Evaluation of the Dental Wellness Plan: Policy Report. July Community Health Center Experiences after Two Years

Transcription

1 Policy Report July 2017 Evaluation of the Dental Wellness Plan: Community Health Center Experiences after Two Years Julie C. Reynolds Visiting Assistant Professor Jennifer Sukalski Graduate Research Assistant Susan C. McKernan Assistant Professor Brooke McInroy Survey Research Manager Raymond A. Kuthy Professor Peter C. Damiano Director, Public Policy Center Professor, Preventive & Community Dentistry University of Iowa Public Policy Center 209 South Quadrangle, Iowa City, IA O F Page 1

2 Contents List of Tables List of Figures Executive Summary Introduction Methods Key Findings Background... 6 Dental Wellness Plan Eligibility Provider Incentives Provider Network... 7 Methods... 8 Survey Instrument Analyses... 8 Response Rates Limitations... 8 Results 9 Dental Clinic Characteristics Changes in Clinic Operations after DWP Implementation Clinic Participation in DWP Clinic Experiences with DWP Overall Experience with DWP DWP Administration and Coverage DWP Patients Provider Network and Specialist Referral Experience with PreViser Risk Assessment Comparisons with Medicaid Comments about DWP Conclusions Appendix 1: Iowa FQHC Locations Appendix 2: Survey Instrument Page 2 Appendix 3: Descriptive Tables

3 List of Tables Table 1. Mean full-time equivalent (FTE) dental staffing per clinic Table 2. Clinic busyness during the previous 12 months, Table 3. Broken appointment rates over the previous 12 months Table 4. Time to third next available appointment* Table 6. Number of dental operatories in main clinic and satellite clinics, Table 7. Attitudes toward aspects of earned benefits approach Table 8. Difficulty referring DWP patients to the following specialists (n=9) Table 9. Helpfulness of the PreViser risk assessment (n=10) Table 10. Other risk assessment tools use in office Table 11. Open-ended comments about most important change to DWP Table 12. Experience with MCNA, the new DWP benefits carrier Table 13. Additional comments from respondents about the DWP List of Figures Figure 1. Earned benefits through Iowa DWP... 7 Figure 2. Changes made to clinic operations in the last 12 months (n=8) Figure 3. Changes in clinic operations under consideration within the next 12 months (n=8) Figure 4. Rating of administration of DWP (n=11) Figure 5. Rating of patient-related issues as problematic (n=11) Figure 6. Rating of provider network issues as problematic (n=11) Figure 7. Experience towards the PreViser risk assessment (n=10) Figure 8. Rating of DWP administration compared to Medicaid (n=11) Figure 9. Rating of DWP patient-related issues compared to Medicaid (n=11) Page 3

4 Executive Summary Introduction The Dental Wellness Plan (DWP) provides dental benefits for members enrolled in the Iowa Health and Wellness Plan (IHAWP), Iowa s version of the Medicaid expansion and was enacted through bi-partisan legislation to provide comprehensive health care coverage to low income adults. The DWP was implemented on May 1, 2014, and is administered by Delta Dental of Iowa. It has a unique earned benefits structure aimed at encouraging preventive health care-seeking behaviors. Enrollees earn additional covered services when they return for regular periodic recall exams every 6-12 months. The aim of this study was to examine the experiences of Iowa s community health center (CHC) dental clinics during the second year of the Dental Wellness Plan (DWP). Methods In fall 2016, online surveys were administered to directors of all CHC dental clinics in Iowa (n=15), of which 12 completed the survey. Descriptive analyses were conducted for all survey questions. Analyses were conducted using IBM SPSS Version 24. Results from this survey are compared with a previous survey of Iowa CHC dental directors conducted in 2015, when appropriate. Key Findings Dental Clinic Characteristics 12 CHC dental clinics in Iowa employed an average of 2.8 full-time-equivalent (FTE) dentists, 2.8 dental hygienists, and 6.6 FTE dental assistants. One-third of clinics were too busy to treat all patients requesting appointments, whereas two-thirds were able to provide care to all requesting it. Two-thirds of the clinics reported being much busier or somewhat busier when compared to 12 months ago. Clinics mean broken appointment rate over the past 12 months was 21% (range 10-35%, n=12). Five clinics (42%) had a broken appointment rate greater than 20%. Clinic Experiences with DWP DWP Administration and Coverage Administrative issues perceived by a majority of respondents as a major problem were intermittent eligibility, difficulty of eligibility determination, and time spent on paperwork. The administrative issues perceived least problematic were reimbursement rate and slow payment. Six of 11 respondents (55%) reported somewhat positive experiences with the earned benefits structures, whereas 5 (45%) reported somewhat negative experiences. DWP Patients A majority of respondents reported that the following patient-related issues were major problems : complexity of patient dental treatment needs, broken appointments, complexity of past medical history, and patient non-compliance with recommended treatment. Eight of 11 respondents (82%) reported that a lack of local DWP providers was a major problem. Five of 11 respondents (46%) rated specialist referral as a major problem in Experiences with PreViser Risk Assessment Page 4 Ten respondents (91%) reported that their clinics were currently using the PreViser risk assessment. Among clinics currently using the PreViser risk assessment, six clinics (60%) had a somewhat positive experience using it. Four clinics (40%) had a somewhat negative or very negative experience.

