Evaluation of Provider Network in the Iowa Dental Wellness Plan during the First Year. Policy Brief. March 2016

Transcription

1 Policy Brief March 2016 Evaluation of Provider Network in the Iowa Dental Wellness Plan during the First Year Susan McKernan Mark Pooley Aparna Ingleshwar Raymond Kuthy Elizabeth Momany Peter Damiano University of Iowa Public Policy Center 209 South Quadrangle, Iowa City, IA O F Page 1

2 Contents Figures Tables Overview...5 Key Findings...6 Dentist supply Distance to general and pediatric dentists....6 Public safety net availability Background....8 Iowa Health and Wellness Plan...8 Dental Wellness Plan...8 Research Methods...9 Study populations Provider inclusion criteria...10 Dentist supply calculations Geocoding...10 Distance calculations...11 Public safety net providers Provider panel overlap...11 Data analysis Member Enrollment and Demographic Characteristics Dentist Supply Dental Wellness Plan provider network...14 Active dentist supply by specialty County level supply of active primary care dentists Distance to nearest active primary care dentist Distance to Treating Provider...23 Public Safety Net Availability Appendix A Page 2

3 Figures Figure 1. Earned benefits in the Iowa Dental Wellness Plan...8 Figure 2. Calculating distance to nearest and treating primary care dentists...11 Figure 3. Monthly enrollment in DWP and Medicaid all enrollees, Year Figure 4. General dentists in the DWP provider network by month...14 Figure 5. Endodontists in the DWP provider network by month Figure 6. Oral surgeons in the DWP provider network by month Figure 7. Periodontists in the DWP provider network by month Figure 8. Prosthodontists in the DWP provider network by month Figure 9. Locations of active DWP and Medicaid dental specialists, Year Figure 10. Active primary care dentist to population ratios, Year Figure 11. Distribution of DWP and Medicaid members by travel distance to the nearest primary care dentist, Year Figure 12. Distribution of DWP and Medicaid members by travel time to the nearest primary care, Year Figure 13. Distribution of DWP and Medicaid members by travel distance to the treating primary care dentist, Year Figure 14. Distribution of DWP and Medicaid members by travel time to the treating primary care, Year Figure 15. Locations of Active Public Dental Safety Net Sites by DWP and Medicaid Participation, Year Page 3

4 Tables Table 1. Unique members by program, Year Table 2. Demographic characteristics of DWP and Medicaid members*, Year Table 3. Table 4. Table 5. Table 6. Overall dentist availability active dentists in private practice settings*, Year County dentist FTEs and population ratios for primary care dentists all settings*, Year Distance to the nearest active primary care dentist for DWP and Medicaid members*, Year Travel time and distance to treating primary care dentist for DWP and Medicaid members, Year Table 7. Active public safety net providers by site, Year Table A1. Active primary care dentist to population ratios by county, Year Page 4

5 Overview The Iowa Health and Wellness Plan (IHAWP) is an expansion of health care coverage, allowed as part of the Affordable Care Act (ACA), primarily to single adults with incomes below 133% of the federal poverty level and not otherwise eligible for Medicaid. Dental coverage within the IHAWP is provided through the Dental Wellness Plan (DWP), which is administered by Delta Dental of Iowa (DDIA). This report is the second provider network adequacy report, and one of several components, in the ongoing evaluation of the DWP program being conducted by the University of Iowa Public Policy Center (UI PPC). The first provider network adequacy report, describing baseline DWP provider network, was published in March and is available on the UI PPC website.1 In the current report, we present updated information about the dental provider network available to DWP members during the first year of DWP implementation (May 1, to April 30, ). In addition, comparisons are made with the provider network in the traditional Medicaid State Plan. The Medicaid comparison group includes non-institutionalized adults, aged 19 to 64, with at least 1 month of enrollment during May through April (comparison group 1). From this group, we identified a subset of adults who were newly eligible during the year through the Iowa Family Medical Assistance Program (FMAP comparison group 2). Newly eligible Medicaid FMAP members were chosen as a comparison group because they were expected to be the most similar to the DWP population in terms of pent-up demand for dental care; they are also expected to face similar challenges finding a dentist who accepts their insurance. We considered two groups of dentists to evaluate the DWP provider network: (1) participating dentists, identified administratively by DDIA as members of their provider network, and (2) active dentists, defined in this report as individuals who submitted at least one claim during the study period. This definition of active dentists is also used by the American Dental Association (ADA) and the Association of State & Territorial Dental Directors (ASTDD) in their Medicaid reporting. Medicaid dentists were also identified based on claims activity; Medicaid does not maintain an updated list of their provider network. Findings from this assessment will be used in conjunction with other components of the UI PPC s evaluation to guide comprehensive review of the DWP program. 1 McKernan, Susan C, Mark J Pooley, Raymond A Kuthy, Elizabeth T Momany, and Peter C Damiano.. Iowa Dental Wellness Plan: Evaluation Of Baseline Provider Network. Iowa City, IA : University of Iowa Public Policy Center. Available at: Page 5

