Oral Health: Factors Contributing to Low Use of Dental Services by
Low-Income Populations (Letter Report, 09/11/2000, GAO/HEHS-00-149).

Pursuant to a congressional request, GAO reviewed Medicaid and the State
Children's Health Insurance Program's (SCHIP) efforts to make dental
care more available to low-income people, focusing on: (1) factors that
explain low dental service use by Medicaid and SCHIP beneficiaries; and
(2) the role of other federal safety-net programs in improving access to
dental care.

GAO noted that: (1) while several factors contribute to the low use of
dental services among low-income persons who have coverage for dental
services, the major one is finding dentists to treat them; (2) some
low-income people live in areas where dental providers are generally in
short supply, but many others live in areas where dental care for the
rest of the population is readily available; (3) dentists generally cite
low payment rates, administrative requirements, and patient issues such
as frequently missed appointments as the reasons why they do not treat
more Medicaid patients; (4) although many states have taken action to
address these concerns, use remains low; (5) raising Medicaid payment
rates for dental services--a step 40 states have taken recently--appears
to result in a marginal increase in use but not consistently; (6) as
expected, states that paid higher rates relative to the average fees
dentists charge were more likely to report increases in dental
utilization; (7) while 20 states use managed care to provide some dental
services for Medicaid patients, state officials reported mixed results
in terms of the extent to which this approach improves access; (8)
although states have not yet evaluated the access to dental services
under SCHIP, the majority of states have modelled their SCHIP dental
services on their Medicaid programs and management and therefore expect
to find similar utilization issues; (9) the impression of some officials
in states that have departed from Medicaid in designing their SCHIP
dental programs, such as using private insurance plans that pay higher
rates, is that there are fewer access problems; (10) the four other
major federal programs that target services or providers to underserved
or special populations with poor dental health--the Health Center
program, National Health Service Corps (NHSC), Indian Health Service
(IHS) dental program, and IHS loan repayment program--currently have a
limited effect on increasing the access to dental services that
low-income and vulnerable populations have; (11) the Health Center
program supports community and migrant health centers in medically
underserved areas, while the IHS loan repayment program provides
incentives for health professionals, including dentists, to practice in
sites serving American Indians and Alaska Natives; (12) however, these
programs are not able to meet the dental needs of their target
populations; and (13) NHSC was able to fill only one of every three
vacant dentist positions in underserved areas in fiscal year 1999.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-149
     TITLE:  Oral Health: Factors Contributing to Low Use of Dental
	     Services by Low-Income Populations
      DATE:  09/11/2000
   SUBJECT:  Dental services
	     Health care programs
	     State-administered programs
	     Disadvantaged persons
	     Dental insurance
IDENTIFIER:  State Children's Health Insurance Program
	     Medicaid Program
	     HHS Community Health Centers Program
	     IHS Dental Program
	     IHS Loan Repayment Program
	     HHS Healthy People 2010 Initiative

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GAO/HEHS-00-149

Report to Congressional Requesters

September 2000 ORAL HEALTH Factors Contributing to Low Use of Dental
Services by Low- Income Populations

GAO/ HEHS- 00- 149

Letter 3 Appendixes Appendix I: Scope and Methodology 28

Appendix II: Healthy People 2010 Oral Health Goals 35 Appendix III: Medicaid
Payment Rates as a Percentage of Average

Regional Dental Fees for Selected Procedures, 1999 36 Appendix IV: Comments
From HHS 38

Tables Table 1: Four Selected Federal Programs That Provide Dental Services
or Providers to Vulnerable Populations 9

Table 2: Comparison of 29 States Reporting Increased Medicaid Payment Rates
and the Effect on Dental Access 14 Table 3: Average Number of Dentist
Vacancies at IHS and Tribal

Operated Facilities and IHS Loan Repayment Awards, Fiscal Years 1995- 99 22
Table 4: Examples of HHS Actions Taken or Planned to Improve

Dental Care Access 23 Table 5: The Dental Procedures in Our Study 29 Table
6: Average Dental Fees for the 15 Procedures by Region, 1999 32

Figures Figure 1: Percentage of Dentists Seeing at Least 100 Medicaid
Patients in 31 States, 1999 11

Figure 2: Distribution of States in the Nine Regions of ADA's Survey of
Dental Fees 31

Abbreviations

ADA American Dental Association EPSDT Early and Periodic Screening,
Diagnostic, and Treatment HCFA Health Care Financing Administration HHS
Department of Health and Human Services HRSA Health Resources and Services
Administration IHS Indian Health Service NHSC National Health Service Corps
SCHIP State Children's Health Insurance Program

Health, Education, and Human Services Division

Lett er

B- 283915 September 11, 2000 The Honorable Jeff Bingaman The Honorable
Russell D. Feingold United States Senate

The Honorable Thomas M. Barrett The Honorable David R. Obey House of
Representatives

For many years, the federal government has taken steps to make dental care
more available to low- income people. The primary vehicle has been Medicaid,
a joint federal and state health financing program for more than 40 million
people from low- income families and poor aged, blind, or disabled people.
The State Children's Health Insurance Program (SCHIP) covers about 2 million
additional low- income children who do not qualify for Medicaid. Still other
programs support community and migrant health centers and other facilities
and medical personnel in locations where lowincome people live. These
programs, although relatively small compared with Medicaid, extend health
care services to many additional low- income and vulnerable populations.

Despite such efforts, the use of dental services remains low for many. In
April 2000, responding in part to a request from you to study this issue, we
reported that Medicaid and SCHIP beneficiaries and other low- income people
have low rates of dental visits and high rates of dental disease relative to
the rest of the population. 1 To help determine why, this report addresses
(1) factors that explain low dental service use by Medicaid and SCHIP
beneficiaries and (2) the role of other federal safety- net programs in
improving access to dental care.

1 Oral Health: Dental Disease Is a Chronic Problem Among Low- Income
Populations (GAO/ HEHS- 00- 72, Apr. 12, 2000).

To address these issues, we surveyed Medicaid and SCHIP programs in all 50
states and the District of Columbia. 2 We analyzed data on dentists'
participation rates in the programs, the use of dental services, and
Medicaid fees that might help quantify access problems. We supplemented this
information with reviews of the Surgeon General's report on oral health and
other studies and interviews with persons knowledgeable about the issues,
including health services researchers, dental association representatives,
and federal, state, and local health officials. 3 Appendix I gives details
on our methodology. We conducted our work from December 1999 to July 2000 in
accordance with generally accepted government auditing standards.

Results in Brief While several factors contribute to the low use of dental
services among low- income persons who have coverage for dental services,
the major one

is finding dentists to treat them. Some low- income people live in areas
where dental providers are generally in short supply, but many others live
in areas where dental care for the rest of the population is readily
available. Dentists generally cite low payment rates, administrative
requirements, and patient issues such as frequently missed appointments as
the reasons why they do not treat more Medicaid patients. Although many
states have taken action to address these concerns, use remains low. Raising
Medicaid payment rates for dental services- a step 40 states have taken
recently- appears to result in a marginal increase in use but not
consistently. As expected, states that paid higher rates relative to the
average fees dentists charge were more likely to report increases in dental
utilization. While 20 states use managed care to provide some dental
services for Medicaid patients, state officials reported mixed results in
terms of the extent to which this approach improves access. And although
states have not yet evaluated the access to dental services under SCHIP, the
majority of states have modeled their SCHIP dental services on their
Medicaid programs and management and therefore expect to find similar
utilization issues. The impression of some officials in states that have
departed from Medicaid in designing their SCHIP dental programs, such as
using private insurance plans that pay higher rates, is that there are fewer
access problems.

2 We include the District of Columbia as a state in the rest of this report.
3 Department of Health and Human Services (HHS), National Institutes of
Health, National Institute of Dental and Craniofacial Research, Oral Health
in America: A Report of the Surgeon General( Rockville, Md.: 2000).

