Supporting Preventive Dentistry Initiatives for Physicians
Supporting Preventive Dentistry Initiatives for Physicians
Respondents in 48 of the 51 states (response rate = 94%) completed questionnaires between December 2008 and April 2009. Forty surveys were completed online and 8 were self-administered by using the abbreviated questionnaire distributed by e-mail. Of respondents, 10.9% had been employed in their current Medicaid position for less than 1 year, 23.9% for 1 to 2 years, 21.7% for 3 to 4 years, 30.4% for 5 to 9 years, and 13.0% for 10 or more years. We confirmed baseline stage of adoption for the 3 states that did not complete the survey by using information available online or by telephone communication with Medicaid staff. We obtained 3-year follow-up information on implementation of a preventive dental initiative for those states that had not adopted one at the time of the baseline survey for all states from online resources.
Twenty-nine (57%) states had an oral health initiative with nondental primary health care providers at the time of the survey (Table 1; Figure 1). Another 9 states (18%) planned to start an initiative. A total of 42 states (82%) had implemented a program by the end of 2011, most (56%) doing so in 2007 through 2009. The percentage of programs that implemented an initiative during the follow-up period among those with plans at baseline (77.7%) was greater than the percentage without plans (46.1%), but the difference was not statistically significant (2-tailed P = .231, Fisher's exact test).
(Enlarge Image)
Figure 1.
Cumulative percentage adoption curve for fluoride varnish: state Medicaid programs, United States, 1998–2011.
All but 1 responding state of those with complete questionnaire information (n = 23) included fluoride varnish applications as part of its identified preventive dental initiative. Most respondents also included referral for follow-up (n = 16; 70%) and counseling on oral health (n = 14; 61%). Fewer than half of the states reported that their initiative provided for clinical screening and risk assessments (n = 10; 43%). Only 9 (39%) states indicated initiatives with a comprehensive set of services (i.e., oral evaluation, referral for follow-up, counseling, and fluoride varnish). Prescription of dietary fluoride supplements was identified as a component of the initiative by 5 states (22%). Infants and toddlers up to 36 or 42 months of age were eligible for services in half of the states, children up to 6 years of age in 2 states, and all children eligible for State Children's Health Insurance Program or Medicaid services in 8 states.
All but 6 states included an oral evaluation or counseling along with fluoride varnish application as part of their initiative, but most (n = 18; 78.2%) only reimbursed for fluoride varnish. The reimbursement rate for fluoride varnish ranged from $12.00 to $53.30 (mean = $24.11). The total reimbursement for all services for the 4 states that reimburse for an oral health evaluation or counseling at the same visit as fluoride varnish ranged from $45.00 to $74.68 (mean = $56.96). One state did not include fluoride varnish in its initiative but reimbursed $39.00 for an oral evaluation and counseling.
Eight (35%) of the states have guidelines that provide recommendations to providers for delivering preventive dental services. These guidelines included forms to document results of an oral evaluation (n = 6; 26%), risk assessment (n = 2; 8%), or referral to a dentist (n = 7; 30%); patient educational materials (n = 4; 17%); and use of an artificial light source (n = 1) or mouth mirror (n = 2) for conducting the oral evaluation. One third of states require the physician to conduct the oral evaluation and 11 (50%) require provider training before reimbursement. Few states provided any information for the section of the questionnaire requesting estimates for the number of participating providers (1 respondent; n = 75), practices (2 respondents; min = 75; max = 450) or children receiving services (7 respondents; min = 9474; max = 385 592).
The influence of perceived attributes of the innovation on the decision to adopt a program differed by domain (Table 2). The mean score for 4 of the 5 attributes in the "relative advantage" domain fell in the "moderate" to "strong" category (overall score ≥ 3.0). One item from "complexity," "compatibility," and "observability" fell in this range, but the only negatively worded item in the 18 attributes suggests that program complexity did not have a strong influence on adoption decisions (mean score = 1.44 for "program too complex to implement"). The ability to test the initiative before wide-scale adoption did not seem to be an important attribute to Medicaid managers (mean score = 1.54 for "we could try the program … without fully committing to it").
Mean scores by baseline adoption status differed at statistically significant levels for all attributes in the "complexity" domain and 2 of the 3 items in the "compatibility" domain. The perceived ease with which medical providers could learn the dental procedures or integrate them into their practice was less important to those who had no plans to adopt than those who had already made the decision to adopt. They also were influenced less by the fit of the initiative with their organization's mission, goals, and practices. Those without plans were influenced more by the complexity of the program than those who had already adopted or were planning to do so.
The extent to which each of 15 barriers was thought by survey respondents to affect program implementation is displayed in Table 3. The most commonly reported barriers were administrative, including limited Medicaid budgets (80%), concerns about reimbursement codes (78%) and claims forms (66%), and lack of personnel (66%). More than half of states reported lack of interest from physicians (61%) and opposition from the dental profession (54%) as barriers to implementation. In general, Medicaid programs that already had an initiative or plans for one had lower mean Likert scores for the extent to which respondents considered an item to be a barrier than did programs with no plans. But with the exception of 1 barrier (required changes in administrative rules or state plan), scores did not differ at a statistically significant level.