6 Key Findings Dentist supply As of April (the end of the first year of the program): 817 general dentists and 155 specialists were contracted with DDIA to participate in the DWP. 18% of DWP participating general dentists (n=150) were identified by DDIA as no longer accepting new DWP patients (see Figure 4); however, no specialists had reportedly stopped accepting new patients. There were 5 contracted endodontists (Figure 5) and 19 participating prosthodontists (Figure 8). During Year 1: This was a decline in participating specialists during the year from 11 to 5 endodontists and from 23 to 19 prosthodontists. 795 dentists were active DWP providers, based on claim activity. In comparison, 1,176 dentists were active Medicaid providers, based on services provided to the non-institutionalized adult Medicaid population (comparison group 1). 7 endodontists provided services to DWP members during Year 1, compared with 4 endodontists who provided services to adults in Medicaid. The number of general dentists, periodontists (Figure 7), and oral surgeons (Figure 6) grew slightly or remained stable. County-level general and pediatric dentist-to-population ratios were similar for the DWP and Medicaid populations on average. However, there was substantial geographic variation between these two groups (Figure 10). 13 counties did not have any active general or pediatric dentists serving the DWP population; many of these areas did not coincide with low Medicaid dentist supply. For example, several of the northeastern most counties in Iowa had no active DWP providers, but relatively high numbers of Medicaid providers per 1,000 members. 2 counties did not have any active general or pediatric dentists serving the Medicaid population during Year 1. Distance to general and pediatric dentists Potential geographic access during Year 1: On average, distance to the nearest active general or pediatric dentist was similar for DWP and Medicaid members (comparison group 2) 4.0 miles and 3.6 miles, respectively (Table 5). 78% of DWP members and 79% of Medicaid adult members lived within 6 miles of the nearest active general or pediatric dentists for members under age 21) (Figure 11). dentist (Figure 11). However, nearly 1% of DWP members and 0.1% of Medicaid adult members lived more than 40 minutes from the nearest general or pediatric dentist (Figure 12). DWP members who saw a general or pediatric dentist during Year 1 lived approximately 19 miles, on average, from their dentists offices (Table 6).Actual geographic access for members with a dental visit during Year 1: Among DWP members with a general or pediatric dental visit during Year 1, mean distance to the treating dentist was 19 miles, which corresponds to an estimated mean travel time of 25 minutes (Table 6). Mean travel distance for newly enrolled Medicaid adult members was similar 16 miles, or 22 minutes. Page 6

7 Similar proportions of DWP (18%) and Medicaid members (17%) had travel times greater than 40 minutes approximately 18% of DWP members compared with 17% of Medicaid members (Figure 14). Public safety net availability 133 dentists in public safety net locations were active DWP providers during Year 1, compared with 109 dentists who provided services to the Medicaid comparison population. Comparison of overlap by safety net site showed similar geographic distribution of DWP and Medicaid providers. However, DWP providers provided care in several Illinois community health centers where Medicaid services were not performed (Table 7). Page 7

