The effect on dental care utilization from transitioning pediatric Medicaid beneficiaries to managed care.

Compared to the fee-for-service (FFS) model, the managed care delivery system has the potential to improve health care management, increase provider accountability, and support better monitoring of health care quality. However, managed care organizations may attempt to control costs by curbing utilization among Medicaid beneficiaries or reducing reimbursement for Medicaid services. It is an empirical question whether managed care increases or decreases utilization of services. Using detailed pediatric public insurance dental claims data from 2016 through 2018, we examined whether the transition from FFS to managed care affects rates of dental care utilization. Between 2016 and 2018, Indiana, Missouri and Nebraska transitioned pediatric Medicaid beneficiaries from public dental fee-for-service programs to private managed care entities. Using an extended two-way fixed-effects estimation framework, we found that dental managed care leads to a decline in dental care utilization, especially when compared to states that maintain FFS provision of Medicaid dental services.

Does Preventive Care Reduce Severe Pediatric Dental Caries?

INTRODUCTION: Tertiary oral health services (caries-related surgery, sedation, and emergency department visits) represent high-cost and ineffective ways to improve a child's oral health. We measured the impact of increased Texas Medicaid reimbursements for preventive dental care on use of tertiary oral health services. METHODS: We used difference-in-differences models to compare the effect of a policy change among children (≤9 y) enrolled in Medicaid in Texas and Florida. Linear regression models estimated 4 outcomes: preventive care dental visit, dental sedation, emergency department use, and surgical event. RESULTS: Increased preventive care visits led to increased sedation visits (1.7 percentage points, P < .001) and decreased emergency department visits (0.3 percentage points, P < .001) for children aged 9 years or younger. We saw no significant change in dental surgical rates associated with increased preventive dental care reimbursements. CONCLUSION: Increased access to preventive dentistry was not associated with improved long-term oral health of Medicaid-enrolled children. Policies that aim to improve the oral health of children may increase the effectiveness of preventive dentistry by also targeting other social determinants of oral health.

The Relationship between Periodontal Interventions and Healthcare Costs and Utilization. Evidence from an Integrated Dental, Medical, and Pharmacy Commercial Claims Database.

Periodontal disease has been linked to poor glycemic control among individuals with type 2 diabetes. Using integrated dental, medical, and pharmacy commercial claims from Truven MarketScan® Research Databases, we implement inverse probability weighting and doubly robust methods to estimate a relationship between a periodontal intervention and healthcare costs and utilization. Among individuals newly diagnosed with type 2 diabetes, we find that a periodontal intervention is associated with lower total healthcare costs (-$1799), lower total medical costs excluding pharmacy costs (-$1577), and lower total type 2 diabetes-related healthcare costs (-$408). © 2016 The Authors. Health Economics Published by John Wiley & Sons Ltd.

The effect of the Affordable Care Act's expanded coverage policy on access to dental care.

BACKGROUND: The Affordable Care Act included a dependent coverage policy that extends parents' or guardians' health insurance to adults aged 19-25. This policy does not apply directly to private dental benefits. However, for various reasons it could still have an indirect "spillover" effect if employers voluntarily expand dental coverage in conjunction with medical coverage. OBJECTIVE: To assess the effect of the Affordable Care Act's dependent coverage policy on private dental benefits coverage, utilization, and financial barriers to dental care. RESEARCH DESIGN: Difference-in-differences models were used to measure the association between the dependent coverage policy and private dental benefits coverage, utilization, and financial barriers to dental care. We analyze 2008-2012 National Health Interview Survey data, comparing results in 2011 and 2012 with results from 2008 to 2010 (prereform period). SUBJECTS: Adults aged 19-25 were compared with adults aged 26-34. MEASURES: Private dental benefits coverage, dental care utilization, and financial barriers to obtaining needed dental care. RESULTS: Relative to the prereform period, private dental benefits coverage among adults aged 19-25 increased by 5.6 percentage points in 2011 (P<0.001) and 6.9 percentage points in 2012 (P<0.001) compared with adults aged 26-34. Dental care utilization among adults aged 19-25 increased by 2.8 percentage points in 2011 (P=0.062) and 3.3 percentage points in 2012 (P=0.038) compared with adults aged 26-34. Adults aged 19-25 experienced a 2.1 percentage point decrease in 2011 (P=0.068) and a 2.0 percentage point decrease in 2012 (P=0.087) in financial barriers to dental care compared with adults aged 26-34. CONCLUSIONS: The dependent coverage policy was associated with an increase in private dental benefits coverage and dental care utilization, and a decrease in financial barriers to dental care among young adults aged 19-25.