The four other major federal programs that target services or providers to
underserved or special populations with poor dental health- the Health
Center program, National Health Service Corps (NHSC), Indian Health Service
(IHS) dental program, and IHS loan repayment program- currently have a
limited effect on increasing the access to dental services that lowincome
and vulnerable populations have. The Health Center program supports
community and migrant health centers in medically underserved areas, while
the IHS loan repayment program provides incentives for health professionals,
including dentists, to practice in sites serving American Indians and Alaska
Natives. However, these programs are not able to meet the dental needs of
their target populations. NHSC was able to fill only one of every three
vacant dentist positions in underserved areas in fiscal year 1999.

Background While the dental health of most Americans has improved
significantly since the 1960s, low- income populations continue to have high
levels of dental

disease. Analysis of key dental health indicators- including untreated tooth
decay, restricted activity days because of pain and discomfort from dental
problems, and tooth loss- showed large disparities between lowincome groups
and their higher- income counterparts. Other populations, such as homeless
people, some minorities, and some rural residents, face similar problems.
Low- income children and adults experience higher levels of dental disease
and use dental care less frequently than higher- income people do. For
example, in 1996, 28 percent of lower- income people reported making a
dental visit in the preceding year, compared with 56 percent of higher-
income people. 4

4 Data are from the Agency for Healthcare Research and Quality and are based
on analysis of the Medical Expenditure Panel Survey of 1996. Figures are for
people with family incomes at or below 200 percent of the federal poverty
level and people with family incomes above 400 percent of the federal
poverty level. In 1996, the federal poverty level for a family of four was
$16, 036.

Recognizing the importance of good oral health, in 1990 the Department of
Health and Human Services (HHS) established oral health goals as part of its
departmentwide Healthy People 2000 objectives. These included goals to
reduce the proportion of children with untreated cavities and to increase
the proportion of people who visit a dentist each year. Interim assessments
showed that progress toward these goals was mixed, with low- income children
and adults furthest from reaching them. For example, while one HHS goal was
to reduce the proportion of children aged 6 to 8 who have untreated cavities
to no more than 20 percent, 47 percent of poor children had untreated
cavities in 1994, the most recent year for which data are available. 5 In
January 2000, HHS established new oral health goals as part of its Healthy
People 2010 initiative (see app. II). In addition, IHS recognized the large
unmet oral health needs of American Indians and Alaska Natives and
established oral health goals as part of its fiscal year 2000 performance
plan. In general, American Indian and Alaska Native populations have oral
health disease rates that are greater than that of the general U. S.
population. For example, American Indian and Alaska Native children aged 2
to 4 years old have five times the rate of dental decay that all children
have.

The disparities in oral health were highlighted in a recent Surgeon
General's report. The report discussed the higher levels of oral diseases
affecting vulnerable populations such as poor children, elderly persons, and
members of many racial and ethnic minority groups. Individuals with
disabilities and individuals with complex health problems may face
additional barriers to dental care. The Surgeon General reported that the
reasons for disparities in oral health are complex and in some cases are
exacerbated by the lack of community programs such as fluoridated water
supplies and other factors. More than a third of the U. S. population (about
100 million people) is without community water fluoridation, which is
recommended as a cost- effective method of preventing cavities in children
and adults, regardless of their socioeconomic status.

HHS' Health Care Financing Administration (HCFA) administers two joint
federal and state programs- Medicaid and SCHIP- that provide health care
insurance, including coverage for dental care, for low- income people.

5 Data are for children with family incomes below the federal poverty level.
In comparison, the data showed that about 29 percent of all children aged 6
to 8 and 16 percent of higherincome children had untreated cavities.

Medicaid. This health care financing program for low- income families and
poor aged, blind, and disabled people covered about 1 in 5 children and 1 in
16 nonelderly adults in 1998. The states operate their Medicaid programs
within broad federal requirements and can elect to cover a range of optional
populations and services, thereby creating programs that differ
substantially from state to state. Despite this variation, some services are
mandated under federal law. For instance, under Medicaid's Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT) service, the states
must provide dental screening, diagnostic, preventive, and treatment
services for all enrolled children, even if the services are not normally
covered by a state's Medicaid program. 6 Adult dental services, in contrast,
are optional under Medicaid. As shown in our April 2000 report, about two-
thirds of the states covered adult dental services to some extent under
Medicaid as of January 2000. SCHIP. Authorized in 1997, this program expands
health care coverage

to children whose families have incomes that are low but not low enough to
qualify for Medicaid. States can cover low- income children in families with
incomes up to 200 percent of the federal poverty level. 7 To implement
SCHIP, the states have three options: They can expand their existing
Medicaid program, develop a separate SCHIP program, or do some combination
of both. If a state elects a Medicaid expansion for its SCHIP program, it
must offer the same comprehensive benefit package, including dental
services, that is required under EPSDT; otherwise, coverage of dental
services is not mandatory for children under SCHIP as it is in Medicaid.
Nearly all the states have chosen to offer dental coverage under SCHIP. As
of January 2000, SCHIP provided a variable but often substantial level of
dental coverage to eligible low- income children in all but two states.
Colorado and Delaware have implemented stand- alone programs that do not
cover dental services.

6 Section 1905( r)( 3) of the Social Security Act defines EPSDT services as
including dental services that are (1) provided at intervals that meet
reasonable standards of dental practice, (2) provided at other intervals as
medically necessary to determine the existence of a suspected illness or
condition, and (3) include relief of pain and infections, restoration of
teeth, and maintenance of dental health.

7 Under Medicaid, the federal government's share of covered expenditures
range from 50 to 77 percent in fiscal year 2000, depending on a state's
average per capita income level. Under SCHIP, the states are eligible for an
enhanced federal matching share of 65 to 84 percent. SCHIP allows states
that cover Medicaid beneficiaries with incomes that already approach or
exceed 200 percent of the federal poverty level to expand eligibility to up
to 50 percentage points above their existing Medicaid eligibility standards.

Despite the availability of insurance coverage through Medicaid, the low use
of dental services by Medicaid beneficiaries is perceived as a significant
pediatric health problem in many states. The Surgeon General's report cited
the National Access to Care Survey, which found that more Medicaid
beneficiaries reported problems obtaining dental care than medical care. The
survey found that about 12 percent of the Medicaid population wanted but did
not obtain dental care in 1994, while only 8 percent reported unmet medical
wants.

Another vulnerable group- many of whom are covered by Medicaid- that
experiences a disproportionate level of dental disease is people with
physical, mental, and developmental disabilities. Disabled individuals often
have special needs that create additional barriers to obtaining dental care.
For example, some disabled individuals require intravenous sedation or
general anesthesia during dental treatment. Treatment for wheelchairbound
patients and blind or deaf patients also requires special accommodations.
Many disabled individuals have moved from institutional to community
settings, and caretakers often report greater difficulty finding community
dentists to treat them. One study using data from the 1994-95 National
Health Interview Survey on Disability found that about 1 in every 12
children with special health care needs was unable to get needed dental
care. 8 In addition, the Surgeon General's report cited localized studies
and other unpublished data as evidence of poorer oral hygiene and increased
levels of periodontal and dental disease among disabled populations.

In addition to Medicaid and SCHIP, the federal government administers other
health care programs providing dental services or providers for lowincome
and vulnerable populations. The four federal programs we reviewed include
programs that directly provide dental services or arrange for them to be
provided and programs that provide incentives for dental professionals to
treat poor and other vulnerable populations. Two are directed at people
living in areas with shortages of health care services and are administered
by HHS' Health Resources and Services Administration (HRSA). Two are
targeted toward American Indians and Alaska Natives and are administered by
IHS (see table 1).

8 P. W. Newacheck and others, “Access to Health Care for Children with
Special Health Care Needs,” Pediatrics, Vol. 105, No. 4 (Apr. 2000),
pp. 760- 66.

Table 1: Four Selected Federal Programs That Provide Dental Services or
Providers to Vulnerable Populations Program Description HRSA programs
targeting areas with shortages of health care services

Health Centers a Grant support for more than 3, 000 sites that provide
primary health care services in medically underserved areas. In 1998, more
than 85 percent of health center users had incomes at or below 200 percent
of the federal poverty level. Health centers are required to directly
provide or arrange for dental screening for children and preventive dental
services. Other dental services are optional. In 1998, health centers
reported providing dental services to 1.2 million of 8. 6 million health
center users.

