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Background: In Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs., Methods: Authors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP., Results: Overall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas., Conclusions: Dentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.

This study explores how travel distance and other transportation barriers are associated with dental utilization in a Medicaid expansion population. We analyzed data from the Iowa Dental Wellness Plan (DWP), which provides comprehensive dental benefits for low-income adults aged 19 to 64 y as part of Iowa's Medicaid expansion. Transportation and geographical characteristics were evaluated as enabling factors within the framework of Andersen's behavioral model of health services use. In March 2015, a random sample of DWP members ( n = 4,800) was surveyed; adjusted survey response rate was 30% ( n = 1,258).The questionnaire was based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey and assessed need for dental care, use of dental services and transportation to visits, and self-perceived oral health status. Respondent and dentist addresses were geocoded and used to calculate distance to the nearest DWP general dentist. A logistic regression model predicting utilization of dental care was developed using variables representing each domain of the behavioral model. Most respondents (57%) reported a dental visit since enrolling. Overall, 11% of respondents reported unmet dental need due to transportation problems. Median distance to the nearest general dentist was 1.5 miles. In the adjusted model, travel distance was not significantly associated with the likelihood of dental utilization. However, other transportation-related issues were significantly associated with utilization, including concern about cost of transportation and driver/passenger status. As concern about transportation cost increased, likelihood of having a dental visit decreased. Targeted approaches to assisting low-income populations with transportation barriers should be considered in designing policies and interventions to improve access to dental care. Knowledge Transfer Statement: The results of this study can be used by policy makers and public health planners when designing programs and interventions to improve access to dental care. Consideration of transportation availability and costs could improve utilization of routine dental care, especially among low-income populations.

Objective: To examine the effects of distance to dentists and dentist supply on dental services use among children with Medicaid coverage in Iowa., Data Source: Iowa Medicaid claims for enrolled children between 2000 and 2009., Study Design: The study sample included 41,554 children (providing 158,942 child-year observations) who were born in Iowa between 2000 and 2006 and enrolled from birth in the Iowa Medicaid program. Children were followed through 2009. We used logistic regression to simultaneously examine the effects of distance (miles to nearest dentist) and county-level dentist supply on a broad range of dental services controlling for key confounders. Additional models only used within-child variation over time to remove unobservable time-invariant confounders., Principal Findings: Distance was related to lower utilization of comprehensive dental exams (2 percent lower odds per 1 mile increase in distance), an effect that also held in models using within-child variation only. Dentist supply was positively related to comprehensive exams and other preventive services and negatively related to major dental treatments; however, these associations became smaller and insignificant when examining within-child changes except for other preventive services., Conclusions: Longer distance to dentists is a barrier for use of comprehensive dental exams, conditional on dentist supply., (© Health Research and Educational Trust.)

Objectives: Using administrative data from Iowa Medicaid and a large private dental insurer, we compared distance to the nearest primary care dentist for children ages 6-15 in 2012. Additionally, we examined rates of provider bypass in both populations as an indicator of spatial accessibility to dental care., Methods: We calculated measures of travel burden, including distance to the nearest primary care dentist and distance to current primary care dentist. Distance outcomes and rates of bypass, traveling beyond the nearest dentist for care, were compared by insurance type., Results: We found that Medicaid-enrolled children lived farther from the nearest dentist and farther from their current dentist than privately insured children. However, rates of bypass were higher among the privately insured population. These results were consistent among urban and rural residents; additionally, both rural populations demonstrated greater travel distances than urban dwellers., Conclusions: Travel burden was greater among Medicaid-enrolled children. Lower rates of bypass, in conjunction with lower rates of dental utilization in this population, may indicate a distance threshold beyond which dental care becomes unattainable., (© 2016 American Association of Public Health Dentistry.)

Objectives: Private practice dentists are the major source of care for the dental safety net; however, the proportion of dentists who participate in state Medicaid programs is low, often due to poor perceptions of the program's administration and patient population. Using a discrete choice experiment and a series of hypothetical scenarios, this study evaluated trade-offs dentists make when deciding to accept Medicaid patients., Methods: An online choice-based conjoint survey was sent to 272 general dentists in Iowa. Hypothetical scenarios presented factors at systematically varied levels. The primary determination was whether dentists would accept a new Medicaid patient in each scenario. Using an ecological model of behavior, determining factors were selected from the categories of policy, administration, community, and patient population to estimate dentists' relative preferences., Results: 62 percent of general dentists responded to the survey. The probability of accepting a new Medicaid patient was highest (81 percent) when reimbursement rates were 85 percent of the dentist's fees, patients never missed appointments, claims were approved on first submission, and no other practices in the area accepted Medicaid. Although dentists preferred higher reimbursement rates, 56 percent would still accept a new Medicaid patient when reimbursement decreased to 55 percent if they were told that the patient would never miss appointments and claims would be approved on initial submission., Conclusions: This study revealed trade-offs that dentists make when deciding to participate in Medicaid. Findings indicate that states can potentially improve Medicaid participation without changing reimbursement rates by making improvements in claims processing and care coordination to reduce missed appointments., (© 2015 American Association of Public Health Dentistry.)

