ACCESS TO DENTAL
CARE FOR LOWINCOME CHILDREN IN
ILLINOIS
Gayle R. Byck
Hollis J. Russinof
Judith A. Cooksey
December 2000
CONTENTS
Executive Summary
Introduction
Background
Children’s Oral Health and Dental Care
The Dental Workforce
Illinois Medicaid Dental Program
The Illinois Study of Access to Dental Care for Medicaid Enrolled Children
Illinois Dental Workforce
Children’s Utilization of Dental Care
Dentists Participation in the Medicaid Program
Projecting Dentist Capacity
Summary of Findings
Policy Initiatives by Midwestern States to Increase Access to Dental Care
Problems
Initiatives
Summary of Findings
Study Limitations
Policy Recommendations
References
Appendices
3
6
7
7
9
12
13
15
20
25
28
33
35
36
37
43
45
46
50
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, Louise
Martinez and Catherine McClure.
Illinois Center for Health Workforce Studies
University of Illinois at Chicago
850 West Jackson Boulevard, Suite 400
Chicago, Illinois 60607
www.uic.edu/sph/ichws
December 2000
Funding was provided by the Health Resources and Services Administration, Bureau of
Health Professions and Bureau of Primary Health Care, and in collaboration with the
Illinois Primary Health Care Association
Access to Dental Care for Low-Income Children in Illinois, December 2000
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EXECUTIVE SUMMARY
While children’s oral health has improved over the past forty years, many children have
inadequate dental care. In the last several years, national attention has focused on the problem of
limited access to dental care for low-income children. The causes of low access to dental care
are complex. The lack of dentists willing to provide care to children with Medicaid has been
called 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 the
University of Illinois at Chicago (UIC) to conduct a study of access to dental care for Illinois
low-income children. This study was a collaborative effort of the Center and the Illinois Primary
Health 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 of
Primary 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. This
analysis describes the dental care expenditures and dental care utilized by children
enrolled in the Illinois Medicaid program (this includes all children enrolled through
Medicaid and 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 care to
Medicaid children, this component concludes with three scenarios that estimate the
numbers of participating dentists needed to provide care to various target numbers of
children.
• 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 findings of this study demonstrate relatively low utilization rates for dental care among
Illinois 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 are
summarized here:
• Statewide, 33% (271,152) of children enrolled in Medicaid or KidCare utilized dental
care during the year. Illinois children in the 4-5 and 6-12 year-old age groups had the
highest 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% of
enrolled children in Cook County visited a dentist, the remainder of the State was below
30%.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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• Total dental claims expenditures were $29.17 million; the average expenditure per user
•
•
•
•
was $108.
34% (2034) of active general and pediatric dentists were enrolled in Medicaid. Of
enrolled dentists, 25% did not participate at all during the year, 39% submitted 1-100
services, 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 dentists
would need to treat 229 children, or each of the 1,537 participating dentists would need to
treat 304 children; at two visits per child per year, these numbers would represent
substantial percentages of a dental practice’s visits. Currently, only 165 dentists provided
at least 1,000 services during the year (treating an estimated 185 children at an average of
5.4 services per dental service user).
The regional variation in both Medicaid children’s utilization and enrollment and
participation of dentists underscores the importance of examining access and workforce
issues at small geographic levels.
All seven states have undertaken a number of recent initiatives to address the problem of
access to oral health care for Medicaid-enrolled children. Each state has formally
acknowledged the problem through the formation of an advisory committee or task force.
The most common changes in state programs and policies focused on increasing private
practice dentist participation. However, in spite of the numerous and varied measures
taken by these states, all seven states reported on-going problems with access to oral
health care for low-income children.
Based on our study and on discussions with groups in Illinois, the following recommendations
were made; they are discussed in greater detail in the report:
• Policy Recommendation 1: More dentists should be recruited to enroll in the Medicaid
•
•
•
•
•
program. Efforts should be made to increase the number of children treated by currently
enrolled dentists. This recommendation includes discussion of: adequate reimbursement
rates; outreach to enroll new dentists in Medicaid; increasing participation levels of
currently participating dentists
Policy Recommendation 2: Consider options to increase the dentist supply in underserved areas of Illinois.
Policy Recommendation 3. Explore the feasibility of maintaining or expanding the
capacity of dental clinics known as safety net providers, such as community health
centers, local health departments and others.
Policy Recommendation 4. Encourage the integration of oral health care with primary
health care.
Policy Recommendation 5. Enhance dental school training to include population-based
studies of oral and dental disease among the high-risk groups, the problems with access
to dental care, and public health dentistry. Expose dental students to community based
private 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 Medicaid
children.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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• 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 – utilization
and provider participation - in the Illinois Medicaid program during the study year. It also
provides scenarios for projecting the capacity of dentists to treat Medicaid enrolled children
under various scenarios. It is hoped that the information presented here will contribute to a
clearer understanding of access to dental care for low-income Illinois children as well as to
dental workforce supply and planning. Further research on the role of safety net dental clinics in
expanding access to dental care for low-income children, and on the characteristics of dentists
who participate in the Medicaid program, would add to our understanding of how to address
problems with access to dental care for low-income children.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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INTRODUCTION
Children’s oral health has improved over the past forty years, due to fluoridation, improved oral
hygiene, better nutrition, and access to oral health care services. However, oral problems related
to dental caries or cavities (painful teeth, missing teeth and poor appearance, impairments in
chewing and nutritional limits) and other oral conditions affect the health and well-being of
children and lead to missed school days and ongoing dental problems. While oral health care
services are an important component of comprehensive primary care services, many children
have inadequate dental care. In the mid-1990s, only one in five children with Medicaid received
dental care in a year. In Illinois, only 27% of children with Medicaid received dental care in
1998 (Holland, 1999).
In the last several years, national attention has focused on the problem of limited access to oral
health care for low-income children. The Surgeon General’s Report on Oral Health in America
has called oral health disease a “hidden epidemic” (US DHHS, 2000). The Healthy People 2010
Program, a national public health agenda, has identified several targets to increase access to
dental 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 Medicaid
program (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 a
variety of barriers facing children and their families that range from beliefs and attitudes about
dental care to transportation problems. The lack of dentists willing to provide care to children
with Medicaid has been called 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 (GAO, 2000a).
This situation prompted the Illinois Center for Health Workforce Studies (Center) at the
University of Illinois at Chicago (UIC) to conduct a study of access to dental care for Illinois
low-income children. The purpose of the study was to assess the capacity of Illinois dentists’ to
meet the dental care needs of low-income children of Illinois, specifically those covered by
Medicaid and KidCare, the State Children’s Health Insurance (CHIP) program. This study was a
collaborative effort of the Center and the Illinois Primary Health Care Association (IPHCA) and
was conducted from November 1999 through September 2000. This report summarizes the
findings of the study and concludes with recommendations. An Advisory Committee assisted
with the study and reviewed this Report. Funding for the study was provided by the Bureau of
Health Professions and the Bureau of Primary Health Care of the Health Resources and Services
Administration.
The study was conducted as three components. The first describes the supply and distribution of
dentists in Illinois. The second describes dental expenditures and children’s utilization of dental
care and the participation of dentists in the Illinois Medicaid program. The findings from these
analyses are presented for seven regions of the State to allow comparisons across regions of the
State. The third component assessed the perspective of seven Midwestern states, including
Illinois, on their views of the problems contributing to low access and the steps being taken to
address the problems.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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We are grateful to each of the organizations that supplied the data used in this study, specifically
the American Dental Association, the Illinois Department of Public Aid, and Doral Dental
Services of Illinois. We also acknowledge the contributions and time given by the interviewees
from 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 Status
National population surveys have noted a decline over time in the number of children with dental
caries and the numbers of teeth with decay. The percent of children ages 6 to 11 years with
dental caries in permanent teeth declined from 56% in 1971 to 23% in 1987; the percent of
adolescents, ages 12 to 17 year, with caries declined from 90% to 71%. These rates have
continued to decline, but some population subgroups have had persistent higher rates of dental
caries and untreated caries. About 25% of children (principally low-income) have untreated
caries, and these children have about 80% of the total population estimates of untreated caries in
permanent teeth (GAO, 2000b; US DHHS, 2000). Further analyses of national survey data that
include socioeconomic characteristics of children have shown significant effects of ethnicity and
poverty on untreated dental caries. The most recent national examination survey (NHANES III,
1988-1994) found higher caries rates among Blacks, Mexican Americans, and low-income
children (Vargas, 1998). These data show significant income effects, with higher rates of
untreated caries among lower income groups.
Data on Illinois children’s caries rates were collected during a statewide oral health survey of
school-aged children conducted in 1993-94 (IDPH, 1996). This was the first and only
comprehensive statewide oral health survey ever conducted in Illinois. This study found that
54% of children had caries in primary or permanent teeth. Twenty-three percent of children had
caries in permanent teeth (16% of children 6 to 8 years of age, and 57% of children 13 to 14
years of age). Untreated caries (in either permanent or primary teeth) were more common in
younger children, with 38% of children 6 to 8 years of age with untreated caries, and 30% of
those 15 years of age. Higher caries rates were noted for Black and Hispanic children compared
to white children.
Children’s Dental Care
Routine dental care for children includes diagnostic exams, preventive services (prophylaxis,
applications of fluoride, sealants, and oral health education) and restorative care (filling carious
teeth). 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 only
limited changes over the twenty year period of 1977 to 1996 (Table 1). Dental visit rates for
children under six years of age have increased only from 14% to 21%; older children’s
utilization 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 have
remained lower among low-income children. Of note is the declining number of visits per user
across each time period.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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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
1977
14%
(2.2)
51%
(3.6)
44%
(3.3)
23%
(2.5)
30%
(3.2)
28%
(3.2)
32%
(3.2)
53%
(3.4)
Under 6 years
6 to 18 years
White
Black
Hispanic
Poor
Low income
High income
1987
20%
(1.7)
51%
(3.2)
47%
(2.9)
26%
(2.4)
26%
(2.5)
24%
(2.5)
30%
(2.7)
56%
(3.0)
1996
21% (1.6)
52% (2.9)
49% (2.9)
27%
39%
--30% (2.1)
60% (3.1)
Source: Edelstein, Manski, and Moeller, 2000; Moeller and Levy, 1996.
In 1996, only 43% of all children visited a dentist in the year. The total visits for children were
estimated at 87 million total visits, or 2.7 visits per child using services. In contrast, only about
25% of children with Medicaid visited a dentist in a year. Studies show that children who had
preventive medical visits are more likely to have had dental visits (Milgrom, 1998). National
data indicate that the proportion of children who have a medical visit in past year is much higher
than the proportion who have a dental visit (74% vs. 43%; Table 2). Of those who had an
ambulatory medical visit, the average number of visits was 4.2. Even among publicly insured
children, 71% of these children had an ambulatory medical visit in the past year, and averaged 4
visits per year. The disparity between medical and dental visits for younger children is most
notable.
Table 2: Use of Medical and Dental Care by Children Under Age 18: United States, 1996
Population
Characteristic
Total Children
Age
Under 6
6-12
13-17
Health Insurance
Any private
Public only
Uninsured
Percent with at least 1
ambulatory medical
care visit
Mean number of
ambulatory medical
care visits
74.2
4.2
42.7
2.7
85.1
69.8
67.1
4.4
3.6
4.6
21.5
54.8
51.2
1.6
2.5
3.7
79.2
70.9
57.8
4.5
4.1
3.0
n/a
n/a
n/a
n/a
n/a
n/a
Source: Krauss, Machlin, and Kass, 1996.
