The effects of insurance carrier market power on dentists and patients.

BACKGROUND: Market power among dental insurance carriers is a carrier's ability to reimburse dentists at rates below what would exist in more competitive areas. Competition among carriers for dentists' participation in their networks protects dentists from highly discounted fees. The authors examined the extent to which dental insurance carriers facing less competition increase fee discounts. METHODS: The authors selected a sample of dentists from listings of general practitioners. They identified 219 metropolitan areas and contacted 11,542 dentists in those areas by mail, telephone or both. A total of 8,017 dentists completed surveys (a response rate of 69.46 percent). The authors' key focus was the possible relationship between carrier market power and the size of the fee discount. The authors compared discounts across metropolitan areas with their differing levels of insurance coverage and carrier market shares. RESULTS: Carrier market power was directly related to the sizes of fee discounts. The larger discounts were found where there was significant dental insurance coverage and few carriers providing this coverage. Dentists' net incomes were significantly less in areas with larger fee discounts. CONCLUSIONS AND PRACTICE IMPLICATIONS: Dental insurance carrier market power leads to increased fee discounts. These higher discounts reduce dentists' earnings. Although the larger discounts may result in lower overall patient costs, this patient benefit is temporary. Ultimately, the number of practicing dentists in these communities will decrease as dentists seek improved practicing conditions elsewhere. This reduction will lead to overall fee increases until the earning potential of dentists is restored.

Public dental expenditures and dental visits among children in the U.S., 1996-2004.

OBJECTIVES: Congress created the State Children's Health Insurance Program (SCHIP) in 1997 as an expansion of the Medicaid program to provide health insurance to children whose family income is above the Medicaid eligibility standards-generally up to 200% of the federal poverty level (FPL). This article examines changes in the utilization of dental services during a period of increasing public funding of dental services. METHODS: Public dental expenditure estimates came from the Centers for Medicare & Medicaid Services (CMS), and a breakdown of these expenditures by patient age and income level was based on the Medical Expenditure Panel Survey (MEPS). RESULTS: According to CMS, funding for dental SCHIP and dental SCHIP expansion grew from $0 prior to 1998 to $517 million in 2004. According to the MEPS, between 1996 and 2004 there was an increase in the number and percent of children 2 to 20 years of age who reported a dental visit during the past year. These increases were most notable among children in the 100% to 200% FPL category. Approximately 900,000 more children in this income group visited a dentist in 2003-2004 than in 1996-1997. Children in this income group reported an increase in the amount of mean dental charges paid for by Medicaid and a real increase in mean dental charges per patient from $217 to $310. CONCLUSIONS: Recent increases in the public funding of dental services targeted to children in the 100% to 200% FPL category were related to increased utilization of dental services among these children from 1996 to 2004.

Orthodontic dental patients and expenditures--2004.

INTRODUCTION: In this article, we describe recent trends in the age of patients receiving orthodontic services and look at how expenditures for these services are related to patient age and income level. METHODS: These findings are based on 3 national health expenditure surveys sponsored by the Agency for Healthcare Policy and Research conducted in 1987, 1996, and 2004. RESULTS: Recent increases in the number of patients receiving orthodontic services were largely due to an increase in the overall population. There has been a shift in the age distribution of patients receiving such services. Children 8 to 18 made up a greater percentage of all patients receiving orthodontic services, but there were fewer adult patients aged 19 years and older. CONCLUSIONS: Children 8 to 18 years old made up a larger percentage of patients who received orthodontic services in 2004 compared with 1996 and 1987. The percentage of total dental expenditures of children 8 to 18 for orthodontic services might increase in the future because of less need for restorative services among this segment of the population.

U.S. dental school applicants and enrollees, 2006 and 2007 entering classes.