National Health Service Corps Offers scholarships and educational loan
repayments for health care professionals, such as physicians, (NHSC) nurse
practitioners, and dentists, who agree to serve for specific periods in
communities that have a

shortage of health professionals. NHSC providers must accept Medicare and
Medicaid patients and offer a sliding fee scale based on the patient's
ability to pay. In 1999, NHSC placed 83 new dentists in underserved areas
through its loan repayment program. At the end of fiscal year 1999, NHSC had
299 dentists and 7 dental hygienists practicing in 41 states, the Pacific
Basin, and Puerto Rico.

IHS programs targeting American Indians and Alaska Natives

IHS facilities IHS and tribally managed dental programs operate in 269 IHS
facilities. Additional dental services are provided through contract care
purchased by IHS or tribes. Of the 1.5 million people in the IHS service
population, about 335,000 received dental services in IHS and tribal
facilities and through contract health services in 1999.

IHS loan repayment Offers educational loan repayments for health care
professionals, including dentists and dental hygienists, who agree to
practice at priority sites designated by IHS and provide services to
American Indians and Alaska Natives. In 1999, 11 of 173 new IHS loan
repayment awards went to dentists.

a Includes community and migrant health centers, health care for homeless
persons, and primary care for residents of public housing. These were
combined under the Health Centers Consolidation Act of 1996, Pub. L. No.
104- 299, 110 Stat. 3626.

Factors Affecting the While several factors influence the access low- income
groups have to

Low Use of Dental dental care, the primary one is limited dentist
participation in Medicaid.

States have taken various steps to improve access to dental care among Care
and State Efforts

Medicaid populations, including raising payment rates, streamlining to
Address Them

administrative processes, and conducting outreach activities to both
dentists and beneficiaries. Despite these steps, most states- including
those reporting improvements in dental access- reported that low utilization
remains a problem. Dental managed care and SCHIP offer opportunities for
greater access for Medicaid and other low- income populations in some
states, but limited data currently preclude an evaluation of their
effectiveness.

Low Rate of Dentist In the absence of HCFA or other data on dentist
participation in state

Participation in Medicaid Medicaid programs, we surveyed Medicaid program
officials in all 50 states

and the District of Columbia. Of 39 states that provided information about
dentists' participation in Medicaid, 23 reported that fewer than half of the
states' dentists saw at least one Medicaid patient during 1999. 9 We also
asked states for data on the number of dentists seeing at least 100 Medicaid
patients in 1999. 10 Of the 31 states that could provide these data, none
reported that more than half of their dentists saw 100 or more Medicaid
patients in 1999, and most states reported that fewer than a fourth did so
(see fig. 1).

9 We collected data from state Medicaid agencies on the number of dentists
treating Medicaid patients and calculated dentist participation rates from
data from the American Dental Association (ADA) on the number of private
practice dentists in each state. We asked for data for calendar year 1999,
but some states could provide data only for fiscal year 1999. In those
cases, we used the fiscal year data. See appendix I for details on our
methodology.

10 We used 100 patients as a measure of more substantial participation,
because 100 patients represent roughly 10 percent of the patients a typical
dentist sees in a year, about the same percentage that Medicaid patients
represent in the general population. According to data from ADA's 1998
Survey of Dental Practice, dentists see, on average, an estimated 944
patients a year.

Figure 1: Percentage of Dentists Seeing at Least 100 Medicaid Patients in 31
States, 1999

5 States

25 - 50 Percent

26 States

Less Than 25 Percent

0 States

More Than 50 Percent

Officials in some states reported that an overall shortage of dentists for
the entire population in some areas makes it difficult to find dentists to
treat Medicaid patients. 11 In other cases, however, there is an adequate
supply of dentists, but few of them treat Medicaid patients. Dentists cite
several reasons why they do not treat more Medicaid patients. These reasons
generally fall into three categories: low Medicaid payment rates,
administrative burden, and patient issues such as failing to keep scheduled
appointments. Most state Medicaid programs have taken steps to address these
problems, with mixed results.

11 Although states point to an overall shortage of dentists, there is no
agreed- upon dentist- topopulation ratio for determining a minimum adequate
supply of dentists.

Medicaid Payment Rates Dentists cite as the primary reason for their not
treating more Medicaid patients that payment rates are too low. To assess
state Medicaid payment rates relative to the fees dentists charged, we
compared 1999 state Medicaid payment rates with average regional fees
dentists charged for 15 selected dental procedures. These procedures cover a
broad spectrum of services, including preventive, diagnostic, restorative,
endodontics (such as root canal), and surgical services. 12 For dentists,
the fees they charge are fairly representative of the amounts they generally
collect. According to a 1998 survey by the American Dental Association
(ADA), dentists collect about 95 percent of the amount that they bill.

Our analysis showed that Medicaid payment rates are often well below
dentists' normal fees. Only 13 states had Medicaid rates that exceeded
twothirds of the average regional fees dentists charged for most of the 15
procedures we examined, while four of these states- Delaware, Indiana, New
Mexico, and South Carolina- paid more than 75 percent of the average
regional fee for all procedures. All other states paid much lower fees for
most of the procedures. For example, New Jersey paid 25 percent or less of
the average regional fee charged for 12 of 14 covered procedures. See
appendix III for additional information on state Medicaid fees for the
procedures we examined.

Medicaid payment rates relative to the average regional fees also varied
significantly within states for the different procedures. For example,
Mississippi paid more than 150 percent of the average regional fee for
periodic oral examinations while paying less than 40 percent of the regional
average for root canals.

We also assessed the relationship of Medicaid fee increases to changes in
access to dental care. Between January 1997 and January 2000, 40 states
increased Medicaid payment rates for dental care at least once, while 9
states reported no rate increases. 13 The magnitude and frequency of rate

12 We selected the 15 procedures in consultation with James Crall, Associate
Dean of the University of Connecticut School of Dental Medicine, and other
dental health researchers. All the procedure codes in our study are used to
treat children and adolescents, and some procedure codes are used for adults
as well. While using the average regional dental fee could be misleading if
there are large state variations within a region, a comparison of the
average regional fee with available fee data for six selected states
indicates that it is, for the most part, a reasonable approximation for
average state fees. See appendix I for additional information on our
methodology.

13 New York and Tennessee did not respond.

increases varied. For example, some states such as Iowa, Washington, and
Wisconsin had frequent but small rate increases of 1 to 5 percent each year
while others such as Maine, New Mexico, and North Carolina had one- time
large increases of 40 to 50 percent. For the 40 states with rate increases,
we asked Medicaid officials to assess their effect and to support their
assessments with data on changes in dentist participation rates and dental
utilization rates during the past 3 years. Of the 40 states with rate
increases,

14 states reported increases in dentist participation or dental utilization,
15 states reported no increase in dentist participation or dental

utilization, and 11 states indicated that either not enough time had elapsed
or the state

did not have reliable data on access changes to report an effect. Most
states that reported increases in dental utilization had only marginal
increases, such as increases in dental utilization of less than 3 percentage
points. For example, despite a 40 percent increase in dental fees in 1998,
the dental utilization in Maine increased by only 2 percentage points in
1999. Further, some states reported increases in utilization, but their
overall rates remained low. For example, Indiana's utilization increased by
6 percentage points from 1998 to 1999 following an increase in fees, yet its
overall utilization rate after the increase was only 26 percent.

To determine whether the fee levels after the rate increases made a
difference in a state's ability to improve access, we compared fee levels of
states reporting improvement with those of the states reporting no
improvement. We found that most of the states reporting improved utilization
paid rates that were at least two- thirds of the average regional fees,
while most of the states without improvement had lower payment rates (see
table 2).

Table 2: Comparison of 29 States Reporting Increased Medicaid Payment Rates
and the Effect on Dental Access Procedures reimbursed at more than two-
thirds of

States reporting States reporting the average regional fee improvements in
access no improvements in access

All 15 procedures a 6 0 Half or more but less than all 3 3 Fewer than half
but more than none 4 11 None 1 1

Total 14 15

a Our analysis examined fees for 15 dental procedures after state fee
increases. Some states did not cover all 15 procedures.

