I S T H E M E D I C A I D D E N TA L PAT I E N T L E S S C O M P L I A N T ?
ARTICLE ABSTRACT Background: Medicaid patients have been associated with lack of compliance during their orthodontic treatment in comparison with the non-Medicaid patients. In this study, Medicaid and non-Medicaid orthodontic patients’ compliance from a state university and private practice orthodontic clinic within close location were analyzed. Methods: Charts of 30 Medicaid and 30 non-Medicaid orthodontic patients at each orthodontic clinic were reviewed. From each chart, mean percentage of failed and late appointments, number of broken appliances, number of comments on compliance with auxiliary wear and number of comments on oral hygiene maintenance were recorded. Results :Statistically significant differences between Medicaid and nonMedicaid orthodontic patients were not found. Conclusions: The results of this study indicated that in general there are no differences between Medicaid and non-Medicaid orthodontic patients. Practical Implications: These results may alleviate the doubts of the dental practitioner in treating Medicaid patients.
KEY WORDS: compliance, dentistry, orthodontics, Medicaid patients, Medicaid participation
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A comparison of compliance in medicaid versus non-Medicaid patients Mary Ellen Dobbs, DDS, MS;1 Robert Manasse, DDS;2* Budi Kusnoto, DDS, MS;3 Maria Grace Costa Viana, MSc;4 Ales Obrez, DMD, PhD5 1Orthodontist, Private Practice, Knoxville, TN; 2Clinical Associate Professor, Department of Orthodontics, University of Illinois at Chicago, IL; 3Associate Professor, Department of Orthodontics, University of Illinois at Chicago, IL; 4Statistician, Department of Orthodontics, University of Illinois at Chicago, IL; 5Associate Professor, Department of Restorative Dentistry, University of Illinois at Chicago, IL. *Corresponding author e-mail: [email protected]
Spec Care Dentist 35(2): 56-62, 2015
In t r od uct ion With a steady increase in the number of individuals enrolled in Medicaid, over half of whom are children, the demand for dental professionals to treat these patients is on the rise.1 Access to care continues to be a significant issue faced by the dental Medicaid population and, unfortunately, provider participation in Medicaid has been declining.2 In addition to cumbersome paperwork and low fee reimbursement, dental professionals cite perceived high patient noncompliance rates, last minute cancellations, and high rates of late and failed appointments as some of the reasons they choose not to participate in the Medicaid program.3 Many of these preconceived notions arise from a general perception of these patients’ compliance levels in all areas of dentistry. In fact, practitioners who have no personal experience with this population and are not currently participating in Medicaid tend to be more concerned about broken appointments than those currently accepting Medicaid.4,5 In a study of more than 20 practitioners in a hospital children’s dental clinic, 10,000 yearly patient visits showed that Medicaid patients were a “High Risk No Show” group using race as a variable to reveal the “No Show” as a significant relationship with minorities. This study takes the position that the experience Medicaid patients have with the health care delivery system is one of deemphasizing rigid scheduling.6 The year 2000 report of the Surgeon General acknowledged that some of our most “vulnerable citizens—poor children” were facing oral health disparities
due in some degree to a lack of access to care.7 The response to the report called for healthcare professionals and legislation to move toward eliminating oral health discrepancies and improve oral healthcare access.8 This challenge to healthcare professionals is of utmost importance as the at risk population, specifically those families receiving Medicaid assistance, has been steadily increasing in conjunction with the rise in unemployment. The Keiser Foundation9 reported that the national enrollment levels of Medicaid have grown at levels not seen since the 1960s when the program was first implemented. Consistent with the national increase in Medicaid enrollment, all participating states have also seen an increase in enrollment.3,4 The majority of the increase in enrollees, at both the state and national level, has been children.9 Children currently make up 58% of the total Illinois Medicaid population
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12085
13/02/15 11:15 AM
I S T H E M E D I C A I D D E N TA L PAT I E N T L E S S C O M P L I A N T ?