Percent with at least 1 Mean number of dental
dental care visit
care visits
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Public Health Objectives For Oral Health and Access to Dental Care
Healthy 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 with
baseline measures and target for each objectives. Note that these objectives are set for the entire
population and the low-income population generally starts from a baseline that is significantly
below 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%
6-8 yrs: 42%
15 yrs: 51%
2-4 yrs: 18%
6-8 yrs: 52%
15 yrs: 61%
Reduce the number of children with untreated caries
2-4 yrs: 9%
2-4 yrs: 16%
6-8 yrs: 21%
15 yrs: 15%
6-8 yrs: 29%
15 yrs: 20%
8 yrs:
14 yrs:
8 yrs:
14 yrs:
Increase the number of children with sealants on their molars
Increase the number of children and adults who use the oral health care system
each year
Increase the proportion of the population served by water systems with optimally
fluoridated water
Increase the number of children (<200% of FPL) receiving any preventive dental
services
Increase the number of local health departments and community health centers
with oral health services
50%
50%
83%
23%
15%
65% ( > 2yrs age, 1997)
75%
62%
57%
20% (1996)
75%
34% (1997)
THE DENTAL WORKFORCE
The American Dental Association (ADA) maintains datasets that allow for several types of
analyses 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, this
yields a dentist-to-population ratio of 58 dentists to 100,000 population (US DHHS, 1999). The
overall supply of dentists is predicted to grow somewhat slower than the population over the next
twenty years, due to reduced dental school graduates. Due to concerns in the 1980s about a
potential oversupply of dentists, and a declining dental school applicant pool, dental schools
reduced their enrollments and several dental schools closed. At the national level, graduates
declined from 5,700 in 1983 to 3,900 in the mid-1990s. Two of the four Illinois dental schools
have closed (Loyola and Northwestern). In Illinois, the total graduates declined from over 400
per year in the mid-1980s to about 110 in 2001.
Dental care is largely a private practice model, with solo practitioners accounting for about twothirds 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 dental
school faculty, or employed by the armed services, government, other health organizations, or in
(1992)
Access to Dental Care for Low-Income Children in Illinois, December 2000
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training (ADA, 2000a). In 1998, 14% of all active dentists were women (ADA, 2000a). The age
distribution 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 the
eight specialties of dentistry1. Pediatric dentists constitute about three percent of all dentists and
they provide both specialty dental care to children with complex medical, dental and
psychosocial needs, and basic dental care to healthy children. The geographic distribution of
pediatric dentists is largely in metropolitan and suburban areas, with fewer than five percent
practicing in rural areas (Erickson, 1997). There are limited data on the portion of children’s
dental care that is provided by pediatric dentists, however due to their numbers, general dentists
are considered to be the major provider of dental care for children. Because of the reluctance of
some general dentists to treat the very young or preschool aged child, pediatric dentists may
provide 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 worked
per 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 patients
per year (2,331 visits, excluding dental hygienist appointments) compared to 2,811 visits for
dentists younger than 35 years, and 2,674 and 2,784 patient visits per year for dentists age 35-44
and 45-54, respectively (ADA, 2000a).
There are approximately 100,000 active dental hygienists in the United States. The majority of
dental hygienists are employed by general practice dentists. Of students enrolled in dental
hygiene schools in 1997-1998, 97% were women and 12% were minorities (ADA, 2000b).
Dental hygiene focuses on health promotion and disease prevention. Dental hygiene services
focus on oral health education and dental prophylaxis, as well as applying dental sealants and
fluoride treatments (ADHA, 2000). Thirty-five states have laws for varying forms of general
supervision, which means that a dentist must authorize the procedures a dental hygienist
performs, but the dentist does not need to be physically present while the hygienist is treating the
patients. Proponents of general supervision believe it expands access to preventive services for
under-served populations by allowing dental hygienists to practice without a dentist physically
present in such locations as public health facilities, schools, nursing homes, hospitals, and
prisons (ADHA, 2000).
Several states have experimented with expanded functions and less restrictive supervision
requirements for registered dental hygienists to increase access to dental care for Medicaid
populations. Under an EPSDT Exception to Policy, registered dental hygienists in Iowa can
provide clinical services, including sealants and fluoride varnishes, in designated maternal and
child health settings. These agencies can bill the state Medicaid program and be reimbursed for
services 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, no
data were available on the number of dental radiologists.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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dental hygienists in public health settings to provide certain preventive services to Medicaid
children without the direct supervision of a dentist (Tobler, 1999). California, Oregon, and
Washington State allow for direct reimbursement from Medicaid to dental hygienists (ADHA,
1999).
Dentists’ Participation in Care of Medicaid Children
A 1998 ADA survey found that 61% of dentists reported not treating any patients who were
covered by public assistance in their practices. State level studies of dentists’ participation in
Medicaid programs over almost twenty years describe a fairly consistent picture of a modest
numbers of dentists enrolled in programs, with fewer dentists actually treating any children, and
even fewer dentists treating a large volume of children. Michigan researchers surveyed dentists
in 1983 and found that almost 50% of dentists were treating no Medicaid patients (children and
adults); 29% reported that less than 10% of their patients were Medicaid; and 22% reported that
more than 10% of their patients were Medicaid (Lang, 1986).
Surveys of dentists in California and Connecticut identified low Medicaid payment rates as the
most important reason cited by dentists who limit their participation in Medicaid, followed by
billing and administrative burdens, poor patient compliance with keeping appointments, and
limited services covered (Damiano, 1990, Nainar, 1996). Studies of the relationship between fee
increases 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 they
were accepting new Medicaid children, others commented that the fee increases would not affect
their 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. Results
of these efforts were mixed with 14 states reporting increases in dentist participation or dental
utilization (generally, less than 3% increase in dental utilization); 15 states reported no changes
in 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 attracting
more dentists. This report also used the measure of treating 100 patients (children or adults) as
an indication of substantial participation by dentists and based this on an ADA survey of dentists
in private practice where 100 represented about ten percent of the average patients treated in a
year.
There are some data available on dentists’ willingness to take Medicaid patients based on
dentists’ demographic characteristics. Several studies have shown that older dentists and/or
dentists 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 likely
to participate in Medicaid compared to men dentists (Mayer, 2000). Two studies found pediatric
dentists 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 to
participate in Medicaid than white dentists were (Mayer, 2000). This finding is consistent with
Access to Dental Care for Low-Income Children in Illinois, December 2000
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studies of physician’s behavior; minority pediatricians were reported as more likely to treat more
minority 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 in
providing dental care for low-income children. For medical care, the term “safety net’ is used to
describe the providers that serve individuals lacking health insurance or the ability to pay
medical costs out-of-pocket. Often these medical care providers receive public subsidies and
charge patients on a sliding fee schedule based on family income. Safety-net medical providers
include public hospitals, community health centers, local health departments, and teaching
hospitals.
Safety-net dental providers may include any of the above groups offering dental care, as well as
dental school clinics and a limited number of other voluntary providers. This group of dental
care providers is significant in that the dentists practicing in safety-net clinics may have a
relatively large volume of their practice committed to low-income children. It has been
estimated that about one third of community health centers and local health departments had
some type of oral health program in 1997. According to a recent study, in 1998, 385 of the
nation’s 686 community health centers reported either providing dental services to at least 1,000
patients or having at least one half FTE dentist working at the health center (GAO, 2000a). A
survey of state Medicaid dental programs conducted in 1999, reported that when asked to
indicate the reliance of states on safety net providers for Medicaid dental care, 31 states reported
either 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 contract
with 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 for
administrative costs and $89 million for dental claims payments. This contract places Doral at
risk only for administrative costs and the State at risk for claims costs. This is a change in the
risk assignment that is considered positive toward increasing access to care, in that it removes the
negative financial risk of increased utilization from the contractor.
From 1984 through February 1999, the Illinois Medicaid dental program had been operated
under contract with Delta Dental. Under this contract, Delta assumed risk for contracting and
claims; they received capitated payments per enrolled child from IDPA. Dentists were paid
through discounted fee for service. Throughout this period, children’s dental services were
continuously covered, although adult services were eliminated from 1995 through 1997. In
September 1999, the Illinois Auditor General reported on a management audit of the contract
with Delta Dental. For the period of 1996 through 1998, the report noted several problems,
including relatively high administrative payments, declining children’s utilization rates, and
declining numbers of dentists providing care (Holland, 1999).
In July 1998, there was a significant increase in dental fees for common procedures, which
helped place Illinois fees at about a midrange compared to other states (previously Illinois fees
Access to Dental Care for Low-Income Children in Illinois, December 2000
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had been in the very low range; rates were also increased in July 1999. A 1999 national study of
Medicaid 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 fees
are 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 dental
care declined slightly from 1996 to 1997, with a marked decline in1998 (Holland, 1999). This
table shows the dental expenditures over the three years. However, the expenditures include a
large 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. In
1998, 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 the
year, showed that 443 dentists had 1- 12 procedures; 414 dentists had 13 - 199 procedures; 403
dentists 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
793,132
Children receiving dental care
280,746
271.746
216,423
Percent children with dental care
Dentists enrolled
Total dental expenditures
33%
33%
27%
3,791
3,476
3,311
$ 26.6 million $ 30.2 million $ 29.2 million
Source: Holland WG, 1999.
The Illinois Study of Access to Dental Care for
MEDICAID ENROLLED CHILDREN
Study Overview
The study was conducted between November 1999 and September 2000. The three study
components are summarized in this report beginning with a description of the supply,
distribution, and characteristics of Illinois dentists, using ADA data. Next, the study examines
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. This analysis describes the dental
care 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 care
to Medicaid children, this component concludes with three scenarios that estimate the number of
participating dentists needed to provide care to various target numbers of children. The third
study component presents an analysis of steps taken by Illinois and six surrounding states to
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 14 -
address the problems of low access to dental care for children with Medicaid. The discussion of
policy recommendations draws on the findings from all three study components.
A project advisory group of key dental groups, policymakers, and other stakeholders was
convened to provide oversight and guidance for this study. Members included representatives
from the Illinois Primary Health Care Association (IPHCA), the Illinois State Dental Society
(ISDS), the Illinois Society of Pediatric Dentistry (ISPD), the Illinois Dental Hygienists
Association (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 the
University of Illinois at Chicago), and a representative from the child health advocacy
community. A complete list of members is included in Appendix A. Two meetings were held
with the advisory group; in February 2000 to review the project work plan; and in September
2000 to review the project progress, and preliminary data analysis. Advisory group members also
provided guidance outside the meetings through personal communications. In addition, the
advisory group members received a draft of the final project report and were given the
opportunity to provide clarifications and comments.
Study Methods
An abbreviated version of the data sources and methods is presented here; Appendix B describes
the 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 enrollment
and participation data from IDPA and Doral; county population data from the U.S. Census
Bureau; 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 into
regions to allow for comparisons across Illinois. The seven regions used by the IDPH Division
of Oral Health were used in this study (see map, Appendix C).
