These analyses have shown that the January 2000 dental Medicaid reform in South Carolina has had a substantial impact on children's access to dental care. From January 1998 through December 1999, there was a downward trend in both the total number of children receiving services and the percent of Medicaid enrollees who received services; the reform reversed this trend. The percentage of children receiving at least one dental service dropped from 32.4 percent in 1998 to 28.5 percent in 1999, but rose back to 31.0 percent in 2000. After multivariate adjustment, the number of services provided per enrollee was significantly greater in 2000 than what would have been expected given the trends in 1998 and 1999 for the both age groups. Substantial increases were also noted in all but one category of dental procedures, and multivariate regression analyses confirmed that the increases in the four categories with the highest volume (diagnostic, preventive, restorative, and surgical) were all highly statistically significant when comparing 2000 to what would have been expected given the trends from the prior years.
While this reform did greatly increased access to dental care for Medicaid enrollees, there clearly remains room for improvement. The reform appears to have lead to a relatively large improvement in access (compared to past reforms in other states) of Medicaid children to dental services. The fact remains, however, that approximately 65 percent of child enrollees received no dental services during the year of reform.
Although the goal of this paper was to discuss the impact of this reform on the percent of children receiving Medicaid dental services and the numbers of procedures performed per enrollee, a separate issue has to do with the experience of the dentists in South Carolina during this time frame. First, it is interesting to note that the practice type distribution (i.e. general dentistry, pediatric dentistry, other) hardly changed at all from 1998 to 2000 period (1998: 77.1 percent general, 3.2 percent pediatric, 19.7 percent other; 1999: 77.6 percent general, 3.2 percent pediatric, 19.2 percent other; 2000: 77.7 percent general, 3.3 percent pediatric, 19.0 percent other). Results from separate analyses (to be described in more detail in a separate paper) indicated that the percent of South Carolina dentists who provided at least 10 Medicaid services per quarter went from 26.1 percent in 1998 to 25.8 percent in 1999, to 34.0 percent in 2000. After adjustment for dentist characteristics and other factors similar to the ones described for the models in the current paper, it was determined that that the reform encouraged about 160 dentists who had not serviced Medicaid recipients prior January of 2000 to begin participation. A separate model that conditional on dentists' participation in the Medicaid program found that the reform had no significant effect on the number of Medicaid services provided by the participating dentists.
Informal interviews with a number of South Carolina dentists indicate that the change in reimbursement is the primary reason for this reform's success. However, the other aspects of the reform also contributed to its success including the children's oral health coalition (which successfully lobbied to secure funding necessary for the reimbursement rate changes), the dental association's efforts (to encourage more dentists to accept Medicaid by making them aware of the reimbursement changes), and to a lesser extent the streamlining of the Medicaid billing process and the efforts by the state Family Support Services agency to address patient compliance with appointments and treatment.
Consequently, while this study did not perform a cost–benefit analysis of the January 2000 dental Medicaid fee reform (a task beyond the scope of this work), the results do strongly indicate that the reform achieved its desired results. Although the reimbursement change was not the only aspect of the reform, other states attempting to improve access to dental care for children covered by Medicaid may wish to consider emulating the South Carolina experiment of setting reimbursement rates at the 75th percentile of dentist's fees. Informal interviews with a number of South Carolina dentists indicate that the change in reimbursement is the primary reason for this reform's success.
This study has several key strengths. Month-by-month “snapshots” of both the number of enrollees receiving services and the number of various procedures performed were available for examination, clearly illustrating the trend that occurred prior to reform. Because data were available on the universe of services covered by Medicaid, no sampling error was introduced into the analyses. Additionally, the analyses were multivariate in nature, so that they were able to adjust for any changes in the number of enrollees served and the number of services provided that could be attributed to a variety of county-specific attributes.
Several limitations should also be noted. Of primary concern is the fact that the study design was not a randomized design; nor was there any type of contemporaneous control group. The pre/postdesign used in this study is subject to biases associated with temporal trends such as those caused by other reforms. Fortunately (from the perspective of being able to interpret our findings), there were no reforms to the South Carolina Dental Medicaid program during the time period of interest, other than the reforms already outlined in this study (personal communication, Janice Tippins, Program Manager of the Medicaid Dental Program Area, May 2004). The State Children's Health Insurance Program (SCHIP) that was instituted in South Carolina in 1997 expanded the eligibility criteria for Medicaid, and the state's welfare reforms of 1995 and 1996 put significant limits on welfare benefits. Both of these policies may have had some residual effects resulting in increased numbers of Medicaid eligible children during our study's time frame. Since all of our analyses are based on a time period after both SCHIP and the welfare reforms became active, and because the statistical models account for any trends that may have been occurring throughout the 1998 to 2000 time frame due to the SCHIP and welfare reform, it is unlikely that our findings would be significantly influenced by effects from such reforms.
There are also other limitations that should be noted. For example, the costs of the entire reform were not available. Medicaid reimbursements for dental procedures totaled approximately $18.6 million for the 2 years prior to reform, and $58.6 million in 2000; however, these figures reflect payments for both children and adults, and no costs were estimated for aspects of the reform aside from the reimbursement rate increase. The study is also somewhat limited by the time frame available for analysis. For example, it is difficult to know how frequently dental services were provided to Medicaid enrollees prior to 1997 or subsequent to 2000. It is possible that the downward trends across 1998 and 1999 and the increase in 2000 in the percent of children receiving services was an artifact of transitory, cyclical changes. Correspondence with the state's Oral Health Coordinator, however, indicates that access continues to improve despite 140,000 additional children being considered Medicaid eligible since 2000 (personal communication, Raymond Lala, South Carolina Oral Health Coordinator, March 2003). The analysis is also limited by only having data available at the county-month-age group level, and thus little information pertaining to the Medicaid enrollees (including those who received dental services) was able to be presented. Also because of this lack of data at the enrollee level, the study was limited by the available age groupings, as only 1 cut point was feasible. The age groupings were chosen based on the thought that fewer children and services would be expected in the younger category, and the fact that the reimbursement changes would not have had as great an impact in that age group.
Overall, South Carolina's dental Medicaid reform of the year 2000 had an overwhelmingly positive effect on the accessibility of dental care to children enrolled in Medicaid. Given the enormity of the problem of caries in this and other similar populations around the country, increasing reimbursement rates for dental services must be considered when addressing this type of public health problem in the future. Given that South Carolina subsequently reduced the budget of all state programs by 4.5 percent in the face of a $246 million projected deficit (Anonymous 2003
), it remains to be seen whether future dental Medicaid reimbursement rates will stay high. Future research should address the sustainability of this type of reform.