Background: Dental emergency department (ED) visits are increasing nationally, but EDs provide only palliative care. The authors examine time to subsequent dentist visit within 6 months after the ED visit, as well as the effect of having a dentist visit in the prior year., Methods: Using 2010-2012 Iowa Medicaid claims data, the authors identified adults with an index dental ED visit. The authors examined the claims data for a subsequent dentist visit within the next 6 months. The authors used Kaplan-Meier curves and log-rank tests for bivariate analyses. The authors included a dentist visit in the year before the index ED visit, subsequent ED visits, and sociodemographic characteristics in a Cox multivariable regression model., Results: A total of 2,430 adults enrolled in Medicaid satisfied the study inclusion criteria. Within 6 months, 52.4% had a subsequent dentist visit, 12.0% lost Medicaid eligibility, and 35.6% did not have subsequent dentist visit. Bivariate and multivariable analyses revealed that nonwhites, those without a dentist visit in the prior year, and those with subsequent ED visits had a significantly lower rate of subsequent dentist visits., Conclusions: Almost one-half of adults with a dental ED visit did not visit a dentist in the next 6 months. Adults who did not visit a dentist in the past year and those with repeated ED visits may be living with unresolved dental problems that can affect their quality of life., Practical Implications: Adults without a dentist visit in the past year and those who visit ED repeatedly can be targeted by ED diversion programs because they are at higher risk of not receiving follow-up dental care., (Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Early preventive dental visits are vital to the oral health of children. Yet many children, especially preschool-age children enrolled in Medicaid, do not receive early visits. This study attempts to uncover factors that can be used to encourage parents to seek preventive dental care for preschool-age children enrolled in Medicaid. The extended parallel process model was used as a theoretical framework for this research. This model suggests that people will act if the perceived threat (severity and susceptibility) is high enough and if efficacy levels (self-efficacy and response efficacy) are likewise high. Following Witte's method of categorizing people's perceptions and emotions into one of four categories based on levels of threat and efficacy, this article describes four groups (high threat/high efficacy, high threat/low efficacy, low threat/high efficacy, and low threat/low efficacy) of parents and how they compare to each other. Using logistic regression to model if a child had a preventive visit, results indicate that parents with low threat/high efficacy and parents with high threat/high efficacy had approximately 2.5 times the odds of having a child with a preventive oral health visit compared to parents with low threat/low efficacy, when controlling for perceived oral health status, health literacy, and child's age. The importance of efficacy needs to be incorporated in interventions aimed at increasing preventive dental visits for young children., (© 2015 Society for Public Health Education.)

Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006-11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: The authors investigated the role of private practitioners in the dental safety net, including the provision of care for Medicaid enrollees and attitudinal factors that affect participation., Methods: In 2013, the authors sent a mixed-mode survey to all general dentists in Iowa assessing their current Medicaid participation and factors affecting participation, including attitudinal statements about altruism, the Medicaid program, and the government's role in providing access to dental care., Results: Fifty-six percent of responding dentists accepted new Medicaid-enrolled patients; dentists living in nonmetropolitan areas were significantly more likely to accept Medicaid than were those in metropolitan areas. Results from a logistic regression model demonstrated that participating dentists scored significantly higher in altruistic attitudes and perceived problems with Medicaid as less important., Conclusions: Dentists who accepted Medicaid-enrolled patients had significantly more positive attitudes about Medicaid administration and altruistic attitudes in general. Investigators in future studies should examine how these attitudes are shaped by educational and professional experiences., Practical Implications: Dentists' perceptions about Medicaid potentially are modifiable by changing program policies in ways to improve access for vulnerable populations, including new Medicaid enrollees., (Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe rates of Medicaid-funded services provided by orthodontists in Iowa to children and adolescents, identify factors associated with utilization, and describe geographic barriers to care., Methods: We analyzed enrollment and claims data from the Iowa Medicaid program for a 3-year period, January 2008 through December 2010. Descriptive, bivariate, and multivariable logistic regression analyses were performed with utilization of orthodontic services as the main outcome variable. Service areas were identified by small area analysis in order to examine regional variability in utilization., Results: The overall rate of orthodontic utilization was 3.1 percent. Medicaid enrollees living in small towns and rural areas were more likely to utilize orthodontic services than those living in urban areas. Children who had an oral evaluation by a primary care provider in the year prior to the study period were more likely to receive orthodontic services. Service areas with lower population density and greater mean travel distance to participating orthodontists had higher utilization rates than smaller, more densely populated areas., Conclusions: Rural residency and increased travel distances do not appear to act as barriers to orthodontic care for this population. The wide variability of utilization rates seen across service areas may be related to workforce supply in the form of orthodontists who accept Medicaid-insured patients. Referrals to orthodontists from primary care dentists may improve access to specialty care for Medicaid enrollees., (© 2013 American Association of Public Health Dentistry.)