8 Background Iowa Health and Wellness Plan The Iowa Health and Wellness Plan (IHAWP), implemented January 1,, expands coverage for low income adults in Iowa with incomes 0 to 133% of the Federal Poverty Level (FPL) who are not otherwise eligible for Medicaid or Medicare. The IHAWP provides coverage through two new programs: the Iowa Wellness Plan and Iowa Marketplace Choice. All members of the IHAWP receive dental benefits through the Iowa Dental Wellness Plan. The Wellness Plan covers adults aged 19 to 64 with incomes up to and including 100% of the FPL. The Wellness Plan is administered by the Iowa Medicaid Enterprise (IME) and members have the option to enroll in a managed care or a fee-for-service program. The Marketplace Choice Plan covers adults aged 19 to 64 with incomes from 101 to 133% of the FPL. Members could choose from two commercial health plans available on the health insurance marketplace, with Medicaid paying the member s premiums. However, CoOportunity Health one of the two commercial health plans withdrew from the IHAWP at the end of November. CoOportunity members were automatically transitioned to the Wellness Plan, but maintained their designation as MarketPlace Choice members. Dental Wellness Plan The Iowa Dental Wellness Plan (DWP), implemented May 1,, is administered by Delta Dental of Iowa (DDIA). The DWP is a fee-for-service plan, with IME making capitated payments to DDIA for administration of the plan. The DWP includes an earned benefits structure (Figure 1) to encourage healthy behaviors, including routine preventive dental care. All DWP members are eligible for Core benefits upon enrollment, which include emergency and stabilization services. If they return for a periodic dental recall exam within 6 to 12 months of the initial exam, members become eligible for Enhanced benefits. Enhanced Plus benefits are available after receiving a second recall exam within 6 to 12 months of the first recall. Figure 1. Earned benefits in the Iowa Dental Wellness Plan Page 8

9 Research Methods In this report, we evaluate provider network adequacy for the first year of the DWP, May through April (hereafter, Year 1 ). The DWP is expected to offer members a larger provider network than the adult Medicaid dental provider network by offering higher reimbursement rates and reduced administrative burdens as compared with the traditional Medicaid program. This report assessed two main components of provider network adequacy: Dentist supply measures Distance measures These two components reflect spatial accessibility, or potential physical accessibility, to dental care. 2 This report addresses Hypothesis 5.1 of the University of Iowa Public Policy Center s evaluation of the Iowa Dental Wellness Plan: DWP Members will have better access to an adequate provider network than those in the Medicaid State Plan as reflected by travel distance and time, access to safety net providers, and provider acceptance of new patients. Two measures are associated with this hypothesis: Measure 28: Travel distance and travel time to regular dentist Measure 29: Provider network inclusion of safety net dental providers, particularly FQHCs Additional components of the DWP evaluation include consumer surveys, which assess members perspectives about access to dental care, and provider surveys, which include questions about the extent to which dentists accept DWP patients into their practices. Study populations Dental Wellness Plan Members DWP provides dental coverage for all low income members enrolled in IHAWP. This population includes adults aged 19 to 64 with income between 0 and 133% of the Federal Poverty Level (FPL) who are not otherwise eligible for Medicaid or Medicare. Dental benefits in DWP are provided by a network of dentists recruited specifically for this program. DWP dental benefit structures are the same for all IHAWP members, irrespective of their type of plan. The study population for this evaluation included individuals enrolled in DWP for at least 1 month during Year 1 of program implementation. Comparison Group: Medicaid State Plan Members Two distinct Medicaid groups were used for network adequacy comparisons: Comparison group 1: The first comparison group includes all adult (19-64 years) noninstitutionalized Medicaid enrollees with at least 1 month of enrollment during Year 1. This study population was limited to members with a valid address on file. This population was chosen to evaluate the question What is participating provider availability at the state and county levels? Dental care for Medicaid enrollees is provided through a fee-for-service state run program. The benefits and payments structures for the provision of dental care are the same for all Medicaid State Plan members. The non-institutionalized adult Medicaid population includes members eligible through income or disability determination (i.e. Supplemental Security Income, Medicaid for Employed People with Disabilities, and FMAP populations). 2 Guagliardo MF (2004). Spatial accessibility of primary care: concepts, methods and challenges. International Journal of Health Geographics. 3(3):1-13. Page 9