Some state officials reported that fee increases may not have improved
dentists' participation or significantly increased the percentage of
Medicaid beneficiaries receiving services but did help retain those already
participating. In addition, officials in several states reporting improved
access said that other efforts besides higher fees- such as outreach to
recruit dentists- helped improve dentists' participation in Medicaid.

Medicaid Administrative Dentists also report that their dissatisfaction with
the administrative

Requirements requirements of state Medicaid programs keeps them from seeing
more

Medicaid patients. Research has found that dentists fault unique Medicaid
claim forms and codes, difficulties with claims handling, preauthorization
requirements, slow Medicaid payments, and what they consider to be arbitrary
denials of submitted claims. They also cite complicated rules and
eligibility- verification processes for patients and provider enrollment.
One survey of New Mexico dentists found that about one in three dentists
cited excessive paperwork and about one in five dentists cited slow payment
as reasons for not accepting Medicaid patients. 14

Many states reported taking some steps to simplify administrative processes.
For example, at least 24 states had simplified administrative processes by
reducing prior authorization requirements or by adopting uniform claim forms
and procedure codes developed by ADA. Some of these states are also taking
steps to make more extensive use of electronic billing and payment.

14 Senate Joint Memorial 21, State of New Mexico, Health Policy Commission,
Oct. 1, 1999.

Patient Issues Affecting the A number of factors related to the patients
themselves also affect dental

Use of Dental Services and service use. As the Surgeon General noted, a lack
of understanding and

Dentists' Acceptance of awareness of the importance of oral health and its
relationship to general

Medicaid Patients good health and well- being affects low use of dental
services for many,

regardless of income. Dental services are often considered deferrable and,
as a result, patients might not practice good oral hygiene or follow the
dentists' instructions until their dental problem becomes painful. In
addition, parents' experience and attitudes about dental care may be a
factor in the children's dental care use. 15

Other factors affecting the use of dental care include characteristics that
may be unique to or more prevalent in the Medicaid or low- income
population. Issues that are a minor inconvenience for higher- income
patients- such as getting time off from work to visit the dentist; arranging
transportation to the dentist, especially in rural areas; or finding child
care- can be major barriers for many low- income patients.

These issues may also contribute to a higher rate of broken appointments- a
major concern among dentists. ADA reports that about one- third of Medicaid
patients failed to keep appointments. And while comparable data for patients
with private insurance are lacking, dentists perceive that the rate of
broken appointments is significantly higher for Medicaid patients. According
to an ADA survey, dentists report that “noshows” result in
average lost time to their practices of 45 minutes per appointment. While
Medicaid prohibits charging for missed appointments to cover operating
costs, dentists can bill private practice patients when they fail to show up
for a scheduled appointment, thus minimizing the financial effect of the no-
shows. The effect of missed appointments by Medicaid and other low- income
patients appears to be less of a problem at public health clinics and
community health centers, where officials report that walk- in patients and
emergency cases generally fill any open appointment times.

Some states have undertaken efforts to educate patients on the importance of
oral health and of keeping dental appointments. For example, Washington's
Access to Baby and Child Dentistry program provides parents

15 In a study of low- income children, mothers who had good oral health,
less fear of the dentist, and a regular source of dental care were found to
be more likely to take their children to the dentist. See P. Milgrom and
others, “An Explanatory Model of the Dental Care Utilization of Low-
Income Children,” Medical Care, Vol. 36 (1998), pp. 554- 66.

with basic education on oral health habits for their children, training on
proper dental office protocol, and the importance of keeping scheduled
appointments. Program officials report that dentists do not report having
significant problems with no- shows for program participants. In addition,
one study of this program found that these and other steps resulted in the
use of dental services among program participants that was three times that
of nonparticipants.

The Effect of Managed Care Many states provide dental care through Medicaid
managed care

on Access Is Unclear arrangements, yet available data are insufficient to
evaluate the effect of

managed care on dental service access. State officials have differing
opinions on whether managed care improves the use of dental care in their
states.

Twenty states reported that they use managed care arrangements to provide
dental care to some or all Medicaid enrollees- that is, the state contracts
with managed care organizations that assume financial risk for providing
needed dental care. 16 Seventeen states contract with managed care
organizations that provide both medical and dental services, while three
states contract with separate dental managed care organizations. Of the 20
states, managed dental care penetration ranges from less than 15 percent of
Medicaid enrollees in 2 states to all Medicaid enrollees in 3 states. States
also have established varying enrollment and eligibility requirements. For
example, in one state dental managed care is mandatory for children and
families while other adults remain in the Medicaid fee- forservice program.
In another, dental managed care is mandatory in one county and optional in
other areas. In several states, dental managed care programs are limited to
major metropolitan areas or certain counties.

16 We defined dental managed care as programs in which a managed care
organization assumed the financial risk for providing needed dental care. We
excluded programs in which the state contracted with a managed care
organization for support functions, such as case management or fiscal
intermediary activities, but the state remained responsible for paying for
needed dental care.

All 20 states pay managed care organizations on a capitated basis- that is,
they pay a set amount per enrollee each month and the managed care
organizations assume the financial risk for providing dental services. This
financial risk, however, is not conveyed to dentists in many instances. Most
states have multiple managed care organizations that establish their own
payment arrangements with participating dentists. In eight states, managed
care organizations pay dentists on a fee- for- service basis only. In the 12
other states, managed care organizations pay dentists through a mix of
feefor- service and other payment methods. 17 Several states do not monitor
reimbursement or fee arrangements between managed care organizations and
their participating dentists and, thus, could not report how many dentists
were covered by various payment plans.

Most of the 20 states have not collected sufficient, reliable data to
measure the extent to which access to dental care has changed under managed
care. Some states report better dental access under managed care, while
others do not. Because of the lack of state data, we could not determine
whether the use of dental services increased under managed care or the
extent to which specific factors in managed care, such as payment rates or
methods or plan structure, contributed to any improvement in the use of
dental services. Officials in states such as Connecticut, Hawaii, Missouri,
and Virginia believed access under dental managed care has improved but had
not gathered utilization data to measure and document the improvement. State
officials said contract requirements with managed care plans, such as
maximum waiting times and provider network requirements, are intended to
provide better access to dental services for managed care enrollees. In
contrast, officials in six other states believed that dental service use
under Medicaid managed care was the same as or lower than that under fee-
forservice. For example, an Oklahoma official told us that access to dental
care is worse under its managed care plans because dentists are dissatisfied
with the managed care plans' low fees and slow payment.

A few states have collected sufficient utilization data to compare managed
care programs with fee- for- service, but no clear trends emerge. For
example, data for one county in California shows dental care use in managed
care programs 12 percentage points lower than in fee- for- service programs.
In contrast, a Minnesota study found utilization in managed care

17 For example, some managed care organizations pay dentists on an adjusted
fee- for- service basis; that is, dentists are paid according to a fee
schedule, but the schedule is adjusted, based on the plan's overall
expenditures.

programs 11 percentage points higher than in fee- for- service plans- 37
percent versus 26 percent.

State Medicaid officials told us that some managed care organizations have
had difficulty building dental networks, primarily because of low fees
offered to dentists. As a result, several states are struggling to keep
dental managed care programs viable, and three states- Illinois, Indiana,
and Nebraska- have abandoned their dental managed care programs. Ohio
Medicaid officials also reported that dentists are leaving the program
because they consider dental payment rates to be low and administrative fees
retained by the managed care organization to be excessive.

It Is Too Early to Evaluate Given the relatively recent start of many SCHIP
programs, data on the

Access to Dental Care effect they have had on access to dental care are even
more limited than

Under SCHIP they are for Medicaid. Early impressions from state officials
are that access

under these programs also varies, with programs that resemble private
insurance reporting fewer problems.

In 18 states where dental coverage for SCHIP children is provided through an
expansion of Medicaid, SCHIP children face the same barriers other Medicaid
children do. In addition, of the 33 states with stand- alone or combination
SCHIP programs, 21 indicated that they use the same fee schedule and network
of dental providers as Medicaid to provide dental care under SCHIP. Children
covered under these programs are also likely to face a situation similar to
the one for children covered by Medicaid.