Background: Well baby visits (WBVs) are a cornerstone of early childhood health, but few studies have examined the correlates of WBVs for socioeconomically vulnerable infants. The study objective was to identify factors related to the number of WBVs received by Medicaid-enrolled infants in the first three years of life and to present a preliminary explanatory model., Methods: We analyzed Iowa Medicaid claims files and birth certificate data for infants born in calendar year 2000 (N = 6,085). The outcome measure was the number of well baby visits (WBVs) received by Medicaid-enrolled infants between age 1 and 41 months (range: 0 to 10). An ecological health model and existing literature were used to evaluate 12 observed factors as potential WBV correlates. We ran multiple variable linear regression models with robust standard errors (α = 0.05)., Results: There were a number of infant, maternal, and health system factors associated with the number of WBVs received by Medicaid-enrolled infants. Infants whose mothers had a greater number of prenatal healthcare visits (ß = 0.24 to 0.28; P = .001) or were married (ß = 0.20; P = .002) received more WBVs. Having a chronic health condition (ß = 0.51; P < .0001) and enrollment in a case management program (ß = 0.48; P < .0001) were also positively associated with WBVs. Eligibility for Medicaid through the Supplemental Security Income Program (ß = -0.70; P = .001), increased maternal age (ß = -0.27 to -0.35; P = .004), higher levels of maternal education (ß = -0.18; P = .005), maternal smoking (ß = -0.13; P = .018), and enrollment in a health maintenance organization plan (ß = -1.15; P < .0001) were negatively associated with WBVs. There was a significant interaction between enrollment in a health maintenance organization plan and enrollment in a Medicaid case management program (P = .015). Maternal race, maternal alcohol use during pregnancy, and rurality were not significantly related to the number of WBVs., Conclusions: Multiple infant, maternal, and health system variables were related to the number of WBVs received by Medicaid-enrolled infants. Additional research is needed to develop strategies to optimize access to WBVs for Medicaid-enrolled infants at risk for poor use of preventive medical care services.

Purpose: The purpose of this study was to estimate age at first dental visit (FDV) and identify variables predicting earlier visits for Medicaid-enrolled children at Iowa Federally Qualified Health Centers (FQHC)., Methods: Statewide Medicaid claims data were used to draw a random sample of children who received their FDV prior to six years old at a FQHC, were Medicaid-enrolled within the first two months of life, and remained continuously enrolled over the study period. Forty children from each of five FQHCs had their dental charts abstracted and merged with other Medicaid records and birth certificate data. The logarithmic age at FDV was regressed against several predictor variables., Results: Mean and median ages for FDV were 25.6 and 23 months old, respectively. When controlling for other variables, there were differences in FDV age according to: mother's marital status (P=.04); whether the child had any medical well-child visits (MCVs) at a FQHC prior to the FDV (P<.001); and which FQHC the child visited. Only approximately 28 percent of these children, however, had any MCV at the FQHC., Conclusions: Medicaid-enrolled children who visited Federally Qualified Health Centers for their first dental visit were seen at an earlier age than previously recorded for such health centers (mean=four years old). Children who also received any medical well-child visits at FQHCs were more likely to have earlier FDVs.

Objectives: We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children., Methods: The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships., Results: Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome., Conclusions: The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.

The purpose of this study was to determine dental utilization and type of dental services for Medicaid-enrolled adults who had been identified as having intellectual and developmental disabilities (IDD). Using Iowa claims data, the authors identified adults who met any of five IDD criteria for inclusion during calendar year 2005. Service utilization rates, including use of preventive dental, routine restorative, and complex restorative services, were determined. Approximately 60% of adults with IDD had at least one dental visit in 2005. Among adults with at least one dental visit, 83% received a preventive service, 31% a routine restorative service, and 16% a complex dental service. Those age 65 and older had fewer preventive dental services than other age groups. In Iowa, dental utilization for adults 22-64 years of age with IDD was reasonably high (64%) in 2005, but individuals over age 65 had lower utilization (45%)., (©2010 Special Care Dentistry Association and Wiley Periodicals, Inc.)

Objectives: To compare preventive dental utilization for children with intellectual and/or developmental disability (IDD) and those without IDD and to identify factors associated with dental utilization., Methods: We analyzed Iowa Medicaid dental claims submitted during calendar year (CY) 2005 for a cohort of children ages 3-17 who were eligible for Medicaid for at least 11 months in CY 2005 (n = 107,605). A protocol for identifying IDD children was developed by a group of dentists and physicians with clinical experience in treating children with disabilities. Utilization rates were compared for the two groups. Crude and covariate-adjusted odds ratios were estimated using conditional logistic regression modeling., Results: A significantly higher proportion of non-IDD children received preventive care than those identified as IDD (48.6 percent versus 46.1 percent; P < 0.001). However, the final model revealed no statistically significant difference between the two groups. Factors such as older age, not residing in a dental Health Professional Shortage Area, interaction with the medical system, and family characteristics increased one's likelihood of receiving preventive dental care., Conclusion: Although IDD children face additional barriers to receiving dental care and may be at greater risk for dental disease, they utilize preventive dental services at the same rate as non-IDD children. Clinical and policy efforts should focus on ensuring that all Medicaid-enrolled children receive need-appropriate levels of preventive dental care.