Table 5 shows general population information for the seven Illinois regions. These seven
regions range in population from over five million residents in Cook County, to slightly more
than one half million residents in the Marion region. The number of counties included in the
regions varies from one county (Cook) to 27 counties in the Marion region. The Collar Counties
refers to the eight counties that surround Chicago/Cook County. Of the 3.2 million children in
Illinois, approximately one-quarter are enrolled in Medicaid/KidCare; the percentage of children
who are enrolled in Medicaid/KidCare varies from 10% in the Collar Counties to 35% in Cook
County.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 15 -
Table 5: Illinois Regions: Counties, Population, and Medicaid Enrolled Children
Illinois
Champaign
Cook
County
102
16
1
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
24.7%
21.8%
34.5%
24.9%
29.5%
21.8%
18.7%
10.1%
Number of counties in
region
Estimated percent of child
population enrolled in
Medicaidb
Edwardsville
Marion
Peoria
Rockford
Collar
Counties
17
27
24
9
8
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 care
Illinois dentists, followed by a more detailed discussion of active patient care dentists practicing
as general dentists and pediatric dentists. This is followed by a description of Illinois dental
hygienists and dental clinics that are safety net providers for dental care, that is, public or private
clinics that receive financial subsidies or have other means to offer dental care at a discounted
cost to their patients.
Illinois Dentists: All Specialties
In February 2000, there were 7,096 active patient care dentists in Illinois (Table 6). This
definition 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 for
Illinois and the regions. When adjusted to the population, the Illinois dentist-to-population ratio
was 59 active dentists to 100,000 population, similar to the national average. However, within
the State, the ratio varies from a high of 67 and 68 in Cook County and the Collar Counties
regions, 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 estimates
show the potential supply of dentists available to residents of the State. The ratio for all residents
is 2,001 persons per one dentist. These ratios vary by region, with higher population-to-dentist
ratios for the areas with a lower supply of dentists (Marion, Peoria and Champaign regions). The
Cook County and Collar county regions have lower population-to-dentist ratios, reflecting a
higher supply of dentists.
2
It is not clear from the data whether some dentists in these categories also provide dental care in safety net
facilities.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 16 -
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 most
relevant to this analysis. The proportion of dentists in each region who are general practitioners
is fairly constant except in Marion, where 91% of dentists are in general practice and there were
no pediatric dentists. Very few dentists specialize in dental public health.
Table 6: Illinois Dentists and Dentists to Population Ratios, All Regions
Illinois
7,096
Champaign
328
Cook
County
3,469
Edwardsville
475
Marion
172
Peoria
427
Rockford
303
Collar
Counties
1,922
1,709
2,399
1,497
2,223
3,287
2,501
2,073
1,473
59
42
67
45
30
40
48
68
6,061
2,001
274
2,872
2,997
1,733
407
2,595
157
3,601
367
2,910
262
2,397
1,597
1,773
50
35
58
39
28
34
42
56
12,128,370
786,896
565,357
1,067,864
628,004
2,831,908
Dentists (all specialties)
Population per dentist (all
specialties)
Dentist to 100,000 pop.
General & pediatric dentists
Pop. per gen/ped dentist
Gen/ped dentists to 100,000
population
Total Population
5,192,326 1,056,015
Source: 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
%
Edwardsville
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
100
100
100
100
100
100
100
100
7,096
328
3,469
475
175
427
303
1,922
***
Total
Total Dentist Count
Source: 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.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 17 -
Dentists in General Dentistry and Pediatric Dentistry
The remainder of this report, where we use the term dentist, we are referring to Illinois dentists
that are active patient care dentists in either general dentistry or pediatric dentistry. We have
chosen to focus on these dentists since they are considered the primary care dentists available to
children. 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 Cook
County, a larger proportion of active dentists were women (21%), while in all five downstate
regions, 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 this
limitation, 85% of these Illinois dentists were white, 9% were Asian American, 3% were African
American, and 3% were Hispanic. Both Cook County and Collar Counties have a higher
proportion of Asian American dentists (12% and 10%), while only Cook County has a higher
proportion (5%) of African American dentists.
Table 8: Gender and Race/Ethnicity of Illinois Active Dentists*, by Region
Cook EdwardsTotal IL Champaign County
ville
Marion
Peoria
Rockford
Collar
Counties
Men
%
83
%
90
%
79
%
88
%
95
%
94
%
89
%
83
Women
Total
17
100
10
100
21
100
12
100
5
100
6
100
11
100
17
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
100
Source: 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% of
dentists were younger than 35 years of age, the majority of the dentists with unknown age
graduated from dental school in 1993 or later; including these 1993-1999 graduates in the
younger than age 35 group would increase that percentage to 11%. Twenty five percent of
dentists were 55 years of age or older (Table 9). The percentage of older dentists is even higher
in three downstate regions (Champaign-30%, Marion-29%, Peoria-31%). Based on the total
dentist counts for these three regions, these regions together have about 300 dentists in the age
range (55 years and greater) that could be expected to retire over the next decade.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 18 -
Table 9: Age of Illinois Active Dentists*, by Region
Total IL
%
Champaign
%
Cook
County
%
Edwardsville
%
Marion
%
Peoria
%
Rockford
%
Collar
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
Unknown
Age
11
14
12
11
12
16
11
7
4
2
5
3
3
3
2
3
Source: 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 (Table
10). 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% were
graduates of SIU, they accounted for substantial proportions of active dentists in the downstate
regions (Edwardsville 66%, Marion 43%, Champaign-28%). Both Northwestern and Loyola
have closed their dental schools.
Table 10: Location of Dental School Attended by Illinois Active Dentist*
by Region and Illinois School Attended
Total IL
Champaign
Cook
County
Edwardsville
Marion
Peoria
Rockford
Collar
Counties
%
%
%
%
%
%
%
%
Illinois School
79
73
80
73
69
79
79
83
Non-IL, US School
20
27
20
27
31
21
21
17
Total
Illinois
100
100
100
100
100
100
100
100
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
100
100
100
100
100
100
100
100
Total
Source: 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.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 19 -
Commentary on the Characteristics of Illinois Active Dentists in General and Pediatric Practice
While the statewide ratio of dentists is at the national mean, several areas of the state have much
lower ratios and the metropolitan Chicago area has a much higher ratio. This maldistribution is
common among health professionals and reflects a variety of factors such as concentration of
training in metropolitan areas (three of the four dental schools); and other professional and
personal preferences for practicing and living.
With about one third of dentists in three regions approaching retirement age, there may be
difficulty in maintaining an adequate overall supply of dentists in these areas. The number of
new 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 and
smaller towns. Thus, these areas are at risk of a continued dentist undersupply over the next
decade.
In addition to the age distribution of Illinois dentists, the data on where these dentists attended
dental school foreshadow future supply problems. Thirty-seven percent of current Illinois
dentists (47% of Illinois dentists who attended dental school in Illinois) are graduates of
Northwestern and Loyola, both of which have closed. There is no mechanism in place to replace
this significant source of dentists in Illinois.
Illinois has a slightly higher percent of women dentists than the national average of 14%; and the
women dentists are more highly concentrated in the greater Chicago metropolitan area. The
distribution 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, this
may yield a slightly lower work capacity on average for women dentists.
Illinois Dental Hygienists
In Illinois, under the Dental Practice Act, dental hygienists are allowed to work under direct
supervision of a licensed dentist, which means that a dentist must authorize the service and be
physically present in the office or approve the work before the patient leaves the office. Detailed
data 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 the
Illinois Department of Professional Regulation (IDPR) can list the number of hygienists who
maintain an active license (includes hygienists currently not working but still licensed), but this
count does not reflect the number in active practice, their full-time or part-time work status, and
may include hygienists from out of state. According to IDPR reports, at the end of fiscal year
1998, 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. In
1998, the BLS reported there were 6,280 dental hygienists in Illinois. However, BLS does not
identify unique employed hygienists, so that hygienists working for two employers would be
counted twice.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 20 -
Safety Net Dental Clinics
The Illinois Department of Public Health has collected information on dental clinics that serve
patients 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 health
departments; three townships; nine community health centers; five school based clinics; five
hospital clinics; eight clinics at dental hygiene schools; three clinics at dental schools; and two
referral clinics. Thirteen private not-for-profit organizations also offered clinics. These included
community centers, Salvation Army, Boys & Girls Club, Catholic Charities, and others. Eleven
new 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 and
sealants). Others offer restorative care including filling cavities. The dental school clinics offer a
full range of dental services, including complex services, and treat large numbers of Medicaid
children. Several of the community health centers, local health department and school-based
clinics can bill for their dental services through the cost-based reimbursement plan of Medicaid
known as FQHC (Federally Qualified Health Centers). The FQHC payment (known as the
encounter rate) includes all dental procedures provided in a single visit; the encounter rate varies
by individual community health center and is capped at $62.31. The amount of care provided by
these clinics can be tracked through the Medicaid FQHC payments. In 1999, these clinics
accounted for 3.3% of all Medicaid dental payments and 1.2% of all services. In Illinois, the
school-based dental programs bill through the EPSDT (Early Periodic Screening Prevention
Treatment) 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 Illinois
as of September 1999. The number and proportion of enrolled children receiving dental services
for the entire twelve-month period of March 1999 through February 2000 will be described for
the State as a whole and by region. The number of and expenditures for dental procedures will
be described for Illinois only.
Medicaid/KidCare Enrollment
As of September 1, 1999 (the midpoint of this study) there were 818,269 children and
adolescents under 21 years of age enrolled in the Medicaid program. These children account for
25% of the Illinois child population (Table 5). Enrollment counts by region are shown for the
following age groups: 0-3 years, 4 to 5 years, 6 to 12 years, 13 to 18 years, and 19 and 20 years
(Table 11).
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 21 -
Table 11: Medicaid/KidCare Enrollment in Illinois, by Age Group and Region, 9/1/99
Illinois
Champaign
Cook
County
Edwardsville
Marion
Peoria
Rockford
Collar
Counties
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
3,403
Total Enrollees
Source: Illinois Department of Public Aid, 2000.
Sociodemographic characteristics of Medicaid/KidCare enrolled children. IDPA provided racial
breakdowns 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% were
Hispanic, 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 received
any dental care services in Illinois during the year. Statewide, 33% of enrollees received at least
one dental service. Children in Cook County had a higher utilization rate (38%) than any other
region. All other regions were below 30%, with the lowest utilization in the Collar Counties, at
only 23%.
When utilization is examined by age groups, the statewide rate for very young children (0 to 3
years of age) was the lowest, at only 13% of children (Tables 12 and 13). Higher proportions of
pre-school aged (4 and 5 year-olds) and school aged children (6 to 12 year olds) received dental
services (51% and 47%, respectively); this pattern of proportionately higher use for these age
groups holds across regions. The adolescent and young adult age groups (ages 13 to 18 years
and 19 and 20 years) had utilization rates of about 27%. Across all age groups, the Cook County
utilization 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.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 22 -
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
33
Source: Illinois Department of Public Aid, 2000.
Table 13: Percentage of Enrolled Children Who Used Dental Services, by Region
Champaign
%
Cook
County
%
Edwardsville
%
Marion
%
Peoria
%
Rockford
%
Collar
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
19
Source: Illinois Department of Public Aid, 2000.
Commentary on Medicaid Children’s Utilization of Dental Care
This 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 was
34% of Medicaid children utilizing at least one dental visit in a year, with state utilization rates
ranging from 22% to 48% of children (GAO, 2000b). However, the Illinois rate does not fare
well against the visit rates for all children or to Healthy People 2010 objectives.
Total Expenditures and Dental Procedures Provided
Expenditures by Age Group. In 1999, $29.16 million dollars was spent on dental care for
Medicaid 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 (0-3
years) to $145 for the 19 and 20 year olds (Table 14). The increases by age group reflect the mix
of dental services used, with higher cost services (oral surgery and orthodontics), as well as a
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 23 -
higher proportion of restorative services, being more common in the older age groups (see
below).
