Young Medicaid recipients have a harder time getting emergency dental appointments than privately insured youngsters, according to a revealing study in which graduate students posed as mothers seeking care for a 10-year-old son who fractured a front tooth in a bicycle accident.
The pretend-moms with private insurance coverage got the boys earlier appointments than their counterparts with public insurance.
The findings, published online Monday in the journal Pediatrics, demonstrated that despite efforts to boost the number of patients and providers in the Medicaid system, low-income families still have limited access to dental care – except when they are able to pay cash.
The study focused on dentists' willingness to provide emergency care to Medicaid patients with front-tooth trauma, a problem that affects 1 in 7 pre-adolescents and nearly 1 in 4 teens between age 16 and 19. About 11 percent of these injuries don't get treated, although they ideally should be seen by a dentist within 24 hours.
For each case, graduate-level research assistants from the University of Chicago placed two calls, a month apart, between February and May 2010, to 85 Chicago-area dental practices, 41 of which participated in the Medicaid/Children's Health Insurance Program.
The pretend-moms followed the same script for both calls: Their son was in pain after breaking his front tooth and was advised by an emergency department to seek dental care. The only difference was whether the child had private Blue Cross dental insurance or Medicaid/CHIP. The pretend-moms only revealed the child's insurance status if asked. If the office declined to take their insurance, they asked about paying cash.
Dr. Karin V. Rhodes, an emergency care researcher at the University of Pennsylvania, and colleagues from the Hennepin County Medical Center in Minnesota, Columbia University dental school in New York, and the Children's Dental Health Project in Washington, D.C., set their study in Cook County, Ill., the nation's second-largest urban county, where fewer than 15 percent of dental practices participate in Medicaid/CHIP.
Illinois has tried to enlarge the supply of Medicaid dentists by boosting reimbursement for basic preventive services and contracting with a national dental benefits management company to streamline office operations and recruit providers.
Nevertheless, Illinois' Medicaid dentists receive slightly more than half of their usual fees, which places the state in the bottom half of states for Medicaid payments.
Dr. Raymond F. Gist, president of the American Dental Association, said the new study underscored the organization's belief that "lack of funding is among the greatest barriers to better oral health in America." Although surveys suggest more dentists might become Medicaid providers if reimbursements were higher, current economic straits make it unlikely that Medicaid could pay dentists more any time soon.
However, Gist said that access to dental services could expand with reforms that cut "unnecessary red tape for dentists and patients" and address lack of transportation and child care. He suggested that dental care could improve with Community Dental Health Coordinators, now being trained through an ADA pilot program to provide dental health education and act "as patient navigators, helping people secure and keep appointments with dentists who are able to treat them."
The research assistants posing as mothers obtained appointments for 95.4 percent of the Blue Cross-insured youngsters, but only 36.5 percent of those in Medicaid/CHIP. Only 7 percent of Medicaid/CHIP covered children got onto the calendars of non-Medicaid dentists, even though Illinois reimburses non-Medicaid providers who tend to Medicaid enrollees on an emergency basis.
Put another way, children with Medicaid benefits were 18 times more likely to be denied an appointment with a Medicaid provider than children with Blue Cross coverage. A child with Medicaid was 38 times likelier to be denied an appointment with a non-Medicaid dentist.
When callers couldn't get Medicaid-covered kids into Medicaid dentists, they then asked nine of those dental practices about paying cash. All agreed to schedule appointments for cash payments ranging from $30 to $205. Of non-Medicaid dental practices that at first said they couldn't accomodate Medicaid kids, 88.6 percent were willing to fit them in if their parents paid cash.
Calling this practice "concerning," the study authors said dentists enrolled in Illinois' Medicaid program are prohibited from collecting cash from Medicaid/CHIP patients. "This signals a need for increased monitoring and education of enrolled practices," the study authors wrote.