Ten states reported that they implemented SCHIP dental programs that differ
significantly from Medicaid. 18 In these states, SCHIP dental care is
contracted with private insurers or the state's public employee health
insurance. State officials reported that these programs generally paid
dentists at private insurance market rates that were significantly higher
than Medicaid rates and that they had administrative requirements similar to
those of private insurance. While no state has conducted a comprehensive
evaluation of dental access under SCHIP, officials in most of these states
reported that they had experienced reports of few or no access problems for
their SCHIP enrollees. In contrast, these 10 states

18 In addition to these 10 states, California and Florida provided dental
care under other arrangements that differ from Medicaid. However, they did
not provide data on the rates paid or on dental access under SCHIP.

reported significant access problems for Medicaid beneficiaries. For
example, according to a Medicaid official in one state, several dentists on
a state task force indicated that they would select SCHIP patients over
Medicaid patients. In addition, she said that several Medicaid patients
reported that they had been turned away by a dentist who told them to come
back only if they could get SCHIP coverage.

Other Federal The four other federal programs we reviewed- Health Centers,
NHSC, IHS

Programs Have a Facilities, and IHS Loan Repayment- have relatively small
capacity to

provide dental care, especially when compared with the total number of
Limited Ability to Meet

Medicaid patients and other low- income or vulnerable people. The first two
the Dental Needs of the

programs are designed to serve a broad spectrum of people who may be Poor

poor or who may be having difficulty obtaining health care services, while
the two IHS programs are targeted at American Indians and Alaska Natives. In
all four cases, the programs report difficulty in meeting the dental needs
of their target populations. Recent initiatives to improve oral health
services by these and other HHS programs are too new to evaluate.

Programs Are Not Able to The four programs use varying approaches to meeting
the needs of their

Meet Identified Needs target populations but are not able to meet them.
While all address health

care needs in general as well as dental health needs, dental care has
typically received a small portion of program resources relative to the
needs of their target populations.

Health Centers HHS and health center officials report that the demand for
dental services significantly exceeds the centers' capacity to deliver it.
In 1998, the latest

year for which data were available at the time of our review, a little more
than half of the nearly 700 health center grantees funded under this program
had active dental programs. 19 About 1. 2 million people- 14 percent of the
8.6 million people who used the health centers nationwide- received center-
based dental care in 1998. These included about 650,000 people receiving
dental care at health centers in urban areas and about

19 Of 357 urban and 329 rural health center grantees, 385 grantees reported
either (1) providing dental services to at least 1, 000 health center users
or (2) having at least half of a full- time dentist working at the health
center in 1998. Of these, 222 were in urban areas and 163 were in rural
areas. Although the 686 health center grantees operated more than 3, 000
sites in 1998, no data are available on the number of sites providing dental
services.

550,000 people receiving dental services at health centers in rural areas.
At the health centers where dental care is available, officials and studies
report long waiting periods to get appointments. No national data are
available on the extent to which (1) health centers with active dental
programs are able to meet the dental care needs of center users or (2)
patients of health centers without active dental programs receive needed
dental care.

The ability to expand dental care through health centers is limited by
several factors. HHS officials said that many health centers do not provide
dental services because dental facilities and equipment are expensive,
centers have difficulties recruiting and retaining dental providers, and
centers have difficulty generating sufficient revenue to support a dental
program. 20 A 1999 phone survey of health centers in Massachusetts
identified three major factors that make it difficult for health centers to
meet dental care needs- inadequate space, lack of dental providers, and lack
of financial resources. 21 In addition, the head of the National Network for
Oral Health Access, an association of dental providers practicing in health
centers, said that even with funds to expand dental programs and buy new
dental equipment, health centers still face difficulties recruiting
dentists.

National Health Service Corps The number of dentists with obligations to
serve in NHSC falls short of meeting the total identified need. At the end
of fiscal year 1999, NHSC had 299 dentists and 7 dental hygienists
practicing in underserved areas in 41 states, the Pacific Basin, and Puerto
Rico. 22 In fiscal year 1999, the program filled only 83 positions- 35 in
urban and 48 in rural areas- of the more than 260 vacant positions that were
eligible for an NHSC dentist through its loan repayment program. 23 These
vacancies were located in 228 areas of

20 HRSA, which administers grants for the Health Center program, recommends
a patient base of 3,000 to 5, 000 for a dental program to be economically
viable. 21 Massachusetts Department of Public Health, The Oral Health Crisis
in Massachusetts: Report of the Special Legislative Commission on Oral
Health( Boston: Feb. 2000).

22 For 257 dentists for whom data were available, 126 were practicing in
urban areas and 131 were practicing in rural areas. Of the 7 dental
hygienists, 3 were practicing in urban areas and 4 were practicing in rural
areas.

23 About 4 of every 10 vacancies eligible for NHSC loan repayment were
located in urban areas.

the country that HHS had identified as needing dental providers. Of these
228 areas, nearly two- thirds (144 areas) did not get any NHSC providers.

According to HRSA officials, competing budget priorities have affected
NHSC's ability to make headway in increasing the number of dental care
professionals available in underserved areas. In March 2000, the
Administrator of HRSA testified that HHS had not requested additional
funding for NHSC for fiscal year 2001 because of competing priorities. NHSC
officials noted that given the flat program funding, any increase in support
for dental health providers would result in a reduction in support for
primary care or behavioral and mental health providers. 24 They said that
the allocation of funds among health disciplines is based on community
demand and that the demand exceeds the program's capacity in every
discipline.

Indian Health Service Facilities According to IHS officials, about one-
fourth of IHS' dentist positions at 269 IHS and tribal facilities were
vacant in April 2000. Vacancies have been chronic at IHS facilities- in the
past 5 years, at least 67 facilities have had one or more dentist positions
vacant for at least a year. According to IHS officials, the primary reason
for these vacancies is that IHS is unable to provide a competitive salary
for new dentists. At IHS, the salary for a typical entry- level position for
a dentist just out of dental school is about $50,000 to $60,000 per year.
This is significantly lower than annual salaries offered in the private
sector, which can start at more than $80, 000.

The IHS' dental personnel shortages translate into a large unmet need for
dental services among American Indians and Alaska Natives. IHS reports that
only 24 percent of the eligible population had a dental visit in 1998. The
personnel shortages have also reduced the scope of services that facilities
are able to provide. According to IHS officials, available services have
concentrated more on acute and emergency care, while routine and restorative
care have dropped as a percentage of workload. Emergency services increased
from one- fifth of the workload in 1990 to more than onethird of the
workload in 1999.

24 In fiscal year 1999, NHSC awarded new loan repayment awards totaling
about $12. 2 million to physicians; about $7. 6 million to nurse
practitioners, physician assistants, and nurse midwives; about $5. 7 million
to dentists and dental hygienists; and about $3.3 million to mental and
behavioral health providers. In addition, NHSC awarded $28. 2 million in new
scholarships to physicians, nurse practitioners, physician assistants, and
nurse midwives in fiscal year 1999. No scholarships were awarded to dental
providers.

IHS Loan Repayment Program The IHS loan repayment program has filled few of
the many dental vacancies at IHS and other facilities serving American
Indians and Alaska Natives. Since 1995, the program has placed an average of
about 11 dentists and 1 dental hygienist each year. The average number of
IHS dentist positions that were vacant each month during that time was
between 46 and 91 (see table 3). IHS officials attribute the limited number
of loan repayments for dentists to (1) static funding levels for the program
and (2) competing priorities among other health professions that limited
loan repayments to dentists to 10 percent of award funding. In fiscal year
2000, the portion of program funding allocated for dentists was increased to
15 percent.

Table 3: Average Number of Dentist Vacancies at IHS and Tribal Operated
Facilities and IHS Loan Repayment Awards, Fiscal Years 1995- 99

Average number of Number of IHS loan Fiscal year vacancies per month
repayment awards

1995 46 20 1996 50 8 1997 53 8 1998 79 10 1999 91 11 Source: IHS dental
program and IHS Loan Repayment Program.