10 Comparison group 2: From comparison group 1, we identified all newly enrolled Medicaid FMAP members. This subset of the first comparison group was used to compare travel outcomes with the DWP population. Members were considered to be newly enrolled if they had no Medicaid coverage for at least 6 months prior to their enrollment during Year 1. This population was chosen as a comparison group because newly eligible members are expected to be the most similar to the DWP population in terms of pent-up demand for dental care; they are also expected to face similar challenges finding a dentist who accepts their coverage. This allowed us to assess the research question How far do newly enrolled members have to travel to reach the nearest active primary care dentist? Provider inclusion criteria DWP Providers Network providers are defined by DDIA. A list of DWP participating providers from DDIA identified monthly status of individual dentists throughout Year 1. Participating providers include all dentists who have a current contract with DDIA. Participating providers are further distinguished based on whether or not they currently accept new DWP patients into their practices; per DDIA, this information is voluntarily self-reported. Active providers are defined for this report based on claim activity and include all dentists who were paid for any services to DDIA on behalf of at least one DWP member during Year 1. Medicaid Providers Dentists were identified as active Medicaid providers if they had submitted at least one claim to Iowa Medicaid Enterprise on behalf of a Medicaid-enrolled adult (comparison group 1) during Year 1. Dentist supply calculations Individual dentists were identified by unique identifiers in the DWP dataset and by National Provider Identifier (NPI) in the Medicaid datasets. Practice locations were identified based on unique street address and city. Dentist supply measures at the state and program levels represent counts of unique dentists. County level supply measures for dental specialists represent counts of unique provider/practice location pairings, or points of access. For example, a dentists with two practice locations, each in a different county, will be counted twice one for each unique practice location. General dentist-to-population ratios County supply measures of primary care dentists are expressed as FTE dentist-to-population ratios and calculated as the number of primary care dentists in private practice per 1,000 FTE members of DWP or Medicaid. These measures were adjusted to account for dentists with multiple practice locations, which are frequently located in multiple counties. Due to the lack of information about how individual dentists split time between multiple practices, we assumed that dentists worked equivalently at each practice location. For example, a dentist with two practice locations was assumed to work 50%, or 0.5 FTE, at each site. Dentist-to-population ratios for the Medicaid population included all non-institutionalized adult members (comparison group 1), which served to adjust dentist ratios to more accurately reflect the total adult Medicaid population served by these dentists. Geocoding Provider and member addresses were geocoded to the street address level. Address data were cleaned prior to geocoding. Members with addresses that could not be geocoded to street address level were estimated to the city/state level to the extent possible. Approximately 91% of Medicaid enrollees and 89% of DWP enrollees with estimated residential locations were located outside of incorporated areas of Iowa. Providers with addresses out of Iowa were considered for this evaluation; however, members with out of state addresses were omitted. Page 10 Geocoding was carried out in multiple steps. Locations were initially geocoded using an address locator created in ESRI ArcMap 10.3 using the North American Detailed Streets dataset maintained by ESRI. Addresses incorrectly located or not located after this process were located using a combination of Google Maps geocoding API and Open Street Map geocoding API. The Google Maps

