The effect of Medicaid primary care provider reimbursement on access to early childhood caries preventive services.

Early childhood caries (ECC) is a significant national problem that disproportionately affects low-income children, and its prevalence is increasing (Tomar and Reeves 2009). ECC has significant short- and long-term adverse consequences (Tinanoff and Reisine 2009). ECC is associated with increased risk of future caries (Gray, Marchment, and Anderson 1991; Reisine, Litt, and Tinanoff 1994; O'Sullivan and Tinanoff 1996), missed school days (Gift, Reisine, and Larach 1992; Hollister and Weintraub 1993), hospitalization and emergency room visits (Sheller, Williams, and Lombardi 1997; Griffin et al. 2000), and, in rare cases, death (Casamassimo et al. 2009). These adverse outcomes are avoidable through ECC preventive services (ECCPS). A randomized clinical trial found that fluoride varnish treatment, combined with parent counseling, can reduce caries by up to 50 percent in high-risk children (Weintraub et al. 2006). National guidelines recommend that children have a dental visit by 12 months of age and receive preventive care at regular intervals thereafter (American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health 2008; American Academy of Pediatric Dentistry 2013). The most common recall interval is 6 months. However, the American Academy of Pediatric Dentistry recommends that children at higher caries risk get check-ups, including topical fluoride application, more often (American Academy of Pediatric Dentistry 2013). Medicaid eligibility has been identified as a risk factor for ECC (American Dental Association 2011). Untreated dental caries occurs among 25 percent of children living in poverty compared with 10.5 percent of children living above poverty (Dye, Li, and Thorton-Evans 2012). Comprehensive dental benefits are required in Medicaid and the Children's Health Insurance Program, which cover 35 percent of all U.S. children (DeNavas-Walt, Proctor, and Smith 2012), but only 31 percent of publicly insured children ages 0–5 years receive dental services (Centers for Medicare and Medicaid Services 2012). Although ECC is largely preventable (Savage et al. 2004; Weintraub et al. 2006; Azarpazhooh and Main 2008), it is difficult to reach preschool aged children for caries prevention. Publicly insured, preschool aged children are more likely to receive medical care than dental care (Bouchery 2012a,b). Consequently, 44 state Medicaid programs have implemented policies to reimburse medical primary care providers (M-PCPs), typically including physicians, physician assistants, and advanced registered nurse practitioners, to provide ECCPS. The specific services reimbursed varies across states but may include an examination of the oral cavity, caries risk assessment, anticipatory guidance, topical fluoride application, and referral to a dental home (American Academy of Pediatrics 2013). Despite widespread adoption, there is little scientific evidence on the effects of M-PCP reimbursement on ECCPS receipt, with published studies from only two states. A North Carolina study examined ECCPS receipt subsequent to policy implementation and found steady growth in the number of medical visits that included ECCPS, but it did not use a pre–post study design to evaluate changes in ECCPS receipt (Rozier et al. 2010). Studies of Wisconsin's Medicaid program, which used pre–post designs, found that M-PCP reimbursement was associated with increased claims rates for fluoride varnish treatment with almost one-half of the increase associated with M-PCPs (Okunseri et al. 2009, 2010). This study extends existing research by analyzing the effect of M-PCP reimbursement on ECCPS receipt for Medicaid-enrolled children in Texas and Florida, which are the second and fourth most populous states, respectively, and account for 15 percent of Medicaid-enrolled children nationally (Kaiser Family Foundation 2013; U.S. Census Bureau 2011). These states are among the most diverse with significant representation of African-American and Hispanic populations (Brewer and Suchan 2001), which disproportionately experience low access to dental care (Edelstein and Chinn 2009). In 2008, the Florida and Texas Medicaid programs implemented M-PCP ECCPS reimbursement for children ages 0–4 years. We used secondary data from these programs to test our central hypothesis that M-PCP reimbursement has improved access to ECCPS. Methodologically, we extend existing research by including a control group of children not subject to M-PCP reimbursement and adopting an analytic strategy that allows us to better isolate the treatment effect by controlling for intrinsic differences between the treatment and control groups, secular time trends, and differential time trends between the two groups. In addition to controlling for standard demographic characteristics, we also control for the children's health status and explicitly incorporate enrollment duration into our model.