5 Comparisons with Medicaid Seven respondents (64%) believed that the difficulty of referring patients to dental specialists was the same in both DWP and Medicaid. When asked how DWP administration compared to Medicaid, the issue most commonly reported as better in DWP was reimbursement rate (n=7). Half or more of respondents rated the following issues as worse in DWP compared to Medicaid: time spent on paperwork, difficulty of eligibility determination, and limited services covered. This analysis of CHC experiences is part of a broader evaluation of the DWP that includes provider adequacy, provider surveys, cost, and outcomes. Page 5

6 Background The aim of this analysis was to examine the experiences of Iowa s community health center (CHC) dental clinics during the second year of the Dental Wellness Plan (DWP). Dental Wellness Plan The DWP is the dental insurance plan for members enrolled in the Iowa Health and Wellness Plan (IHAWP), Iowa s version of the Medicaid expansion. This was sanctioned through bi-partisan legislation to provide comprehensive health care coverage to low-income adults. The IHAWP was implemented on January 1, It replaced the IowaCare program with plans that offer more covered services and a larger provider network. Dental coverage under the IowaCare program included tooth extractions only and they had to be provided at one of two locations in Iowa: University of Iowa Hospitals and Clinics in Iowa City or Broadlawns Dental Clinic in Des Moines. Starting on April 1, 2016, IHAWP members, together with most of the state s traditional Medicaid State Plan (MSP) members, were moved into one of three managed care organizations (MCOs) that manage all physical, behavioral, and long term care services. These MCOs are not responsible for dental care. The DWP was implemented on May 1, From May 2014 through July 2016, Delta Dental of Iowa was the sole dental carrier for the DWP. As of July 2016, MCNA Dental became the second carrier to join the DWP. Both carriers are required to offer the same benefits; however, each carrier maintains a separate network of dental providers. Eligibility IHAWP includes adults aged years with income between 0-133% of the Federal Poverty Level (FPL) who are not otherwise eligible for Medicaid. All IHAWP members are automatically enrolled in the DWP. In year 2 of the program (May 2015-April 2016), 211,012 individuals were enrolled in DWP for at least one month. 1 Dental Benefits in DWP The DWP has a unique earned benefits structure to encourage preventive health care-seeking behaviors. Members earn additional covered services when they return for regular periodic recall exams. All members are eligible for a Core set of benefits upon enrollment that includes emergency and stabilization services. When they return for a periodic recall exam within 6-12 months of an initial comprehensive exam, members become eligible for Enhanced services. After receiving a second recall exam within 6-12 months, members become eligible for Enhanced Plus services. Figure 1 summarizes dental services covered in each earned benefit tier. Page 6 1 McKernan S, Momany E, Ingleshwar A, Ayyagari P, Singhal A, Ghattas A, Damiano P. Access, Utilization & Cost Outcomes: Iowa Dental Wellness Plan Evaluation December University of Iowa Public Policy Center.

7 Figure 1. Earned benefits through Iowa DWP Core (at enrollment) Diagnostic/Preventive Emergency Stabilization Large restorations near pulp Acute periodontal Dentures Endodontic care (following pulpal debridement and exam) Enhanced (After recall in 6-12 mos.) Restorative Non-surgical periodontal Endodontic care Enhanced plus (After 2nd recall in 6-12 mos.) Crown Tooth replacements Periodontal surgery Provider Incentives The DWP also includes several provider incentives. First, provider reimbursement is approximately 50% higher than Medicaid. Second, a Bonus Pool program incentivizes participating DWP general dentists based on the number of exams performed on DWP members. The Bonus Pool for dental specialists is based on the number of unique DWP patients seen. This includes providers working at CHCs. General dentists are only eligible for the Bonus Pool if they complete an online risk assessment form for each new DWP patient and update it annually; providers are also reimbursed on a fee-for-service basis for conducting each risk assessment. When federally qualified health centers (FQHCs) provide care to patients enrolled in traditional Medicaid, they are paid a certain amount per visit (i.e., encounter payments). This is different from private providers who are reimbursed on a fee-for-service (FFS) basis. In the DWP, FQHCs were originally paid FFS for services provided to DWP patients. However, this changed to encounter rate payments in July In addition to the standard encounter rate, FQHCs are paid FFS for completed risk assessments for DWP patients, and are eligible to participate in the Bonus Pool. Provider Network As of May 2016, 822 dentists in Iowa had provided at least one service to DWP members during year 2. By comparison, 1069 dentists had provided at least one service to adult MSP members during year 2. Of the 822 dentists, 146 providers practiced in public safety net sites, including FQHCs, nonfederally qualified CHCs, academic institutions, and Indian Health Service clinics. Page 7

