Medicaid Dental Coverage Survey Analysis

Medicaid Dental Coverage Survey Analysis An evaluation of survey responses whose children are eligible for Medicaid dental coverage Analysis By.. Kevin Robinson Graduate Research Assistant Kennesaw State University Center of Statistics and Analytical Services Survey Design By. Margaret Faso Graduate Student Emory University Rollins School of Public Health Claire Ainsley Pelura Graduate Student Emory University Rollins School of Public Health

PROJECT: CLIENT: OBJECTIVE: Medicaid Dental Coverage Survey Analysis Benevis LLC / Constant Analytics Analyze survey data in order to determine the level of awareness and utilization of Medicaid dental coverage benefits, and identify barriers to both.

EXECUTIVE SUMMARY This study is an evaluation of survey responses provided by parents of children who are eligible for Medicaid dental coverage, with a focus on potential links between awareness of the benefit, and current or intended Medicaid dental utilization. Additionally, the report attempts to identify the barriers to both awareness and utilization. Survey Respondent Profile The 166 respondents in this analysis were surveyed by phone between December 3, 2014 and April 9, 2015. Respondents resided in Texas with at least one child under the age of 18, and all were eligible for Medicaid or CHIP. Most notably, these children had been assigned a dental home, but according to usage data had not actually visited a dentist using their Medicaid benefit (the child may have visited a dentist and not utilized their benefit). Furthermore, the families surveyed were within reasonable distance boundaries (as defined by the state s dental home assignment rules). Therefore, these children were eligible for full Medicaid dental coverage (little/no-cost to the patient/family), were within a reasonable distance and were assigned a dentist however, they had not utilized the dental benefit. Demographic distributions of respondents are shown in Figure 1. A list of cities and counties represented in the study is included in the Appendix in order of frequency. Hispanic 72.3% n=120 Race Distribution White 15.1% n=25 African American 8.4% n=14 Other 4.2% n=7 Under $15,000 33.6% n=43 Household Income $15,000 - $30,000 46.1% n=59 Over $30,000 20.3% n=26 Center for Statistics and Analytical Services 3

Number of Respondents 80 70 60 50 40 30 20 10 0 Age Distribution 72 44 25 21 Under 24yrs. 25-34 yrs. 35-44 yrs. Over 44 yrs. Level of Education Some High School 18.1% n=27 College Degree 16.1% n=24 High School 44.3% n=66 Some College 21.5% n=32 Key Indicators Figure 1: Demographic Distributions of Respondents Based on responses to survey questions, respondents were assigned two key indicators: Intention and Interruption. Intention indicates whether a person, through responses to similar survey questions, exhibits an understanding of the importance of dental hygiene, by consistently communicating a desire and commitment to visiting the dentist at least twice per year. Interruption indicates that, regardless of the respondent s intentions, they report circumstances which affect or have affected their ability to bring their children to the dentist on a regular basis. A critical piece of the analysis focuses on where attention is needed to help educate parents and children of the importance of dental hygiene, and equally important, where relief is needed to help those with good intentions to maintain consistent dental care. Center for Statistics and Analytical Services 4

Summary of Key Findings Key Findings are presented in three categories: Dental Visit Frequency, Public Awareness and Education, and Regional Characteristics. Survey Respondent Profile 71.6% of the respondents were of Hispanic race or ethnicity. The median age of respondents is 33 years old. The median household income is $15,000 - $30,000, with 80% of those responding having an income below $30,000 per year. 66.9% have not had any college education. 71.5% were families with either two parents in the household or a parent with a second caretaker in the household. Dental Visit Frequency While 78.3% of respondents try to bring their children to the dentist every six months, twothirds of them have circumstances which prevent them from meeting these important goals. This means that only 26.5% of those surveyed are able to consistently visit the dentist as frequently as they should. Of those not able to visit as often as they would like, more than half (51.2%) say that finances are the reason they cannot go frequently. Public Awareness and Education Eight respondents (5% of those surveyed), are not insured even though they are eligible for Medicaid; six of those eight say they do not visit the dentist regularly due to financial reasons. Only 12.8% of respondents whose children attend a public school were aware that Texas public schools do not require a dental exam for enrollment. Though Texas does not require a dental exam for admittance into public schools, 63.7% believe it does, and of those, 81.7% believe it is important to visit the dentist twice a year. By contrast, of those who (correctly) believe it is not a requirement, only 65.4% believe semiannual visits are important. Regional Characteristics While 77% of all Texas respondents appear to have satisfactory knowledge of their dental options, three regions Laredo, Lubbock, and Odessa, (representing 46% of respondents in the state), show signs they are lagging behind in public awareness of dental information. Center for Statistics and Analytical Services 5