and account of 50.2% of the nationwide Medicaid population.10 Despite the evident need and the call for action, the problem of access to care remains a significant issue faced by the Medicaid dental population. Provider participation is one of the most significant factors affecting access to care and unfortunately provider participation in Medicaid has been declining.5 Lang and Weintraub11 showed in their survey in Michigan that 50% of dentists do not treat Medicaid patients, 29% of dentists had less than 10% of their patients to be Medicaid eligible and only 22% of dentists had more than 10% of their patients as Medicaid eligible. Along with a general lack of clinicians treating Medicaid patients in their practices, there is also a poor distribution of Medicaid patients among practitioners. For example, for orthodontic care in the states of Washington and North Carolina, only 10% of orthodontists provide over 80% of the treatment.2,3 Damiano et al.4 showed that nonparticipating dentists were concerned about broken appointments and the complicated paperwork even though the complexity of the paperwork has decreased. Many orthodontists perceive Medicaid patients as uncooperative and cite their belief that Medicaid patients have high noncompliance rates and are more likely to fail appointments, show up late for appointments, and cancel at the last minute as some of the reasons they chose not to participate in the Medicaid program.7 However, few studies have been conducted to determine if these orthodontists’ perceptions regarding compliance in the Medicaid population are justified. To date, the few studies conducted on Medicaid orthodontic patient compliance have yielded varying results and most have been limited to institutional settings.12–14 This study intends to clarify these perceived views. With the recent increase in individuals enrolled in Medicaid and lack of providers willing to treat them, there is a need to determine what, if any, problems with patient compliance are truly seen in this population. Once determined, an
Dobbs et al.
scd12085.indd 57
effective strategy can be devised in an effort to improve any shortcomings with compliance within this population, to increase provider participation in Medicaid, and ultimately to help improve access to care. The purpose of this study was to determine if perceived compliance problems with the Medicaid patient population are justified. Is this a perceived problem or is this, possibly, biased? To answer this question, an empirical study was conducted on an orthodontic patient population as a study model. This patient population could be studied in a longitudinal manner and the degree of difficulty of treatment could be quantified by the Modified Salzmann Index (a numerical score to quantify the degree of difficulty of the malocclusion). Variables measured were: late and failed appointments, broken orthodontic appliances, compliance with orthodontic/ orthopedic auxiliary wear, and oral hygiene maintenance. These variables of the Medicaid patient population could be compared to the self-pay patient population and compared between two different sites. The null hypothesis in this study is that there will be no difference between Medicaid and non-Medicaid orthodontic patients regarding their compliance with their orthodontic treatment.
M at er ia l s a nd Met h od s A retrospective chart review was conducted at two sites: (1) a private orthodontic practice and (2) a university orthodontic clinic. Two sites were studied to avoid bias in the investigation so that factors studied regarding compliance would be applicable to one or both the university setting and/or the private practice setting. Charts of 30 patients whose orthodontic treatment was paid for by Medicaid and 30 patients who paid for treatment themselves (non-Medicaid patients) were reviewed at each site. The sample contained a total of 60 Medicaid patients and 60 non-Medicaid patients. The research protocol was granted exemption from the UIC Institutional
Review Board (Research Protocol Number 2010-0871). The total sample consisted of patients who were treated with comprehensive orthodontic treatment between August 1, 2007 and August 1, 2009 collected in a sequential manner until the sample size was achieved. The private practice patients were collected in a prospective fashion and treated by one orthodontist. The university sample was also chosen prospectively with patients who started treatment in the time period described but treated by a number of orthodontic residents. However, each individual patient was treated by one resident. As variability of recording patient compliance exists between residents, an effort was made to minimize the number of university orthodontic residents treating the sample. All patients who initiated comprehensive treatment during the specified time were divided into two groups: Medicaid and non-Medicaid. These groups were further divided into subgroups according to the resident treating the case. The subgroups for the Medicaid group were arranged in a hierarchal fashion beginning with the resident with the highest Medicaid patients to the resident with the fewest number of Medicaid patients. Selecting the resident with the most patients whose treatment was paid for by Medicaid followed by the next resident with the second largest Medicaid patient base, etc., a total of 30 charts of university orthodontic patients whose treatment was paid for by Medicaid were examined. The same residents’ nonMedicaid patients were also examined until the desired sample size of 30 had been achieved. Patient selection was made to meet the following criteria: 1. in active orthodontic treatment for 24 months, 2. age range 13–15, 3. even distribution of patients in each group in regard to sex, 4. Modified Salzmann Index for the Medicaid group was equal or greater than 42 and the Non-Medicaid group was equal or greater than 25, 5. similar location of residence area of patients for the private office as well
S p e c C a r e D e n t i s t 3 5 ( 2 ) 2 0 1 5 57
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I S T H E M E D I C A I D D E N TA L PAT I E N T L E S S C O M P L I A N T ?
