PUBLIC HEALTH BRIEFS
The Massachusetts Dental Medicaid Program 1967-1971 GEORGE M. GLUCK, DDS, MPH, AND ANTHONY JONG, DDS, MPH
The purpose of this paper is to describe significant ramifications of the dental Medicaid program in Massachusetts during the period 1967-1971. The areas of focus include the following: dental treatment provided, financial ramifications of the dental program, and the nature of recipients of care. The Department of Public Welfare is the state agency responsible for the administration of the Medicaid program. Eligibility for Medicaid services included persons on public assistance who qualified for the federally mandated social welfare categories. Those excluded from public assistance because of state regulations such as durational residence requirements, any citizenship requirement which excludes any U.S. citizens, or a minimum age requirement were included under the state's Medicaid program.' The anticipated number of Massachusetts recipients under these eligibility guidelines was estimated to be 626,000 persons or 6.7 percent of the national Medicaid program.2 In 1954, the Commonwealth of Massachusetts had implemented a Public Welfare Medical Care Plan which included provisions for dental services, through vendor payments to providers reimbursed according to a fee schedule. The program was expanded in 1963 to broaden the range of services to include 54 treatment categories. The 1967 Medicaid schedule listed over 90 treatment categories for which providers could be reimbursed. This increased comprehensiveness of the schedule and, an increase in fees, which responded to a statewide survey, increased dentist participation in the program. The effectiveness of the initial Medicaid fee schedule was reflected in a contrast of dentist attitudes for 1968 and 1971.3 In 1968, only 5 per cent of the dentists surveyed felt that the fees were less than adequate while 10 per cent felt that they were more than adequate. In 1971, with only minimal changes in the fee schedule, dentists indicated serious dissatisfaction with the schedule. A random sample of all vendor bills in November of 1967 indicated that 44 per cent of all services fell under the categories of diagnostic and preventive dentistry.4 The prevalence of preventive services reflected the relative preponderance (79 per cent) of recipients under age 21, and the better than average fees for preventive services (when compared with the National Dental Fee Survey, 1970, for Massachusetts). Address reprint requests to Dr. George M. Gluck, Chairman, Department of Community Dentistry, School of Dentistry, Fairleigh Dickinson University, 110 Fuller Place, Hackensack, NJ 07601. Dr. Jong is Chairman, Department of Public Health and Community Dentistry, Boston University. This paper, submitted September 15, 1975, was revised and accepted for publication in the Journal on February 23, 1976.
AJPH June, 1976, Vol. 66, No. 6
Financial Impact The fiscal impact of the Commonwealth's Medicaid dental program was significant in terms of the proportion of Medicaid expenditures. The dental program in 1967 represented 5.0 per cent of the state's health services budget, as compared to 2.7 per cent in 1965. In 1968 the program peaked to 10.5 per cent of the total medical-dental expenditures and payments to vendor dentists exceeded payments to physician vendors. Massachusetts and New York were the only states to experience this phenomenon. The economic magnitude of the Title XIX program in Massachusetts ranked it as one of the most expensive programs in the nation. In a comparison of states during the period January to JUne of 1968, the Commonwealth, although ranked ninth in population, ranked fourth in the number of Medicaid recipients, and third in terms of vendor payments.2 Dental payments during this period were $10,769,000, or 10 per cent of the all Massachusetts vendor payments; physician payments were $9,630,000, 9.5 per cent of all vendor payments. Dental vendor payments reached their proportional zenith in 1968. In 1970, vendor dental bills amounted to $18,000,000, or 6.3 per cent of the total bills compared to the 7.2 per cent reported for physician's services. The trend continued through 1971. A comparison of expenditures for dentistry among three major Medicaid states indicated that Massachusetts, despite spending less per inhabitant for Medicaid, spent more per inhabitant for dentistry (Table 1). Despite the relative decrease in expenditures for dentistry, Massachusetts maintained a significant dental program when compared to two of the leading Medicaid states. The proportionate decrease in expenditures for dentistry reflected several factors: (1) a proportional increase in hospital and nursing home costs under the Medicaid program; (2) changes in eligibility which may have adversely afTABLE 1-Cost Per InhabItantforNew York, Californiaand Massachusetts forTltle XIX Vendor Dental Payments, 1970 Cost per
inhabitant
Total Medicaid Dental costs
New York
Califomia
Massachusetts
$66.05
$49.75
$46.75
3.00
2.40
3.30