The number of applicants to dental schools in the United States continues to rise at a double-digit rate, 12 percent from 2005 to 2006 and 14 percent from 2006 to 2007. The number of applicants to the 2006 and 2007 years' entering classes of U.S. dental schools was 12,500 and 13,700, respectively. The number of first-time enrollees (4,600) in 2007 was the highest recorded since 1989. Men continue to comprise the majority of all applicants, 55 percent in 2006 and 53 percent in 2007. However, the percentage of women applicants to each school ranged from a third to more than half. Underrepresented minority (URM) applicants comprised 12 percent of the applicant pools in both 2006 and 2007. For the 2007 entering class, URM enrollees comprised 13 percent of enrollees. As in previous years, in 2007, the largest number of applicants and enrollees came from states that are among the largest in population in the United States: California, Texas, New York, and Florida. Grade point average and Dental Admission Test scores were the highest in more than a decade. More than three out of four of the 2007 first-time, first-year enrollees earned a baccalaureate degree either in biological/life or physical sciences or in health. Regardless of major field of study, the percent rates of enrollment generally exceeded 30 percent, though there were exceptions (e.g., engineering and education). The majority of enrollees to the 2007 entering classes were twenty-two or twenty-three years of age.

U.S. state-supported dental schools: financial projections and implications.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Economic impact of regulating the use of amalgam restorations.

OBJECTIVE: This article estimates the financial impact of a ban on amalgam restorations for selected population groups: the entire population, children, and children and women of childbearing age. METHODS: Using claim and enrollment data from Delta Dental of Michigan, Ohio, and Indiana and the American Dental Association Survey of Dental Services Rendered, we estimated the per capita use and annual rate of change in amalgam restorations for each age, gender, and socioeconomic subgroup. We used population projections to obtain national estimates of amalgam use, and the dental component of the Consumer Price Index to estimate the annual rate of change in fees. We then calculated the number of dental amalgams affected by the regulation, and the fees for each of the years 2005 to 2020. RESULTS: If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion. CONCLUSIONS: An amalgam ban would have a substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease. Based on the available evidence, we believe that state legislatures should seriously consider these effects when contemplating possible restrictions on the use of amalgam restorations.

The urban and rural distribution of dentists, 2000.

BACKGROUND: The authors examine urban and rural variation in the number of dentists in relation to the U.S. population. They focus on the number and distribution of dentists who practice in rural counties. METHODS: The authors divided U.S. counties into categories based on nine rural-urban continuum codes. They based county-level estimates of population on the 2000 census. They based county-level estimates of dentists on the Distribution of Dentists in the U.S. by Region and State, 2000--a report resulting from the annual census of dentists conducted by the American Dental Association. RESULTS: Although dentists were found to be more concentrated in urban areas, 84.7 percentage of the population living in the most rural counties lived in a county with one or more private practice dentists. CONCLUSIONS: Private practice dentists are distributed widely across rural areas and are available to a large proportion of the population living in these areas. PRACTICE IMPLICATIONS: A combination of population and per capita income largely determine the viability of a private dental practice located in a rural area. In areas in which this combination is insufficient, publicly funded or philanthropic programs will be necessary to ensure access to dental services.

Dentist-prescribed drugs and the patients receiving them.

BACKGROUND: Outpatient prescription drugs continue to play an ever-increasing role in health care delivery in the United States. This paper focuses on the drugs prescribed by dentists and the patients who receive those drugs. METHODS: The authors analyzed data from the 2001 Medical Expenditure Panel Survey (MEPS) for the U.S. community-based population. They developed estimates of the total market for prescription drugs related to a dental visit in terms of total number of prescriptions, total expenditures, and sources of payment. Also included are breakdowns by the type of dentist and the therapeutic class of drug prescribed. They also present a model that identifies the patient characteristics that best predict the likelihood of receiving a dental visit related prescription drug. RESULTS: Dental patients who were 18 years and older, African American patients, patients whose education level was less than a college degree, patients whose dental visit frequency was less than twice a year, and patients without medical insurance were most likely to report a prescription drug. CONCLUSION: Respondents' socioeconomic background and other demographic factors were related to the likelihood of receiving a prescription drug related to a dental visit. Patient age was related to the therapeutic class of the drug prescribed. PRACTICE IMPLICATIONS: Patients with fewer than two dental visits per year were more likely to report a dental prescription than patients with at least two visits per year.

Future Organization of Oral Health Services Delivery: From 2012 to 2042.