Table 14: Average Payment per Dental Services User
Total Dental
Services Paid
Number of Users
Payment/User
Age 0-3
Age 4-5
Age 6-12
Age 13-18
Age 19-20
Total
Enrollees
$2,369,221
$5,037,292
$14,252,951
$6,278,546
$1,231,349
$29,169,359
29,292
51,617
137,073
44,698
8,472
271,152
$81
$98
$104
$140
$145
$108
Source: Illinois Department of Public Aid, 2000.
Expenditures by Procedures Category Individual procedure codes were grouped into procedure
categories3 to examine the aggregate expenditures by procedure category. The list of procedure
codes 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 settings
where the services occurred, certain safety net dental clinics for FQHC, and school-based
settings for EPSDT.
The total number of services provided in 1999 was over 1.4 million, with an average cost per
procedure of $19.86 (Table 15). Average expenditures for commonly performed procedure
categories were $12.34 for diagnostic services, $17.61 for preventive services, $38.12 for
restorative (filling cavities) services, and $28.81 for oral surgery services. The FQHC encounter
fee was $52.46 (this is for a visit, which includes several procedures); and the EPSDT average
was $10.71.
3
These categories were provided to us by the Illinois State Dental Society and are available from the Illinois Center
for Health Workforce Studies by request.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 24 -
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
$12.34
Preventive
Restorative (fillings)
$7,501,193
$7,951,737
425,859
208,595
$17.61
$38.12
$712,151
14,093
$50.53
Endodontic
$1,325,671
17,166
$77.23
Periodontics
$41,434
487
$85.08
Removable prosthodontics
$50,058
173
$289.35
Implants, fixed prosthodontics
$23,940
160
$149.63
$1,637,302
56,821
$28.81
Orthodontics*
$413,414
n/a
n/a
Miscellaneous
$186,601
8,553
$21.82
FQHC Encounter Fee
$961,638
18,330
$52.46
$3,020,812
$29,159,690
282,017
1,468,133
$10.71
$19.86
Restorative (other)
Oral surgery
EPSDT
TOTAL
Source: 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 category
included 18% on diagnostic, 26% on preventive, and 30% on restorative care services (Table
16). However, these estimates provide an incomplete picture of the total expenditures on these
services since EPSDT includes diagnostic and preventive services, and FQHC includes a variety
of service types. Differences in types of services used by different age groups can also be seen
in Table 16. For the children under 13 years of age, most of the services fell under the
preventive, 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 of
adolescents.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Table 16: Percentage of Total Expenditures by Procedure Category, by Age Group
Procedure Category
Age 0-3
Age 4-5
Age 6-12
Age 13-18
Age 19-20
Illinois Total
Diagnostic
%
26
%
20
%
17
%
17
%
20
%
18
Preventive
33
26
27
24
11
26
Restorative (All)
24
31
26
37
42
30
Oral Surgery
4
4
6
5
14
6
Orthodontics
0
0
1
4
1
1
FQHC Encounter Fee
4
4
3
3
3
3
EPSDT
3
8
16
3
0
10
6
100
7
100
4
100
7
100
10
100
6
100
Other Procedures
TOTAL
Source: Illinois Department of Public Aid, 2000.
Average Number of Dental Procedures by Age Group
The average number of procedures used per year per child user is shown in Table 17. This
shows an increasing number of procedures by age group up to 18 years of age. The data show
that over the year period, children received on average 5.4 procedures. The data that were
obtained for this study do not allow for an estimation of the number of visits, nor the number of
procedures per visit.
Table 17: Procedures per User
Age 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
Total Illinois
32,100
818,269
8,472
271,152
46,777
1,468,133
5.5
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 Medicaid
dental provider. This requires the dentist to complete an application and agree to the terms of the
Medicaid program as administered by the dental intermediary. In 1999, when Doral became the
IDPA dental intermediary, all dentists had to re-enroll; therefore, the counts of participating
dentists should be current in reflecting providers willing to participate in the Medicaid program
as evidenced by their recent enrollment. Dentists’ participation was examined in terms of
enrollment and, more importantly, the level of services provided and billed during the year.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Dentists enrolled in the Medicaid Program
IDPA data show that 34% (2,034 of 6,061) of active patient care general and pediatric Illinois
dentists were enrolled as Medicaid/KidCare providers on June 30, 2000 (Table 18)4. The
proportion of dentists enrolled by region ranged from 18% (281 of 1,597) in Collar Counties to
61% (168 of 274) in Champaign. Higher enrollment may reflect greater outreach and
recruitment efforts by Doral or greater willingness of dentists in a certain area to treat Medicaid
children.
Table 18 also shows that 497 dentists enrolled in Medicaid (24% of all enrolled dentists) had not
submitted a claim for services during the year. Thus, 76% of enrolled dentists provided at least
one service in the year. A higher proportion of enrolled dentists provided care in the Marion and
Peoria regions (82% of enrolled dentists).
Dentists Providing Services Through the Medicaid Program
In Illinois 1,537 dentists provided some service. The measure for service is any procedure billed
and paid for by Medicaid. Thus service and procedure are used interchangeably. The level of
participation was assessed by examining the number of dentists who submitted (a) 1-100
services/year, (b) 101-999 services/year, and (c) greater than 999 services/year. The proportion
of active dentists who participated at these different levels was calculated as both a proportion of
enrolled dentists in Illinois and of all active dentists, enrolled and not enrolled, in Illinois (Table
18). The data do not allow for an estimate of the number of free or pro bono care provided by
dentists.
It should be noted that a single visit by a child might include more than one procedure. The data
received do not allow us to estimate the number of dental visits per child nor does it provide the
number of children receiving each level of care. However, the data do allow for an estimation of
the number of children treated per dentist. We can estimate the number of children served by
using the average of 5.4 procedures per child per year. Thus, dentists with 0 to 100 procedures
would be estimated to have treated between one and 19 children; dentists with 101 and 999
procedures would be estimated to have treated between 19 and 185 children; dentists with more
than 999 procedures would have treated more than 185 children.
However, this estimate has a serious limitation in that some children may receive only a single
procedure and others may receive large numbers of procedures. Another way to estimate the
number 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 an
estimate of 176 children per dentist; this estimate is a statewide average that does not reflect the
reality that many dentists provide a low volume of services and a few dentists provide a high
volume of services.
4
As noted in the Data and Methods Appendix, there were 385 providers with more than one practice site.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Table 18: Medicaid Enrollment and Participation of Illinois Active and Enrolled Dentists
Cook
County
Illinois Champaign
Edwardsville
Collar
Counties
Marion Peoria Rockford
DENTISTS 1
Active dentists a
# Enrolled dentists 2
% of Active Dentists Enrolled
6,061
2,034
34%
274
168
61%
2,997
1,058
35%
407
182
45%
157
77
49%
367
150
41%
262
118
45%
1,597
281
18%
Dentists with 0 services
# Enrolled dentists
% Enrolled
497
24%
39
23%
277
26%
42
23%
14
18%
27
18%
26
22%
74
26%
Dentists with 1-100 services b
# Enrolled dentists
% Enrolled
% Active dentists
802
39%
13%
88
51%
32%
334
32%
11%
83
46%
20%
33
43%
21%
70
47%
19%
67
57%
26%
127
45%
8%
Dentists with 101-999 services b
# Enrolled dentists
% Enrolled
% Active dentists
570
28%
9%
36
21%
13%
346
33%
12%
39
21%
10%
21
27%
13%
34
23%
9%
22
19%
8%
72
26%
5%
Dentists with >999 services b
# Enrolled dentists
% Enrolled
% Active dentists
165
8%
3%
5
3%
2%
101
10%
3%
18
10%
4%
9
12%
6%
19
13%
5%
5
4%
2%
8
3%
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 dentists
submitted between 1-100 services during the year, 28% submitted 101-999 services during the
year, and 8% submitted at least 1000 services per year. Participation levels as a proportion of
active dentists demonstrate much lower levels of participation. The number of active dentists is
seen as the upper limit of dentists available to provide care to Medicaid/KidCare enrolled
children; it is recognized, however, that an unknown number of these dentists would not be
willing to enroll in Medicaid under any circumstances, and an unknown number of the general
dentists 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 the
year, and 3% submitted at least 1000 services per year.
Using our estimates of number of children treated, these data can be summarized as follows: for
every 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),
Access to Dental Care for Low-Income Children in Illinois, December 2000
•
•
- 28 -
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 1,000
services during the year, from data not shown in the table found that 109 dentists submitted
between 1,000-1,999 services, 51 submitted between 2,000-4,999 services, and 5 submitted
5,000 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 dental
services. Fifty-seven dentists in other states received reimbursement; 51 dentists were in states
contiguous to Illinois, with Iowa accounting for 21 dentists. Most of these dentists submitted
between 1-100 services for IDPA reimbursement.
PROJECTING DENTIST CAPACITY
Population to Dentist Ratios
As noted earlier in the report, the statewide supply of all active dentists in Illinois is at the
national average of 58 dentists per 100,000 population. Other ratios of dentist-to-population can
be used to assess the dentist-to-population supply. For example, Illinois has 4.4 active patient
care pediatric dentists per 100,000 children, age less than 18. The pediatric dentists ratios are
less commonly reported, although a 1993 estimate reported 4.4 private practice pediatric dentists
per 100,000 children <18 nationally, or 5.1 professionally active (private and non-private
practice) pediatric dentists per 100,000 children <18 (Waldman, 1995).
The supply of dentists can also be examined by reversing this ratio and discussing the population
per active dentist. The national ratio of population to all active dentists would be estimated as
1,724 persons per dentist in 1996. This ratio allows one to consider the relationship between a
dentist and an estimated potential population served.
While there is no standard for an adequate supply, the federal government does have criteria for
areas considered to have a shortage of dentists. The existing total population-to-full-timeequivalent-dentist ratio standards for a geographic area to qualify as either a geographic or
special population Dental Health Professional Shortage Area (DHPSA) is at least 5,000 persons
to one dentist or 4,000 persons to one dentist, respectively. The American Academy of Pediatric
Dentistry does not have any standards for child population-to-pediatric dentists. A recent GAO
report 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 treat
children enrolled in Medicaid. The first section of this table shows that the number of enrolled
Medicaid children per enrolled dentists is 402 children. This varies by region, with Marion and
Cook County having high numbers of Medicaid children to enrolled dentists (556 and 456
children) and Champaign and Rockford having low numbers of children to dentists (260 and 269
children). Another way to look at these same data is to reverse the ratio and look at the number
of dentists available to a standard number of children such as 1,000. From this perspective, there
Access to Dental Care for Low-Income Children in Illinois, December 2000
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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 highest
dentist-to-population ratios and Marion region had the lowest. However, when examining the
Medicaid child population, Cook County falls to just above Marion for dentist to enrolled
children ratios. Part of the explanation may be found in Table 18, which shows that Marion has
a 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 dentists
and enrolled children. The number of Medicaid children using dental care per participating
dentist are seen to range from about 90 children per dentist (Champaign, Rockford, and Collar
Counties regions) to around 200 children (Cook County and Marion region). With the statewide
average of 176 children users per participating dentist, there would have to be a threefold
increase in the number of children seen by each participating dentist in order for all enrolled
children to receive dental care (to 532 children per participating dentist).
If all enrolled dentists were actively treating children, the 2,034 enrolled dentists would on
average have to treat 402 children to have all children receive care. These averages do not
reflect the reality that most dentists treat very small numbers of children and others treat much
larger numbers. The dentist participation data presented above show that 570 dentists provide a
moderate to substantial volume of care (100 to 999 procedures); and only 165 dentists provide
large to very large volumes of care (1,000 or more procedures). For purposes of comparison, a
recent GAO report defined “substantial participation” as seeing at least 100 Medicaid patients in
a year (GAO, 2000a). In most states, less than 25% of dentists met this definition. In Illinois, it
appears that about 12% of dentists come near this level of participation.
