Provision of fluoride varnish to Medicaid-enrolled children by physicians: the Massachusetts experience.

Dental caries disproportionately affects low-income and minority children. Indeed, as much as 80 percent of tooth decay in permanent teeth occurs in only 25 percent of children (Brown et al. 1996; Kaste et al. 1996). These children are more likely to suffer consequences of untreated tooth decay, including pain, difficulty chewing, missed school days, infection, and costly restorative dental treatments (Government Accountability Office 2000b; Siegal, Yeager, and Davis 2004; Clarke et al. 2006; Tickle, Blinkhorn, and Milsom 2008; Casamassimo et al. 2009). Although low-income and minority children bear a disproportionate burden of dental disease, they are less likely to receive dental care (Flores and Tomany-Korman 2008). Rates of dental caries are also high among children enrolled in Medicaid, despite the fact that comprehensive dental services are a covered benefit under the Early and Periodic Screening, Diagnosis and Treatment Medicaid program (Kaiser Commission on Medicaid and the Uninsured 2007). Only one in three Medicaid-enrolled U.S. children has a dental visit each year (Government Accountability Office 2008). Factors often cited as contributing to poor dental care access among Medicaid members include a geographic maldistribution of dentists, an inadequate supply of dentists who accept Medicaid payment and treat Medicaid-insured children, and administrative issues (Government Accountability Office 2000a; Mouradian, Wehr, and Crall 2000). In Massachusetts (MA), although 73 percent of all children had a dental visit in 2005, <30 percent of children enrolled in MassHealth (MA Medicaid Program) saw a dentist (The Catalyst Institute. 2006). A 2000 report by the MA Special Legislative Commission on Oral Health revealed that only 14 percent of practicing MA dentists were active MassHealth providers (Report of the Special Legislative Commission on Oral Health 2000), further contributing to the state's dental care access problem. In that same year, reports of MassHealth enrollees' hardships accessing dental care led to a lawsuit filed by a MA-based advocacy group against the state. Following the Court's decision, both parties agreed to a remediation plan (United States District Court of Massachusetts 2005) and the MA Executive Office of Health and Human Services agreed to implement specific measures. One measure in the plan was a new policy specifying that MassHealth reimburse primary care physicians (PCPs) for providing fluoride varnish (FV) treatments to eligible MassHealth members <21 years old. The new policy became effective on October 1, 2008. To be eligible for reimbursement, physicians had to complete an approved training program on preventive dental care (PDC) skills (oral health examination, education, and FV application). Currently, 37 state Medicaid programs reimburse PCPs for providing one or more elements of PDC (Deinard and Cantrell 2010). These policies stemmed from a goal to reduce dental disease by encouraging shared responsibility for children's oral health among the medical and dental communities (Cantrell 2008). State reimbursement rates vary from U.S.$9 to U.S.$53.30 per application, with about two to six applications allowed per year, depending on the state (Deinard and Cantrell 2010). Some states also reimburse physicians separately for oral examinations and family oral health education. MA physicians are only reimbursed for FV applications. A few studies have demonstrated success of this Medicaid reimbursement strategy in increasing low-income children's access to FV treatments (Rozier et al. 2003; Okunseri et al. 2009). In Iowa, policy implementation was followed by a significant involvement of medical providers in FV delivery (Okunseri et al. 2009). Total claims for FV increased from 3,361 prepolicy to 28,303 postpolicy. Physicians accounted for 38 percent of the FV claims submitted after the policy was implemented (Okunseri et al. 2009). The North Carolina “Into the Mouth of Babes” program, developed in 2000, trained and reimbursed physicians for providing preventive dental services during medical visits (Rozier et al. 2003). By 2006, these services were provided during over 100,000 medical visits for children <3 years of age (Cantrell 2008). A few studies have documented some important factors determined to influence provision of FV in medical settings, including physician attitudes (e.g., perceived difficulty applying FV), and logistics (e.g., available practice systems used to identify eligible patients for FV application) (Lewis, Lynch, and Richardson 2005; Close et al. 2010). Because these studies targeted providers who had already completed the PDC skills training, their perspectives and experiences could differ from providers who had not been trained. The goal of this study was to evaluate the impact of the new Medicaid policy in MA in regard to child health PCP's provision of FV treatments, one year after policy implementation. We sought to answer the following questions: (a) What are MA physicians' knowledge, practices, and attitudes about providing PDC among MassHealth-enrolled children?; (b) What are MA physicians' knowledge, experiences, and attitudes related to FV?; (c) What percentage of MA physicians are aware of the new Medicaid FV reimbursement policy and what is their attitude toward the policy?; and (d) What are the rates of participation in the PDC skills training and FV provision among MA physicians, as well as associated barriers and facilitators? Findings could lend insight into the state's progress in encouraging physician integration of preventive dental services into routine delivery of medical care, highlight areas for improvement, and enable comparisons with other states.