Findings Dental Visit Frequency When evaluating dental visit tendencies and factors affecting frequency, variables were created to indicate whether or not a person felt it was important to visit the dentist at least twice per year. Those respondents may not have actually visited on a regular basis, but showed good intent, expressing the desire to do so; we refer to those in this study as having Good Intentions. By comparison, if a respondent s answers did not consistently indicate an understanding of the importance of frequent dental visits, they are referred to as having a Lack of Concern. Another important consideration is if the respondent has good intentions, but circumstances have prevented them from consistently visiting the dentist on a regular basis. These occurrences are referred to as Interruptions in this report, and are categorized as Financial, Inconvenience, Fear/Dislike, or Other. Only those with good intentions are considered to have interruptions, with the assumption made that without the circumstance they would consistently visit the dentist. Overall, 78.3% of the respondents feel six month dental visits are important as shown in Figure 2: Are the respondent's intentions regarding dental care at a level consistent with good dental hygiene? Good 78.3% n=130 Lacking 21.7% n=36 Figure 2: Importance of Frequent Dental Visits Center for Statistics and Analytical Services 6

Barriers to Utilization Figure 3 shows that of those who have the good intention of taking their children to the dentist frequently, 66.2% report they have circumstances preventing them from visiting the dentist as frequently as they would like to. Financial circumstances are the reported cause of interruption in 51.2% of those cases, while 27.9% state that inconveniences such as lack of transportation, time conflicts, and difficulty making an appointment, are other significant obstacles (Figure 4). If the respondent has good intentions, have circumstances prevented them from visiting the dentist frequently? Yes 66.2% n=86 No 33.85% n=44 Figure 3: Do circumstances interrupt the ability to visit regularly? What circumstances have prevented respondents with good intentions from visiting the dentist regularly? Financial 51.2% n=44 Transport. / Time Conflicts 27.9% n=24 Other 14.0% n=12 Fear / Dislike 7.0% Figure 4: Types of Interruption to Routine Visits Center for Statistics and Analytical Services 7

From this we can conclude that whether it is due to how important routine visits are to an individual, or if circumstances exist preventing them from taking their children regularly, only 26.5% consistently visit the dentist on a regular basis, as shown below in Figure 5: Dental Visit Behavior in Practice Interrupted 51.8% n=86 Visit Frequently 26.5% n=44 Lack of Concern 21.7% n=36 Figure 5: Intent vs. Practice Center for Statistics and Analytical Services 8

Characteristics Common to Each Behavior Type While Hispanics appear to consider frequent dental visits more important than other races, they also more often report have circumstances preventing them from visiting as often as they would like to. Roughly half of Hispanics blame financial issues for these interruptions, while 29% consider time constraints, lack of transportation, or difficulty making appointments, as the major obstacle. (Figures 6 & 7) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hispanic (n=120) Figure 6: Behavior Tendency by Race White (n=25) Black/African American (n=14) Other (n=7) Visit Frequently Interrupted Lack of Concern *Chi Square statistic: 15.06 p=value: 0.0198 Figure 7: Types of Interruption for Hispanics with Good Intentions Transport. / Time Conflicts 28.8% n=19 Financial 51.5% n= 34 Other 13.6% n=9 Fear / Dislike 6.1% n=4 Center for Statistics and Analytical Services 9

Potential prejudice associated with parent s past experience or a child s negative impression of dentists do not seem to be related to dental visit behavior; in fact, of those reporting a negative impression of dentists within the household, only 13% say it prevents them from visiting the dentist frequently. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 8: Effect of Impression on Behavior Visit Frequently Interrupted Lack of Concern Negative Impression (n=54) No Negative Impression(n=112) *Chi Square statistic: 1.02 p-value: 0.601 Figure 9: Reason for Interruption When Negative Impression Exists Financial 45.2% n=14 Transport. / Time Constraints 19.4% n=6 Fear / Dislike 12.9% n=4 Other 22.6% n=7 Center for Statistics and Analytical Services 10

Similarly, other factors such as income and education are also not predictive of dental visit behavior. Figure 10 shows behavior based on level of education, while Figure 11 shows behavior depending on the household income of the respondent. While at first glance it appears income level might be related to dental visit behavior, when holding race constant, there is clearly no relationship between household income level and behavior. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 10: Behavior by Education Level No College (n=93) Some College (n=32) College Degree (n=24) Visit Frequently Interrupted Lack of Concern *Chi Square statistic: 4.79 p-value: 0.90 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Under $15,000 (n=43) Figure 11: Behavior by Income Level $15,000-$30,000 (n=59) Over $30,000 (n=26) Visit Frequently Interrupted Lack of Concern *Chi Square statistic: 7.93 p-value: 0.09 Center for Statistics and Analytical Services 11