Table 19: Illinois Medicaid Enrolled and Participating Dentists, and Dentists to Medicaid
Children Ratios, All Regions
Illinois
Champaign
Cook
County
Edwardsville
Marion
Peoria
Rockford
Collar
Counties
2,034
168
1,058
182
77
150
118
281
402
260
456
396
556
410
269
300
2.5
3.9
2.2
2.5
1.8
2.4
3.7
3.3
1,537
129
781
140
63
123
92
207
532
338
617
514
679
500
345
408
1.9
3.0
1.6
1.9
1.5
2.0
2.9
2.5
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
19,114
Medicaid enrolled gen/peds
dentist
Medicaid children to enrolled
dentist
Medicaid enrolled dentist to
1000 children
Medicaid participating dentists
Medicaid children to
participating dentist
Medicaid participating dentist
to 1000 children
Medicaid children users to
participating dentists
Source: Illinois Department of Public Aid, 2000. Calculations based upon these data.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 30 -
Projecting Dentist Capacity Required to Serve Medicaid Children
The scenarios shown in Table 20 present another approach for analyzing the required dentist
capacity needed to treat larger volumes of Medicaid children. The output from this analysis is
the 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 in
Medicaid/KidCare is held constant at the 1999 count (818,269 children); and 2) the total number
of Illinois active dentists (general and pediatric dentistry) is held constant (6,061 dentists, with
50% of all active dentists equaling 3,030 dentists); the number of Medicaid enrolled dentists is
held constant (2,034 dentists), and the number of participating dentists, i.e. those who treated at
least 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 year
with the following levels: 1) current level of 33% of Illinois Medicaid enrolled children who
received at least one dental service (271,152 children); 2) 57% of children, based on the Healthy
People 2010 objective of low-income children receiving preventive dental care (466,413
children); and 3) 83% of children, based on the Healthy People 2010 target of the number of
children and adults using the oral health care system each year (679,163). Recognizing that the
target of 83% utilization – while an established national goal - is extremely ambitious, we will
focus 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, thereby
overestimating the number of children in these scenarios. However, the American Academy of
Pediatric 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 1999
due to intensive outreach and enrollment efforts, which would underestimate the number of
children per dentist.
The scenarios vary by the dentist group (general and pediatric dentists only) assumed available to
provide care and include:
• Scenario A: all currently participating dentists (1,537dentists) accept the children
targeted to receive care, (three levels of care 33%, 57%, 83% of children);
• Scenario B: all currently enrolled dentists (2,034 dentists) accept children targeted to
receive care, (all three levels of children);
• Scenario C; 50% of all active Illinois dentists (3,030 dentists) accept children targeted to
receive care, (all three levels of children).
For simplicity, the percentages of current users and of enrolled and participating dentists in the
calculations for each region are based on the Illinois average.
These scenarios show the number of children that each dentist in that scenario would need to
serve. For example, under scenario A for all participating dentists, at the current Medicaid child
utilization rate of 33%, each dentist would need to treat 176 children. The expectation would be
that all needed care would be provided. To estimate the impact on the dentist’s practice, at two
visits 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
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 31 -
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 scheduled
visits.
Still using scenario A, if the percentage of children treated were to increase to 57%, then each
participating 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 most
dentists are willing to devote to Medicaid patients. This demonstrates that if the number of
dentists participating in Medicaid is not substantially increased, and barring major increases in
the public sector capacity, a greater number of children cannot be served.
Under scenarios B and C, assuming more dentists treat Medicaid children, the number of
children per dentist, and the corresponding percentage of practice visits, would decline. Even
assuming that the number of available dentists almost doubles from 1,537 (currently
participating) to 3,030 (50% of active dentists), and assuming the 57% utilization goal is
reached, that amounts to 154 children (308 visits) per dentist, or between 12% and 8% of all
scheduled 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 1999
average 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 current
users), which at $108 per child yields an additional cost of $21.1 million, for a total cost of $50.3
million (466,413 x $108). The most likely way to achieve this target is for incremental
expansion of services over several years. For example, the Healthy People 2010 allows ten years
to meet this goal. Since Illinois starts at a higher baseline (33%) than the 20% Healthy People
baseline, 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 Medicaid
services for children in FY98 (Tang, 1999).
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 32 -
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
Rockford
Collar
Counties
415
285
145
281
193
87
339
232
92
Scenario A: Varying utilization* of enrolled children to all participating dentists; 25% of active dentists; 1537 IL dentists
83% enrolled children
442
281
512
427
564
57% enrolled children
Current users (33% of enrolled children)
304
176
193
91
352
233
293
144
387
190
Scenario B: Varying utilization* of enrolled children to all enrolled dentists; 34% of active dentists; 2034 IL dentists
83% enrolled children
334
212
379
328
461
57% enrolled children
Current users (33% of enrolled children)
229
133
145
69
260
172
225
111
317
155
340
234
119
224
154
70
249
171
68
294
202
117
453
311
180
279
191
111
201
138
80
88
60
35
Scenario C: Varying utilization* of enrolled children to 50% of active dentists; 3030 IL dentists
83% enrolled children
57% enrolled children
Current users (33% of enrolled children)
224
154
89
264
181
105
* 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.
267
183
106
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 33 -
SUMMARY OF FINDINGS ON ACCESS TO DENTAL CARE IN ILLINOIS
Comparisons across Time: 1996-1999
In 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 rates
in 1998 (when 27% of children utilized dental care). Despite some fluctuations in enrollment
numbers, the number of children receiving care in 1999 was very close to the number receiving
care 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 of
enrolled dentists was out-of-date and included many dentists who were deceased or retired. This
drop may also reflect the requirement that dentists re-enroll with Doral, giving nonparticipating
dentists the opportunity to drop their enrollment. Of note is the consistent number of dentists
who 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 dental
claims payments in 1998 ($17.7 million of the total expenditures of $29.2 million, with the
remaining $11.5 million as administrative costs). The 1999 average expenditure per user was
$108.
Enrollment and Utilization
A positive finding is that 76% of enrolled dentists submitted at least one service for
reimbursement during the year. Studies have indicated that it is easier to encourage already
participating Medicaid dentists to increase their level of participation than it is to encourage nonparticipants 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 dentists
participated at 1,000 or more services/year. A dentist who submitted 1,000 services for
reimbursement, performed an average of 20 services/week.
Consistent with national data, Illinois children in the 4 to 12 year old ages had the highest
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% of Medicaid-enrolled
children in Cook County visited a dentist, the remainder of the State was below 30%. The
overall lower dentist supply in the downstate regions may contribute to lower utilization rates in
those 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 need
to 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 dental
practice’s visits. Currently, only 165 dentists provided at least 1000 services during the year, or
treated at least 185 children at an average of 5.4 services per dental service user. The costs of
expanding dental care can be estimated by multiplying the per user average cost by the number
of new children receiving care.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 34 -
Regional Variation
Regional variations were seen in the supply of all dentists (all specialties) and in the supply of
general and pediatric dentists, after adjusting to the population size. The Cook County and the
Collar 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 enrolled
and participated in Medicaid. Only 18% of active dentists in the Collar Counties enrolled in
Medicaid compared to 61% in Champaign. However, about the same proportion, approximately
three-fourths of enrolled dentists in both of those regions participated at any level, although
slightly more of the participants in the Collar Counties were moderate participants (101-999
services) 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 varied
by 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 and
Rockford regions to 352 in Cook County and 387 in Marion. At 57% utilization and achieving
50% participation of all active dentists (3,030 statewide), the number of children per dentist
would range from 60 in the Collar Counties to 311 in Marion.
The regional variation in both Medicaid children’s utilization and enrollment and participation of
dentists underscores the importance of examining access and workforce issues at small
geographic levels.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 35 -
POLICY INITIATIVES BY MIDWESTERN STATES
TO INCREASE ACCESS TO DENTAL CARE
The seven-state policy assessment was designed to capture a regional perspective on access to
dental care services for low-income children by surveying key informants in states adjacent to
Illinois. 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 strategies
states 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 of
organized dentistry (state dental associations) were identified by review of State and Territorial
Dental Director directories and on-line dental and primary care association sources.
Structured interviews were conducted using a 12-14-question interview guide5. Three different
questionnaires were developed to capture a description of the problem of access to dental care
for low-income children and information on the measures put in place to address it. One
questionnaire was used for both departments of public aid and state dental associations, who
were asked to provide a brief history of their state’s Medicaid and CHIP dental programs and
actions taken to increase access for children. A second questionnaire asked public health dental
directors to describe the objectives and activities of their departments, the nature of dental
services offered by local health departments and any efforts underway to increase access at the
community level. A third questionnaire was employed to learn how primary care association
member health centers increase capacity and the problems they encounter in doing so. All
respondents were asked to share any pertinent reports, analyses or evaluations of administrative
or programmatic changes to dental programs in their states.
The survey instruments were pilot-tested with representatives from Illinois and Michigan. In
March 2000 letters were sent to the remaining potential interviewees describing the research
effort and asking for their participation in a 20-30 minute telephone interview. Interviews were
scheduled in advance and conducted by a trained research associate. In almost all instances, an
additional 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 informant
interviews (93%) were completed in seven states. Non-respondents included one department of
public health and one primary care association.
Responses from each interview were written up in narrative format corresponding to the
structure 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 contributing
to the problem of access for low-income children and 2) a state-by-state tally of the measures
undertaken to address access to dental care. Written documentation received from key
informants, ranging from formal reports to legislative bodies to brochure style program
5
The interview guides are available from the Center upon request.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 36 -
descriptions, was analyzed only for measures to improve oral health and access to dental services
for 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 and
correct any misrepresentations. Responses were received from 16 of the 30 (53%) by the
requested 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 characterize
the oral health status of low-income children and barriers to dental care. Our survey also
describes 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 recent
national and academic assessments of children’s oral health needs (see Background). The
findings of our interviews and analysis of documentation received are organized and enumerated
by common element or theme. The numbers in parenthesis represent the number of states
identifying that topic or issue.
Poor oral health status
Key informants in several states reported that low-income children suffer disproportionately
from poor oral health status, often presenting with severe and advanced dental disease and
requiring extensive treatment (3). In addition, respondents felt that the Medicaid program for
Early and Periodic Screening, Diagnosis and Treatment (EPSDT), which includes dental services
for Medicaid enrolled children aged 0-21, is under-utilized and that there is insufficient
infrastructure to receive children referred from an EPSDT screening for further care, especially
to dental specialists (3). Finally, two states reported that too few public health programs focus on
oral health and that local communities are extremely limited in their capacity to provide patient
education and preventive care.
Barriers to care
The low participation rate of private practice dentists in Medicaid and CHIP programs was
reported to be a significant barrier to care. Reimbursement rates, typically well below both the
overhead and the usual, customary, and reasonable rate (UCR) charged by dentists, were
consistently cited as a major cause of low participation (7). Respondents said that dentists
described 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-show
rates among Medicaid patients as another disincentive for dentists to enroll (7), and felt that
dentists have a poor perception of, if not a prejudice against, Medicaid patients, viewing them as
disruptive and non-compliant (6). Others cited a general dislike/distrust among dentists of state
programs as a reason for low participation (4).