8 Methods In November 2016, online surveys were administered to all CHC dental clinics in Iowa (n=15). Surveys were sent by to one primary recipient and two secondary recipients for each clinic; primary recipients were the dental clinic directors, and secondary recipients were the dental clinic manager and the CHC s chief executive officer (CEO). The inclusion of secondary recipients was a recommendation from the Iowa Primary Care Association in order to help facilitate completion of the survey, which includes information about clinic administration. An introductory was sent 1 week prior to the survey distribution, and two reminder s were sent (one and three weeks after the first). addresses of dental directors were provided by the Iowa Primary Care Association. A map of Iowa CHCs can be found in Appendix 1. Results from this survey are compared with a previous survey of Iowa CHC dental directors. In 2015, the University of Iowa Public Policy Center conducted an online survey of all CHCs in Iowa that provided direct dental services. Several questions from the 2015 survey were included in the 2016 survey to allow comparisons before and after DWP implementation. Survey Instrument Survey questions were either original or adapted from other sources. These sources include the 2013 Public Policy Center survey to Iowa CHC dental directors about the capacity of the public dental safety net (safety net capacity), as well as a 2015 Public Policy Center survey to private practice dentists in Iowa about their experiences with the Dental Wellness Plan. The survey instrument was approved by Iowa Medicaid prior to distribution. A copy of the survey is located in Appendix 2. Analyses Descriptive analyses were conducted for all survey questions. Due to the small respondent group size, no comparative analyses were conducted. Analyses were conducted using IBM SPSS Version 24. Response Rates In total, 12 out of 15 CHCs participated in the survey for an overall response rate of 80%. Nine respondents were federally qualified health centers (FQHCs) and 3 were non-federally qualified CHCs. Six surveys were completed solely by the dental director, 3 solely by the clinic manager, and 3 by a combination of individuals (1 clinic manager + staff dentist, 1 dental director + CFO, 1 dental director + dental clinic manager). Limitations There are several limitations to this study. First, since there are few CHCs in the state of Iowa, our ability to perform analyses beyond descriptive statistics is limited. Second is the potential for recall bias, which may have impacted respondents ability to provide accurate information about events that occurred up to two years prior. Finally, although questions were asked about the overall clinics experiences with the DWP, respondents own personal experiences may have influenced their responses. Page 8

9 Results Dental Clinic Characteristics There were 9 clinics that provided information about dentist, dental hygienist, and dental assistant staffing in both 2015 and Among these, the number of FTE dentists increased in 2 clinics and stayed the same in 7; the number of FTE dental hygienists increased in 7 clinics and stayed the same in 2; and the number of FTE dental assistants increased in 4 clinics, stayed the same in 2, and decreased in 3 clinics. CHC dental clinics employed an average of 2.8 full-time-equivalent (FTE) dentists, 2.8 FTE dental hygienists, and 6.6 FTE dental assistants (Table 1). The number of mean FTE dentists per clinic did not change from 2015 to However, average FTE dental hygienists increased, and FTE dental assistants decreased slightly. Table 1. Mean full-time equivalent (FTE) dental staffing per clinic 2015* N=11 Mean (Range) 2016 N=12 Mean (Range) Dentists 2.8 ( ) 2.8 ( ) Dental hygienists 2.0 ( ) 2.8 ( ) Dental assistants 6.8 ( ) 6.6 ( ) *From 2015 survey of Iowa CHC dental clinics We asked about dental clinics busyness during the past 12 months. One-third were too busy to treat all patients requesting appointments, whereas two-thirds were able to provide care to all requesting it (Table 2). When we asked about the change in clinics busyness over the past 12 months, 3 clinics (25%) were much busier, 5 (42%) were somewhat busier, 3 clinics (25%) had no change in busyness, and 1 clinic (8%) was somewhat less busy. Table 2. Clinic busyness during the previous 12 months, 2016 N(%) Too busy to treat all requesting appointments; sometimes lost patients because it took too long to get an appointment Provided care to all requesting it, but often took a long time to get an appointment Provided care to all requesting it, and could see all patients in a reasonable timeframe 4 (33%) 5 (42%) 3 (25%) Not busy enough, could accommodate more patients 0 Clinic limited, no new patients taken 0 Clinics mean broken appointment rate over the past 12 months remained constant from 2015 (20%, range 7-40%, n=10) to 2016 (21%, range 10-35%, n=12). In 2016, 5 clinics (50%) had a broken appointment rate greater than 20% (Table 3). Broken appointment rates are calculated based on all CHC patients, not only those in DWP. Table 3. Broken appointment rates over the previous 12 months 2015 N=10 N(%) 2016 N=10 N(%) 10% or less 1 (10%) 1 (8%) 11-20% 6 (60%) 6 (50%) 21-30% 2 (20%) 3 (25%) 31-40% 1 (10%) 2 (17%) Page 9

10 Measuring the time until the third next available appointment is a reliable estimate of appointment wait times since it is not subject to last-minute cancellations. The mean time to the third next available appointment at CHC main dental clinics in 2016 was 21 days (range 1-50). This is slightly lower than findings from the 2015 survey in which it was 25 days (range 7-60). In 2016, 4 clinics (34%) reported third next appointment wait times greater than 4 weeks (Table 4). Table 4. Time to third next available appointment* 2015 N=10 N(%) 2016 N=12 N(%) 2 weeks 6 (60%) 5 (42%) 15 days 4 weeks 1 (10%) 3 (25%) 29 days 6 weeks 0 2 (17%) 43 days 8 weeks 1 (10%) 2 (17%) >8 weeks 2 (20%) 0 Changes in Clinic Operations after DWP Implementation Clinics that reported an increase in busyness over the past 12 months were asked what changes they have made, as well as changes they are considering making in the future, to accommodate this increased demand for care. The most common changes that clinics had already made were hiring additional staff; 5 clinics had hired dental hygienists, 5 had hired dental assistants, and 4 had hired general dentists (Figure 2). Similarly, the most common changes clinics are considering making in the future were related to staffing and expanding facilities; 6 clinics were considering hiring dentists, 5 hiring dental assistants, 4 hiring dental hygienists, and 4 were considering expanding existing facilities (Figure 3). Figure 2. Changes made to clinic operations in the last 12 months (n=8) Hire dental hygienists Hire dental assistants 5 5 Hire general dentists 4 Expand existing facilities 3 Add/expand satellite clinic 2 Hire dental specialists Expand the scope of services provided Expand clinic hours Improve referral network None of the above N Page 10