The effect of chairside chronic disease screenings by oral health professionals on health care costs.

OBJECTIVES: We estimated short-term health care cost savings that would result from oral health professionals performing chronic disease screenings. METHODS: We used population data, estimates of chronic disease prevalence, and rates of medication adherence from the literature to estimate cost savings that would result from screening individuals aged 40 years and older who have seen a dentist but not a physician in the last 12 months. We estimated 1-year savings if patients identified during screening in a dental setting were referred to a physician, completed their referral, and started pharmacological treatment. RESULTS: We estimated that medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the health care system from $42.4 million ($13.51 per person screened) to $102.6 million ($32.72 per person screened) over 1 year, dependent on the rate of referral completion from the dental clinic to the physician's office. CONCLUSIONS: Oral health professionals can potentially play a bigger role in detecting chronic disease in the US population. Additional prevention and monitoring activities over the long term could achieve even greater savings and health benefits.

Dentists Who Participate in Medicaid: Who They Are, Where They Locate, How They Practice.

Low utilization of dental services among low-income individuals and racial minorities reflects pervasive inequities in U.S. health care. There is limited research determining common characteristics among dentists who participate in Medicaid or the Children's Health Insurance Program. Using detailed Medicaid claims data and a provider database, we estimate that among dentists with 100 or more pediatric Medicaid patients, 48% practice in high-poverty areas, 10% practice in rural areas, and 29% work in large practices (11 or more dentists). Among those with zero Medicaid patients, 18% practice in high-poverty areas, 4% practice in rural areas, and 11% work in large practices. We found that dentist race/ethnicity has an independent effect on Medicaid participation even when adjusting for community characteristics, meaning non-White dentists are more likely to treat Medicaid patients, regardless of the median income or racial/ethnic profile of the community.

A closer look at disparities in earnings between white and minoritized dentists.

OBJECTIVE: To examine the factors that account for differences in dentist earnings between White and minoritized dentists. DATA SOURCES: We used data from the American Dental Association's Survey of dental practice, which includes information on 2001-2018 dentist net income, practice ZIP code, patient mix between private and public insurance, and dentist gender, age, and year of dental school graduation. We merged the data on dentist race and ethnicity and school of graduation from the American Dental Association masterfile. Based on practice ZIP code, we also merged the data on local area racial and ethnic composition from the American Community Survey. STUDY DESIGN: We used a linear Blinder-Oaxaca decomposition to assess observable characteristics that explain the gap in earnings between White and minoritized dentists. To assess differences in earnings between White and minoritized dentists at different points of the income distribution, we used a re-centered influence function and estimated an unconditional quantile Blinder-Oaxaca decomposition. DATA EXTRACTION METHODS: We extracted data for 22,086 dentists ages 25-85 who worked at least 8 weeks per year and 20 hours per week. PRINCIPAL FINDINGS: Observable characteristics accounted for 58% of the earnings gap between White and Asian dentists, 55% of the gap between White and Hispanic dentists, and 31% of the gap between White and Black dentists. The gap in earnings between White and Asian dentists narrowed at higher quantiles of the income distribution. CONCLUSIONS: Compared to other minoritized dentists, Black dentists have the largest earnings disparities relative to White dentists. While the level of the explained component of the disparity for Black dentists is comparable to the explained part of the disparities for other minoritized dentists, the excess percentage of the unexplained component for Black dentists accounts for the additional amount of disparity that Black dentists experienced. Persistent income disparities could discourage minoritized dentists from entering the profession.

