
Conclusions. Programs offering early orthodontic treatment could increase access. Important barriers would be low fees and unfamiliarity with Medicaid.
Practice Implications. Medicaid should design programs aimed at early treatment with reasonable reimbursement and an educational component.
Key Words: Access; health care disparities; interceptive orthodontics; early orthodontic treatment; Medicaid
Access to orthodontic services for children from low-income families who are enrolled in Medicaid is limited nationwide. Low participation by orthodontists in Medicaid programs is an important contributing factor. The status of Medicaid-funded orthodontics in Washington state is typical. More than 500,000 children statewide were eligible for dental treatment under the Medicaid program in 1999. Of these, less than 1 percent received any orthodontic care in 1999 (Washington State Department of Social Health Services, written communication, 1999), despite estimates of the incidence of malocclusion being between 15 and 60 percent.1–5 Given that most Medicaid orthodontic programs target the most severe types of malocclusions, these estimates of unmet need may be high, but they remain significant. Approximately one-quarter of practicing orthodontists in Washington state participated in the Medicaid program in 1999 but most treated only a few patients enrolled in Medicaid (Washington State Department of Social Health Services, Olympia, Wash., unpublished data, 1999). Ten orthodontists provided approximately 81 percent of the orthodontic treatment statewide, excluding those for patients with cleft lip and palate.
Orthodontists may not provide treatment to patients enrolled in Medicaid because of actual or perceived problems with the Medicaid program and its clients. These problems may include low fee reimbursement, uncooperative patients and high rates of noncompliance. A few studies have examined the perceptions of general dentists and pediatric dentists regarding the treatment of patients enrolled in Medicaid.6–8 Results from these studies show that the most commonly reported deterrent to being a Medicaid participant is low fees. In a study conducted in Washington state, participants reported patient behavioral issues to be of only minor importance.8 Despite both pediatric and general dentists’ reporting dissatisfaction with the allowable fees, they had significant differences in their attitudes toward the Medicaid program. Pediatric dentists were more likely to accept and treat patients enrolled in Medicaid than were general dentists, and they saw treatment of children as more important than did general dentists.7,9 No similar data exist on barriers to Medicaid participation by orthodontists. In addition to low participation by dentists, there are other possible explanations for this disparity between the need and the availability of service for low-income children. For example, there may be fundamental differences in malocclusion patterns in children from low-income families. Cultural, socioeconomic or behavioral differences also may act as barriers to seeking orthodontic treatment.
Most publicly funded programs ration orthodontic treatment by limiting it to only the patients with the most severe malocclusions. This approach has profound effects on the level of participation by orthodontists because it selects for patients who will require more resources and who often are at risk of having poorer outcomes even under ideal conditions. This issue is compounded by reimbursement rates of about 60 to 65 percent of the customary fee.
An alternative rationing strategy would be to select patients who may be at risk of developing severe malocclusions and intervene early using approaches that have reduced complexity and expense compared with full treatment in the permanent dentition. Orthodontists consider early interventions to be partial treatments that may require a second phase in the permanent dentition to completely alleviate both functional and esthetic problems.10 Orthodontists recognize that the approach to early orthodontic treatment today does not provide finished results and, ideally, should be followed by elective finishing in a second phase of treatment. These two-phase approaches often are more costly than one-phase treatment in late adolescence. Patients, however, benefit significantly from early treatment, which usually is less complex and costly than second-phase finishing or one-phase treatments during adolescence.
As a public health measure, early intervention—without a publicly funded elective second phase of finishing—would provide substantial benefit at a reduced cost per patient compared with full treatment in the permanent dentition. Although most orthodontists may accept this approach, no researchers have examined its usefulness as a means for increasing access to orthodontic services for low-income families. We hypothesize that orthodontists would perceive early orthodontic treatment as a useful means of reducing the severity of malocclusion, that orthodontists who favor early intervention also would favor other innovative orthodontic treatments, that the practice demographic of orthodontists who are Medicaid participants would differ from that of orthodontists who are not, and that these perceptions and practices would predict acceptance of a Medicaid program focusing on early orthodontic treatment in children at risk of developing severe malocclusions.