11 Figure 3. Changes in clinic operations under consideration within the next 12 months (n=8) Hire general dentists 6 Hire dental assistants 5 Expand existing facilities Hire dental hygienists 4 4 Expand clinic hours 3 Hire dental specialists Improve referral network Add/expand satellite clinic Expand the scope of services provided 1 None of the above N Seven (58%) clinics stated that they have one or more satellite dental clinics, in contrast to only three (27%) reported in Table 6 presents numbers of operatories in the main dental clinics and satellite dental clinics. The mean number of operatories was 10.4 among main clinics and 6.0 among satellite clinics. Table 6. Number of dental operatories in main clinic and satellite clinics, 2016 Number of operatories Main Clinic (n=12) N (%) Satellite Clinic (n=7) N (%) (8.3) 4 (57.2) (58.1) 2 (28.6) (8.3) (16.7) 1 (14.3) Above 20 1 (8.3) 0 Clinic Participation in DWP FQHCs are required to accept all patients regardless of ability to pay. However, three respondent CHCs are not federally qualified and may only accept children as patients. Therefore, some may not have experiences with the DWP program. Eleven respondents (92%) reported currently accepting DWP patients. 2 Results presented in this section are limited to the 11 dental clinics that currently accept DWP patients. Clinic Experiences with DWP Overall Experience with DWP All clinics reported that their overall experience with DWP was positive (Figure 3); 2 (18%) reported their overall experience was very positive, and 9 (82%) reported it was somewhat positive. In 2015, 2 respondents (20%) reported a negative overall experience, whereas none did in Although all FQHCs were encouraged by the Iowa Primary Care Association to credential with MCNA, the survey did not confirm whether DWP participation was with Delta Dental of Iowa only or both Delta Dental and MCNA. Page 11

12 DWP Administration and Coverage When asked about clinics experiences with the administration of the DWP, respondents perceived some issues with DWP administration as more concerning than others. Figure 4 shows respondents ratings of the extent to which their clinic experienced each issue as problematic. The three issues perceived by a majority of respondents as a major problem were intermittent eligibility, difficulty of eligibility determination, and time spent on paperwork, The frequency that these issues were rated as major problems remained relatively unchanged from The two issues perceived by the most respondents as no problem were slow payment and reimbursement rate. Figure 4. Rating of administration of DWP (n=11) Major problem Minor problem No problem Not sure/don't know Intermittent eligibility 91% 9% Difficulty of eligibility determination 73% 18% 9% Time spent on paperwork 55% 45% Denial of payment 45% 55% Limited services covered 36% 46% 18% Reimbursement rate 67% 33% Slow payment 57% 43% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% When asked about clinics experiences with the earned benefits approach, six respondents (55%) reported somewhat positive experiences, whereas five reported (45%) somewhat negative experiences. Table 7 presents respondents attitudes toward aspects of the earned benefits approach. Eight respondents (73%) agreed that the earned benefits approach would increase the likelihood that patients would return for regular exam. However, eight (73%) also agreed that the earned benefits approach prevents patients from getting the care they need when they need it, and seven (64%) agreed that makes it difficult to provide comprehensive treatment. Table 7. Attitudes toward aspects of earned benefits approach Agree Disagree Not sure/ Don t know Makes it difficult to provide comprehensive treatment to DWP patients, N(%) Will increase the likelihood that patients return for regular exams, N(%) Prevents DWP patients from getting the care they need when they need it, N(%) Will increase the likelihood that patients will take better care of their oral health, N(%) 7 (64%) 4 (36%) 0 8 (73%) 1 (9%) 2 (18%) 8 (73%) 3 (27%) 0 4 (36%) 4 (36%) 3 (27%) Page 12

13 DWP Patients Respondents were asked about their attitudes regarding DWP patient-related issues (Figure 5). A majority of respondents cited patient non-compliance, broken appointments, and dental treatment complexity as major problems among DWP patients. The most cited major problem in 2015 was complexity of patient dental treatment needs, whereas that was less of a major problem in Figure 5. Rating of patient-related issues as problematic (n=11) Major problem Minor problem No problem Broken appointments 73% 27% Patient non-compliance with recommended treatment 73% 27% Complexity of patient dental treatment needs 64% 36% Complexity of patient medical history 46% 36% 18% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Provider Network and Specialist Referral We also asked about attitudes toward DWP provider network issues, including the extent to which a shortage of local DWP providers and referrals to dental specialists were problematic. Eight respondents (82%) reported that a shortage of local DWP providers was a major problem in 2016, whereas only five respondents (50%) had in Five respondents (46%) rated specialist referral similarly as a major problem in 2016, whereas nine respondents (90%) in 2015 (Figure 6). Figure 6. Rating of provider network issues as problematic (n=11) Major problem Minor problem No problem Not sure/don't know Not enough general dentists in area accepting patients with DWP 82% 18% Ability to refer to dental specialists 46% 54% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% When asked whether clinics had difficulty referring their DWP patients to dental specialists, 9 clinics (82%) indicated that they had. When asked which types of specialists were most difficult to refer to, all respondents reported difficulty referring to endodontists (Table 8). Additionally, a majority of respondents reported difficulty referring to periodontists, prosthodontists, and oral surgeons. Page 13