Public Awareness and Education A major focus of the study was to determine the level of public awareness and knowledge about dental services available to them. Overall, most respondents report awareness of available services about the services available, as well as feeling that their dental services are accessible. 93.6% say they understand their dental benefits. 90.4% know who to contact about their dental coverage. 92.2% are able to find the closest dentist office. Respondents answering affirmatively to the three questions above are considered to be knowledgeable about the dental services available to them. 77.1% of all respondents fall into this category. While overall awareness is relatively high, knowledge of dental exam requirements for public schools is not. Texas statutes do not require students to have a dental exam in order to attend public school. (Texas Constitution and Statutes Home, n.d.) When parents of students attending public school were asked about whether their children were required by their school to have a dental exam, 18.5% responded that they didn t know, while almost two-thirds incorrectly believed it was a requirement (Figure 12). Figure 12: Whether Respondents Believe Dental Exams are Required in Public Schools "Yes" 63.7% n=93 "No" 17.8% n=26 "Don't Know" 18.5% n=27 Center for Statistics and Analytical Services 12

Dental Exam Requirements for Public Schools Ironically, it seems that it s a good thing more people don t know the correct answer to that question; of those who correctly believe an exam is not required, only 8% visit the dentist frequently, while 25% of those incorrectly thinking it is required bring their children frequently (Figure 13). Similarly, those mistakenly believing a dental exam is required are 25% more likely to believe semi-annual visits are important (81.7% vs. 65.4%). 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 13: Behavior Based Belief that Dental Exams are Required in Public Schools "Yes" (n=93) "No" (n=26) "Don't Know" (n=27) Visit Frequently Interrupted Lack of Concern Since we have no way of knowing whether or not this affects their behavior, consideration should be given to future studies comparing areas with and without requirements, to determine if this has a significant impact on behavior and attitude towards good dental hygiene. Families Falling Through the Cracks It is concerning for anyone to be eligible for Medicaid dental coverage and not be aware of it, so it is troubling to have eight respondents say their children have no coverage. Making this issue even more compelling is the fact that six of those eight say that they fail to visit the dentist regularly due to financial reasons. In the next section, we examine who these people might be who are falling through the cracks and missing out on this important health benefit available to them. Center for Statistics and Analytical Services 13

Regional Characteristics Since the study was conducted in Texas, an enormous state with many different socioeconomic regions, an attempt was made to determine if some regions performed better or worse than others. These regions were examined to identify any characteristics that might be common to a specific area, and any potential associations to a lack of awareness or utilization in that area. The regions were determined accordingly to the Texas Department of State Health Services Public Health Regions. Due to the low number of respondents from four regions in the northeast corner of the state, as well as the small proportion of Hispanic populations common to them, these regions were consolidated into one. We refer to that region as the Dallas/Ft. Worth region, shown in pink in Figure 14. Regions are named after the most populated city in each region, rather than its regional public health office seat, since names of the office seats might not be as familiar to those outside the state. Laredo was the exception since it had the most respondents of any city, while Corpus Christi, the most populous city in the region, had no respondents. Respondents were from 50 cities and 39 counties throughout the state, with nearly 50% of them from the counties of Hidalgo, El Paso, Webb, Ector, and Harris, while more people responded from El Paso, Laredo, Odessa, and Weslaco, than other cities. Lubbock 14 Dallas/Ft. Worth 17 El Paso 13 Odessa 18 Austin 13 San Antonio 11 Houston 12 Laredo 44 Figure 14: Number of Survey Respondents by Region. Center for Statistics and Analytical Services 14

Race by Region The distribution of race in each region displayed in Figure 15, clearly demonstrates the disparity of racial mixes between the regions. For example, the Laredo region, while by far most heavily represented, also consisted 100% of Hispanics, while by contrast, the Dallas region was the only region without a majority of Hispanic respondents. 50 45 40 35 30 25 20 15 10 5 0 Figure 15: Race Representation by Region Other African American White Hispanic Center for Statistics and Analytical Services 15

Behavior by Region While it is not statistically significant, there does appear to be differences in behavior between different regions; this is largely a product of the racial mix within each region, though it would be imprudent to assume there are no other factors at work. (Figure 16) 100% 90% 80% 70% 60% Figure 16: Behavior by Region 50% 40% 30% Visit Frequently Interrupted Lack of Concern 20% 10% 0% *Chi Square statistic: 14.57 p-value: 0.408 Center for Statistics and Analytical Services 16