Comparative analysis of dental procedure mix in public and private dental benefits programs.

BACKGROUND: There is little published research on whether public and private dental benefits plans affect the types of oral health care procedures patients receive. This study compares the dental procedure mix by age group (children, working-age adults, older adults), dental benefits type (Medicaid and Children's Health Insurance Program, private), and level of Medicaid dental benefits by state (emergency only, limited, extensive). METHODS: The authors extracted public dental benefits claims data from the 2018 Transformed Medicaid Statistical Information System. To compare procedure mix with beneficiaries who had private dental benefits, the authors used claims data from the 2018 IBM MarketScan dental database. The authors categorized dental procedures into specific service categories and calculated the share of procedures performed within each category. They analyzed procedure mix by age, plan type (fee-for-service, managed care), and adult Medicaid benefit level. RESULTS: Aside from orthodontic services, the dental procedure mix among children with public and private benefits is similar. Among adults with public benefits, surgical interventions make up a higher share of dental procedures than routine preventive services. CONCLUSIONS: Children with public benefits have a procedure mix comparable with those with private benefits. There are substantial differences in procedure mix between publicly and privately insured adults. Even in states that provide extensive dental benefits in Medicaid, those programs primarily finance invasive surgical treatment as opposed to preventive treatment. PRACTICAL IMPLICATIONS: There is a need to assess best practices in publicly funded programs for children and translate those attributes to programs for adults for more equitable benefit design and care delivery across public and private insurers.

Pricing in commercial dental insurance and provider markets.

OBJECTIVE: To examine the impact of commercial dental insurer and provider concentration on dentist reimbursement. DATA SOURCES: We utilized provider data from the American Dental Association, reimbursement data from IBM Watson MarketScan® Commercial Research Databases, submitted billed charges from FAIR Health® , dental insurance market concentration data from FAIR Health® , and county-level demographic and economic data from the Area Health Resources File and the Council for Community and Economic Research. STUDY DESIGN: We used the Herfindahl-Hirschman Index to separately measure commercial dental insurance concentration and dentist concentration. We studied the effect of provider and insurance concentration on dentist reimbursement. Using two-stage least squares, we accounted for potential endogeneity in dental insurer and provider concentration. PRINCIPAL FINDINGS: Across the dental procedures we examined, a 10 percent increase in dental insurance concentration is associated with a 1.95 percent (P-value = .033) reduction in gross payments to dentists. Conversely, a 10 percent increase in dentist concentration is associated with a more modest 0.71 percent (P-value = .024) increase in gross payments. A 10 percent increase in dental insurance concentration is associated with a 1.16 percentage point (P-value = .016) decline in the allowed-to-list price ratio, while a 10 percent increase in dentist concentration is associated with a 0.56 percentage point (P-value = .001) increase in the allowed-to-list price ratio. Similar patterns were found across dental procedure subcategories. CONCLUSIONS: Dental provider markets are substantially less concentrated than insurance markets, which may limit the ability of dentists to garner higher reimbursement.

Consolidation in the dental industry: a closer look at dental payers and providers.

We examine the effect of commercial dental insurance concentration on the size of dental practices, the decision of dentists to own a practice, and the choice of dentists to work at a dental management service organization-a type of corporate group practice that has become more prevalent in the United States in recent years. Using 2013-2015 dentist-level data from the American Dental Association, county-level data on firms and employment from the United States Census, and commercial dental insurance market concentration data from FAIR Health®, we find a modest effect of dental insurance market concentration on the size of dental practices. We also find that a higher level of commercial dental insurance market concentration is associated with a dentist's decision not to own a practice. There is inconclusive evidence that higher levels of dental insurance market concentration impact a dentist's decision to affiliate with a dental management service organization. Overall, our findings imply that dentists consolidate in response to increases in concentration among commercial dental insurers.

Access to primary and dental care among adults newly enrolled in Medicaid.