14 Table 8. Difficulty referring DWP patients to the following specialists (n=9) N(%) Endodontists 9 (100%) Periodontists 7 (78%) Prosthodontists 7 (78%) Oral Surgeons 5 (56%) Experience with PreViser Risk Assessment 10 respondents (91%) reported that their clinics were currently using the PreViser risk assessment. Among clinics currently using the PreViser risk assessment, six clinics (60%) had a somewhat positive experience using it, three (30%) had a somewhat negative experience, while one clinic had a very negative experience (Figure 7). The number of clinics reporting positive experience using the PreViser risk assessment represents an increase from 44% in Figure 7. Experience towards the PreViser risk assessment (n=10) Very positive Somewhat positive Somewhat negative Very negative 60% 30% 10% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% We asked about the helpfulness of the PreViser risk assessment in discussing patients oral health and systemic health. For both activities, five respondents (50%) reported that the PreViser risk assessment was somewhat helpful, three respondents (30%) were a little helpful, and 2 (20%) reported not at all helpful (Table 9). This contrasts with the findings in the 2015 survey, in which a majority of respondents (56%) reporting that the PreViser was not at all helpful for each of these activities. Table 9. Helpfulness of the PreViser risk assessment (n=10) Very helpful Somewhat helpful A little helpful Not at all helpful Discussing patients oral health, N(%) 0 5 (50%) 3 (30%) 2 (20%) Discussing patients systemic health, N(%) 0 5 (50%) 3 (30%) 2 (20%) Table 10 presents respondents open-ended comments about other risk assessment tools that clinics use. Comments include caries risk assessment (CRA) for children and tools provided by the American Dental Association (ADA). Page 14

15 Table 10. Other risk assessment tools use in office Caries risk assessment for kids ages 6-9 CRA for children 6 to 12 years Open-ended comments All patients are assessed for risk using a tool provided by ADA ADA Caries Risk assessment Caries risk assessment per ADA for children Comparisons with Medicaid Respondents were asked to compare DWP with Medicaid on several characteristics, including provider network, administration, and patient-related issues. For most issues, the highest proportion of respondents believed they were similar in both DWP and Medicaid. However, 5 respondents (45%) stated that time spent on paperwork was worse in DWP (Figure 8). Figure 8. Rating of DWP administration compared to Medicaid (n=11) Worse Same Better Not sure/don't know Time spent on paperwork 45% 55% Difficulty of eligibility determination 36% 45% 18% Limited services covered 20% 50% 30% Intermittent eligibility 18% 64% 18% Denial of payment 18% 36% 36% 9% Reimbursement rate 50% 40% 10% Slow payment 46% 18% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% For all patient-related issues, seven (64%) or more respondents reported the issues were the same in both programs (Figure 9). Page 15

16 Figure 9. Rating of DWP patient-related issues compared to Medicaid (n=11) Worse Same Better Ability to refer to dental specialists 9% 64% 27% Complexity of patient dental treatment needs 9% 73% 18% Broken appointments 9% 73% 18% Complexity of patient medical history 91% 9% Patient non-compliance with recommended treatment 82% 18% Not enough general dentists in the area accepting patients with the plan 64% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Comments about DWP Respondents were asked to provide open-ended comments about 1) how the DWP could be improved, 2) whether they have had experiences with MCNA, the new DWP dental benefits carrier, and 3) any other thoughts about the DWP (Tables 11-13). Improvement to the PreViser risk assessment was a common theme, as well as concerns with the earned benefits structure. Table 11. Open-ended comments about most important change to DWP What is the most important change that could be made to improve the Dental Wellness Plan? 1) All restorations should be covered in Tier 1 since they tend to get larger within the one year return time.cra needs to be improved for patient education purposes. 2) Allow [scaling and root planning] and non urgent restorative needs to be completed during core benefits including elective extractions and fabrication of dentures and partials as it is a very long wait for patients in need of these services and insurances sometimes get switched mid treatment plan. 3) Allowing dentist to treat disease, instead of managed neglect. Also allowing more than 1 limited/ emergent exam per 12 months. 4) I like the plan. I think the tiered earned benefit model is good for our patients. The main complaint is the switching between plans from month to month. 5) Improvements regarding the services requiring Prior Auths and limitation on services. 6) It is hard to follow the history of a patient and their eligibility when they are switched between Medicaid and DWP. The need for an exam under DWP sometimes creates duplicity of procedures, just to be sure it is documented and covered. (ie. they had a comp exam while on Medicaid but then switched to DWP and exam must be repeated) 7) Previsor should be less cumbersome 8) Removing the restriction of restoring caries of any size, and extracting teeth, within the core benefits. Too many dentists that I have conversed with have voiced frustration with this requirement. Patients have also voiced frustration with having to come in for multiple visits. I do not like to watch decay for 6 months, and in patients that come in infrequently, a area of small caries turns into something much more complex. 9) The requirement of the risk assessment. It is time consuming and dentists feels as though they can make a decision on the patient level of risk without completing the assessment tool. Also, trying to figure out what tier that the patients are on. We have had some issues with patients falling back to the first tier while treatment is being started or that they changed insurance plans in the middle of treatment as well. Page 16