11 API is fast and accurate, but has 24 hour period query limits. When limits were reached, the Open Street Map API was employed to geocode the remaining locations. Sample sizes noted throughout the report may vary due to loss in the process of geocoding members addresses. Distance calculations Nearest primary care dentist: Travel distance to the nearest primary care dentist (i.e. general or pediatric dentist, as appropriate) was calculated for DWP and Medicaid members (Figure 2). The newly enrolled Medicaid FMAP population (ages 19-64) was used as a comparison group (comparison group 2). Dentists included primary care dentists submitting at least one claim during Year 1 (i.e. active dentists). A network dataset was created using the North American Detailed Streets dataset. An origindestination (OD) cost matrix was used to determine the closest active provider to each member, which calculated travel time (in minutes) and distance (miles) for each member to the closest provider along the fastest travel route on the network using Manhattan distance (e.g., distance based on a grid). This method optimized travel time in order to reflect actual route choice, but may not always result in the shortest travel distance. Treating primary care dentist: For members with a primary care dental visit during Year 1, we calculated distance to the treating dentist (Figure 2). This analysis included DWP and newly enrolled Medicaid FMAP members (comparison group 2) who were enrolled for any length of time during Year 1. All primary care dentists in public and private practice settings were considered for this analysis. Due to computational limitations, we were not able to include out of state providers located >150 miles from the Iowa border; these visits were excluded from analysis. However, services provided by these out of state dentists including dentists in Wyoming, California, etc. are unlikely to be representative of general travel patterns. In cases where members received services from multiple primary care providers, we calculated distance from the most recent visit on file. Figure 2. Calculating distance to nearest and treating primary care dentists Members Distance to nearest PCD *IA and adjacent states Distance to trea:ng PCD *limited to <150 miles of IA border Age <21: PCD includes general and pediatric den:sts Age 21: PCD limited to general dentists only Most recent PCD who submi>ed a claim during Year 1 Public safety net providers For this evaluation, public safety net sites include Federally Qualified Health Centers (FQHCs), non- FQHC Community Health Centers, academic institutions, Indian Health Service clinics, and other non-profit clinics. Provider panel overlap For this report, we were not able to evaluate provider panel overlap. NPI data for many active DWP providers were missing; therefore, we were not able to match providers across the DWP and Medicaid data. Data analysis Univariate and bivariate statistics were calculated using IBM SPSS Statistics 22. Maps were produced Page 11

12 using ESRI ArcMap Member Enrollment and Demographic Characteristics During Year 1, there were 128,540 members enrolled for at least one month in DWP (Table 1). In comparison, there were 169,811 adults enrolled in adult, non-institutionalized Medicaid population for at least one month during Year 1 (comparison group 1). Among the Medicaid comparison group, 2,872 individuals were newly enrolled in that program (comparison group 2). Table 1. Unique members by program, Year 1 Program Members DWP 128,540 Medicaid (comparison group 1) Newly enrolled FMAP (comparison group 2) 169,811 2,872 Monthly enrollment for DWP and Medicaid Comparison Group 1 are shown in Figure 3. Enrollment in DWP rose continuously during Year 1, with 91,835 members enrolled in April. The adult, noninstitutionalized Medicaid population grew slightly over the same time period, with 147,822 members enrolled in April. Figure 3. Monthly enrollment in DWP and Medicaid all enrollees, Year May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 DWP Medicaid Overall, DWP members were more likely to be male and older than the adult Medicaid population (Table 2). Page 12

13 Table 2. Demographic characteristics of DWP and Medicaid members *, Year 1 Characteristic DWP Number (%) Adult Medicaid* Number (%) Sex Female (45.4) (68.0) Male (54.6) (32.0) Race White (62.9) (63.6) Black 9838 (7.7) (9.1) American Indian 1592 (1.2) 1963 (1.2) Asian 2282 (1.8) 2764 (1.6) Hispanic 4619 (3.6) 6473 (3.8) Pacific Islander 680 (0.5) 951 (0.6) Multiple-Hispanic 1107 (0.9) 2185 (1.3) Multiple-Other 801 (0.6) 1418 (0.8) Undeclared (20.8) (18.0) Age years 3890 (3.0) (9.5) years (27.6) (32.4) years (21.7) (25.0) years (20.4) (14.5) 51 and over (27.2) (18.6) County rural/urban status Metropolitan (61.4) (58.3) Non-metropolitan (38.6) (41.7) Total *Comparison group 1 Page 13

14 Dentist Supply Dental Wellness Plan provider network Figure 4 shows the number of general dentists participating in DWP by month and status. Network providers include contracted dentists; network providers are further differentiated by DDIA based on whether or not they currently accept new DWP patients, as reported to DDIA. Non-network providers are non-contracted dentists with approval to treat DWP patients for emergency or access issues. Figure 4. General dentists in the DWP provider network by month May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Network - AccepEng New Pts Network - No New Pts Non-network In April, there were 817 general dentists in the DWP network; 18% (n=150) were identified by DDIA as not accepting new patients. This includes providers in all practice settings (i.e. private practice and public safety net) in any state. At the beginning of Year 1, there were 11 endodontists enrolled in the DWP provider network (Figure 5). By April, this had decreased to 5 providers all located at the University of Iowa College of Dentistry. Page 14