OBJECTIVES: Adequate access to primary and dental care is essential for population health, and some state Medicaid programs have expanded insurance coverage for both. However, there are few data on new Medicaid enrollees' ability to access services. We examined the relationship between provider supply and enrollees' identification of usual sources of care. STUDY DESIGN: Between November 2015 and February 2016, we surveyed low-income adults newly insured through Medicaid in Philadelphia, Pennsylvania, to determine if they had a usual source of care. Additionally, we used geospatial methods to calculate adult population per provider ratios by Census tract for primary and dental care providers who accepted Medicaid patients, then identified low-supply clusters. METHODS: We used multivariable logistic regression models to describe the odds of identifying usual sources of care based on being in low- or high-supply clusters, adjusting for patient demographics. RESULTS: Of 1000 contacted individuals, 312 completed the survey. Among respondents, 168 were previously uninsured and newly enrolled in Medicaid; 66.7% of this group identified a usual primary care provider and 42.3% identified a usual dental care provider. In adjusted analyses, individuals living in low- and high-supply areas had similar likelihoods of identifying a usual source of primary or dental care. CONCLUSIONS: Many new Medicaid enrollees did not have usual sources of primary or dental care, regardless of nearby provider supply. Efforts to understand what improves access or engagement in healthcare among Medicaid enrollees are critical after low-income adults gain insurance.

Earnings of Employed and Self-employed US Health Care Professionals, 2001 to 2015.

Importance: Over the last 15 years, the health care practitioner landscape has changed significantly. Fewer practitioners are self-employed and more are employed by for-profit or nonprofit organizations. These shifts can have an impact on annual labor earnings. Objectives: To examine trends in self-employment and employment and to assess the gap in annual labor earnings between self-employed and employed US health care professionals from 2001 to 2015. Design, Setting, and Participants: Survey study in which data on employment type (self-employed, employed by private sector, or employed by government) and annual labor earnings for 50 states and the District of Columbia were extracted from the 2001 to 2015 American Community Survey. The analyses were restricted to 175 714 self-identified dentists, physicians, pharmacists, optometrists, podiatrists, chiropractors, and physical therapists aged 30 years and older who worked at least 40 weeks per year and 20 hours per week. Controlling for age, sex, race/ethnicity, year, and state of residence, median regression models were used to measure the gap in annual labor earnings between self-employed and employed health care professionals. Main Outcomes and Measures: Annual labor earnings, defined as the sum of self-employment and wages or salary income. Results: Our sample of 175 714 respondents included 99 077 physicians, 20 008 dentists, 26 143 pharmacists, 4238 optometrists, 6076 chiropractors, 1164 podiatrists, and 19 008 physical therapists. The weighted percentage of self-employed physicians decreased from 35.2% (95% CI, 34.4%-36.1%; 6807 of 18 726 physicians) in 2001 through 2005 to 24.7% (95% CI, 24.2%-25.2%; 10 974 of 41 205 physicians) in 2011 through 2015. The percentage of self-employed dentists decreased from 73.0% (95% CI, 71.2%-74.8%; 3117 of 4153 dentists) in 2001 through 2005 to 65.1% (95% CI, 63.7%-66.4%; 5260 of 7820 dentists) in 2011 through 2015. Among physicians, the regression-adjusted earnings gap reversed from $19 679 (95% CI, $14 431-$24 927; P < .001) during 2001 through 2005 to -$10 623 (95% CI, -$14 547 to -$6699; P < .001) during 2011 through 2015. Among dentists, the regression-adjusted earnings gap narrowed from $30 448 (95% CI, $23 040-$37 855; P < .001) during 2001 through 2005 to $21 291 (95% CI, $15 723-$26 859; P < .001) during 2011 through 2015. From 2001 to 2015 the earnings gap also reversed among pharmacists, optometrists, and podiatrists. The regression-adjusted earnings gap narrowed among chiropractors and physical therapists. Conclusions and Relevance: Since 2001, the percentage of health care professionals who are self-employed declined, and the gap in earnings between self-employed and employed health care professionals narrowed.