as the university as determined by zip code, and 6. each patient had the same provider throughout the 24 months of treatment. In some states Medicaid programs only cover severe malocclusions for orthodontic treatment (indicated by criteria of the malocclusion which is measured with a point system based on clinical orthodontic values to total a numerical score of ≥42 on the Modified Salzmann Index). It was anticipated that the malocclusions of the Medicaid subjects examined would be more severe than those of the non-Medicaid subjects. In an effort to minimize discrepancies in malocclusion severity between the two groups, individuals with minor malocclusions were excluded from this study (indicated by a score of
ARTICLE ABSTRACT Background: Medicaid patients have been associated with lack of compliance during their orthodontic treatment in comparison with the non-Medicaid patients. In this study, Medicaid and non-Medicaid orthodontic patients’ compliance from a state university and private practice orthodontic clinic within close location were analyzed. Methods: Charts of 30 Medicaid and 30 non-Medicaid orthodontic patients at each orthodontic clinic were reviewed. From each chart, mean percentage of failed and late appointments, number of broken appliances, number of comments on compliance with auxiliary wear and number of comments on oral hygiene maintenance were recorded. Results :Statistically significant differences between Medicaid and nonMedicaid orthodontic patients were not found. Conclusions: The results of this study indicated that in general there are no differences between Medicaid and non-Medicaid orthodontic patients. Practical Implications: These results may alleviate the doubts of the dental practitioner in treating Medicaid patients.
KEY WORDS: compliance, dentistry, orthodontics, Medicaid patients, Medicaid participation
56 S p e c C a r e D e n t i s t 3 5 ( 2 ) 2 0 1 5
scd12085.indd 56
A comparison of compliance in medicaid versus non-Medicaid patients Mary Ellen Dobbs, DDS, MS;1 Robert Manasse, DDS;2* Budi Kusnoto, DDS, MS;3 Maria Grace Costa Viana, MSc;4 Ales Obrez, DMD, PhD5 1Orthodontist, Private Practice, Knoxville, TN; 2Clinical Associate Professor, Department of Orthodontics, University of Illinois at Chicago, IL; 3Associate Professor, Department of Orthodontics, University of Illinois at Chicago, IL; 4Statistician, Department of Orthodontics, University of Illinois at Chicago, IL; 5Associate Professor, Department of Restorative Dentistry, University of Illinois at Chicago, IL. *Corresponding author e-mail: [email protected]
Spec Care Dentist 35(2): 56-62, 2015
In t r od uct ion With a steady increase in the number of individuals enrolled in Medicaid, over half of whom are children, the demand for dental professionals to treat these patients is on the rise.1 Access to care continues to be a significant issue faced by the dental Medicaid population and, unfortunately, provider participation in Medicaid has been declining.2 In addition to cumbersome paperwork and low fee reimbursement, dental professionals cite perceived high patient noncompliance rates, last minute cancellations, and high rates of late and failed appointments as some of the reasons they choose not to participate in the Medicaid program.3 Many of these preconceived notions arise from a general perception of these patients’ compliance levels in all areas of dentistry. In fact, practitioners who have no personal experience with this population and are not currently participating in Medicaid tend to be more concerned about broken appointments than those currently accepting Medicaid.4,5 In a study of more than 20 practitioners in a hospital children’s dental clinic, 10,000 yearly patient visits showed that Medicaid patients were a “High Risk No Show” group using race as a variable to reveal the “No Show” as a significant relationship with minorities. This study takes the position that the experience Medicaid patients have with the health care delivery system is one of deemphasizing rigid scheduling.6 The year 2000 report of the Surgeon General acknowledged that some of our most “vulnerable citizens—poor children” were facing oral health disparities
due in some degree to a lack of access to care.7 The response to the report called for healthcare professionals and legislation to move toward eliminating oral health discrepancies and improve oral healthcare access.8 This challenge to healthcare professionals is of utmost importance as the at risk population, specifically those families receiving Medicaid assistance, has been steadily increasing in conjunction with the rise in unemployment. The Keiser Foundation9 reported that the national enrollment levels of Medicaid have grown at levels not seen since the 1960s when the program was first implemented. Consistent with the national increase in Medicaid enrollment, all participating states have also seen an increase in enrollment.3,4 The majority of the increase in enrollees, at both the state and national level, has been children.9 Children currently make up 58% of the total Illinois Medicaid population
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12085
13/02/15 11:15 AM
I S T H E M E D I C A I D D E N TA L PAT I E N T L E S S C O M P L I A N T ?