Results
Respondents in 48 of the 51 states (response rate = 94%) completed questionnaires between December 2008 and April 2009. Forty surveys were completed online and 8 were self-administered by using the abbreviated questionnaire distributed by e-mail. Of respondents, 10.9% had been employed in their current Medicaid position for less than 1 year, 23.9% for 1 to 2 years, 21.7% for 3 to 4 years, 30.4% for 5 to 9 years, and 13.0% for 10 or more years. We confirmed baseline stage of adoption for the 3 states that did not complete the survey by using information available online or by telephone communication with Medicaid staff. We obtained 3-year follow-up information on implementation of a preventive dental initiative for those states that had not adopted one at the time of the baseline survey for all states from online resources.
Adoption of Innovation and Readiness to Change
Twenty-nine (57%) states had an oral health initiative with nondental primary health care providers at the time of the survey (Table 1; Figure 1). Another 9 states (18%) planned to start an initiative. A total of 42 states (82%) had implemented a program by the end of 2011, most (56%) doing so in 2007 through 2009. The percentage of programs that implemented an initiative during the follow-up period among those with plans at baseline (77.7%) was greater than the percentage without plans (46.1%), but the difference was not statistically significant (2-tailed P = .231, Fisher's exact test).
(Enlarge Image)
Figure 1.
Cumulative percentage adoption curve for fluoride varnish: state Medicaid programs, United States, 1998–2011.
All but 1 responding state of those with complete questionnaire information (n = 23) included fluoride varnish applications as part of its identified preventive dental initiative. Most respondents also included referral for follow-up (n = 16; 70%) and counseling on oral health (n = 14; 61%). Fewer than half of the states reported that their initiative provided for clinical screening and risk assessments (n = 10; 43%). Only 9 (39%) states indicated initiatives with a comprehensive set of services (i.e., oral evaluation, referral for follow-up, counseling, and fluoride varnish). Prescription of dietary fluoride supplements was identified as a component of the initiative by 5 states (22%). Infants and toddlers up to 36 or 42 months of age were eligible for services in half of the states, children up to 6 years of age in 2 states, and all children eligible for State Children's Health Insurance Program or Medicaid services in 8 states.
All but 6 states included an oral evaluation or counseling along with fluoride varnish application as part of their initiative, but most (n = 18; 78.2%) only reimbursed for fluoride varnish. The reimbursement rate for fluoride varnish ranged from $12.00 to $53.30 (mean = $24.11). The total reimbursement for all services for the 4 states that reimburse for an oral health evaluation or counseling at the same visit as fluoride varnish ranged from $45.00 to $74.68 (mean = $56.96). One state did not include fluoride varnish in its initiative but reimbursed $39.00 for an oral evaluation and counseling.
Eight (35%) of the states have guidelines that provide recommendations to providers for delivering preventive dental services. These guidelines included forms to document results of an oral evaluation (n = 6; 26%), risk assessment (n = 2; 8%), or referral to a dentist (n = 7; 30%); patient educational materials (n = 4; 17%); and use of an artificial light source (n = 1) or mouth mirror (n = 2) for conducting the oral evaluation. One third of states require the physician to conduct the oral evaluation and 11 (50%) require provider training before reimbursement. Few states provided any information for the section of the questionnaire requesting estimates for the number of participating providers (1 respondent; n = 75), practices (2 respondents; min = 75; max = 450) or children receiving services (7 respondents; min = 9474; max = 385 592).
Perceived Attributes of Innovation
The influence of perceived attributes of the innovation on the decision to adopt a program differed by domain (Table 2). The mean score for 4 of the 5 attributes in the "relative advantage" domain fell in the "moderate" to "strong" category (overall score ≥ 3.0). One item from "complexity," "compatibility," and "observability" fell in this range, but the only negatively worded item in the 18 attributes suggests that program complexity did not have a strong influence on adoption decisions (mean score = 1.44 for "program too complex to implement"). The ability to test the initiative before wide-scale adoption did not seem to be an important attribute to Medicaid managers (mean score = 1.54 for "we could try the program … without fully committing to it").
Mean scores by baseline adoption status differed at statistically significant levels for all attributes in the "complexity" domain and 2 of the 3 items in the "compatibility" domain. The perceived ease with which medical providers could learn the dental procedures or integrate them into their practice was less important to those who had no plans to adopt than those who had already made the decision to adopt. They also were influenced less by the fit of the initiative with their organization's mission, goals, and practices. Those without plans were influenced more by the complexity of the program than those who had already adopted or were planning to do so.
Barriers to Implementation of Innovation
The extent to which each of 15 barriers was thought by survey respondents to affect program implementation is displayed in Table 3. The most commonly reported barriers were administrative, including limited Medicaid budgets (80%), concerns about reimbursement codes (78%) and claims forms (66%), and lack of personnel (66%). More than half of states reported lack of interest from physicians (61%) and opposition from the dental profession (54%) as barriers to implementation. In general, Medicaid programs that already had an initiative or plans for one had lower mean Likert scores for the extent to which respondents considered an item to be a barrier than did programs with no plans. But with the exception of 1 barrier (required changes in administrative rules or state plan), scores did not differ at a statistically significant level.