The relationship between education debt and career choices in professional programs: The case of dentistry.

BACKGROUND: The authors examined the relationship between education debt and career choice, particularly dentists' decisions to specialize, participate in public health insurance programs, and join dental management service organizations (DMSOs). METHODS: The authors used data from the American Dental Association 2015 office database, which contains dentist demographic information and identifies dentists who participate in public health insurance programs for pediatric dental care services. The authors merged this database with the 2002-2015 American Dental Association Survey of Dental Graduates, which contains information about education debt, to assess the relationship between education debt and career choices. The authors used probit and multinomial logit models to determine the relationships among education debt, demographic characteristics, and dentist career choices. RESULTS: For each $10,000 increase in education debt, dentists were 0.9% more likely to join a DMSO (relative risk ratio, 1.009; 95% confidence interval, 1.0021 to 1.0164) and 0.6% less likely to join a non-DMSO group practice (relative risk ratio, 0.994; 95% confidence interval, 0.9897 to 0.9987) over a solo practice. Education debt did not have a statistically significant association with the decision to participate in public health insurance programs, but it did have a statistically significant association with the decision to specialize. CONCLUSIONS: Education debt had a modest association with some career choices among dentists. Demographic characteristics, such as race and sex, had a greater association. PRACTICAL IMPLICATIONS: Dental education debt has increased substantially in recent years. Debt had only a modest association with some career choices. Policy makers could consider this when considering education debt relief.

The impact of the affordable care act's Medicaid expansion on dental care use through 2016.

OBJECTIVE: To examine the impact of the Affordable Care Act on dental care use among low-income adults ages 21-64. METHODS: Our analysis uses national survey data from the 2010-2016 Gallup Wellbeing-Index. We use a differences-in-differences analysis to assess changes since the end of 2013 in dental care use among low-income adults. We compare changes in states that expanded Medicaid and offer adult Medicaid dental benefits versus changes in other states. RESULTS: Relative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased 3-6 percentage points in 2016. CONCLUSIONS: In Medicaid expansion states with adult dental benefits, evidence suggests that low-income adults have greater access to dental care.

Dental plan premiums in the Affordable Care Act marketplaces trended downward from 2014 through 2016.

BACKGROUND: Pediatric dental benefits must be offered in the health insurance marketplaces created under the Affordable Care Act. The authors analyzed trends over time in premiums and the number of dental insurers participating in the marketplaces. METHODS: The authors collected dental benefit plan data from 35 states participating in the federally facilitated marketplaces in 2014, 2015, and 2016. For each county, they counted the number of issuers offering stand-alone dental plans (SADPs) and medical plans with embedded pediatric dental benefits. They also analyzed trends in premiums. RESULTS: From 2014 through 2016, the number of issuers of stand-alone dental plans and medical plans with embedded pediatric dental benefits either did not change or increased in most counties. Average premiums for low-actuarial-value SADPs declined from 2014 through 2016. CONCLUSIONS: The increase in the number of issuers of stand-alone dental plans and medical plans with embedded dental benefits may be associated with lower premiums. However, more research is needed to determine if this is the case. PRACTICAL IMPLICATIONS: Affordable dental plans in the marketplaces could induce people with lower incomes to sign up for dental benefits. Newly insured people could have significant oral health needs and pent-up demand for dental care.

Early Impact of the Affordable Care Act's Medicaid Expansion on Dental Care Use.

OBJECTIVE: To examine the impact of the Affordable Care Act on dental care use among poor adults ages 21-64 in 2014. DATA: 2010-2014 Gallup-Healthways Wellbeing Index Survey. STUDY DESIGN: Among poor adults with income at or below 138% of the Federal Poverty Level, a differences-in-differences analysis was used to compare the changes in dental care use in states with different Medicaid expansion and adult dental policies. PRINCIPAL FINDINGS: Relative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased between 2 and 6 percent points in the second half of 2014, but most of these changes were not statistically significant. CONCLUSIONS: Early evidence suggests that the Affordable Care Act may either not be having a substantial impact on dental care use or it is too early to assess the impact.