Source: Data abstracted from a 1971 lecture by Dr. William D. Wellock, Director of Dentistry for the Massachusetts Department of Publc Health, at the Harvard School of Dental Medicine. Determined by the Department of Public Health, Massachusetts. fected the "medically indigent" eligibility; (3) a requirement
of the prior authorization for certain dental services; (4) the ratio of maintenance dental care to episodic care; and (5) 583
PUBLIC HEALTH BRIEFS
changes in the age distribution of recipients. The prior authorization mechanism consisted of systematic review of dental requests involving expensive treatment such as full and partial dentures, crowns, bridges, certain treatment of root canals, space maintainers, and orthodontic treatment. For the calendar year 1968, approximately $7 million worth of dental requests were made to the Department of Public Welfare; 25 per cent of this amount was disapproved. The relative frequency of emergency and episodic dental care to maintenance or periodic care, too, may have altered costs. Hypothetically, maintenance care should be less expensive than the care delivered to an individual with enormous, accumulated needs. Over a period of time, the proportion of individuals seeking maintenance and complete care may have increased thereby diminishing expenditures. In a random survey of dentists during the summer of 1961, 60 per cent of the respondents felt that Medicaid patients sought complete care as opposed to episodic care.3 One implication of maintenance care is prevention of dental disease. An age-specific analysis of all Title XIX costs indicated that, in 1970, over 50 per cent of such costs were attributable to individuals over the age of 65.1 This phenomenon was clearly due to the expensive institutional care provided under the program. Dental charges by age presented the reverse situation. The major proportion of dental charges were attributable to those under age 21 (62 per cent) whereas charges for those over age 65 accounted for 8 per cent of the total dental payments to vendors. Payments to dental vendors for those over age 65 did, however, represent a disproportionate expenditure. In February, 1970, senior citizens accounted for only 3 per cent of all patients receiving dental care (Table 2). TABLE 2-Per Cent Distribution, Recipients of Care and Charges for Dental Services by Age Groups In Massachusetts, February, 1970.
Age Groups (years)
7 7-13
14-20 21-64 65+
Distribution Charges (%)
Distribution Recipients of Care (%)
12 41 26 18 3
8 29 25 30 8
Source: Wellock, W. D. and Baker, M.
Recipients ofDental Care Recipients of dental care under Title XIX are generally considered to be low utilizers of primary care facilities. Experience in New York and Massachusetts indicated that the utilization of dental services by the medically indigent (the
584
working poor) far exceeded utilization by those receiving cash payments (those on public assistance).5 Although eligibility of the medically indigent decreased their utilization remained significantly high and costly. Distribution of recipients by public assistance and medically indigent categories for February, 1970 indicated that over one-half of the dental patients were from the medically indigent population, as compared to 72 per cent in November of 1967.5
Conclusions This brief description of the Dental Medicaid Program in Massachusetts during the years 1967-1971 has emphasized several points: (1) the Medicaid program tended to expand the scope of services available to public assistance recipients; (2) dentists accepted the program at inception and continued to participate although the fee schedule remained relatively constant over time; (3) expenditures for dentistry were a significant proportion of the total Medicaid budget: (4) it was possible through program restrictions such as "prior approval" on expensive items to control the cost of the program; (5) dental care for those under age 21 was proportionately less expensive than dental care for the elderly; (6) the dentally indigent were important contributors to dental care utilization in the Massachusetts program.
REFERENCES 1. Callahan, J. J., Jr. Medical Assistance; Selected Trends. Boston, Massachusetts Department of Public Welfare. March 30, 1970. 2P. Mimeog. 2. Chapin, S. Comparisons of Massachusetts and U.S. Figures on Medical Assistance. Boston, Massachusetts Department of Public Welfare, March 1970. 9P. Mimeog. 3. Gluck G., Jong, A., The attitudes of dentists and their sentiments for change under the Massachusetts Medicaid program. Medical Care, 12:582-589, July, 1974. 4. Glass, R. L. An Evaluation of Dental Services Provided Under Title XIX in Massachusetts During November, 1967. l IP. Typed Report. 5. Wellock, W. D., Baker, M., Some Characteristics of Utilization of Dental Services in the Massachusetts Public Assistance Program During February, 1970 (Unpublished Manuscript).
SELECTED REFERENCES Baum, B. J., Medicaid and the practicing dentist. Mass. Dent. Soc. J., 18:30-31, Winter, 1969. Greenfield, M. Medicare and Medicaid: The 1965 and 1967 Social Security Amendments. Berkely, University of California, Institute of Governmental Studies, 1968, 143P. (P.126-43). National dental fee survey, 1970. J. Amer. Dent. Association 83:5769, July, 1971.