15 Figure 5. Endodontists in the DWP provider network by month May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr Network - Accep@ng New Pts Network - No New Pts Non-network The number of oral surgeons in the DWP provider network increased from 110 in May to 116 in April (Figure 6). Figure 6. Oral surgeons in the DWP provider network by month May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr Network - AccepDng New Pts Network - No New Pts Non-network The number of periodontists in the DWP provider network remained relatively constant, with 15 network providers in each month except for May, when there were 13 (Figure 7). Page 15

16 Figure 7. Periodontists in the DWP provider network by month May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr Network - AccepAng New Pts Network - No New Pts Non-network The number of prosthodontists in the DWP provider network during Year 1 decreased from 23 to 19 (Figure 8). Figure 8. Prosthodontists in the DWP provider network by month May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr Network - AccepBng New Pts Network - No New Pts Non-network Active dentist supply by specialty From May through April, 795 unique dentists submitted at least one paid claim on behalf of DWP members (Table 3). During that same period, 1,176 unique dentists (excluding orthodontists) submitted at least one claim on behalf of adult non-institutionalized Medicaid members (comparison group 1). Orthodontists were excluded from this comparison since orthodontic services are not covered by DWP. Table 3 displays total active dentists by specialty and practice setting. Note that there is some overlap between dentists who work in both private practice settings and safety net settings; these categories are not mutually exclusive. For example, among the 59 oral surgeons who provided care to DWP members during Year 1, 7 dentists provided services in both safety net and private practice settings. Page 16

17 Table 3. Overall dentist availability active dentists in private practice settings *, Year 1 Specialty General Dentists DWP Total Private Practice Safety Net Medicaid* Total Private Practice N (%) N N N (%) N N 703 (88.4%) (90.5%) Endodontists 7 (.9) (.3) 2 2 Oral Surgeons 59 (7.4) (4.9) Pediatric Dentists 7 (.9) (3.1) 32 4 Periodontists 6 (.8) (.6) 3 4 Prosthodontists 13 (1.6) (.6) 0 7 Total Safety Net *Comparison group 1 Locations of active dental specialists are indicated by city in Figure 8; these maps do not indicate relative number of each specialist, only locations where these providers can be found. Page 17

18 Figure 9. Locations of active DWP and Medicaid dental specialists, Year 1 County level supply of active primary care dentists Primary care dentist FTEs (Table 4) were calculated based on the proportion of each dentist s clinic addresses located in each county. For example, if a dentist had 2 addresses, each located in a different county, they were assigned 0.5 FTE per county. Thirty-two primary care dentists in the DWP sample and 35 dentists in the Medicaid sample had clinic addresses in more than 1 county. These supply estimates were limited to active providers only. The denominator for each dentist-to-population ratio was the number of FTE members per county, based proportionally on the number of months enrolled during Year 1. For example, a member enrolled for 12 months during Year 1 contributed 1.0 FTE to the denominator. Medicaid ratios are based on comparison group 1. Page 18

19 Table 4. County dentist FTEs and population ratios for primary care dentists all settings *, Year 1 Primary care dentists (FTEs) Primary care dentist FTEs per 1,000 FTE members * DWP Medicaid DWP Medicaid Mean Median Std. Dev Range Percentiles *Comparison group 1 As shown in Table 4, the mean number of active primary care dentist FTEs per county for the DWP population was 7.1, which translates into 9.3 FTE providers per 1,000 FTE members. Although mean number of Medicaid dentist FTEs was slightly higher (10.4), this translates into a comparable dentistto-population ratio, with 9.1 FTE dentists available per 1,000 FTE Medicaid members. Figure 10 displays geographic variation in these county dentist ratios for the DWP and Medicaid populations. Thirteen counties did not have any active primary care providers serving the DWP population during Year 1, including: Allamakee, Clarke, Clay, Greene, Howard, Humboldt, Madison, Monona, Monroe, Pocahontas, Ringgold, Winneshiek, and Worth Counties. In comparison, two counties did not have any active primary care providers serving the adult Medicaid population: Ringgold and Osceola Counties. Dentist to population ratios are listed by county in Appendix A (Table A1). Page 19