Further barriers to access were reported to result from the undersupply and maldistribution of
dentists. States described severe problems in rural areas where there are few participating
Access to Dental Care for Low-Income Children in Illinois, December 2000
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dentists (especially specialists) and patients must travel great distances to find a dentist who will
see them, or in any area where patients lack transportation to get to appointments (4). Lack of
child care and employment flexibility that would allow Medicaid recipients to take children to
appointments during typical dentist office hours were also cited (3), as was the stigma associated
with Medicaid and dealing with dentists who will not accept it (1). Finally, the increasing
number of children covered by CHIP and expanded Medicaid programs, coupled with the pentup demand for services, was expected to exacerbate the already limited availability of both
private providers and public dental facilities (3).
Informants described the capacity of public-sector dental clinics, i.e. community health centers
or local public health departments offering dental services, as severely limited (3), many of
which maintain long waiting lists for dental appointments. Recruitment and retention of dentists
to these settings/geographic areas is difficult. Many federally qualified health centers must rely
on 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 to
start-up new dental clinics or assist existing facilities in maintaining or enhancing the services
currently being offered (3).
Finally, states identified an overall shortage of dentists in the workforce (5). Some attributed this
to recent dental school closures (2) and an insufficient number of new graduates to replace a
rapidly retiring dental workforce (3). Private practices are reported to be full with private-pay
patients and dentists are able to build, and seen as preferring to build, comfortable practices from
among these patients (3). Two respondents expressed concern over a lack of exposure in dental
training and support in practice for community health dentistry, which would prepare and sustain
professionals who are interested in treating this population.
INITIATIVES
The following section describes measures undertaken by states to improve the oral health status
of low-income children and decrease barriers to dental care. These measures took place largely
within 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 child
oral health status, to decrease barriers to dental services, and to increase capacity of dentists to
serve low-income children. Table 22 describes unique programs or efforts underway in
individual states.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Table 21: State Measures to Improve Oral Health Status and Access to Dental Care Services for Low-Income Children, 1997-2000
Initiatives
1.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 implement
interventions
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 Participation
Raised reimbursement rates to dentists
Simplified program administration
Conducted outreach to dentists
7. Improve Client Participation & Utilization
Conducted outreach to clients
8. Public Sector Capacity
Start-up funds to local health departments, under-served
communities to establish dental clinics and increase capacity of
existing facilities
9. Practice Acts:
Hygienists and/or pediatricians can apply some treatments
independent of DDS and obtain reimbursement from state
Medicaid program
1.
2.
3.
4.
Data missing: Unable to speak to Iowa Primary Care Association
EPSDT Exception to Policy allows Maternal & Child Health Clinics in
some counties to bill for services performed by hygienists in their employ.
No state funds available to licensed primary care or rural health care
centers, M/CHCs or FQHCs.
FY 1999 $5 million in state funds allocated for competitive capacity
building grants to both public and private entities
Illinois
Indiana
Iowa1
Kentucky
Michigan
Missouri
Wisconsin
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3
✔4
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✔2
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 Center
for Health Workforce Studies in collaboration with the Illinois Primary Health Care Association.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 39 -
Table 22: State Specific Strategies to Improve Oral Health Status and Access to Dental Care
Services 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 implementing
school-based dental sealant programs, providing preventive oral health care to children participating in the
reduced meals program. The Division also makes funds available to communities wanting to conduct an
Oral Health Needs Assessment and Planning Program.
The Illinois Department of Public Aid established a grant program to fund clinic start-up costs. In order to
be eligible for funding, local areas must have completed an Oral Health Needs Assessment and Planning
Program.
Indiana
Statewide dental sealant campaign planned during upcoming year.
Iowa
ABCD Program: Identifies barriers & seeks to ease them through building public infrastructure, providing
state-supported care coordination, and working with local dentists to provide a dental home for Medicaid
recipients.
Kentucky
Michigan
None reported.
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 to
conduct focus group studies and town hall meetings with local residents, providers, legislators, etc. to
identify problems and solutions to access to oral health services.
Legislation pending that would allow hygienists to perform screenings in “public health” settings and would
also 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 and
local 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 includes
a “how to” manual, some state sealant funding and free sealant materials from Oral Health America. About
22 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 and
primary care associations, conducted by the Illinois Center for Health Workforce Studies.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 40 -
1. Advisory Committee, Task Force or Coalition on Access
All seven states indicated that some form of coalition, task force or advisory committee had been
formed, either voluntarily or as charged by the state, to address the issue of access to dental care. In
several instances, both a task force and a coalition were present, sometimes working together. One
state 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 from
Medicaid, public health, organized dentistry, dental schools, dental hygienists, primary care
associations, private and public sector dentists, Head Start programs, Area Health Education Centers
(AHECs), legislative bodies, adult and pediatric medicine, child advocacy and hospitals. These groups
served to convene some or all of the entities responsible for programs or services to low-income
children; to communicate the issue among themselves and coordinate their disparate efforts; to publish
reports to influence policy changes; to make recommendations to legislative bodies, state agencies or
governors’ 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 the
case of one state, three large-scale dental summits were held from 1998 – 2000 and regular meetings
between Medicaid staff and the dental association were also reported.
2. Oral Health Assessment & Planning
The extent to which states were able to conduct child oral health screenings, surveys and/or oral health
needs assessments varied widely, although all states provided some form of technical assistance to
local communities to assist their efforts to improve access to dental services. Although these measures
were cited as improvements, only four states had undertaken screening of children for oral health
needs, 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 Efforts
Water fluoridation was the most widely cited form of prevention, provided by all states interviewed. In
local areas where water fluoridation was not possible, state public health agencies were sometimes able
to assist with funding for school fluoride mouthrinse programs.
Dental sealant programs, typically offered to school-age children identified by their eligibility for
free/reduced school lunch, were available to children in five states and were also identified by
informants as an effective but under-funded preventive measure.
4. Expand Children’s Coverage for Dental Services through CHIP
Each 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 a
separate CHIP program, or through some combination of both, each state had increased eligibility for
and/or coverage of dental services for low-income children.
5. Changes in Medicaid Program Administration
Three states indicated that new leadership in the state Medicaid office led to improvements in the
administration of the dental program. In each instance, the change in personnel meant a new
recognition of the problem and subsequently a new approach or commitment to improving access to
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 41 -
dental care for low-income people. In Illinois, an Auditor General inquiry into the contract with a past
dental intermediary led to a new contractual design awarded to a new external intermediary.
6. Improving Private Practice Dentist Participation
All seven states reported making administrative changes to the Medicaid program that were designed
to improve private practice dentist participation. First among these was an increase or series of
increases 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 on
select procedure codes an average of 56% in 1999, with $8.5 million going toward children’s
preventive 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 by
reducing or eliminating prior authorizations for some services (6); moving to ADA uniform billing
codes (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 the
number of patients referred to them by the Medicaid program; holding workshops on billing and
policy; 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 programmatic
improvements and encourage either first time or increased participation (6). In some instances, the
state’s dental intermediary conducted recruitment and outreach activities, while in others the state
dental society did so. Collaborative efforts were also reported. The president of one state dental society
enrolled in the Medicaid program and used a recruitment mailing to encourage members to do the
same. One state’s recruitment plan was implemented in phases, targeting dentists who were already
enrolled but not billing the Medicaid program, attempting to increase the number of Medicaid clients
seen by lower volume dentists and, finally, recruiting dentists who were never enrolled. Another state
created a campaign urging dentists to “Share the Care” by taking several Medicaid clients into their
practices. This program also supplied dentists with a monthly newsletter and sent letters thanking them
for their participation.
7. Improving Client Participation and Utilization
Efforts to increase Medicaid enrollee participation and utilization were made by six of seven states
through 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 and
office etiquette. At least four states reported the existence of toll-free numbers for referral of Medicaid
clients to enrolled dentists, and these numbers were published in enrollment and promotional materials
and 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 Care
Dental services offered by community health centers, federally qualified health centers, and local
health departments varied from state to state, as did each state’s ability to increase capacity. (Dental
school clinics, hospitals and community-based organizations were not included in this survey.) Most
states (6) made grant funds available to help local communities establish dental clinics; purchase
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 42 -
equipment; expand physical facilities; prolong hours of operation; increase the number of dental
chairs; 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 to
low-income children in designated school settings, local health department clinics and Head Start
programs. 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, including
donated space and equipment, to establish dental services in local areas. In 1998, the Illinois
Department of Public Aid began making grants to local health departments to establish or expand
“much needed” dental services.
9. Practice Acts
Dental hygienist practice acts vary by state, with some requiring little to no general or direct
supervision by dentists for diagnostic and preventive services. Only one state in our study had
enhanced the practice act of dental hygienists and pediatricians to enable them to apply preventive
treatments independent of a general dentist and be reimbursed by the state Medicaid program (Iowa).
A second state had such legislation pending.
State-specific initiatives
The following are descriptions of unique initiatives undertaken by individual states as described both
by key informants and in documentation provided by them.
Illinois described a number of local collaborations designed to establish or expand oral health facilities
for under-served populations or dental Health Provider Shortage Areas. Public and private agencies
collaborate on the local level for service provision (a few county health departments partner with state
dental 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 access
to 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, Washington
program, employs care coordinators in one rural (nine-county service area) and one urban area of the
state 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 schedule
and keep regular and referral appointments; assist with day care and transportation; provide follow-up
and monitoring; and refer families to other community services. Care coordinators act as a bridge
between low-income children and both public and private dental resources. In this way they contribute
to the oral health infrastructure of the state by identifying all dentists in their designated areas, creating
relationships with them and acting as liaison between dentists, patients and responsible public
agencies. Two additional areas are projected for state fiscal year 2001.
Michigan created Healthy Kids Dental, a private insurance look-alike demonstration project in 22
counties for Medicaid beneficiaries. (Funds have been appropriated to expand demonstration to 15
additional counties in FY 2001.) Healthy Kids Dental automatically enrolls Medicaid beneficiaries
under age 21 in those counties and provides them with private insurance cards. Modeled on it’s own
successful MI-CHILD CHIP program, dentists are reimbursed at competitive rates using a private
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 43 -
insurance compatible system (ADA codes and standard claim forms). Patients have no co-payment and
there is no annual maximum coverage per child. The demonstration project targets participation by
private 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 legislative
representatives. In a separate initiative, the University of Missouri Kansas City School of Dentistry
has created a manpower task force and many of the stake holders (MDA, PCA, MO Coalition for Oral
Health) are members.
Missouri also has legislation pending that would allow dental hygienists to practice in public health
settings serving Medicaid children without a dentist’s supervision. Hygienists would be able to provide
cleaning, sealant, fluoride and oral hygiene instructions. The Dental Board has not yet determined
what constitutes a “public health setting.” This bill would also allow pediatricians to apply fluoride and
would mandate oral hygiene curricula in all accredited elementary schools.
The Missouri Department of Health will appropriate $1 million for PRIMO Grants. These are five-year
contracts of $100,000 to dentists who agree to establish their practices in under-served areas for a
minimum 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 no
money is provided to augment practice revenues.