We conducted a study to assess the likelihood that programs focusing on early interception of malocclusions could increase Medicaid participation by orthodontists and, thereby, increase access for low-income families.
Study respondents.
We identified and surveyed the 210 members of the American Association of Orthodontists who practiced in Washington state in 1999. They represented most of the orthodontists practicing in the state in 1999.
Survey.
The survey included questions in four general categories that represent the important factors affecting acceptance of a Medicaid program of early orthodontic treatment: practice demographics, attitudes toward early orthodontic treatment, acceptance of innovative orthodontic approaches and perceptions of the Medicaid system.
Practice demographics.
We designed the first section of the survey to determine if any differences existed between the demographics of Medicaid participants and nonparticipants that could predict acceptance of an early treatment program. We categorized as Medicaid participants only those respondents who treated at least one patient enrolled in Medicaid during the previous year. This section asked for the respondents’ number of years in practice, number of years at their location, total number of patients they started seeing in the past six months, the ZIP code for their main office, the number of patients who they provided discounted fees and who they started seeing in the past six months and the number of Medicaid inquiries in a typical month. We collected the respondent’s ZIP codes so we could assess sociodemographic data such as median family income and population density. First, we determined the county for each ZIP code,11 and then we recorded the median family income12 and population density13 we obtained from 1999 U.S. census data. We also asked respondents what their average fee was for a 24-month case, how busy their practice was during the past year and what their practice arrangement was (that is, self-employed, partner, employee).
Attitudes toward early orthodontic treatment.
We designed this section of the survey to determine if orthodontists have a common vision of the acceptability of early treatment approaches. We asked orthodontists how much benefit patients derived from early treatment and to rank the effectiveness of early treatment for 10 malocclusions on a five-point scale, with 1 being "never effective" and 5 being "always effective." We designed a subsection to determine if early treatment without a second phase was acceptable. Our rationale for this question stemmed from our belief that an early treatment program under Medicaid may not include funding for a second phase of treatment.
Acceptance of innovative orthodontic approaches.
We designed the third section of the survey to determine if acceptance of innovative approaches to treatment would predict the likelihood of participation in a proposed new Medicaid program. We asked respondents how many cases involving indirect bonding and how many involving orthognathic surgery they started in the past six months. We also asked them whether they had used self-ligating brackets, self-etching primers, lingual braces or aligners to treat patients.
Perceptions of the Medicaid system.
We designed the fourth section of the survey to explore how orthodontists felt about the Medicaid system and a proposed program aimed at increasing participation through early treatment of patients. We asked the orthodontists to provide information regarding their patients’ methods of payment during the past six months. Specifically, we asked them what percentages of their patients had Washington Dental Service (WDS) insurance (WDS [Seattle] is the Delta Dental provider in the state), other private insurance, Medicaid, no insurance or other.
We listed 10 commonly cited problems with the Medicaid system and patients enrolled in Medicaid. We asked respondents to indicate if they perceived each of these problems to be a "major problem," "minor problem" or "not a problem" or to respond "don’t know." We asked this to determine if any of these perceived problems were barriers to participation in Medicaid programs.
Study design.
Two orthodontists pretested the survey. One had considerable experience with patients enrolled in Medicaid, while the other’s experience with this population was limited. We chose only two orthodontists to avoid any reduction in the sample size or in significantly biasing the sample. One of the orthodontists (the Medicaid participant) was in the process of retiring, so we did not include him in the survey population. We included the other orthodontist in the final survey population. After the pretesting was completed, we revised the survey instrument.