20 Figure 10. Active primary care dentist to population ratios, Year 1 Page 20

21 Distance to nearest active primary care dentist Distance to the nearest active primary care dentist (i.e. general or pediatric dentist) was calculated for all DWP members who were enrolled for any length of time during Year 1 (Table 5). All primary care dentists in public and private practice settings who submitted at least 1 claim during Year 1 on behalf of the DWP or Medicaid study populations were considered for this analysis; dentists also included primary care dentists located in other states. Table 5. Distance to the nearest active primary care dentist for DWP and Medicaid members *, Year 1 DWP Medicaid* Mean Median Std. Dev. Distance (miles) Time (minutes) Distance (miles) Time (minutes) Range *Comparison group 2 Mean distance to the nearest active primary care dentist, which included pediatric dentists for individuals <21 years of age, was 4.0 miles for DWP members, with mean travel time of 6.6 minutes. Mean distance to the nearest primary care dentist for comparison group 2 (newly enrolled FMAP members) was slightly less 3.6 miles, although the maximum distance was 36.8 miles compared to 60.7 miles for DWP members. Distributions for travel distance and time to the nearest active primary care dentist are displayed in Figure 11 and Figure 12, respectively. A majority of both DWP and Medicaid members lived within 5 miles or 10 minutes of the nearest active primary care dentist. HRSA designation criteria for dental Health Professional Shortage Areas (HPSAs) consider travel times of more than 40 minutes to dental professionals to be excessively distant or inaccessible. 3 Approximately 1% of DWP members lived more than 40 minutes from the nearest primary care dentist (Figure 11), compared to 0.1% (n=44) of the Medicaid comparison group. 3 HRSA Health Workforce. Dental HPSA Designation Criteria. Available at: designationcriteria/dentalhpsacriteria.html. Accessed: 3/28/16. Page 21

22 Figure 11. Distribution of DWP and Medicaid members by travel distance to the nearest primary care dentist, Year % 80.0% 60.0% 40.0% 20.0% 0.0% 0-5 miles 6-15 miles miles miles >35 miles DWP 77.5% 16.5% 4.7% 1.1% 0.2% Medicaid 78.7% 16.8% 4.3% 0.2% 0.0% Figure 12. Distribution of DWP and Medicaid members by travel time to the nearest primary care, Year % 80.0% 60.0% 40.0% 20.0% 0.0% 0-10 min min min min >40 min DWP 79.1% 11.9% 6.3% 1.9% 0.9% Medicaid 80.2% 12.0% 6.5% 1.4% 0.1% Page 22

23 Distance to Treating Provider For DWP and Medicaid members experiencing a primary care dental visit during Year 1, we calculated distance to treating dentist (Table 6). Among DWP members, mean travel distance was 19.1 miles; mean travel time was 24.6 minutes. Among newly-enrolled Medicaid FMAP members (comparison group 2), mean travel distance was slightly lower 16.3 miles, or 21.6 minutes. Median travel distances and times were equal for both populations 6.3 miles and approximately 10 minutes, indicating that the primary difference lies in the maximum distance/time travelled Table 6. Travel time and distance to treating primary care dentist for DWP and Medicaid members, Year 1 DWP (N=28425) Medicaid* (N=2860) Distance (miles) Time (minutes) Distance (miles) Time (minutes) Mean Median Std. Dev Maximum *Comparison group 2 Note: even though pediatric dentists are included for consideration in this analysis, only 32 DWP members and 3 members from the Medicaid comparison group saw a pediatric dentist for their most recent visit. Distributions for travel distance and time to treating primary care dentist are displayed in Figure 13 and Figure 14, respectively. Among DWP members who saw a primary care dentist during Year 1, 17.2% had travel times of over 40 minutes; this excludes members who saw an out-of-state dentist >150 miles beyond Iowa borders (Figure 13). This is nearly identical to the proportion of Medicaid members who had travel times over 40 minutes (17.1%) (Figure 14). Page 23