Wisconsin has been awarded a Centers for Disease Control and Prevention (CDC) grant that will allow
a coalition in the state to create a plan to address access to oral health education, prevention and
treatment services by working with schools and communities. Specifically, this initiative will seek to
establish 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 the
Back to School for Healthy Smiles initiative, dental hygiene education programs in the state will
collaborate to share strategies and create a plan for promoting partnerships between themselves and the
state’s elementary schools to create school-based and school-linked education, prevention and service
delivery 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 oral
health care for Medicaid-enrolled children. Each state has formally acknowledged the problem through
the formation of an advisory committee or task force. The most common changes in state programs
and policies focused on increasing private practice dentist participation. Some of these initiatives are
discussed in more detail below. However, in spite of the numerous and varied measures taken by these
states, all seven states reported on-going problems with access to oral health care for low-income
children.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Private practice dentist participation. Our survey found that states consistently addressed issues that
effected private practice dentist participation in their Medicaid programs. All seven states had raised
reimbursement rates to dentists, simplified the processes for enrollment, approval and billing, and
conducted outreach to dentists with information on these improvements, either to improve existing
relationships or recruit new dentists. At least one state said provider participation increased as a result
of 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 Medicaid
reimbursement rate increases failed to demonstrate an increase in access to dental services for that
state’s Medicaid population (Mayer, 2000). State respondents felt that these were necessary steps to
keep and recruit dentists, but respondent(s) in at least one state (Michigan) believed that some
percentage of dentists would always decline to participate, under any circumstances (Michigan
survey).
A further limitation of this measure is that it does not benefit populations in areas where there simply
are no dentists or where the few dentists who do practice in the area do not participate in the Medicaid
program. For example, three Illinois counties, all in the Marion region, have no active dentists at all
and eleven additional counties have no dentists who are enrolled in Medicaid. As a baseline, increased
enrollment 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 a
collective 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 nature
of the problem of prevention and treatment of oral health disease among low-income populations. The
work of such groups is intended, in part, to address the splintered nature of policy development and
service delivery but it is not clear how much of their efforts has translated into more coordination of
care or to what extent the authority exists to implement substantive change in policy or access to dental
care.
Issues not addressed by these initiatives Finally, although the seven states we surveyed described a
comprehensive list of measures to improve access, issues were identified that remain unaffected by
these 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 have
reduced the number of graduates entering the workforce.
• Potential benefits of exposing dental students to community practice. Respondents were not
routinely aware of possible efforts in their states to expose dental students to the principles of
community-oriented dentistry or to opportunities to practice in low-income communities, although
such 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 dental
practice, dentists are perceived as having the discretion to build their practices with the clients of
their choice. Absent any intervention, respondents felt that the dental profession would continue to
produce large numbers of independent, private practitioners working in small business settings and
cultivating a clientele that allows them to build a viable business.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 45 -
STUDY LIMITATIONS
There were several important limitations to this study. The first was simply the fact that this detailed
look at the Illinois Medicaid dental care experience was the first of its kind in Illinois. While we could
refer to the study done by the Illinois Auditor General that provided helpful comparison data from
1996 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 of
utilization and participation in Illinois Medicaid dental care. The data we received were provided as
county level counts, not individual records for either children or dentists. We could not perform any
tests on the quality of the data; we simply used it as presented to us. Common problems with Medicaid
data, such as inadequate reporting of all dental services, duplicate reporting of services, inaccuracies in
dentist assignments for services, changes in addresses of recipients, and other issues could not be
assessed. This argues strongly for the continued study of the Illinois experience and the use of data at
the 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 practice
characteristics of dentists) with the IDPA/Doral data on participation in Medicaid. This would have
been useful in studying the characteristics of dentists who participated in Medicaid. Data from
IDPA/Doral were provided in services/procedures, rather than visits, preventing us from discussing
participation in terms of patient visits per dentist. Also, data from safety net dental clinics were not
available by site; dentists at these sites bill under their own provider ID number. These dentists may
split their time among multiple private offices and safety net clinics, making it impossible to
differentiate what and how many services where provided at each location. An understanding of the
role safety net dental clinics play in the overall provision of dental services to low-income children
would be useful. Also, understanding the differences in provision of dental services by private and
public sector providers, as well as an examination of what makes those settings and patient interactions
successful, 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 to
the information provided by the interviewee and supplemented with reports and other written materials
sent to us. The interviewees were selected from four organizations (public health dental program,
Medicaid dental program, state dental society, and association representing the community health
centers.) and presented their perspectives. Missing from this list of stakeholders are the dental
hygienists and the patients/consumers or advocates for children enrolled in Medicaid and CHIP.
Access to Dental Care for Low-Income Children in Illinois, December 2000
- 46 -
POLICY RECOMMENDATIONS
The findings of this study demonstrate relatively low utilization rates for dental care among Illinois
children with Medicaid and limited levels of Medicaid participation by Illinois dentists. Since it
appears that expanding Illinois dentists’ capacity for care of sufficiently large numbers of Medicaid
children will be at best an incremental process, other options to deliver care should be explored. There
are significant barriers for the strategies to increase dentists’ participation; for example, if there are no
dentists located in a particular area, then increasing the Medicaid reimbursement rate is not going to
increase participation in that area. Studies of dentists have shown that there are substantial proportions
of dentists who will not participate in Medicaid regardless of reimbursement rates. If community
health centers cannot recruit enough dentists to operate a dental clinic, then having space and
equipment for a dental clinic will not enable their clients to receive dental care. Several areas of
Illinois with low dentist volumes may not have enough dentists to serve the insured and private pay
population, much less the Medicaid and uninsured populations. In addition, the findings from
interviews with key informants in Illinois and surrounding states indicated that a variety of initiatives
have been tried by most or all states to address these issues, yet every state still reported problems with
access to dental care for their Medicaid and low-income populations.
These findings raise several questions. Have these state initiatives not had sufficient time to generate
an impact? Are the initiatives too limited in their scope? Are there sufficient financial resources for
expansion of state Medicaid dental programs? Is a multifaceted approach with a combination of
coordinated initiatives needed for change to occur? Must more outreach be directed at the families and
consumers of care? Or is there a need for new initiatives, new solutions, to the persistent problem of
low access to dental care for low-income children?
Based on our study and on discussions with groups in Illinois, the following recommendations are
presented. Since our study did not address problems affecting access from the perspective of families
and children in the Medicaid program, we can offer only limited recommendations. However, we
strongly encourage the State to continue to work with groups addressing these issues such as the
Illinois IFLOSS coalition. Our study did not assess the financial consequences of expanding services
to children, nor options for targeted dental fee increases, although these are important issues for
consideration.
Recommendation 1: More dentists should be recruited to enroll in the Medicaid program. Efforts
should be made to increase the number of children treated by currently enrolled dentists.
a. Adequate reimbursement rates. The literature, our key informant interviews, and discussions
with dentists and other experts all indicate that without adequate reimbursement, as well as simplified
billing 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 that
fees nearer 70 to 75% of UCR may be needed to attract dentists. However, even with these
improvements, studies show that dentists’ increases in participation may be modest. While adequate
reimbursement and simplified billing and administration are crucial, addressing these issues may be
called a necessary, but not sufficient, policy solution.
b. Outreach to enroll new dentists in Medicaid Targeted efforts should be continued to reach more
dentists and their office staff to inform them about positive changes with Doral as the Medicaid dental
Access to Dental Care for Low-Income Children in Illinois, December 2000
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intermediary, such as current fees, simplified billing, and shortened payment cycles. Dentists who
already participate in Medicaid could validate these improvements. Information on the number of
dentists enrolled in their area could be provided as a way to allay concerns about being the only
Medicaid dentist in the area and, consequently, being overwhelmed with Medicaid patients. A
substantial number of eligible children are enrolled under the CHIP program and dentists should be
aware that this population differs from the Medicaid population (Byck, 2000) and they may behave
more like private pay or privately insured dental patients in terms of keeping appointments and
complying 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 be
directed at enrolled dentists with the goal of increasing their participation and asking about problems
with the program. Perhaps innovative incentives or awards could be developed for dentists with greater
service volumes; of course, this would need to be balanced by concerns of encouraging “Medicaid
mills” for children’s dental care.
Policy Recommendation 2: Consider options to increase the dentist supply in under-served areas of
Illinois.
For several regions of Illinois, the dentist supply, based on ADA data, is quite low, notably the Marion
region, and to a lesser extent Peoria and Champaign regions. The markedly reduced output of new
graduates from Illinois dental schools will make it difficult for these communities to recruit new
dentists. This situation should be further assessed and key groups should review findings of this and
other studies. At a minimum this review should include the dental schools, the Illinois State Dental
Society, the regional dental societies, Doral and IDPA, as well as other groups that are community
stakeholders, such as businesses, and educational institutions. These discussions may require
consideration 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 providers
may be more likely to treat a minority and under-served populations.
Other options include the development of State loan forgiveness programs for dentists willing to
practice 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 who
commit 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 of
dental clinics known as safety net providers, such as dental school clinics, community health
centers, local health departments and others.
While our study had only limited information on the dental services provided by these clinics, they
represent 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 training
sites). The Illinois Department of Public Health is collecting information on these sites and this is an
Access to Dental Care for Low-Income Children in Illinois, December 2000
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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 may
be useful to Illinois. Healthy People 2010 sets a target of increasing to 75% the proportion of local
health departments and community health centers that have an oral health component. More start-up
funds and grants to existing and new safety net providers are needed, as are incentives to improve the
success of recruiting and retaining dentists. In addition, greater use of existing facilities may be
possible. For example, many community colleges have dental hygiene and dental technician programs
and 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 dental
visits. National data also indicate that the proportion of children who had a medical visit in past year is
much higher than the proportion who had a dental visit (74% vs. 43%). Thus, children who may not
see a dentist in one or more years may see a medical care provider; this is particularly true for children
under 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, family
practice physicians, nurse practitioners – and their representative organizations (e.g., American
Academy of Pediatrics) to address the problem of children’s oral and dental health. This is particularly
important for high-risk children (low-income or minority children), the groups least likely to see a
dentist and at higher risk for having untreated dental caries. Primary medical care providers need to
learn more about the importance of oral health, how to talk to parents about their children’s oral health
needs, and how to perform basic oral health screenings. They could be encouraged to include oral
health in well-child visits. In addition, they should have information for Medicaid and uninsured
children on where to obtain dental care in their community.
Policy Recommendation 5. Enhance dental school training to include population-based studies of
oral and dental disease among the high-risk groups, the problems with access to dental care, and
public health dentistry. Expose students to community based private practices and safety net clinics
where 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 private
dental 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 the
traditional model of private practice dentistry. The intent of this exposure during dental school is to
foster a greater awareness of dental access problems and of successful practice model that provide
access 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 expanded
role in the care of Medicaid children should be seriously considered and tested.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Over one quarter of Medicaid dental expenditures and a larger percent of all procedures were for
preventive care services (cleanings, fluoride, sealants). Hygienists are trained to provide these
services. Hygienists are also trained to counsel children and their families on oral health and dental
self-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 certain
services (e.g. cleanings, fluoride, sealants, and screening exams. If properly designed, this would
allow for the testing of conditions that would enable under-served children to have access to preventive
dental care – and possibly reduce dental problems in the future and thus prove cost-effective. Access
to dental providers is a critical barrier to oral health care; access could potentially be improved by
expanding 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 health
professionals, 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 of
children, thus, providing a picture of oral health status (i.e., caries experience) over time. At least one
state (North Carolina) collects data on workforce characteristics of dentists and dental hygienists as
part of the licensure renewal process.
A comprehensive oral health surveillance system will enable Illinois to collect and analyze oral health
data in order to monitor the oral health status of the population and subgroups, identify needs, make
decisions, influence policy makers, secure program resources, and evaluate programmatic success in
improving oral health. The oral health surveillance system could have the capacity to assess oral
health 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 that
raise awareness and educate low-income families about the importance of oral health care and
influence their behavior in seeking oral health care for their children should be developed and or
expanded.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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American Dental Association. The 1998 Survey of Dental Practice. Chicago. March 2000a.