It Is Too Early to Evaluate In response to our April 2000 report on oral
health, HHS provided

Recent HHS Initiatives to information on various ongoing or planned
initiatives to improve dental

care for low- income and other populations. 25 Examples that relate Increase
Dental Service Use

specifically to issues raised in this report are shown in table 4. Because
the majority of these initiatives are in the early stages or have yet to
begin, it is too early to determine the effects they will have on improving
access to dental care. However, because of their relatively small size, the
efforts by the health centers, NHSC, and IHS, while valuable, are unlikely
to meet the significant unmet dental needs of Medicaid and other low- income
and vulnerable populations. In addition, it is unclear the extent to which
the efforts of these programs and other efforts by HRSA and HCFA will
address

25 See GAO/ HEHS- 00- 72, app. III.

the problems we identified, such as attracting dentists to treat Medicaid,
SCHIP, and other vulnerable populations.

Table 4: Examples of HHS Actions Taken or Planned to Improve Dental Care
Access Type of action Explanation

Improved coordination Following a HCFA- and HRSA- sponsored national
leadership conference on children's access to oral health services in July
1998, HCFA and HRSA established an oral health initiative that proposes to
coordinate dental activities across both agencies, partner with other public
and private agencies, and promote the integration of new science and
technologies into programs that HCFA and HRSA manage.

Expansion of dental Under the expansion, each health center receives about
$170, 000 to pay for equipment, other start- up costs,

programs at health and operating costs. Between 1994 and 1998, 25 new dental
programs were developed at health centers. In

centers fiscal year 2000, HRSA plans to award about $1. 6 million to
establish oral health services at seven to nine

health centers serving migrant and seasonal farmworkers and at four to seven
health centers serving homeless persons.

Improved oversight HRSA plans to use a new oral health module for its
periodic evaluations of health centers. It has the potential to provide
oversight to ensure that health centers are providing required dental
services.

NHSC dental After a 6- year hiatus, NHSC is piloting a program to award 10
to 20 dental student scholarships in fiscal year scholarships 2000. This
project will work with specific dental schools that agree to terms such as
(1) training the dental

students in working with low- income and other vulnerable populations and
(2) identifying and developing sites where the dentists can practice when
they graduate.

Actuarial models for HRSA is developing a Web page to provide information to
states, Medicaid officials, and others on (1)

Medicaid and SCHIP and actuarial models for state financing of dental care
for children under Medicaid and SCHIP, (2) the geographic

other information distribution of dental health resources at the county
level, and (3) workforce models.

Medicaid managed care HRSA is planning to conduct state- level case studies
on dental managed care to evaluate the effect of workshop Medicaid managed
care on the availability of dental services as it relates to providers,
patients, payers, and

plans. IHS Oral Health Initiative Started in 1999 by the Director of IHS, it
focuses on improving the oral health status of the American Indian

and Alaska Native populations through existing services and increasing
resource commitments to recruiting dentists for IHS and tribal programs.
This includes a $1 million allocation toward IHS loan repayment for dentists
and a special salary rate for dentists hired as civil servants that is more
competitive with the private sector.

Medicaid and SCHIP Under this 4- year demonstration project, HCFA will award
grants to one or two states for innovative grant demonstration

approaches for young Medicaid or SCHIP children that will result in improved
oral health and cost savings. project

Conclusions Despite the availability of dental coverage through public
programs such as Medicaid, SCHIP, and other HHS programs, access to dental
services

remains low for low- income populations. Structural issues that affect
service use across all income levels- including the availability of dentists
and the priority that individuals assign to preventive dental care- are
often more pronounced for low- income populations. Despite federal and state

efforts to improve access to dental care for low- income or otherwise
disadvantaged populations, difficulties remain. The experience of states
working to attract more dentists to Medicaid by paying higher fees,
streamlining administrative requirements, and providing patient education
has resulted typically in some incremental improvements in access. The
effects of dental managed care programs and expanded access for lowincome
children through SCHIP have yet to be determined. And while HHS finances
safety- net programs that provide dental care and help place providers to
serve low- income and uninsured persons and Native Americans, these programs
are not able to fully respond to the sizable unmet needs of these
populations. As the Surgeon General recognized in his recent report on oral
health, this is a public health issue that requires the concerted and
focused attention of many, especially the public and private sectors at
federal, state, and local levels.

Agency Comments In commenting on this report, HHS generally concurred with
our findings and conclusions. It stated that the report communicates the
oral health

needs of low- income and other underserved populations and documents many of
the barriers to care facing those populations.

HHS commented that our report could emphasize more the dental needs of
residents of rural areas and low- income adults. Regarding residents of
rural areas, data limitations prevented direct comparisons of the dental
needs among residents of urban, suburban, and rural areas. HHS has noted
these same kinds of limitations in the data. We acknowledged that some
factors affecting dental access, such as lack of transportation, may be more
difficult for rural residents, and we have modified the report to include
additional data on the urban and rural location of health center grantees
and NHSC health professionals providing dental care. Regarding lowincome
adults, with the exception of the discussions of SCHIP programs that
specifically addressed the dental needs of children, we addressed the dental
needs of low- income adults throughout the report. Although adult dental
coverage is optional under Medicaid, as of January 2000, about twothirds of
the states covered adult dental services to some extent under Medicaid. In
addition, regardless of insurance status, low- income adults can receive
dental services at health centers and from NHSC dental health professionals.

HHS suggested that we expand our report to include more detail on all
efforts that HHS and its partners have undertaken to address oral health
issues rather than limiting our discussion to the programs we reviewed.

Our report highlighted examples of initiatives undertaken by HCFA, HRSA, and
IHS dealing with the programs that we reviewed; it was not intended to be an
exhaustive list of all HHS oral health activities. 26 HHS also questioned
the basis for our statement that the efforts by the health centers, NHSC,
and IHS, while valuable, appear to be limited in capacity and in their
ability to significantly reduce the unmet need. Because of the large unmet
need for dental services and the relatively small size of these programs, we
believe it is unlikely that these programs will be able to meet that need.
We revised the report to better reflect this view. Regarding the many
initiatives HHS and its partners have under way and planned, it is too early
to assess their effect on meeting unmet need for dental care.

Finally, HHS commented on the relationship between Medicaid payments and
dental access, noting the correlation we identified between increases in
Medicaid payment rates- determined by each state individually- and dental
service utilization. HHS suggested that while federal efforts are important,
the states, local dental societies, and advocates must work together to
determine payments that are affordable for states and feasible for
practitioners. In addition to addressing this payment issue, our work
suggests that while raising Medicaid payment rates for dental services
appears to result in a marginal increase in utilization, this alone does not
ensure significant increases in dental utilization. Other factors, such as
administrative requirements, dentists' attitudes toward low- income
patients, and patient behavior, also affect dentists' participation and
service utilization for these populations.

HHS also provided technical comments that we incorporated where appropriate.
HHS' comments are included as appendix IV.

As we agreed with your offices, unless you publicly announce the report's
contents earlier, we plan no further distribution of it until 14 days from
the date of this letter. We will then send copies to the Honorable Donna E.
Shalala, Secretary of HHS; the Honorable Nancy- Ann Min DeParle,
Administrator of HCFA; the Honorable Claude Earl Fox, Administrator of HRSA;
and others who are interested. We will make copies available to others on
request.

26 For a more detailed list of planned or recently started HHS oral health
activities, see GAO/ HEHS- 00- 72, app. III.

This report was prepared under the direction of Frank Pasquier, Assistant
Director. Others who made key contributions include Rashmi Agarwal, Sophia
Ku, Terry Saiki, Stan Stenersen, and Kim Yamane. Please call me at (202)
512- 7118 if you or your staff have any questions.