Geographic access to dental care varies in Missouri and Wisconsin.

OBJECTIVE: To examine geographic access to dental providers for the general population and children with public insurance in Missouri and Wisconsin. METHODS: Using a newly constructed dentist office database from the American Dental Association master file and other sources, we use the two-step floating area catchment area method to calculate population to provider ratios at the census block group level. These ratios are used to determine potential geographic dentist shortage areas. We utilize street network data to estimate travel times and catchment areas between population centers and dental offices. This methodology accounts for the actual spatial distribution of dental providers and potential dental patients. RESULTS: Within and across Missouri and Wisconsin, there is some variation in geographic access to dental offices for the general population and publicly insured children. More than 90 percent of publicly insured children have access to dental providers within 30 minutes. Among the states examined, Missouri has more geographic disparities to dental care. CONCLUSION: The Health Resources and Services Administration, which designates dental health professional shortage areas, relies on administrative boundaries to calculate population to dental provider ratios. These boundaries may not reflect actual or "real-time" dental care markets. The methods employed in this paper may give policymakers a template to better determine geographic dentist shortage areas.

The Impact of Medicaid Reform on Children's Dental Care Utilization in Connecticut, Maryland, and Texas.

OBJECTIVE: To measure the impact of Medicaid reforms, in particular increases in Medicaid dental fees in Connecticut, Maryland, and Texas, on access to dental care among Medicaid-eligible children. DATA: 2007 and 2011-2012 National Survey of Children's Health. STUDY DESIGN: Difference-in-differences and triple differences models were used to measure the impact of reforms. PRINCIPAL FINDINGS: Relative to Medicaid-ineligible children and all children from a group of control states, preventive dental care utilization increased among Medicaid-eligible children in Connecticut and Texas. Unmet dental need declined among Medicaid-eligible children in Texas. CONCLUSIONS: Increasing Medicaid dental fees closer to private insurance fee levels has a significant impact on dental care utilization and unmet dental need among Medicaid-eligible children.

A decade in dental care utilization among adults and children (2001-2010).

OBJECTIVE: To decompose the change in pediatric and adult dental care utilization over the last decade. DATA: 2001 through 2010 Medical Expenditure Panel Survey. STUDY DESIGN: The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition. PRINCIPAL FINDINGS: Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p<.05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (-0.018, p<.01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences. CONCLUSIONS: Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.

The effect of growing income disparities on U.S. adults' dental care utilization.

OBJECTIVE: The authors conducted a study to measure the gap in dental care utilization between poor and nonpoor adults at the state level and to show how the gap has changed over time. METHODS: The authors collected data from the 2002, 2004, 2006, 2008 and 2010 Behavioral Risk Factor Surveillance System prevalence and trends database maintained by the Centers for Disease Control and Prevention to measure differences in dental care utilization between poor and nonpoor adults. Poor adults are defined as those at or below the federal poverty threshold. The authors estimated a series of linear probability models to measure the dental care utilization gap between poor and nonpoor adults, while controlling for potentially confounding covariates. RESULTS: In 12 states (Arkansas, California, Florida, Georgia, Illinois, Indiana, Nebraska, Ohio, Oklahoma, South Carolina, Texas and Washington), the gap in dental care utilization between poor and nonpoor adults grew from 2002 through 2010. The remaining states had a stable utilization gap from 2002 through 2010. The study results show that four states (Alaska, Massachusetts, Minnesota, New York) and the District of Columbia had a smaller gap in dental care utilization in 2010 than that in other states. CONCLUSIONS: At the state level, poor adults face greater access barriers to dental care than do nonpoor adults. As states limit dental coverage through Medicaid, poor adults are at greater risk of experiencing poor oral health outcomes. Practical Implications In states that are experiencing increasing inequality in dental care utilization between poor and nonpoor adults, policymakers may wish to explore alternative approaches that could address this situation.