GAO

United States General Accounting Office

Report to Congressional Requesters

September 2000 ORAL HEALTH

Factors Contributing

to Low Use of Dental

Services by

Low-Income

Populations

GAO/HEHS-00-149

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

Contents

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
Contents

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

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
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-283915 Letr

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).
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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).
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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.
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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.
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• 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.
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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.
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Table 1: Four Selected Federal Programs That Provide Dental Services or Providers to Vulnerable Populations

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

Low Use of Dental

Care and State Efforts

to Address Them

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

dental care, the primary one is limited dentist participation in Medicaid.

States have taken various steps to improve access to dental care among

Medicaid populations, including raising payment rates, streamlining

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.

Program Description

HRSA programs targeting areas with shortages of health care services

Health Centersa 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

(NHSC)

Offers scholarships and educational loan repayments for health care professionals, such as physicians,

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.
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Low Rate of Dentist

Participation in Medicaid

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

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.

10We 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.
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Figure 1: Percentage of Dentists Seeing at Least 100 Medicaid Patients in 31 States,

1999

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.

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

5 States

25 - 50 Percent

26 States

Less Than 25 Percent

0 States

More Than 50 Percent
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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

12We 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.

13New York and Tennessee did not respond.
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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).
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Table 2: Comparison of 29 States Reporting Increased Medicaid Payment Rates and the Effect on Dental Access

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

Requirements

Dentists also report that their dissatisfaction with the administrative

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.

Procedures reimbursed at more than two-thirds of

the average regional fee

States reporting

improvements in access

States reporting

no improvements in access

All 15 proceduresa 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

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

Use of Dental Services and

Dentists’ Acceptance of

Medicaid Patients

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

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

awareness of the importance of oral health and its relationship to general

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

15In 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.
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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

on Access Is Unclear

Many states provide dental care through Medicaid managed care

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.

16We 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.
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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

17For 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.
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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

Access to Dental Care

Under SCHIP

Given the relatively recent start of many SCHIP programs, data on the

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

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

18In 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.
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Page 19 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

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

Programs Have a

Limited Ability to Meet

the Dental Needs of the

Poor

The four other federal programs we reviewed—Health Centers, NHSC, IHS

Facilities, and IHS Loan Repayment—have relatively small capacity to

provide dental care, especially when compared with the total number of

Medicaid patients and other low-income or vulnerable people. The first two

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

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

Meet Identified Needs

The four programs use varying approaches to meeting the needs of their

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

19Of 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.
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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

20HRSA, 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.

21Massachusetts Department of Public Health, The Oral Health Crisis in Massachusetts:

Report of the Special Legislative Commission on Oral Health (Boston: Feb. 2000).

22For 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.

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

areas.
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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.

24In 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.
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Page 22 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

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

Source: IHS dental program and IHS Loan Repayment Program.

It Is Too Early to Evaluate

Recent HHS Initiatives to

Increase Dental Service Use

In response to our April 2000 report on oral health, HHS provided

information on various ongoing or planned initiatives to improve dental

care for low-income and other populations.25 Examples that relate

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

Fiscal year

Average number of

vacancies per month

Number of IHS loan

repayment awards

1995 46 20

1996 50 8

1997 53 8

1998 79 10

1999 91 11

25See GAO/HEHS-00-72, app. III.
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Page 23 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

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

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

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

programs at health

centers

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

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

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

scholarships

After a 6-year hiatus, NHSC is piloting a program to award 10 to 20 dental student scholarships in fiscal year

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

Medicaid and SCHIP and

other information

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

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

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

Medicaid managed care

workshop

HRSA is planning to conduct state-level case studies on dental managed care to evaluate the effect of

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

grant demonstration

project

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

approaches for young Medicaid or SCHIP children that will result in improved oral health and cost savings.
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Page 24 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

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

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.