17 Table 12. Experience with MCNA, the new DWP benefits carrier We are interested in comments about experience with MCNA, the new DWP benefits carrier. 1) A lot of gray areas as to allowables and restrictions. Unclearly defines requirements and some requirements are not logical or best practices. 2) Many specialists are refusing MCNA Dental and are taking Delta Dental only. Claims are not getting paid the same way as Medicaid and Delta Dental. X-rays are not paid on the same day as full mouth debridement. 3) MCNA is NOT good. 4) MCNA operates with additional limitation. I would be beneficial if both Delta and MCNA had the same requirements and limitations in order to keep all items needed straight. 5) More preauths are required by both wellness and MCNA compared to Medicaid which requires more time and s and the paperwork part is also more time consuming. 6) We have had less than 10 patients come through so far with this insurance provider. It is too early to determine how they are doing. Table 13. Additional comments from respondents about the DWP Please provide any other comments you may have about the Dental Wellness Plan. 1) DWP has overall been positive due to the population it covers. Previously we were seeing patients on a slide discount that paid below what DWP reimburses at. With these people covered under DWP we have seen improved compliance with treatment, improved oral health, and improved patient satisfaction. We have also been seeing fewer ER referrals indicating that our patients are not seeking care in the ER as frequently. It has also allowed us to keep our doors open by becoming profitable. It is imperative that the DWP plan remain viable for the health of low-income patients in our state. 2) I appreciate the effort that Delta Dental put into the education of the implementation of DWP. They were very comprehensive. I don t feel the same for MCNA and do not have the confidence in the product they offer because of that. 3) It is improving quite a bit over time. Regarding the previous question, we cannot pull out DWP data separately. 8 % of patients are medicare. 4) keep the enhanced levels at least have to put some effort in to come for regular recare appts. Is major benefit over title 19 I would really support the same levels same benefits for title 19 as DWP. When people get anything for nothing, it builds no value for them, so why show up for appt. let alone on time 5) Little things like making sure stabilization is written for core restorations or requiring preauths for things that used to be covered with Medicaid is frustrating because it take time and in a busy practice when you are already stretched thin makes is hard Page 17

18 Conclusions Two-thirds of CHCs reported an increase in clinic busyness over the past 12 months. One-third to one-half of clinics reported hiring different types of dental staff to accommodate increased demand for care; however, there was not a substantial change in the mean number of FTE dental staff members across all clinics from A majority of clinics reported that their overall experiences with the DWP as positive. However, clinics were divided in their overall experiences with certain aspects, such as the earned benefits structure. For example, a majority of clinics reported positive overall experience with the earned benefits structure, and most also agreed that it makes it difficult to provide comprehensive care and prevents DWP patients from getting the care they need when they need it. Among all administrative, patient-related, and provider network-related issues, the issue rated as the most problematic for clinics was intermittent eligibility. 9 out of 10 clinics rated this issue as a major problem; however, a majority believed that it was the same in both Medicaid and DWP. The most important DWP patient-related problems for clinics were broken appointments and patient non-compliance. However, most clinics indicated that these problems were similar in both DWP and Medicaid. Provider network issues were noted as a problem for CHC dental clinics. A large majority (82%) of clinics reported having difficulty referring DWP patients to dental specialists, and a similar proportion believed that a shortage of general dentists who accept DWP was a major problem. A majority of clinics had positive experiences using the PreViser risk assessment, an increase from However, several open-ended comments cited frustrations with the instrument. Some administrative issues were perceived to be worse in DWP compared to Medicaid, and some were perceived to be the same or better. However, most patient-related issues were perceived as the same in both DWP and Medicaid by a majority of respondents. Half or more of respondents rated the following issues as worse in DWP compared to Medicaid: time spent on paperwork and difficulty of eligibility determination. Page 18

19 Appendix 1: Iowa FQHC Locations Appendix 1: Iowa FQHC Locations *Image provided by the Iowa Primary Care Association, Mar This map does not include nonfederally qualified health centers. Page 19

20 Appendix 2: Survey Instrument Iowa Dental Wellness Plan Survey INSTRUCTIONS: Once you begin this survey, you can close it at any time and come back later, starting where you left off. In order for the results of this study to reflect all CHC dental clinics in Iowa, it is important that we hear from you. Several questionnaire items inquire about dental clinic data; if you do not currently have access to the data, please utilize other health center staff to obtain the necessary information. However, if any question asks about information that you are unable to obtain, please skip to the next question. Note: We are interested in your experiences solely with Delta Dental s administration of the DWP. Please do not include experiences regarding the new DWP dental benefits carrier, MCNA. 1. Does your clinic currently accept Dental Wellness Plan patients? 1 2 Yes No IF NO SKIP TO Q14 2. Which best describes your clinic s overall experience with the Dental Wellness Plan? Very positive Somewhat positive Somewhat negative Very negative 3 Page 20

21 EARNED BENEFITS APPROACH The next several questions are regarding the DWP s earned benefits approach, whereby members can earn additional covered benefits (i.e., Core benefits, Enhanced benefits, and Enhanced Plus benefits) by going to the dentist for regular exams, and members who do not return for recall exams every 6-12 months are only eligible for Core Benefits. 3. Based on your clinic s experiences, please indicate the degree to which you agree or disagree with the following statements about the Dental Wellness Plan earned benefits approach: Strongly disagree Disagree Agree Strongly agree Not sure/ Don t know The earned benefits approach has made it difficult to provide comprehensive treatment to DWP patients The earned benefits approach has increased the likelihood that DWP patients return for regular exams The earned benefits approach has prevented DWP patients from getting the care they need when they need it The earned benefits approach has increased the likelihood that DWP patients take better care of their oral health 4. Which best describes your clinic s experiences with the earned benefits approach? Very positive Somewhat positive Somewhat negative Very negative 4 Page 21