The United States is currently experiencing a vortex of change in both general health and oral health care delivery, the ultimate outcome of which is still not well understood. The specific focus of this article is to examine the future organization of the oral health services delivery system (OHSDS) in the U.S., with special attention given to the role of large group dental practices (LGDPs) in that future. The article describes the various types of LGDPs and their ability to change the economic characteristics of the OHSDS. Large geographically distributed corporate group dental practices (LGDCGDPs) are the type that may expand their market share to the extent that they could change the economic characteristics of the OHSDS. A wide range of scenarios is used to project the expansion of LGDCGDPs into the future. The scenarios modeled are not intended as predictions but rather to present a range of possible OHSDS market structures that may emerge over the next 30 years. The implications of each scenario for the economic competition within the OHSDS are described. Possible implications of these trends for dental education are also discussed. This article was written as part of the project "Advancing Dental Education in the 21st Century."

The endodontic workforce.

The amount of endodontic care provided in the US requires an understanding of the supply and demand for such care. The supply side includes the number and location of endodontists, type of provider, and productivity. The demand side consists of the changing demographics of the age groups that endodontists predominantly treat along with changes in their dental health. To address these issues, we have compiled and analyzed data from American Dental Association (ADA) with other sources such as US government census data and the National Health and Nutrition Examination Surveys (NHANES). From 1982 to 2002, the supply of endodontists increased at a rate greater than that observed with general practitioners or the other specialty areas. The growth of endodontists in relation to general practitioners is important. The latter are co-providers of endodontic care as well as a primary source for referral of patients to endodontists. Demographic and disease changes are likely to impact the need and demand for endodontic services. Endodontists' patients are generally between the ages of 25 and 64 yrs. Currently, the majority of endodontists' patients are members of the large baby boom generation who in 2000 ranged in age from their late 30s to their late 50s. During the next 20 yrs the Baby Boom generation will be replaced by the numerically smaller Generation-X cohort. This generation has experienced substantially less total caries than baby-boomers and they most likely will have fewer endodontic sequela as they age. A moderating factor that could partially offset the predicted decline in numbers of patients is the increased number of teeth that Generation-Xers are likely to retain. A flexible endodontic workforce strategy must assess the impending demographic and disease trends in relation to future growth rates of both endodontists and general practitioners.

U.S. State-supported dental schools: financial projections and implications.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

A look at allied dental education in the United States.

BACKGROUND: The American Dental Association conducts surveys of educational programs in dental assisting, dental hygiene and dental laboratory technology. The 2002-2003 survey included questions about enrollment, graduates, program information and trends. METHODS: The ADA Survey Center mailed the Survey of Allied Dental Education to 548 program directors of dental assisting, dental hygiene and dental laboratory technology educational programs. They also sent several follow-up notices as a reminder to complete the survey. A 100 percent response rate is mandatory for continued accreditation by the Commission on Dental Accreditation. Association staff members resolved inconsistencies in the data and analyzed them before producing a final report. RESULTS: The number of applications to, first-year enrollment in and number of graduates in dental hygiene and dental assisting educational programs have increased during the last five years. During the same period, the number of applications to, and graduates of, dental laboratory technology educational programs decreased, but first-year enrollment increased slightly. CONCLUSIONS: Results from these surveys help address the concerns of the public and the profession regarding allied dental manpower levels. They also provide information for those interested in applying to individual allied dental educational programs. PRACTICE IMPLICATIONS: Private dental practices employ the majority of graduates of allied dental educational programs. Recent graduates of dental assisting and hygiene programs continue to supply the office staff members needed to support the delivery of dental care.

The impact of concentration in dental insurance markets on dental reimbursement in Minnesota.

The following article has been prepared by the American Dental Association (ADA) at the request of the Minnesota Dental Association (MDA). The article is the culmination of a rigorous national study by the ADA to measure the concentration of dental insurance in major dental marketplaces around the country. Five Metropolitan Statistical Areas (MSA's)from Minnesota were compared to other MSA's around the country. The results of this study are very significant for dentists and dental patients in Minnesota. Minnesota' practicing dental community may find the results of the study to be somewhat disturbing. Nevertheless, the MDA believes that it is important to share the results of this study with MDA members and others in the Minnesota dental community. It is important to consider both the study's short-term ramifications, as well as its long-term implications, as we attempt to better understand Minnesota's dental marketplace. It is also important for MDA members to know that the ADA brought the results of this study as they relate to the Minnesota Dental Marketplace to the appropriate federal agencies. The ADA believed that these agencies might choose to develop it into an anti-trust case. After reviewing the matter and working with the ADA over a long period of time, these agencies decided that they would not proceed with a Minnesota-based anti-trust case; additional information beyond what the ADA was legally able to provide was needed by the federal agencies in order for them to proceed. The MDA will continue to analyze and respond to these dental marketplace developments.