We collected data through a mail survey using the Total Design Method.14 First, we sent a letter on University of Washington School of Dentistry stationery that described the study and identified us. Two weeks later, we mailed the survey, a cover letter and a postage-paid return envelope to all 210 members of the American Association of Orthodontists practicing in Washington state. We did not include an incentive with the survey. We mailed a reminder postcard to the nonrespondents six weeks later followed by a replacement copy of the survey after eight more weeks. The total data collection period was 19 weeks. We kept the survey responses confidential and destroyed links between the contact information and the actual questionnaires after we received the surveys.
Data analysis.
We analyzed the data using Statistical Package for the Social Sciences (Version 8.0, SPSS, Chicago). All of the respondents did not answer every question. Therefore, we calculated percentages based only on the number of orthodontists who responded to a particular question.
We compared orthodontists’ perceptions of the benefits of early treatment and the frequency of presenting two-phase treatment options using 2 x 4 tables (tables with two columns and four rows) and
We separated respondents into two groups for each of the six "innovative" orthodontic techniques shown in Table 1
SUBJECTS, MATERIALS AND METHODS
TOP
ABSTRACT
SUBJECTS, MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
The institutional review board of the University of Washington approved our study. 
2 tests. We calculated, ranked and compared the mean response scores for the respondents’ ratings of the perceived effectiveness of early treatment for 10 malocclusions using 2 tests. 
, according to whether they used that particular technique. We defined a user of indirect bonding and orthognathic surgery techniques as anyone who had used these techniques during the past six months. We defined a user of the other techniques as anyone who had ever used that particular technique. We then compared the differences between Medicaid participants and nonparticipants using individual 2 x 2 tables and 2 tests.
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2 tests. We calculated respondents’ means and standard deviations (SDs) for the number of patients they offered discounted fees, number of Medicaid inquiries, number of years in practice, number of years at location, percentage of each payment method, population density and median family incomes. We analyzed mean differences between participants and nonparticipants using nonparametric tests because the data were not distributed normally. We also calculated a mean response score for each of the perceived problems with the Medicaid system. We gave the response of "not a problem" a value of 0, the response of "minor problem" a value of 1 and the response of "major problem" a value of 2. We compared mean scores using the Mann-Whitney test. We excluded respondents who chose the "don’t know" response from our calculation.
To compare perceptions of Medicaid problems with a respondent’s willingness to participate in future Medicaid programs, we separated the respondents into two groups based on their mean perceived problem scores, discussed previously. We placed respondents with a mean problem score of 0 to 1 in the "low" group and those with a score of 1.1 to 2 in the "high" group. We then compared their differences in willingness to participate in the two Medicaid programs using 2 x 3 tables and 2 tests. Next, we compared the mean perceived problem scores for those willing to participate in each of the programs with the mean scores for those who were not willing or were not sure if they would participate. We performed the Mann-Whitney test to determine significance.
To determine if orthodontists’ use of innovative techniques is related to willingness to participate in future Medicaid programs, we created an index of each respondent’s propensity toward innovation by adding the number of innovative techniques each respondent used. Possible scores ranged from 0 to 6. We then separated respondents into high and low innovation groups. We analyzed various cutoffs for each group and analyzed the data using 2 x 3 tables and 2 tests.
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RESULTS |
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TOPABSTRACTSUBJECTS, MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Practice demographics.
Fifty of the 159 respondents (31.4 percent) reported some level of Medicaid billing during the past six months. A total of 6.1 percent of patients in these practices were enrolled in Medicaid (Table 2). There were no differences in the mean fees charged by participants and nonparticipants. Overall, respondents reported that 60.3 percent of their patients had some form of private insurance. Medicaid participants had slightly fewer patients with private insurance, treated more patients at discounted fees and received more than twice as many inquiries from patients enrolled in Medicaid compared with nonparticipants.
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). The respondents had a mean number of years in practice of 15.9 years with no differences based on participant status. This is consistent with the mean of 16.2 (SD = 10.2) years in practice for all American Association of Orthodontists members in Washington state. Medicaid participants more often were located in rural counties or counties with lower population densities and with lower median family incomes. Medicaid participants also started seeing fewer new patients per year but were more likely to report feeling overworked, while nonparticipants were more likely to report feeling busy enough but not overworked.
