Increased children's access to fluoride varnish treatment by involving medical care providers: effect of a Medicaid policy change.

Although the oral health of most Americans has improved (U.S. Department of Health and Human Services 2000), dental caries, a preventable disease, still remains the single most prevalent childhood disease (Edelstein 1998; Vargas, Crall, and Schneider 1998; Vargas and Ronzio 2006;). Untreated dental caries cause many children to experience needless pain, suffer from social stigma, lowered self-esteem, and loss of school time (Newacheck et al. 2000b; Chu et al. 2007;). In addition, the burden of dental caries is disproportionately shouldered by poor and racial/ethnic minority children, as well as those with special health care needs (Newacheck et al. 2000a). Most of these children rely on public programs, such as Medicaid, to pay for medical and dental care services. Under Medicaid, the Early, Periodic Screening, Diagnosis, and Treatment program requires that basic dental services be covered for children (Department of Health and Human Services, Medicaid at-a-Glance 2005), including services aimed at caries prevention. However, inadequate access to these services have led to oral health disparities for Medicaid enrolled children (U.S. Department of Health and Human Services 2000). Currently, a number of explanations for inadequate access to dental care for the Medicaid-enrolled population have been put forth in the literature. One reason is the geographic maldistribution of dentists (Mertz and Grumbach 2001), leading to severe shortages in communities where oral health care services are needed the most. Another reason is the severe shortage of minority dentists to serve this population, as one study has reported that minority dentists are more likely to accept new Medicaid patients (Okunseri et al. 2008). In addition, Valdes et al. (2007) pointed out that while parents of enrolled children are aware of the need for preventive dental procedures covered by Medicaid, their lack of usage may be driven by inappropriate pain management and a lack of cultural sensitivity among dentists. From a public health perspective, it is important to provide adequate access to measures aimed at primary prevention of caries because of their self-compounding effects. As discussed by Vargas et al. (2002) and Vargas and Ronzio (2006) dental caries produce a self-sustaining spiral of unmet needs whereby untreated caries become more severe and difficult to treat, thereby increasing treatment costs and reducing the availability of clinicians able to perform more complicated treatments. Therefore, a reduction in the prevalence of caries for high-risk populations requires the early availability of services designed to stop the initiation of this cycle. One such measure, fluoride varnish treatment (FVT), has been advocated by the American Dental Association (ADA) for high-risk children as young as 6 months old, where the definition of high-risk includes children from low-socioeconomic backgrounds (American Dental Association Council on Scientific Affairs 2006). The ADA's recommendation states that from 6 months of age, children at high risk of caries development should receive FVT at 6-month intervals (American Dental Association Council on Scientific Affairs 2006). However, many of these high-risk children are unable to receive care from a dentist, due in part to low number of dentists who are Medicaid providers in most states. Thus, there is need to pursue alternative delivery mechanisms for preventive dental services to public program patients in a sustainable and effective manner. One such alternative put forth by oral health stakeholders in America is the involvement of medical care providers such as physicians and nurses. The involvement of medical care providers was proposed because (1) physician offices represent an opportune site to reach a large number of children who make medical visits, but do not see a dentist (Casamassimo 1996; American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine 2000; Schafer and Adair 2000; Sonis and Zaragoza 2001; American Academy of Pediatrics 2003;); (2) physicians have a relatively high participation rate in Medicaid, compared with a much lower rate among dentists (Dela Cruz, Rozier, and Slade 2004); (3) most infants and children see their pediatricians and family physicians for early preventive procedures such as immunizations and for other health care checks; and (4) medical provider clinics are often open for longer hours than regular dental offices. Therefore, by allowing dental providers and medical care providers to apply FVT, a wider array of access points for Medicaid-enrolled children may be created. In 2004, the State of Wisconsin introduced a change to their Medicaid Policy allowing medical care providers to be reimbursed for FVT. This allowed pediatricians and other primary health care providers to become sources of FVT, risk assessment, preventive oral health education, and care for young children and others who are unable to readily gain access to dental care. Before the implementation of the policy change, employees of the Wisconsin Department of Health and Family Services, Division of Public Health conducted a series of training sessions for physicians, physician assistants, pediatricians, and nurse practitioners regarding the need and proper application techniques for FVT to young children's teeth. However, to date, there has not been any assessment of whether this policy change and additional training have led to an improvement in access to FVT for Medicaid-enrolled children. Despite the lack of evidence indicating whether the involvement of medical care providers has been effective in improving access to FVT, presently about 24 other states in America have adopted similar policies. The primary purpose of the present study was to evaluate whether the inclusion of medical care providers has led to an increase in the rate of FVT claims for Medicaid-enrolled children in Wisconsin.