Kathryn G. Allen Associate Director, Health Financing

and Public Health Issues

Appendi Appendi xes xI

Scope and Methodology We reviewed studies about access to dental care
conducted by researchers and by state task forces and surveyed Medicaid and
State Children's Health Insurance Program (SCHIP) programs in all 50 states
and the District of Columbia to determine dentists' participation in
Medicaid, the use of dental services, and actions to address barriers to
dental care for Medicaid beneficiaries. In addition, we analyzed dentist
participation rates for each state's Medicaid program and compared each
state's payment rates with average regional dental fees for selected dental
procedures. We also analyzed data on other safety- net programs from the
Health Resources and Services Administration (HRSA) and the Indian Health
Service (IHS). Finally, we interviewed (1) officials at the Health Care
Financing Administration (HCFA), HRSA, and IHS; (2) state and local health
officials responsible for Medicaid, SCHIP, and dental public health
programs; (3) health services researchers; (4) dental association
representatives; and (5) dental providers. We performed our work from
December 1999 to July 2000 in accordance with generally accepted government
auditing standards.

Dentists' Participation To calculate dentists' participation rates for each
state, we collected data

Rates from state Medicaid agencies on the number of dentists who saw at
least

one Medicaid patient and the number who saw at least 100 patients in 1996
and 1999. We divided these numbers by the total number of dentists in
private practice for each state, using data published in the American Dental
Association's (ADA) Distribution of Dentists in the United States by Region
and State, 1997. ADA's 1997 survey was the most recent survey for which the
data were available, and data from its earlier surveys indicate that the
number of dentists in private practice in most states has not changed
significantly from year to year.

Comparison of Fees for To compare Medicaid fees with average fees dentists
charge, we obtained

Selected Dental state Medicaid fee data for 15 dental procedures and
compared them with

the average regional dental fees for 1999. The 15 procedures were proposed
Procedures

by James J. Crall, Department Head and Associate Dean of the University of
Connecticut School of Dental Medicine and a recognized expert in the field
of dental research, and were based on his work involving a separate analysis
of Medicaid dental reimbursement rates. The 15 procedures represent a
variety of diagnostic, preventive, restorative, and surgical procedures used
to assess, prevent, and treat dental disease in children and adolescents.
While some procedure codes in our sample, such as dental cleaning, were
specifically for children, other procedure codes we

examined, such as periodic oral examination, crowns, and root canal
treatments, are used for both children and adults. Several procedures-
examinations, dental cleaning, fluoride application, and radiographs- are
commonly provided at initial or periodic assessment visits. Others represent
a broad range of services for treating basic to advanced dental disease,
primarily dental caries (see table 5). We also consulted with HCFA's Chief
Dental Officer and the Director of the Children's Dental Health Project of
Washington, D. C., who agreed that the procedures selected were appropriate
for our study.

Table 5: The Dental Procedures in Our Study ADA code Procedure Diagnostic

00110/ 00150 Initial/ comprehensive oral examination 00120 Periodic oral
examination 00210 Radiographs- complete series (including bitewings) 00272
Radiographs- bitewings- 2 films 00330 Radiographs- panoramic film

Preventive

01120 Dental cleaning- child 01203 Topical application of fluoride
(excluding cleaning) 01351 Dental sealant- per tooth

Restorative

02150 Metal filling- 2 surfaces, permanent teeth 02331 Plastic filling- 2
surfaces, front teeth 02751 Crown- porcelain fused predominately base metal
02930 Prefabricated stainless steel crown- primary teeth

Root canal treatment

03220 Root canal treatment for primary teeth (excluding final restoration)
03310 Root canal therapy for front teeth (excluding final restoration)

Surgery

07110 Extraction- single tooth

We verified data on the 1999 state Medicaid fees for the 15 procedures with
information from fee schedules obtained from each state Medicaid program.
For states that had more than one fee schedule (such as may occur in a state
with multiple managed care plans providing dental care),

we used the fees for the plan with the most persons enrolled in Medicaid, to
the extent possible. Some states, such as Hawaii and Oregon, did not provide
fee schedules for the dental services provided under managed care. In these
cases, we used the fee schedule that applies to the state's fee- forservice
population. For procedures with separate fees for children and adults, we
used the Medicaid fees for treating children.

The Determination of Because comparable data are not readily available on
the dental fees

Average Regional dentists charge in each state, we used the regional mean
fees from ADA's

1997 Survey of Dental Fees. The ADA survey collected fee data from Dental
Fees

dentists across nine geographic regions of the country and reported the mean
fees for each dental procedure for each region (see fig. 2).

Figure 2: Distribution of States in the Nine Regions of ADA's Survey of
Dental Fees

We adjusted the ADA fees for inflation, using the dental services component
of the consumer price index to get a 1999 regional mean fee for each
procedure (see table 6). While there are limitations to using regional

dental fees in lieu of state fees, a limited comparison of state fee data
with the regional fees for six selected states shows that the regional fees
are fairly representative of the state fees for these states. We compared
each state's Medicaid fee with the inflation- adjusted regional mean fee for
each procedure.

Table 6: Average Dental Fees for the 15 Procedures by Region, 1999 East

East West

West New

Middle South

South North

North South Procedure England Atlantic Atlantic

Central Central

Central Central Mountain Pacific Diagnostic

Initial/ comprehensive oral examination $45 $41 $40 $32 $36 $32 $34 $44 $45

Periodic oral examination 25 28 24 20 23 21 21 26 32

Radiographs- complete series (including bitewings) 79 75 71 66 69 67 61 69
85

Radiographs- bitewings- 2 films 27 22 22 20 21 20 20 22 32

Radiographs- panoramic film 74 65 62 55 63 57 53 60 71

Preventive

Dental cleaning- child 41 40 37 32 33 30 34 36 52

Topical application of fluoride (excluding cleaning) 24 24 19 17 22 18 17 20
28

Dental sealant- per tooth 32 31 27 26 27 24 25 26 37

Restorative

Metal filling- 2 surfaces, permanent teeth 86 84 82 68 74 72 78 83 101

Plastic filling- 2 surfaces, front teeth 101 98 97 79 87 88 93 100 135

(Continued From Previous Page)

East East

West West

New Middle

South South

North North

South Procedure England Atlantic Atlantic

Central Central

Central Central Mountain Pacific

Crown- porcelain fused predominately base metal 670 630 577 482 553 517 549
516 636

Prefabricated stainless steel crown- primary teeth 160 155 141 119 139 131
120 133 148

Root canal treatment

Root canal treatment for primary teeth (excluding final restoration) 101 96
99 73 87 79 78 91 97

Root canal therapy for front teeth (excluding final restoration) 412 390 376
324 337 316 341 348 405

Surgery

Extraction- single tooth 87 88 77 60 71 67 71 75 94

Effect of State Assessing the effect of state Medicaid fee increases on
access to dental

Medicaid Fee Increases care is difficult. Medicaid fees are only one of many
factors that affect

dentists' decisions to treat Medicaid patients, so it is difficult to
isolate on Access

their effect from others. In addition, changes in dentists' behavior in
response to any payment increase may take time. Data limitations further
complicate analysis. For example, comparable data were not readily available
on the frequency of the provision of each of the 15 dental procedures. In
addition, lack of comparable utilization data among states prevented a
correlation analysis between 1999 Medicaid fees and dental utilization. As a
result, we used a broad approach to assess the overall relationship of fee
increases to dental access. First, we classified the states into states that
reported a rate increase (40 states), states that reported no rate increase
(9 states), and states that did not respond (2 states). We relied on data
supplied by state officials on changes in dentist participation and dental
utilization rates to group the 40 states that reported recent rate increases
into three groups- states with some improvement in access, states with no
improvement in access, and states that reported that it was too soon to tell
or that they did not have reliable data. We then compared

the fee levels of “states with some improvement” with
“states with no improvement” to see whether the fee levels
appeared to make a difference. We tested the strength of the relationship
between fee increases and access by using chi- square analysis.

Other Federal SafetyNet To assess other federal safety- net programs'
abilities to meet the demand

Programs for dental care by their target populations, we interviewed
officials at

HRSA and IHS, reviewed documents, and analyzed data they provided. We also
interviewed representatives of several national organizations representing
health centers and dentists practicing at health centers.

For the Health Center program, we relied on national staffing and
utilization information on health centers from HRSA's Uniform Data System
for 1998, the most recent year for which data were available. The Uniform
Data System information provides data for each health center grantee. While
each grantee may operate multiple sites, data were not available on the
dental care provided at specific health center sites. Because of known
limitations with the disaggregated data in the Uniform Data System, we used
results that were aggregated nationally. We used 0.5 full- timeequivalent
dentists or 1,000 dental users as a threshold for an active dental program
because that is what HRSA officials consider to be an active health center
dental program.