Private practicing endodontists: production of endodontic services and implications for workforce policy.

The methods and techniques used by private practicing endodontists to provide patient care are at the core of endodontic workforce policy. Productivity influences both the amount of care provided and the required number of practicing endodontists in the future. Data was collected from practicing endodontists in order to characterize the technical methods of producing endodontic services. This data was then used to develop a statistical model for use in assessing the national endodontic workforce conditions in the United States. A survey was mailed to a random sample of 2,075 private practicing endodontists in the United States based on membership files from the American Association of Endodontists and the American Dental Association. The overall survey consisted of three means of data collection: (1) a survey about the endodontic practice as a whole; (2) a survey about the endodontist; and (3) patient encounter forms used when collecting detailed endodontic procedure data for a single day in the practice. The model was used to obtain a projection of 4,016 endodontists in the year 2005 and 4,671 practicing endodontists in 2010 required to meet the projected demand for endodontic care. The model and survey data provide valuable information to practicing endodontists for use in identifying critical elements used to render care, how the elements are combined in the practice of endodontics, and the minimum number of endodontists required to provide a given volume of endodontic care.

Predictors of tooth loss in two US adult populations.

OBJECTIVES: This study determines tooth loss rate over a 10-year period and identifies predictors of tooth loss in two separate US adult longitudinal study populations. METHODS: Subjects from the Baltimore Longitudinal Study of Aging (BLSA), consisting of 47 men and 47 women, ages ranging from 30 to 69 years, were compared to subjects from the VA Dental Longitudinal Study (VADLS) in Boston, MA, consisting of 481 men in the same age range. Baseline and follow-up examinations were performed on each cohort over a 10-year period. Using multivariate regression models, significant predictors of tooth loss were identified. RESULTS: A mean rate of tooth loss of 1.5 teeth lost per 10 years was noted in the VADLS cohort compared to 0.6 teeth lost per 10 years in the BLSA (P < .001). Combining subjects from both populations, significant predictors of tooth loss were baseline values of: percent of teeth with restorations, mean probing pocket depth score, age, tobacco use, alcohol consumption, number of teeth present, and male sex. However, the set of significant predictor variables differed between the two populations and sexes. In BLSA men, number of teeth present, percent of teeth with restorations, mean probing pocket depth score, and alcohol consumption, but not age, were significant, while in BLSA women, only age was a significant predictor. CONCLUSIONS: Over a 10-year period, the incidence of tooth loss, the rates of tooth loss, and the predictors of tooth loss were found to vary by population and by sex. These results illustrate the limits of generalizing tooth loss findings across different study cohorts and indicate that there may exist important differences in risk factors for tooth loss among US adult populations.

Recent trends in dental visits and private dental insurance, 1989 and 1999.

BACKGROUND: This article describes recent trends in dental visits and private dental insurance in the United States. METHODS: This study is based on the analyses of data regarding dental visits and private dental insurance among the population 2 years of age or older from the 1989 and 1999 National Health Interview Surveys. RESULTS: Overall, the percentage of the population with a dental visit rose from 57.2 percent in 1989 to 64.1 percent in 1999, while the percentage with private dental insurance fell from 40.5 percent to 35.2 percent. CONCLUSIONS: Although a higher percentage of people with private dental insurance reported having a dental visit than did those without private dental insurance in both years, the increase from 1989 to 1999 in the percentage of those with a visit was larger among the uninsured. PRACTICE IMPLICATIONS: If this trend persists, a smaller portion of practicing dentist's clientele will be insured. This may affect demand for services, as well as front office operations.

Dental visits among Hispanics in the United States, 1999.