22 5. Does your clinic currently use the PreViser risk assessment with any of your DWP patients? 1 o Yes 2 o No è skip to #9 PREVISER RISK ASSESSMENT The PreViser risk assessment is an online risk assessment tool to determine the risk of oral disease of your patients. 6. How helpful is the PreViser risk assessment in facilitating discussions with patients about their oral health? Very helpful Somewhat helpful A little helpful Not at all helpful 7. How helpful is the PreViser risk assessment in facilitating discussions with patients about their systemic health? Very helpful Somewhat helpful A little helpful Not at all helpful 8. Which best describes your clinic s experience with the PreViser risk assessment? Very positive Somewhat positive Somewhat negative Very negative 9. Not counting PreViser, do you use any other risk assessment tools in your office? 1 o Yes, please describe: 2 o No 5 Page 22

23 DWP PROVIDER NETWORK AND ADMINISRTATION 10. Has your clinic had difficulty referring DWP patients to any dental specialists? 1 o Yes 2 o No è skip to # Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply Oral surgeon Periodontist Endodontist Prosthodontist 12. Below are some issues that dentists may have with the administration of dental insurance plans. Please select a number to indicate how much you think that issue is a problem in the Dental Wellness Plan as administered by Delta Dental only (not MCNA). (1 = No problem and 5 = Major problem) Then, please select whether you think the Dental Wellness Plan is better, same, or worse compared to Title 19 on each issue. DENTAL WELLNESS PLAN TITLE 19 No Problem Major Problem Not sure/ Don t know DWP is than Title 19 Not sure/ Don t know a. Time spent on paperwork NS Better Same Worse NS b. Denial of payment NS Better Same Worse NS c. Slow payment NS Better Same Worse NS d. Reimbursement rate NS Better Same Worse NS e. Intermittent eligibility NS Better Same Worse NS f. Difficulty of eligibility determination NS Better Same Worse NS g. Limited services covered NS Better Same Worse NS 6 Page 23

24 13. Below are some patient-related issues that dentists may have with dental insurance plans. Please circle the number to indicate your opinion about the degree to which that issue is a problem in the Dental Wellness Plan, where 1 = No problem and 5 = Major problem. Then, please circle whether you think the Dental Wellness Plan is better, same, or worse compared to Title 19 on each issue. DENTAL WELLNESS PLAN TITLE 19 No Problem Major Problem Not sure/ Don t know DWP is than Title 19 Not sure/ Don t know a. Broken appointments NS Better Same Worse NS b. Complexity of patient medical history NS Better Same Worse NS c. Complexity of patient dental treatment needs NS Better Same Worse NS d. Patient non-compliance with recommended treatment NS Better Same Worse NS e. Not enough general dentists in the area accepting patients with the plan NS Better Same Worse NS f. Ability to refer to dental specialists NS Better Same Worse NS CLINIC CHARACTERISTICS We would like to ask some questions about your dental clinic to identify how, or whether, the Dental Wellness Plan has affected your clinic operations. If you do not have direct access to data for any question in this section, please utilize other health center staff to obtain this information. However, if any question asks about information that you are unable to obtain, please skip to the next question. 14. Does your center have one or more satellite dental clinics? 1 2 Yes No 7 Page 24

25 15. Please indicate the number of staff (as of Nov 1, 2016) at your center for the following types of dental providers employed at your clinic. 1 FTE (full-time equivalent) = 40 hours per week Main Clinic Satellite Clinic(s) Current Staff (FTEs) Current Staff (FTEs) Dentists Dental Hygienists Dental Assistants (chair side) 16. Please indicate the number of dental operatories (as of Nov 1, 2016) at your center. Main Clinic Satellite Clinic(s) Dental operatories 17. How would you best describe your dental clinic(s) during the past 12 months? Too busy to treat all requesting appointments; sometimes lost patients because it took too long to get an appointment Provided care to all requesting it, but often took a long time to get an appointment Provided care to all requesting it, and could see all patients in a reasonable timeframe Not busy enough, could accommodate more patients Clinic limited, no new patients taken 18. Are your dental clinic(s) busier, the same, or less busy compared to 12 months ago? Much busier Somewhat busier No change Somewhat less busy Much less busy 8 Page 25

26 19. [only those who reported much busier or somewhat busier in Q18] What changes have you already made in the last 12 months to accommodate this increased demand for dental care? Select all that apply. Hiring: 01 General dentists 02 Dental specialists 03 Dental hygienists 04 Dental assistants Adding/Expanding: 05 Clinic hours 06 Existing facilities 07 Satellite clinic 08 Referral network 09 Scope of services provided 10 None of the above 20. [only those who reported much busier or somewhat busier in Q18] What changes are you considering making in the following 12 months to accommodate this increased demand for dental care? Select all that apply. Hiring: 01 General dentists 02 Dental specialists 03 Dental hygienists 04 Dental assistants Adding/Expanding: 05 Clinic hours 06 Existing facilities 07 Satellite clinic 08 Referral network 09 Scope of services provided 10 None of the above 21. What is the broken appointment rate for your dental clinic over the past 12 months? % 22. When is your clinic s third next available appointment for a scheduled dental visit? This is the average length of time (in days) between the day a patient makes a request for a dental appointment and the third available appointment for a new patient comprehensive exam or a recall exam. 9 Page 26