Appendi xII

Healthy People 2010 Oral Health Goals Objective 2010 target Baseline

Reduce the proportion of children and adolescents with dental 2- 4 years:
11%

2- 4 years: 18% (1988- 94) caries experience in their primary or permanent
teeth 6- 8 years: 42%

6- 8 years: 52% (1988- 94) 15 years: 51%

15 years: 61% (1988- 94) Reduce the proportion of children, adolescents, and
adults with

2- 4 years: 9% 2- 4 years: 16% (1988- 94)

untreated dental decay 6- 8 years: 21% 6- 8 years: 29% (1988- 94)

15 years: 15% 15 years: 20% (1988- 94)

35- 44 years: 15% 35- 44 years: 27% (1988- 94)

Increase the proportion of adults who have never had a 42% 35- 44 years: 31%
(1988- 94) permanent tooth extracted because of dental caries or periodontal
disease

Reduce the proportion of older adults who have had all their 20% 65- 74
years: 26% (1997) natural teeth extracted Reduce periodontal disease in
adults aged 35- 44 Gingivitis: 41%

Gingivitis: 48% (1988- 94) Destructive periodontal

Destructive periodontal disease: 22% disease: 14%

(1988- 94) Increase the proportion of oral and pharyngeal cancers

50% 35% (stage I, localized) (1990- 95) detected at the earliest stage
Increase the proportion of adults who, in the past 12 months,

35% 40+ years: 14% (1998) report having had an examination to detect oral
and pharyngeal cancer

Increase the proportion of children who have received dental 8 years: 50%

8 years: 23% (1988- 94) sealants on their molars 14 years: 50% 14 years: 15%
(1988- 94)

Increase the proportion of the U. S. population served by 75% 62% (1992)
community water systems with optimally fluoridated water Increase the
proportion of children and adults who use the oral

83% 2+ years: 65% (1997) health system each year Increase the proportion of
long- term care residents who use the

25% 19% (1997) oral health care system each year Increase the proportion of
children and adolescents younger

57% 20% (1996) than 19 at or below 200 percent of the federal poverty level
who received any preventive dental services during the past year

Increase the proportion of local health departments and 75% 34% (1997)

community- based health centers, including community, migrant, and homeless
health centers, that have an oral health component

Increase the number of states, including the District of All states and the
District of

23 states and the District of Columbia Columbia, that have a system for
recording and referring infants

Columbia (1997) and children with cleft lips, cleft palates, and other
craniofacial anomalies to craniofacial anomaly rehabilitative teams

Increase the number of states, including the District of All states and the
District of

0 (1999) Columbia, that have an oral and craniofacial health surveillance

Columbia system Source: Healthy People 2010, Conference Edition, Oral
Health, data as of November 30, 1999.

Medicaid Payment Rates as a Percentage of Average Regional Dental Fees for
Selected

Appendi xI II

Procedures, 1999 Of 15 procedures a Number for which

Range of Periodic

Dental Medicaid exceeded

Medicaid rates oral

cleaning- Metal filling-

Root canal Extraction-

2/ 3 of average as % of average

Region and state examination

child 2 surfaces treatment single tooth regional fees

regional fees New England

Connecticut 67% 52% 48% 46% 46% 1 45%- 67% Maine 52 72 56 49 63 2 50- 75
Massachusetts 36 46 47 30 52 0 30- 64 New Hampshire 73 68 61 44 46 2 43- 73
Rhode Island 40 53 43 58 45 1 40- 77 Vermont 68 63 68 65 75 5 53- 85

Middle Atlantic

New Jersey 22 17 25 13 17 0 13- 34 New York 36 38 32 26 28 0 24- 59
Pennsylvania 62 55 60 52 51 2 27- 82

South Atlantic

Delaware b 15 District of Columbia 42 55 23 22 33 0 22- 55 Florida 63 38 50
51 35 1 35- 63 Georgia 81 53 63 50 54 1 48- 81 Maryland 59 66 49 71 50 3 37-
73 North Carolina 96 57 80 68 58 7 49- 96 South Carolina 93 85 92 88 81 15
81- 99 Virginia 51 68 64 63 56 4 51- 88 West Virginia 63 71 51 43 52 2 43-
79

East South Central

Alabama 66 50 66 64 56 1 45- 84 Kentucky 96 87 61 37 48 4 37- 96 Mississippi
157 107 61 37 68 10 37- 157 Tennessee 67 56 51 49 46 2 33- 72

East North Central

Illinois 66 72 66 64 42 1 34- 72 Indiana 87 103 98 109 101 14 87- 109
Michigan 61 56 66 73 61 2 26- 73 Ohio 73 60 73 73 73 13 48- 86 Wisconsin 66
68 59 54 57 1 54- 68

(Continued From Previous Page)

Of 15 procedures a Number for which

Range of Periodic

Dental Medicaid exceeded

Medicaid rates oral

cleaning- Metal filling-

Root canal Extraction-

2/ 3 of average as % of average

Region and state examination

child 2 surfaces treatment single tooth regional fees

regional fees West North Central

Iowa 56 56 52 47 35 1 35- 70 Kansas 51 83 76 76 67 12 46- 84 Minnesota 56 59
55 52 50 3 49- 79 Missouri 72 61 44 25 27 1 25- 72 Nebraska 70 56 77 57 74 6
39- 83 North Dakota 88 81 77 78 74 15 72- 90 South Dakota 73 57 58 47 49 2
47- 73

West South Central

Arkansas c 69 65 58 59 8 45- 97 Louisiana 61 27 42 42 40 0 27- 61 Oklahoma
77 48 63 47 47 2 46- 84 Texas 61 54 49 50 46 0 44- 64

Mountain

Arizona 106 118 85 88 90 15 67- 118 Colorado 67 66 69 69 69 12 66- 72 Idaho
67 77 67 55 57 5 55- 78 Montana 63 64 75 55 56 4 35- 75 Nevada 72 128 91 67
89 11 51- 128 New Mexico 78 77 79 78 79 15 77- 80 Utah 39 48 40 20 42 0 20-
49 Wyoming 59 64 61 51 53 6 51- 85

Pacific

Alaska 97 93 94 100 82 13 63- 106 California 29 68 47 18 48 1 17- 68 Hawaii
47 29 27 37 29 0 27- 53 Oregon 72 54 35 46 46 2 30- 81 Washington 63 45 62
46 83 2 26- 83

a Some states do not cover all 15 procedures. b Delaware does not have a fee
schedule. It pays 85 percent of billed charges by dentists for all covered
procedures. c This procedure is not covered in Arkansas' Medicaid fee
schedule. These services may be billed

under a different procedure code.

Appendi xI V Comments From HHS

Lett er (101872) Lett er

GAO United States General Accounting Office

Page 1 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Contents

Contents Page 2 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

Page 3 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services
United States General Accounting Office

Washington, D. C. 20548 Page 3 GAO/ HEHS- 00- 149 Factors Affecting the Use
of Dental Services

B- 283915 Page 4 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 5 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 6 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 7 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 8 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 9 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 10 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 11 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 12 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 13 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 14 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 15 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 16 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 17 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 18 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 19 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 20 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 21 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 22 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 23 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 24 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 25 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

B- 283915 Page 26 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental
Services

Page 27 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Page 28 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I

Appendix I Scope and Methodology

Page 29 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I Scope and Methodology

Page 30 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I Scope and Methodology

Page 31 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I Scope and Methodology

Page 32 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I Scope and Methodology

Page 33 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix I Scope and Methodology

Page 34 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Page 35 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix II

Page 36 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix III

Appendix III Medicaid Payment Rates as a Percentage of Average Regional
Dental Fees for Selected Procedures, 1999

Page 37 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Page 38 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix IV

Appendix IV Comments From HHS

Page 39 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix IV Comments From HHS

Page 40 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

Appendix IV Comments From HHS

Page 41 GAO/ HEHS- 00- 149 Factors Affecting the Use of Dental Services

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