BACKGROUND: This article describes dental visits among Hispanics and Hispanic subgroups in the United States. METHODS: This study is based on an analysis of data regarding dental visits among Hispanics two years of age and older from the National Health Interview Survey of 1999. The authors compared the 1999 data with a combined sample from 1978 through 1980. RESULTS: Although the level of dental visits for all Hispanic subgroups increased between the period of 1978 through 1980 and 1999, the level of dental visits was lowest among Mexican-Americans. For Mexican-Americans born outside the United States, the longer they had lived in the United States, the more likely they were to have visited a dentist. CONCLUSIONS: Increases in the utilization of dental services among Hispanics provide some optimism for reductions in the level of untreated oral disease among Hispanics in the future. However, if increases in dental care utilization among Mexican-Americans fail to keep pace with those among other segments of the U.S. population, this population group risks falling further behind. PRACTICE IMPLICATIONS: Hispanic patients will make up a greater percentage of all dental patients in the future. The impact of this growth will vary greatly by state.

The American Dental Association's oral cancer campaign: the impact on consumers and dentists.

BACKGROUND: The ADA conducted a public service campaign in late 2001 to raise awareness of oral cancer and of the dentist's role in early detection. METHODS: To gather information about the impact of this campaign, the ADA undertook two surveys. A telephone survey was conducted among 1,270 adult consumers, and a second survey was mailed to a national sample of 2,500 dentists. RESULTS: The majority of the consumers did not recognize the fact that dentists are responsible for examining their patients for oral cancer and that oral cancer claims more lives than melanoma or cervical cancer. The majority of dentists was aware of the ADA campaign and agreed that it helped raise the public's awareness of oral cancer and the importance of early detection. As a result, more dentists said that they are likely to educate their patients about early detection, adjust their own practice routines to include discussion about the disease, and look more closely for small oral lesions and test them with the brush biopsy test. CONCLUSIONS: The results of the survey of dentists demonstrated that the oral cancer awareness initiative sponsored by the ADA resulted in positive behavioral changes targeted toward the early detection of oral cancer. CLINICAL IMPLICATIONS: Continued efforts to provide health education and health promotion interventions aimed at consumers and dentists invariably will result in the detection of oral cancers at early and curable stages.

Trends in caries among adults 18 to 45 years old.

BACKGROUND: This article focuses on changes in the caries status of adults 18 to 45 years old in the United States during the periods of 1971-1974 (the First National Health and Nutrition Examination Survey, or NHANES I) and 1988-1994 (the Third National Health and Nutrition Examination Survey, or NHANES III). METHODS: Using data from NHANES I and NHANES III, the authors based this study on analyses of data regarding the trends in total caries, untreated caries and filled caries among adults 18 to 45 years old. RESULTS: There was a decrease of 27.26 percent in the total number of carious surfaces among adults aged 18 to 45 years, or a decline from 38.30 surfaces in NHANES I to 27.86 surfaces in NHANES III. The number of untreated caries also declined from 3.64 to 1.82, a decrease of 50.0 percent. CONCLUSIONS: These caries improvements may be associated with birth cohort effects. Young adults 18 to 25 years old in NHANES I grew up before widespread fluoridation, while people the same age in NHANES III grew up when fluoridation and preventive dentistry were more widely available. Practice Implications. The reduction in caries previously demonstrated in children has extended to adults. The impact is a decline in the need for restorative dentistry.

The importance of productivity in estimating need for dentists.

BACKGROUND: Although the number of dentists is an important determinant of supply, other factors also contribute. Technological advancements and well-trained and managed auxiliary personnel affect supply by allowing dentists to produce more dental services per unit of time. METHODS: This article examines trends in dental output, productivity, number of dentists and dental care utilization from 1960 through 1998. The authors estimated growth rates for the entire period and selected subperiods using regression analysis. Growth rates for dentist productivity and per capita utilization are important to estimate the number of active dentists needed in the year 2020. RESULTS: Based on ADA practice survey data, the annual growth rate in dentists' productivity was 1.41 percent from 1960 through 1998. However, productivity grew at different rates during this period. It increased 3.95 percent per year from 1960 to 1974. There was a decline in productivity of 0.13 percent annually from 1974 to 1991. From 1991 to 1998, productivity grew 1.05 percent annually. CONCLUSIONS: Accurate estimates of changes in dentist productivity are important in evaluating the adequacy of the number of dentists to meet the demand for dental services. PRACTICE IMPLICATIONS. Since productivity generally increases over time, failure to account for changes in productivity can lead to an overestimation of the number of dentists required for any given level of demand for dental services.