American Dental Association. Dental Hygiene: Career Fact Sheet. 2000b.
http://www.ada.org/prof/ed/careers/factsheets/hygiene.html
American Dental Hygienist Association. Results from the ADHA 1999 Medicaid Director’s Survey.
Chicago:IL.
American Dental Hygienist Association. The Future of Oral Health. Chicago:IL: 2000.
American Public Health Services Association, 2000.
Bader JD, Kaplan AL, Lange KW, Mullins MR. Production and economic contributions of dental
hygienists. J Public Health Dent. 1984;44(1):28-34.
Brotherton SE, Stoddard JJ, Tang SS. Minority and Nonminority Pediatricians’ Care of Minority and
Poor Children. Arch Pediatr Adolesc Med. 2000;154:912-917.
Byck GR. A Comparison of the Socioeconomic and Health Status Characteristics of Uninsured,
SCHIP-Eligible Children in the United States to Other Groups of Insured Children: Implications for
Policy. Pediatrics. 2000;106:14-21.
Damiano P, Brown R, Johnson J, Scheetz J. Factors Affecting Dentist Participation in a State
Medicaid Program. J Dent Educ. 1990;54:638-643.
Edelstein B, Manski R, Moeller J. Pediatric dental visits during 1996: An Analysis of the federal
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Erickson PR, Thomas HF. A survey of the American Academy of Pediatric Dentistry membership:
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Holland WG. Management Audit: Department of Public Aid’s Contracts with The DeltaDental Plan of
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Illinois Department of Public Health. Division of Dental Health. The Oral Health Status of Illinois
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Lang WP, Weintraub JA. Comparison of Medicaid and non-Medicaid dental providers. J Public
Health Dent. 1986;46:207-211.
Mayer ML, Stearns SC, Norton EC, Rozier RG. The effects of Medicaid expansions and
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Moeller J, Levy H. Dental services: A comparison of use, expenditures, and sources of payment, 1977
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Pediatr Dent. 1996;18:152-153.
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Pediatr Dent. 1997;19:315-316.
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Tang SS, Siston AM, Yudkowsky BK. Medicaid State Reports – FY 1998. Elk Grove Village, IL:
American Academy of Pediatrics, 2000.
Tobler L. CHIP: Dental Care for Kids. National Conference of State Legislatures. Denver: CO.
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U.S. Department of Health and Human Services, Health Resources & Service Administration. United
States Health Workforce Personnel Factbook. 1999.
U.S. Government Accounting Office. Oral Health: Factors Contributing to Low Use of Dental
Services by Low-Income Populations. September 2000. GAO/HEHS-00-149, September 2000a.
U.S. General Accounting Office. Oral Health: Dental Disease is a Chronic Problem Among LowIncome Populations. GAO/HEHS-00-72, April 2000b.
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Vargas C, Crall J, Schneider D. Sociodemographic Distribution of Pediatric Dental Caries: NHANES
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Venezie RD, Vann WFJ, Cashion SW, Rozier RG. Pediatric and general dentists' participation in the
North Carolina Medicaid program: trends from 1986 to 1992. Pediatr Dent. 1997;19:114-117.
Venezie RD, Vann WFJ. Pediatric dentists' participation in the North Carolina Medicaid program.
Pediatr Dent. 1993;15:175-181.
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Access to Dental Care for Low-Income Children in Illinois, December 2000
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Appendix A
Illinois Center for Health Workforce Studies
Dental Advisory Group – Members & Invited Guests
Diann Bomkamp, RDH, BSDH
ADHA District VIII Trustee
American Dental Hygienists' Association
Lewis Lampiris, DDS, MPH
Chief, Division of Oral Health
Illinois Department of Public Health
Ann Boyle, DMD
Associate Dean
School of Dental Medicine
Southern Illinois University
Ann Lattig
Senior Public Service Administrator
Bureau of Comprehensive Health Services
Illinois Department of Public Aid
Gerald Ciebien, DDS, MPH
Chairman, Access to Care Committee
Chicago Dental Society
Pat Law
Manager
Bureau of Comprehensive Health Services
Illinois Department of Public Aid
Shelly Duncan
Vice President
Community Health Services
Illinois Primary Health Care Association
Patrick Ferrillo, Jr., DDS
Dean, School of Dental Medicine
Southern Illinois University
Robyn Gabel, MSPH, MJD
Executive Director
Illinois Maternal & Child Health Coalition
Steve Geiermann, DDS
Regional Dental Consultant
Bureau of Primary Health Care
Health Resources and Services Administration
Julie Janssen, RDH, MA
Public Service Administrator
Division of Oral Health
Illinois Department of Public Health
Greg Johnson
Director
Professional Services
Illinois State Dental Society
Henry Lotsof, DDS
Vice President
Doral Dental Services of Illinois
Tim Lynch
Manager
Governmental Affairs
American Dental Hygienists Association
Laura Neumann, DDS, MPH
Group Associate Executive Director,
Professional Services
American Dental Association
Matt Powers
Administrator
Division of Medical Programs
Illinois Department of Public Aid
Indru Punwani, DDS, MSD
Head, Pediatric Dentistry
University of Illinois at Chicago
Mark Rosenberg, MD, FAAP
President, Illinois Chapter
American Academy of Pediatrics
Access to Dental Care for Low-Income Children in Illinois, December 2000
Mary Catherine Ring
Chief, Center for Rural Health
Illinois Department of Public Health
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Staff
Maria L.S. Simon, DDS, MS
President, Illinois Society of Pediatric Dentistry
Pediatric & Adolescent Dental Associates
Gayle Byck, PhD
Senior Research Specialist
Illinois Center for Health Workforce Studies
University of Illinois at Chicago
Dave Spinner
Manager
Medical Assistance Dental Program
Illinois Department of Public Aid
Judith Cooksey, MD, MPH
Director
Illinois Center for Health Workforce Studies
University of Illinois at Chicago
Rodney Vergotine, DDS
Undergraduate Clinic Director
College of Dentistry
University of Illinois
Julie Mansour, MBA
Analyst
Illinois Center for Health Workforce Studies
University of Illinois at Chicago
Debra Whitmer
President
Illinois Dental Hygienists' Association
Hollis Russinof, MUPP
Center Manager & Policy Analyst
Illinois Center for Health Workforce Studies
University of Illinois at Chicago
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Appendix B: Data Sources and Methods
This appendix describes the data sources for the first two study components: (1) describing the supply
and distribution of Illinois dentists; and (2) describing dental expenditures, children’s utilization of dental
services, and dentists participation in the Medicaid program. In addition, some comments on the
methodology 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 Midwestern
states 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 February
2000. This data set included both ADA members and non-members. The data set included: address
information including zip code, birth date, gender, race, year of graduation from dental school, dental
school 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 active
dentists).
Zip codes matched to counties
A data set from the United States Postal Service (USPS) was purchased which listed all zip codes and
their corresponding county and state (USPS, 2000). The Illinois zip codes and counties were extracted
and merged with the ADA file to add county information for each dentist. It should be noted that an exact
zip code to county match was not feasible as some zip codes cross county lines, and zip code boundaries
do 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 Estimates
Program, Population Division, U.S. Census Bureau. (CO-99-13) Population Estimates for Counties by
Age Group: July 1, 1999. Internet release data: August 30, 2000.
Dentist enrollment and participation in Medicaid; and Medicaid/KidCare enrollee utilization of
dental care
Data on dentist enrollment and participation in Medicaid, Medicaid/KidCare enrollee utilization of dental
care, and procedures performed were provided by the Illinois Department of Public Aid (IDPA) and Doral
Dental Services (Doral), the state’s Medicaid dental intermediary. Except for Medicaid/KidCare
enrollment and provider enrollment, all data were for services provided from March 1, 1999 through
February 29, 2000, for claims paid through June 30, 2000. Medicaid/KidCare enrollment figures were as
of September 1, 1999 (the midpoint of the claims data provided). The list of enrolled providers was dated
June 30, 2000. Table B-1 below shows a list of all data files received from IDPA.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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The enrollee-level data were provided by county (often by zip code for Cook County), and for the
following age groups: 0-3 years, 4-5 years, 6-12 years, 13-18 years, and 19-20 years. The Cook county
zip 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 1-100
services, 101-999 services, 1000-1999 services, 2000-4999 services, and 5000 or more services; this is the
measure 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 aggregated
into the following categories, as provided by the Illinois State Dental Society: (a) Diagnostic (exams, xrays); (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. The latter two categories were
not 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 with
representatives of IDPA, IDPH Division of Oral Health, and ISDS to review the data analysis and clarify
questions. This call clarified the following points of interest:
•
data relevant to utilization were for individual services rather than visits or claims (a visit or
claim usually consists of more than one service). This limits the ability to discuss how many
Medicaid 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 enrolled
providers. Since, for our study, each site needs to be counted, this overestimates the number of
participating dentists in our analysis. Analysis of the list indicated that 385 (19%) of the 2,078
Illinois provider identification numbers were listed more than once; of these, 278 (72%) had
only 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 of
number 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.
Access to Dental Care for Low-Income Children in Illinois, December 2000
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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
Access to Dental Care for Low-Income Children in Illinois, December 2000
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Table B-2: County Information about Providers with Multiple Sites
Number
of sites
2
3
4
Number of
providers
278 (72%)
75 (19%)
18 (5%)
All same county
All different county
Other
199
31
4
79
6
41
5
7 (2%)
3
0
6
6 (2%)
1
0
7
TOTAL
1 (0%)
385 (100%)
0
238 (62%)
0
89 (23%)
NA
38 – 2 of 3 same
5 – 2 same, other 2 different
4 – 3 of 4 same
1 – 2 same, 2 same
2 – 2 same, 2 same, 1 different
1 – 3 of 5 same
1 – 2 same, other all different
3 – 5 of 6 same
2 – 2 same, 2 same, others different
1 – 5 same, 2 same
58 (15%)
1
3 of these 4 provider ID numbers had the same 4 counties: Iroquois, Livingston, Logan, McLean
Notes on Methodology
6
•
It was not possible to merge the ADA and IDPA data files, so sociodemographic characteristics of
Medicaid providers could not be studied.
•
Active patient care general practice and pediatric dentists were defined from ADA data as dentists
whose 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 likely
providers of dental care services to low-income children. In addition, as explained below, the ADA
data set is believed to be most useful and reliable for private practice dentists as opposed to dentists
who work in government or public health settings.
•
There was some discussion as to how dentists who work at safety net sites (i.e., community health
centers) would be classified in the ADA occupation codes. Personal communication with advisory
board members revealed that these types of dentists would probably identify themselves as “other
federal services – VA, public health” or “other health organization staff”. There were 144 general and
1 pediatric dentists who were listed as “other federal services”, and 242 general and 3 pediatric
dentists who were listed as “other organization staff”. An attempt was made to determine the practice
site of these 390 dentists. However, only 71 of these dentists had office addresses listed, as opposed to
home addresses, in the ADA data file, and it was difficult to determine their practice type.
Excluded occupation codes: full time faculty; armed forces-army, navy, air force, marines; other federal services-VA, public
health; state or local government; graduate student/resident; other non-dental student; other health organization staff; not in
practice-seeking employment; no longer in practice (retired); and other occupation.
Access to Dental Care for Low-Income Children in Illinois, December 2000
Appendix C
Illinois Department of Public Health Division of Oral Health Regions
Chicago /
Cook
Rockford
Collar
Counties
Peoria
Champaign
Edwardsville
Marion
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Access to Dental Care for Low-Income Children in Illinois, December 2000
Appendix D
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