Public Knowledge by Region While examining public knowledge at a regional level, it was apparent that three regions in particular were lagging behind the rest of the state: Laredo, Lubbock, and Odessa. These three regions, representing 46% of the respondents, include six of the eight respondents who said they are insured while being eligible for Medicaid. When comparing the proportion of parents knowledgeable about dental services in Figure 17, the same three regions stand out as having a statistically significant lower proportion than the rest of the state 65.8% versus 86.7% respectively. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 17: Knowledgeable About Their Dental Options Laredo-Lubbock-Odessa n=76 *Chi Square statistic: 10.17 p-value: 0.001 Other Regions n=90 No Yes Center for Statistics and Analytical Services 17

Breaking it down further, the same three regions are the only regions in which less than 90% of respondents know who to contact for their dental coverage (Figure 18); moreover, every parent expressing the inability to find the closest dentist office, resides in one of these three regions. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 18: Know Who to Contact about their Dental Coverage Laredo-Lubbock-Odessa n=71 *Chi Square statistic: 7.96 p-value: 0.005 Other Regions n=85 No Yes Center for Statistics and Analytical Services 18

Conclusion This study clearly indicates that while Medicaid dental benefits are helping many lower-income families receive the dental services that are essential to long-term dental health, there are still children falling through the cracks. The survey results reveal that even when parents are assigned a dental home and dental care benefits at little or no cost to them, some are not taking advantage of this valuable service at all, while others are under-utilizing it. Other discoveries associated with these results: 1. Even with Medicaid dental benefits covering all dental costs to the family, parents cite financial hurdles as their key barrier. Possible reasons: a. They may not be aware of the complete financial coverage of the benefit. b. There may be secondary/corollary costs to visiting the dentist, such as transportation or unpaid time off work, which create financial hardship fo them. c. The parent cites this reason because it would be seen by others as the least condemning excuse for someone who has not yet made visiting the dentist a priority for their child. 2. A parent believing that dental visits are required by schools tends to be a strong motivator. This could possibly be due to education efforts which are misinforming parents, but positively affecting behavior. Future studies might be considered to compare behaviors in places where requirements exist with those in which they do not exist, as well as researching whether there is the same effect for other health exam requirements (or lack thereof) in Texas, such as vision and medical. 3. Race is the only significant factor uncovered in the survey which showed a relationship to the level of concern as it applies to dental health. According to the results, Hispanics are more likely put a higher level of importance on frequent dental visits than other races, while African Americans tend to feel it is less important. 4. Factors related to past experience or general attitude towards dentists, are not significantly related how frequently a parent believes a child should visit the dentist, or how frequently they actually take their children to the dentist. 5. There appears to be a higher proportion of people not fully aware of the dental services available to them in the health regions of Texas: Lubbock, Laredo, and Odessa. These regions each have low population densities and very high proportions of Hispanics. Deeper examination might be considered to determine why more people in these regions seem to be uninformed. Center for Statistics and Analytical Services 19

Appendix TABLE A1: CITIES BY FREQUENCY CITY Frequency Percent Cumulative Frequency Cumulative Percent El Paso 13 8.67 13 8.67 Laredo 13 8.67 26 17.33 Odessa 11 7.33 37 24.67 Weslaco 10 6.67 47 31.33 Houston 9 6.00 56 37.33 San Antonio 8 5.33 64 42.67 Amarillo 7 4.67 71 47.33 Killeen 7 4.67 78 52.00 Abilene 5 3.33 83 55.33 Lubbock 5 3.33 88 58.67 42 Others 62 41.33 150 100.00 Center for Statistics and Analytical Services 20

TABLE A2: COUNTIES BY FREQUENCY County Frequency Percent Cumulative Frequency Cumulative Percent Hidalgo 27 18.00 27 18.00 El Paso 13 8.67 40 26.67 Webb 13 8.67 53 35.33 Ector 11 7.33 64 42.67 Harris 9 6.00 73 48.67 Bexar 8 5.33 81 54.00 Bell 7 4.67 88 58.67 Potter 6 4.00 94 62.67 Lubbock 5 3.33 99 66.00 Taylor 5 3.33 104 69.33 29 Others 46 30.67 150 100.00 Center for Statistics and Analytical Services 21

Citations Texas Constitution and Statutes - Home. (n.d.). Education Code. 38.001. Immunization; Requirements; Exceptions. Retrieved from http://www.statutes.legis.state.tx.us/. Center for Statistics and Analytical Services 22