27 Main Clinic Satellite Clinic(s) days days 23. Of the total patients seen in your dental clinic in the years 2015 and 2016, approximately what percent had each of the following insurance types? % of Total Patients Medicaid CHIP/hawk-i Dental Wellness Plan Private/Commercial Insurance Uninsured Unknown Status TOTAL 100% 100% 24. What is the most important change that could be made to improve the Dental Wellness Plan? 25. We are interested in comments about your clinic s experiences with MCNA, the new DWP benefits carrier. 26. Please provide any other comments you may have about the Dental Wellness Plan. 10 Page 27

28 27. Please identify the position of the person(s) who completed this survey. Select all that apply Dental director Dental clinic manager CEO CFO Other (write in): You have completed all of the survey questions. Thank you for your participation and your responses will be used to improve the Dental Wellness Plan program. 11 Page 28

29 Appendix 3: Descriptive Tables Q1: Does your clinic currently accept Dental Wellness Plan patients? Yes 11 (91.7) No 1 (8.3) Total Responding 12 Q2: Which best describes your clinic s overall experience with the Dental Wellness Plan? Very positive 2 (18.2) Somewhat positive 9 (81.8) Somewhat negative 0 Very negative 0 Q3_1: Based on your clinic s experiences, please indicate the degree to which you agree or disagree with the following statements about the Dental Wellness Plan earned benefits approach: The earned benefits approach has made it difficult to provide comprehensive treatment to DWP patients Strongly disagree 0 Disagree 4 (36.4) Agree 5 (45.5) Strongly Agree 2 (18.2) Not sure/don t know 0 Total Responding 11 Q3_2: Based on your clinic s experiences, please indicate the degree to which you agree or disagree with the following statements about the Dental Wellness Plan earned benefits approach: The earned benefits approach has increased the likelihood that DWP patients return for regular exams Strongly disagree 0 Page 29

30 Disagree 1 (9.1) Agree 7 (63.6) Strongly Agree 1 (9.1) Not sure/don t know 2 (18.2) Total Responding 11 Q3_3: Based on your clinic s experiences, please indicate the degree to which you agree or disagree with the following statements about the Dental Wellness Plan earned benefits approach: The earned benefits approach has prevented DWP patients from getting the care they need when they need it Strongly disagree 0 Disagree 3 (27.3) Agree 5 (45.5) Strongly Agree 3 (27.3) Not sure/don t know 0 Total Responding 11 Q3_4: Based on your clinic s experiences, please indicate the degree to which you agree or disagree with the following statements about the Dental Wellness Plan earned benefits approach: The earned benefits approach has increased the likelihood that DWP patients take better care of their oral health Strongly disagree 0 Disagree 4 (36.4) Agree 3 (27.3) Page 30

31 Strongly Agree 1 (9.1) Not sure/don t know 3 (27.3) Total Responding 11 Q4: Which best describes your clinic s experience with the earned benefits approach? Very positive 0 Somewhat positive 6 (54.5) Somewhat negative 5 (45.5) Very negative 0 Q5: Does your clinic currently use the PreViser risk assessment with of your DWP patients? Yes 10 (90.9) No 1 (9.1) Q6: How helpful is the PreViser risk assessment in facilitating discussions with patients about their oral health? Very helpful 0 Somewhat helpful 5 (50.0) A little helpful 3 (30.0) Not at all helpful 2 (20.0) Total Responding 10 Q7: How helpful is the PreViser risk assessment in facilitating discussions with patients about their systemic health? Very helpful 0 Somewhat helpful 5 (50.0) A little helpful 3 (30.0) Not at all helpful 2 (20.0) Total Responding 10 Q8: Which best describes your clinic s experience with the PreViser risk assessment? Very positive 0 Page 31

32 Somewhat positive 6 (60.0) Somewhat negative 3 (30.0) Very negative 1 (10.0) Total Responding 10 Q9: Not counting PreViser, do you use any other risk assessment tools in your office? Yes 5 (45.5) No 6 (54.5) Q10: Has your clinic had difficulty referring DWP patients to any dental specialists? Yes 9 (81.8) No 2 (18.2) Q11: Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply. Oral surgeon 5 (56) Periodontist 7 (78) Endodontist 9 (100) Prosthodontist 7 (78) Total Responding 9 Q11_1: Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply. Oral Surgeon 5 (55.6) Not Selected 4 (44.4) Total Responding 9 Missing = 3 Q11_2: Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply. Periodontist 7 (77.8) Page 32

33 Not Selected 2 (22.2) Total Responding 9 Missing = 3 Q11_3: Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply. Endodontist 9 (100) Not Selected 0 Total Responding 9 Missing = 3 Q11_4: Which types of specialists has your clinic had trouble referring DWP patients to? Select all that apply. Prosthodontist 7 (77.8) Not Selected 2 (22.2) Total Responding 9 Missing = 3 Q12_1_a: Below are some issues that dentist may have with the administration of dental insurance plans. Please select a number to indicate how much you think that issue is a problem in the Dental Wellness Plan as administered by Delta Dental only (not MCNA). Time spent on paperwork 1 = No problem (18.2) 3 3 (27.3) 4 4 (36.4) 5 = Major problem 2 (18.2) Not sure/don t know 0 Q12_2_a: Then, please select whether you think the Dental Wellness Plan is better, same, or worse compared to Title 19 on each issue. Time spent on paperwork Page 33