AJPH June, 1976, Vol. 66, No. 6
The Massachusetts Dental Medicaid Program 1967-1971 GEORGE M. GLUCK, DDS, MPH, AND ANTHONY JONG, DDS, MPH
The purpose of this paper is to describe significant ramifications of the dental Medicaid program in Massachusetts during the period 1967-1971. The areas of focus include the following: dental treatment provided, financial ramifications of the dental program, and the nature of recipients of care. The Department of Public Welfare is the state agency responsible for the administration of the Medicaid program. Eligibility for Medicaid services included persons on public assistance who qualified for the federally mandated social welfare categories. Those excluded from public assistance because of state regulations such as durational residence requirements, any citizenship requirement which excludes any U.S. citizens, or a minimum age requirement were included under the state's Medicaid program.' The anticipated number of Massachusetts recipients under these eligibility guidelines was estimated to be 626,000 persons or 6.7 percent of the national Medicaid program.2 In 1954, the Commonwealth of Massachusetts had implemented a Public Welfare Medical Care Plan which included provisions for dental services, through vendor payments to providers reimbursed according to a fee schedule. The program was expanded in 1963 to broaden the range of services to include 54 treatment categories. The 1967 Medicaid schedule listed over 90 treatment categories for which providers could be reimbursed. This increased comprehensiveness of the schedule and, an increase in fees, which responded to a statewide survey, increased dentist participation in the program. The effectiveness of the initial Medicaid fee schedule was reflected in a contrast of dentist attitudes for 1968 and 1971.3 In 1968, only 5 per cent of the dentists surveyed felt that the fees were less than adequate while 10 per cent felt that they were more than adequate. In 1971, with only minimal changes in the fee schedule, dentists indicated serious dissatisfaction with the schedule. A random sample of all vendor bills in November of 1967 indicated that 44 per cent of all services fell under the categories of diagnostic and preventive dentistry.4 The prevalence of preventive services reflected the relative preponderance (79 per cent) of recipients under age 21, and the better than average fees for preventive services (when compared with the National Dental Fee Survey, 1970, for Massachusetts). Address reprint requests to Dr. George M. Gluck, Chairman, Department of Community Dentistry, School of Dentistry, Fairleigh Dickinson University, 110 Fuller Place, Hackensack, NJ 07601. Dr. Jong is Chairman, Department of Public Health and Community Dentistry, Boston University. This paper, submitted September 15, 1975, was revised and accepted for publication in the Journal on February 23, 1976.
AJPH June, 1976, Vol. 66, No. 6
Financial Impact The fiscal impact of the Commonwealth's Medicaid dental program was significant in terms of the proportion of Medicaid expenditures. The dental program in 1967 represented 5.0 per cent of the state's health services budget, as compared to 2.7 per cent in 1965. In 1968 the program peaked to 10.5 per cent of the total medical-dental expenditures and payments to vendor dentists exceeded payments to physician vendors. Massachusetts and New York were the only states to experience this phenomenon. The economic magnitude of the Title XIX program in Massachusetts ranked it as one of the most expensive programs in the nation. In a comparison of states during the period January to JUne of 1968, the Commonwealth, although ranked ninth in population, ranked fourth in the number of Medicaid recipients, and third in terms of vendor payments.2 Dental payments during this period were $10,769,000, or 10 per cent of the all Massachusetts vendor payments; physician payments were $9,630,000, 9.5 per cent of all vendor payments. Dental vendor payments reached their proportional zenith in 1968. In 1970, vendor dental bills amounted to $18,000,000, or 6.3 per cent of the total bills compared to the 7.2 per cent reported for physician's services. The trend continued through 1971. A comparison of expenditures for dentistry among three major Medicaid states indicated that Massachusetts, despite spending less per inhabitant for Medicaid, spent more per inhabitant for dentistry (Table 1). Despite the relative decrease in expenditures for dentistry, Massachusetts maintained a significant dental program when compared to two of the leading Medicaid states. The proportionate decrease in expenditures for dentistry reflected several factors: (1) a proportional increase in hospital and nursing home costs under the Medicaid program; (2) changes in eligibility which may have adversely afTABLE 1-Cost Per InhabItantforNew York, Californiaand Massachusetts forTltle XIX Vendor Dental Payments, 1970 Cost per
inhabitant
Total Medicaid Dental costs
New York
Califomia
Massachusetts
$66.05
$49.75
$46.75
3.00
2.40
3.30
