Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

What Does the New Data on Children with Special Health Care Needs Tell Us?

ROHINI SINGH:  Good morning.  Thank you.  In my presentation I'm going to address how we used the National Survey in New Mexico to assess the status of dental care with children with special healthcare needs.  As you probably know, dental care is the most prevalent chronic disease in children and it's of special importance to children with special healthcare needs.  Just so you have some background information, the prevalence of children with special healthcare needs in New Mexico, as determined from this survey, was 11.43 percent.  And that was actually lower than the National estimate, which was surprising because New Mexico uses an estimate of 16 to 18 percent, as I remember, so were a little bit surprised by that.  We used the Federal Poverty Level Guidelines that were given to us to determine who would be potentially eligible for Medicaid and SCHIP, because we know that dental care disproportionately effects children below 200 percent of the Federal Poverty Level.  And as you can see from the slide over 50 percent of children with special healthcare needs from the survey are below 200 percent of the Federal Poverty Level.  From the reported insurance estimates from the Survey, nine percent of families said that they had no insurance coverage, 45 percent said that they had Medicaid or SCHIP, five percent said that they were covered by TITLE V, and a little over 50 percent said that they have private insurance.  And actually from Medicaid estimates, fewer than one in five participants in Medicaid actually take advantage of their dental care coverage, so that's something to keep in mind. 

Children with special healthcare needs are at increased risk for dental caries and other oral health afflictions and that's because some of them are born with oral diseases like cleft lip and cleft pallet and some have ectodermal dysplasia.  And others just by taking their medication, the medication causes gum hypertrophy or dental caries.  Also, the nature of their condition may be severe enough that dentists can't provide the appropriate care or they're not willing to provide the appropriate care because they won't accept Medicaid.  And the reliance on family for daily oral healthcare is also a problem because parents may not prioritize dental care if they have a child with severe needs that has other concerns.  This is just an example of a special oral healthcare need, cleft lip and pallet.  This slide shows the dental health professional shortage areas in New Mexico.  As you can see the darkest counties are the health professional shortage areas and there are 12 counties that have that annotation.  And there are also five that are partial health professional shortage areas.  As for dental care and insurance, 30 percent of children with special healthcare needs without private insurance said that they didn't need healthcare.  And over 90 percent of children with special healthcare needs with private insurance received all the care that they needed, compared to the 76 percent of those that weren't covered by private insurance.  And 86 percent of those with any insurance received dental care compared to 66 percent of those without insurance.  One of the questions on the survey was, "During the past 12 months was there any time when your child needed dental care including check-ups?"  And so this 74 percent of the respondents answered, "Yes," their child needed dental care.  Forty percent of families who claimed that their doctor didn't spend enough time with their child said that they didn't need dental care and 60 percent of families whose provider was never sensitive to their families' customs and values said that they didn't need dental care.  And this just goes to show you the importance of the primary healthcare provider and talking to families and telling them that they need dental care and that they should get it. 

Another question on the survey was, "Did the child receive all the dental care that they needed?"  And to that question, 85 percent answered, "Yes, they received all the care that they needed."  These were some of the variables that we found dental care to be significantly associated with.  Severity of a child's condition, missed school days, care coordination, financial problems, needing hearing aids, and communication aids.  One of the conclusions we came to was that children whose condition is considered severe are less likely to be receiving dental care.  And as you can see from this graph, 90.86 percent of children whose special healthcare needs weren't severe are receiving all the dental care that they need, and less than 80 percent of children with severe needs are getting the healthcare that they needed.  And in doing this analysis I consulted one of the pediatric dentists in New Mexico and he said that one of the reasons for this was probably because children with special healthcare needs include behavioral problems and also other severe needs that dentists might not be as able work with the children with these needs because there are so severe and dentistry is such an interactive field of medicine and they need to speak to their children and get a lot of information from them.  This is a little bit more about severity as it relates to dental care.  About half of the children who needed communication aids and devices aren't receiving the dental care that they needed.  And only three-quarters of children who needed physical, occupational or speech therapy are receiving all the dental care that they needed.  This is an example of how not receiving dental care can effect the quality of a child's life.  As you can see, 71 percent of children who miss 11 or more days of school are receiving all the dental care that they needed, as opposed to 90 percent of those who miss fewer days of school.  Children receiving care coordination are far more likely to be receiving dental care. 

This is a relief because the point of care coordination is to make sure that families are getting all the services that they needed and that the services are cost-effective.  So, it just goes to show you that care coordination is working and paying off when it's actually taken advantage of.  So the take home messages that we arrived at were that there is a low dental IQ in New Mexico for families with children with special healthcare needs.  Families aren't understanding the importance of everyday dental care and check-ups and that needs to be stressed.  There's defiantly a dentist shortage in New Mexico.  We need more pediatric dentists and more dentists that are willing to accept Medicaid.  And socio-economic status is definitely a barrier because families who have difficulties with finances are not going to prioritize dental care.  Our action and policy conclusions were that a Statewide social marketing campaign should begin for dental hygiene and its importance, we should work with primary care providers to make sure that they are encouraging oral health, we should have insurance companies, like Medicaid, better advertise their dental benefits, and also work with Medicaid to improve their reimbursement rates and recruit more pediatric dentists.  These are some of the limitations of this survey.  Under representation of various minority ethnic groups.  That probably explains some of the low prevalence of children with special healthcare needs in our State because we have such a high population without telephones that weren't included.  The lack of geographical data.  We weren't able to distinguish between urban and rural areas. 

The income levels that we received through the survey didn't match with New Mexico income cutoffs.  To qualify for Medicaid or SCHIP in the State, you need to be below 235 percent of the Federal Poverty Level and we only got estimates for 200 percent and 300 percent.  And then self (inaudible) bias and recall bias due to the random digit dial mechanism.  And finally my acknowledgements, Dr. (inaudible), Dr. Wang, Lynn Christenson, Jane Pica, Dr. Lines.  Now I'm done.