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, page 92). A total of 53.9 percent of the respondents reported they "often" or "always" offer an early treatment or a two-phase treatment option to their patients.
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Acceptance of innovative orthodontic techniques.
Medicaid participants were more likely to express a willingness to participate in a Medicaid-sponsored program of early orthodontic treatment (Table 1
). Both Medicaid participants and nonparticipants were similar in their use of innovations in orthodontics, with the only difference being that participants reported using aligners more than did than nonparticipants. We found that orthodontists’ perceptions of early treatment and their use of innovative approaches to treatment did not predict a willingness to participate in the proposed Medicaid program.
Perceptions of the Medicaid system.
Medicaid participants had fewer problems with Medicaid in only two ("getting billing questions answered" and "need for prior authorization") of the 10 issues cited in the survey (Table 5, page 93). Medicaid respondents reported that these were only minor problems, whereas the majority of nonparticipants saw them as major problems. "Fee reimbursement too low" was the largest problem for both participants and nonparticipants. Seventy-nine percent of all respondents reported that low fees were a major problem (data not shown). Other issues considered to be of some significance by both participant groups were, in descending order of importance, "patient may fail to show up for appointments," "difficulty collecting from Medicaid," "delays in receiving payment" and "patients are often late." Most respondents in both groups considered "unruly or uncooperative patients," "loss of coverage during treatment" and "patients cancel at the last minute" issues considered not to be significant.
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DISCUSSION |
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TOPABSTRACTSUBJECTS, MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The low level of Medicaid participation in general by orthodontists in Washington state (approximately 25 percent) and the poor distribution of those providing these services (10 orthodontists provided approximately 81 percent of the orthodontic treatment statewide) resulted in a low average percentage of patients enrolled in Medicaid per practice (6.1 percent). This raises the concern that the comparisons of participants and nonparticipants based on acceptance of any patients enrolled in Medicaid may have minimal value because of the small difference between levels of participation in the two groups. An alternative approach to this study design would have been to compare the 10 orthodontists who provided the majority of the treatment with the remainder of the orthodontists in the state. This could have provided clearer differences in participation, but it may not have been representative. Because of these differences, we felt that programs designed to increase access should target the rank and file orthodontists, not the practitioners who already are doing the work. The value of us using a more liberal definition of Medicaid participation in this study was that it provided us with a large enough group of practitioners so we could have some confidence that it was representative. Moreover, we felt that the characteristics of practitioners who elect to participate in the Medicaid program, regardless of the level, would likely be different from those who do not.
Practice demographics. Our failure to find differences based on participant status in practice arrangement, fees, number of new cases started, years in practice and practice location indicates that these are not important determinants in the likelihood of a clinician’s participating in a Medicaid program. However, Medicaid participants provided more discounted fees than and received twice as many inquiries from patients enrolled in Medicaid as did nonparticipants. The former may be due to a higher level of altruism or greater exposure to low-income families. The latter suggests that reduced access and referral patterns tend to funnel patients enrolled in Medicaid to practitioners who are known to accept them. Medicaid participants treated fewer privately insured patients than did nonparticipants. This may reflect fewer privately insured patients in the areas in which Medicaid participants are located. It also was interesting to note that Medicaid participants tended to feel more overworked than nonparticipants, despite having similar caseloads to nonparticipants. This may be a reflection of differing practice management styles, such as less use of auxiliary personnel.