and account of 50.2% of the nationwide Medicaid population.10 Despite the evident need and the call for action, the problem of access to care remains a significant issue faced by the Medicaid dental population. Provider participation is one of the most significant factors affecting access to care and unfortunately provider participation in Medicaid has been declining.5 Lang and Weintraub11 showed in their survey in Michigan that 50% of dentists do not treat Medicaid patients, 29% of dentists had less than 10% of their patients to be Medicaid eligible and only 22% of dentists had more than 10% of their patients as Medicaid eligible. Along with a general lack of clinicians treating Medicaid patients in their practices, there is also a poor distribution of Medicaid patients among practitioners. For example, for orthodontic care in the states of Washington and North Carolina, only 10% of orthodontists provide over 80% of the treatment.2,3 Damiano et al.4 showed that nonparticipating dentists were concerned about broken appointments and the complicated paperwork even though the complexity of the paperwork has decreased. Many orthodontists perceive Medicaid patients as uncooperative and cite their belief that Medicaid patients have high noncompliance rates and are more likely to fail appointments, show up late for appointments, and cancel at the last minute as some of the reasons they chose not to participate in the Medicaid program.7 However, few studies have been conducted to determine if these orthodontists’ perceptions regarding compliance in the Medicaid population are justified. To date, the few studies conducted on Medicaid orthodontic patient compliance have yielded varying results and most have been limited to institutional settings.12–14 This study intends to clarify these perceived views. With the recent increase in individuals enrolled in Medicaid and lack of providers willing to treat them, there is a need to determine what, if any, problems with patient compliance are truly seen in this population. Once determined, an
Dobbs et al.
scd12085.indd 57
effective strategy can be devised in an effort to improve any shortcomings with compliance within this population, to increase provider participation in Medicaid, and ultimately to help improve access to care. The purpose of this study was to determine if perceived compliance problems with the Medicaid patient population are justified. Is this a perceived problem or is this, possibly, biased? To answer this question, an empirical study was conducted on an orthodontic patient population as a study model. This patient population could be studied in a longitudinal manner and the degree of difficulty of treatment could be quantified by the Modified Salzmann Index (a numerical score to quantify the degree of difficulty of the malocclusion). Variables measured were: late and failed appointments, broken orthodontic appliances, compliance with orthodontic/ orthopedic auxiliary wear, and oral hygiene maintenance. These variables of the Medicaid patient population could be compared to the self-pay patient population and compared between two different sites. The null hypothesis in this study is that there will be no difference between Medicaid and non-Medicaid orthodontic patients regarding their compliance with their orthodontic treatment.
M at er ia l s a nd Met h od s A retrospective chart review was conducted at two sites: (1) a private orthodontic practice and (2) a university orthodontic clinic. Two sites were studied to avoid bias in the investigation so that factors studied regarding compliance would be applicable to one or both the university setting and/or the private practice setting. Charts of 30 patients whose orthodontic treatment was paid for by Medicaid and 30 patients who paid for treatment themselves (non-Medicaid patients) were reviewed at each site. The sample contained a total of 60 Medicaid patients and 60 non-Medicaid patients. The research protocol was granted exemption from the UIC Institutional
Review Board (Research Protocol Number 2010-0871). The total sample consisted of patients who were treated with comprehensive orthodontic treatment between August 1, 2007 and August 1, 2009 collected in a sequential manner until the sample size was achieved. The private practice patients were collected in a prospective fashion and treated by one orthodontist. The university sample was also chosen prospectively with patients who started treatment in the time period described but treated by a number of orthodontic residents. However, each individual patient was treated by one resident. As variability of recording patient compliance exists between residents, an effort was made to minimize the number of university orthodontic residents treating the sample. All patients who initiated comprehensive treatment during the specified time were divided into two groups: Medicaid and non-Medicaid. These groups were further divided into subgroups according to the resident treating the case. The subgroups for the Medicaid group were arranged in a hierarchal fashion beginning with the resident with the highest Medicaid patients to the resident with the fewest number of Medicaid patients. Selecting the resident with the most patients whose treatment was paid for by Medicaid followed by the next resident with the second largest Medicaid patient base, etc., a total of 30 charts of university orthodontic patients whose treatment was paid for by Medicaid were examined. The same residents’ nonMedicaid patients were also examined until the desired sample size of 30 had been achieved. Patient selection was made to meet the following criteria: 1. in active orthodontic treatment for 24 months, 2. age range 13–15, 3. even distribution of patients in each group in regard to sex, 4. Modified Salzmann Index for the Medicaid group was equal or greater than 42 and the Non-Medicaid group was equal or greater than 25, 5. similar location of residence area of patients for the private office as well
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I S T H E M E D I C A I D D E N TA L PAT I E N T L E S S C O M P L I A N T ?
as the university as determined by zip code, and 6. each patient had the same provider throughout the 24 months of treatment. In some states Medicaid programs only cover severe malocclusions for orthodontic treatment (indicated by criteria of the malocclusion which is measured with a point system based on clinical orthodontic values to total a numerical score of ≥42 on the Modified Salzmann Index). It was anticipated that the malocclusions of the Medicaid subjects examined would be more severe than those of the non-Medicaid subjects. In an effort to minimize discrepancies in malocclusion severity between the two groups, individuals with minor malocclusions were excluded from this study (indicated by a score of