24 Figure 13. Distribution of DWP and Medicaid members by travel distance to the treating primary care dentist, Year % 40.0% 20.0% 0.0% 0-5 miles 6-15 miles miles miles >35 miles DWP 48.9% 20.3% 10.5% 5.6% 14.7% Medicaid 48.7% 19.9% 11.0% 6.7% 13.7% Figure 14. Distribution of DWP and Medicaid members by travel time to the treating primary care, Year % 40.0% 20.0% 0.0% 0-10 min min min min >40 min DWP 52.6% 14.2% 9.3% 6.7% 17.2% Medicaid 52.9% 14.4% 8.5% 7.1% 17.1% Page 24

25 Public Safety Net Availability We identified active public safety net providers located at Federally Qualified Health Centers (FQHCs), non-fqhc Community Health Centers, academic institutions, Indian Health Service clinics, and other non-profit clinics. Clinic names and locations of Year 1 active safety net providers are listed in Table 7. Overall, 133 dentists in safety net locations were active DWP providers during Year 1 (Table 7); 47% of these dentists had an affiliation with the University of Iowa College of Dentistry (n=63). By comparison, 109 dentists in safety net locations were active providers for the Medicaid comparison population (Comparison Group 1), which included all adult noninstitutionalized members; 62% of Medicaid safety net providers were affiliated with the University of Iowa College of Dentistry. Page 25

26 Table 7. Active public safety net providers by site, Year 1 Type Site Clinic Name Location DWP Medicaid FQHC Iowa All Care Health Centers Council Bluffs, IA X X Non-FQHC Community Health Center or Non-profit Out of State Community Health Care Inc. Davenport, IA X X Community Health Center of Ft. Dodge Community Health Center of Southern Iowa Community Health Centers of Southeastern Iowa Crescent Community Health Center Peoples Community Health Clinic Primary Health Care Inc. Promise Community Health Center Inc. River Hills Community Health Center Siouxland Community Health Center United Community Health Center Eagle View Community Health System Eagle View Community Health System Community Health Care Inc. Fort Dodge, IA X X Leon, IA X X Burlington, IA Columbus City, IA Dubuque, IA X X Waterloo, IA Clarksville, IA Des Moines, IA Marshalltown, IA Sioux Center, IA X X Ottumwa, IA Richland, IA Centerville, IA Sioux City, IA X X Storm Lake, IA X X Oquawka, IL X X Stronghurst, IL Rock Island, IL East Moline, IL Moline, IL Iowa Broadlawns Medical Center Des Moines, IA X X Out of State St. Luke s Dental Health Center Cedar Rapids, IA Des Moines Health Center Des Moines, IA X X Story County Dental Clinic (Mid-Iowa Community Action) Hancock County Health Department Ames, IA X X Carthage, IL X X X X X X X X X X X Page 26

27 Table 7, continued Dental School Iowa University of Iowa College of Dentistry & Dental Clinics Indian Health Services Clinic Out of State Iowa Out of State UIHC Hospital Dentistry Institute Iowa Central Community College Creighton University Dental Clinic University of Nebraska Medical Center Dental Plan University of Nebraska Medical Center Adult General Dentistry Meskwaki Dental Health Clinic Winnebago Tribe of Nebraska Dental Clinic Iowa City, IA X X Iowa City, IA X X Fort Dodge, IA X Omaha, NE Omaha, NE X Omaha, NE X X Tama, IA X X Winnebago, NE X X Page 27

28 Figure 15. Locations of Active Public Dental Safety Net Sites by DWP and Medicaid Participation, Year 1 Page 28

29 Appendix A Table A1. Active primary care dentist to population ratios by county, Year 1 County Members (FTEs) Primary Care Dentists (FTEs) Primary Care Dentists per 1,000 FTE Members Members (FTEs) Primary Care Dentists (FTEs) Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Primary Care Dentists per 1,000 FTE Members Page 29

30 Table A1, continued Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine Obrien Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Page 30

31 Table A1, continued Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright Page 31