Source: Data abstracted from a 1971 lecture by Dr. William D. Wellock, Director of Dentistry for the Massachusetts Department of Publc Health, at the Harvard School of Dental Medicine. Determined by the Department of Public Health, Massachusetts. fected the "medically indigent" eligibility; (3) a requirement
of the prior authorization for certain dental services; (4) the ratio of maintenance dental care to episodic care; and (5) 583
PUBLIC HEALTH BRIEFS
changes in the age distribution of recipients. The prior authorization mechanism consisted of systematic review of dental requests involving expensive treatment such as full and partial dentures, crowns, bridges, certain treatment of root canals, space maintainers, and orthodontic treatment. For the calendar year 1968, approximately $7 million worth of dental requests were made to the Department of Public Welfare; 25 per cent of this amount was disapproved. The relative frequency of emergency and episodic dental care to maintenance or periodic care, too, may have altered costs. Hypothetically, maintenance care should be less expensive than the care delivered to an individual with enormous, accumulated needs. Over a period of time, the proportion of individuals seeking maintenance and complete care may have increased thereby diminishing expenditures. In a random survey of dentists during the summer of 1961, 60 per cent of the respondents felt that Medicaid patients sought complete care as opposed to episodic care.3 One implication of maintenance care is prevention of dental disease. An age-specific analysis of all Title XIX costs indicated that, in 1970, over 50 per cent of such costs were attributable to individuals over the age of 65.1 This phenomenon was clearly due to the expensive institutional care provided under the program. Dental charges by age presented the reverse situation. The major proportion of dental charges were attributable to those under age 21 (62 per cent) whereas charges for those over age 65 accounted for 8 per cent of the total dental payments to vendors. Payments to dental vendors for those over age 65 did, however, represent a disproportionate expenditure. In February, 1970, senior citizens accounted for only 3 per cent of all patients receiving dental care (Table 2). TABLE 2-Per Cent Distribution, Recipients of Care and Charges for Dental Services by Age Groups In Massachusetts, February, 1970.
Age Groups (years)
7 7-13
14-20 21-64 65+
Distribution Charges (%)
Distribution Recipients of Care (%)
12 41 26 18 3
8 29 25 30 8
Source: Wellock, W. D. and Baker, M.
Recipients ofDental Care Recipients of dental care under Title XIX are generally considered to be low utilizers of primary care facilities. Experience in New York and Massachusetts indicated that the utilization of dental services by the medically indigent (the
584
working poor) far exceeded utilization by those receiving cash payments (those on public assistance).5 Although eligibility of the medically indigent decreased their utilization remained significantly high and costly. Distribution of recipients by public assistance and medically indigent categories for February, 1970 indicated that over one-half of the dental patients were from the medically indigent population, as compared to 72 per cent in November of 1967.5
Conclusions This brief description of the Dental Medicaid Program in Massachusetts during the years 1967-1971 has emphasized several points: (1) the Medicaid program tended to expand the scope of services available to public assistance recipients; (2) dentists accepted the program at inception and continued to participate although the fee schedule remained relatively constant over time; (3) expenditures for dentistry were a significant proportion of the total Medicaid budget: (4) it was possible through program restrictions such as "prior approval" on expensive items to control the cost of the program; (5) dental care for those under age 21 was proportionately less expensive than dental care for the elderly; (6) the dentally indigent were important contributors to dental care utilization in the Massachusetts program.
REFERENCES 1. Callahan, J. J., Jr. Medical Assistance; Selected Trends. Boston, Massachusetts Department of Public Welfare. March 30, 1970. 2P. Mimeog. 2. Chapin, S. Comparisons of Massachusetts and U.S. Figures on Medical Assistance. Boston, Massachusetts Department of Public Welfare, March 1970. 9P. Mimeog. 3. Gluck G., Jong, A., The attitudes of dentists and their sentiments for change under the Massachusetts Medicaid program. Medical Care, 12:582-589, July, 1974. 4. Glass, R. L. An Evaluation of Dental Services Provided Under Title XIX in Massachusetts During November, 1967. l IP. Typed Report. 5. Wellock, W. D., Baker, M., Some Characteristics of Utilization of Dental Services in the Massachusetts Public Assistance Program During February, 1970 (Unpublished Manuscript).
SELECTED REFERENCES Baum, B. J., Medicaid and the practicing dentist. Mass. Dent. Soc. J., 18:30-31, Winter, 1969. Greenfield, M. Medicare and Medicaid: The 1965 and 1967 Social Security Amendments. Berkely, University of California, Institute of Governmental Studies, 1968, 143P. (P.126-43). National dental fee survey, 1970. J. Amer. Dent. Association 83:5769, July, 1971.
AJPH June, 1976, Vol. 66, No. 6