26For a more detailed list of planned or recently started HHS oral health activities, see

GAO/HEHS-00-72, app. III.
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Page 26 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

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
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

Scope and Methodology ApApenednxidexiIs

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

Rates

To calculate dentists’ participation rates for each state, we collected data

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

Selected Dental

Procedures

To compare Medicaid fees with average fees dentists charge, we obtained

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

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

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
Appendix I

Scope and Methodology

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

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

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),

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
Appendix I

Scope and Methodology

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

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

Average Regional

Dental Fees

Because comparable data are not readily available on the dental fees

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

dentists across nine geographic regions of the country and reported the

mean fees for each dental procedure for each region (see fig. 2).
Appendix I

Scope and Methodology

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

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
Appendix I

Scope and Methodology

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

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

Procedure

New

England

Middle

Atlantic

South

Atlantic

East

South

Central

East

North

Central

West

North

Central

West

South

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
Appendix I

Scope and Methodology

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

Effect of State

Medicaid Fee Increases

on Access

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

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

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

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

(Continued From Previous Page)

Procedure

New

England

Middle

Atlantic

South

Atlantic

East

South

Central

East

North

Central

West

North

Central

West

South

Central Mountain Pacific
Appendix I

Scope and Methodology

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

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 Programs

To assess other federal safety-net programs’ abilities to meet the demand

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

Appendix II

Healthy People 2010 Oral Health Goals ApendxiI

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

Objective 2010 target Baseline

Reduce the proportion of children and adolescents with dental

caries experience in their primary or permanent teeth

2-4 years: 11%

6-8 years: 42%

15 years: 51%

2-4 years: 18% (1988-94)

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

15 years: 61% (1988-94)

Reduce the proportion of children, adolescents, and adults with

untreated dental decay

2-4 years: 9%

6-8 years: 21%

15 years: 15%

35-44 years: 15%

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

6-8 years: 29% (1988-94)

15 years: 20% (1988-94)

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

Increase the proportion of adults who have never had a

permanent tooth extracted because of dental caries or

periodontal disease

42% 35-44 years: 31% (1988-94)

Reduce the proportion of older adults who have had all their

natural teeth extracted

20% 65-74 years: 26% (1997)

Reduce periodontal disease in adults aged 35-44 Gingivitis: 41%

Destructive periodontal

disease: 14%

Gingivitis: 48% (1988-94)

Destructive periodontal disease: 22%

(1988-94)

Increase the proportion of oral and pharyngeal cancers

detected at the earliest stage

50% 35% (stage I, localized) (1990-95)

Increase the proportion of adults who, in the past 12 months,

report having had an examination to detect oral and pharyngeal

cancer

35% 40+ years: 14% (1998)

Increase the proportion of children who have received dental

sealants on their molars

8 years: 50%

14 years: 50%

8 years: 23% (1988-94)

14 years: 15% (1988-94)

Increase the proportion of the U.S. population served by

community water systems with optimally fluoridated water

75% 62% (1992)

Increase the proportion of children and adults who use the oral

health system each year

83% 2+ years: 65% (1997)

Increase the proportion of long-term care residents who use the

oral health care system each year

25% 19% (1997)

Increase the proportion of children and adolescents younger

than 19 at or below 200 percent of the federal poverty level who

received any preventive dental services during the past year

57% 20% (1996)

Increase the proportion of local health departments and

community-based health centers, including community, migrant,

and homeless health centers, that have an oral health

component

75% 34% (1997)

Increase the number of states, including the District of

Columbia, that have a system for recording and referring infants

and children with cleft lips, cleft palates, and other craniofacial

anomalies to craniofacial anomaly rehabilitative teams

All states and the District of

Columbia

23 states and the District of Columbia

(1997)

Increase the number of states, including the District of

Columbia, that have an oral and craniofacial health surveillance

system

All states and the District of

Columbia

0 (1999)
Page 36 GAO/HEHS-00-149 Factors Affecting the Use of Dental Services

Appendix III

Medicaid Payment Rates as a Percentage of

Average Regional Dental Fees for Selected

Procedures, 1999 ApendxiI

Region and state

Periodic

oral

examination

Dental

cleaning—

child

Metal filling—

2 surfaces

Root canal

treatment

Extraction—

single tooth

Of 15 proceduresa

Number for which

Medicaid exceeded

2/3 of average

regional fees

Range of

Medicaid rates

as % of average

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

Delawareb 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
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

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.

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

(Continued From Previous Page)

Region and state

Periodic

oral

examination

Dental

cleaning—

child

Metal filling—

2 surfaces

Root canal

treatment

Extraction—

single tooth

Of 15 proceduresa

Number for which

Medicaid exceeded

2/3 of average

regional fees

Range of

Medicaid rates

as % of average

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

Appendix IV

Comments From HHS ApendxiIV
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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