Our survey shows that orthodontists with practices in areas with lower population densities (rural areas) and lower median family incomes were more likely to treat patients enrolled in Medicaid than were orthodontists with practices in more densely populated areas with higher median family incomes. This differs from an earlier report9 that found no difference in Medicaid participation rate based on practice location. However, the previous study categorized practices as downtown/city, suburban or rural, whereas our study categorized practices strictly on the basis of county census data. The finding that orthodontists practicing in rural areas treated more patients enrolled in Medicaid has a few potential interpretations. Orthodontists who choose to practice in rural counties may be more community-oriented and may have more inclusive practices.15 Rural environments also may provide more pressure not to deny treatment to patients enrolled in Medicaid because there would be fewer other orthodontists to whom to refer these patients. This difference also may relate to fees.9 Our data showed that the average fee for rural practices was lower than that for urban practices, and, therefore, the difference between the Medicaid reimbursement and the standard fee may not have been sufficient to influence an orthodontist’s acceptance of patients. This finding also may be unique to the demographics of Washington state and not generalizable to other states because the rural areas of the state are primarily agricultural with large numbers of low-income migrant farm workers.
Attitudes toward early orthodontic treatment. Almost all respondents reported that there was at least some benefit to early orthodontic treatment. This finding supports our hypothesis that orthodontists perceive early orthodontic treatment as a useful means of reducing the severity of malocclusion. However, about one-half of the respondents always or often tell patients there is a need for a two-phase treatment plan, suggesting that many view early treatment as only partial treatment. Our conclusions are supported by frequent reports of success of early treatment in reducing the severity of several types of malocclusion in the mixed dentition.16–21 Our failure to find significant differences between Medicaid participants and nonparticipants regarding their perceptions of early treatment effectiveness suggests that negative perceptions of the effectiveness of early treatment would not be a barrier to acceptance of such a program by orthodontists. However, a better understanding of the frequency of elective phase 2 treatments would be important because orthodontists may be uncomfortable with accepting patients for publicly funded phase 1 treatment without assurances that needed phase 2 treatment would be available.
The generally favorable perceptions of the effectiveness of early treatment for most malocclusions suggest that orthodontists feel comfortable using the approach for a wide variety of conditions. This further suggests that a program aimed at early orthodontic treatments could affect most types of malocclusions.
Acceptance of innovative orthodontic approaches. For a new program to improve access, an important requirement would be that a substantial number of nonparticipating orthodontists would find it appealing enough to become Medicaid participants. Our survey failed to show this trend with respect to early orthodontic treatment. The greater acceptance of a Medicaid-sponsored program of early orthodontic treatment by participants suggests that practitioners’ familiarity with the Medicaid system and its clients may be an important prerequisite for such a program to improve access. Educational initiatives designed to familiarize nonparticipants and their staff members with Medicaid and the new program would be essential for these programs to affect access much.
Our study failed to show differences in the use of innovative techniques based on participant status, except with respect to aligners. The failure to find associations between orthodontists’ perceptions of early treatment, their use of innovative or new techniques and their willingness to participate in the proposed Medicaid program does not support our hypothesis that openness to innovative orthodontic treatments predicts a willingness to participate in new Medicaid programs.
Perceptions of the Medicaid system. Medicaid’s low reimbursement rate is an important problem for both participants and nonparticipants.9,22 However, the impact of low fees on access is unclear, because we do not know if nonparticipating dentists would be willing to treat patients enrolled in Medicaid without increasing fees. An evaluation of the effect of fees on participation by Medicaid participants would be required to confirm this. A program targeting early treatment has the potential to reduce the costs per patient because these procedures tend to be less complex and, therefore, less expensive. For the same orthodontic budget, this approach would permit more patient treatments, but it may not increase the level of participation or access. Bureaucratic hurdles seem to be less of a problem, and the differences between participants and nonparticipants suggest that these hurdles could be overcome by more familiarity with the program.
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CONCLUSIONS |
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TOPABSTRACTSUBJECTS, MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We also found that Medicaid participants had fewer patients with private insurance, provided more discounted fees, received more inquiries from patients enrolled in Medicaid, practiced in more rural areas with lower family incomes, were more likely to feel overworked and had fewer problems with the Medicaid system. The most significant problem with Medicaid cited by both participants and nonparticipants was low fee reimbursement.
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FOOTNOTES |
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TOPABSTRACTSUBJECTS, MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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