Impact of Medicaid dental coverage expansion on self-reported tooth loss in low-income adults

BackgroundLow-income adults delay oral health care due to cost more than any other health care service. These delays lead to caries, periodontal disease, and tooth loss. Expanding Medicaid dental coverage has increased dental visits, but the potential impact on previously unmet oral health needs is not well understood.MethodsIn this analysis, the authors estimated the association between Medicaid dental expansion and tooth loss. Data on self-reported tooth loss among adults below 138% federal poverty guideline were obtained from the Behavioral Risk Factor Surveillance System. A difference-in-differences regression was estimated. Additional analyses stratified according to age and separated extensive and limited dental benefits.ResultsExpanding Medicaid dental coverage is associated with increased probability of total tooth loss of 1 percentage point in the total sample, representing a 20% relative increase from the pre-expansion rate. This increase was concentrated in states offering extensive dental benefits and was largest (2.5-percentage-point greater likelihood) among adults aged 55 through 64 years for whom both extensive and limited dental benefits were associated with total tooth loss.ConclusionsMedicaid expansion with extensive dental benefits was associated with increased total tooth loss among low-income adults. This finding suggests that greater access to oral health care addressed previously unmet oral health needs for this population.Practical ImplicationsAs public dental coverage continues to expand, dental care professionals may find themselves treating a greater number of patients with substantial, previously unmet, oral health needs. Additional research to understand the long-term effects of Medicaid dental insurance for adults on their oral health is needed.     

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

BackgroundThere 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).MethodsThe 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.ResultsAside 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.ConclusionsChildren 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 ImplicationsThere 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.     

The impact of dental Medicaid reform on dental care provider activity and market penetration of dental support organizations

BackgroundMedicaid state dental programs have experienced changes related to provider practice settings with the increased growth of dental support organizations (DSOs). The authors conducted this study to assess the impact of state Medicaid reform on the dental practice environment by examining provider activity and practice setting.MethodsThis was a retrospective cohort study of more than 13 million dental claims in the Virginia Medicaid program. It included children and dental care providers in the Virginia dental Medicaid program at some time during a 9-year period (fiscal years 2003-2011). The independent variable was the provider practice setting: private practice, DSO, and safety-net practice. The outcomes included annual measures of claims, patients, and payments per provider. The outcomes were examined over 3 phases of the study period: prereform (2003-2005), implementation phase (2006-2008), and postreform maturation (2009-2011).ResultsProvider activity increased after dental program reform, with private-practice providers delivering most of the dental care in the Medicaid program. There was a significant penetration of DSO providers in number of providers, claims per provider, and patients per provider (P < .001). Regression results found that providers in DSO settings had an increased number of patients and claims compared with private-practice providers.ConclusionsMedicaid reform has resulted in a significant increase in provider participation and growth of DSO-affiliated providers.Practical ImplicationsAreas of the state with more dense population had a higher penetrance of dentists practicing in DSO settings providing dental services to children enrolled in Medicaid.     

Should Medicaid include adult coverage for preventive dental procedures? What evidence is needed?

BackgroundMedicaid programs may have a salient financial incentive to provide adult coverage for cost-effective preventive dental procedures because they face responsibility for catastrophic costs of dental disease. Whether there is sufficient evidence to support adult Medicaid coverage of preventive dental services is unclear.MethodsUsing an optimal insurance model, the author examines what evidence there is to support coverage of cost-effective preventive dental services in Medicaid and what evidence gaps remain.ResultsThere is insufficient evidence to support adult Medicaid coverage for preventive dental procedures.ConclusionsMore research is needed to identify preventive dental procedures that are cost-effective from a Medicaid perspective, quantify the impact dental prevention has on dental-related health care costs and overall health care costs, and quantify the impact patient-side and provider-side financial incentives have on take-up of specific preventive dental treatments.Practical ImplicationsAlthough Medicaid programs may have an interest in preventing catastrophic costs of dental disease (that is, dental-related emergency department visits), there is insufficient evidence for Medicaid programs to provide coverage for preventive dental procedures.     

Medicaid adult dental benefits and oral health of low-income older adults

BackgroundOlder adults are keeping their natural teeth longer, spurring calls for dental coverage under Medicare. Although Medicare dental coverage would benefit all older adults, the poorest among them are already eligible for dental benefits through Medicaid. The authors examine the association between states’ Medicaid adult dental benefits and dental care use and tooth loss among low-income older adults.MethodsUsing the Behavioral Risk Factor Surveillance System data from 2014, 2016, and 2018, the authors examined adults 65 years or older. The outcomes examined included annual dental visit and partial and complete tooth loss. Poisson regressions were used to obtain risk ratios after adjusting for covariates.ResultsStates’ Medicaid adult dental benefits were significantly associated with dental care use, with low-income older adults in states with no coverage having the lowest probability of visiting a dentist (risk ratio [RR], 0.83; 95% CI, 0.74 to 0.94), followed by emergency-only coverage (RR, 0.91; 95% CI, 0.84 to 0.98) and limited benefits (RR, 0.91; 95% CI, 0.85 to 0.98) relative to states with extensive benefits. There were no significant differences in either partial or complete tooth loss.ConclusionsStates’ Medicaid adult dental benefits are significantly associated with dental visits among low-income seniors. Providing comprehensive dental benefits under Medicaid can improve access to dental care among low-income older adults.Practical ImplicationsAs the older adult patient population grows, the poorest older adults may face barriers to dental care in the absence of dental coverage. Dental professionals must engage in advocating for comprehensive dental coverage, especially for vulnerable populations.     

Evaluating access to pediatric oral health care in the southeastern states

BackgroundIn this article, the authors addressed shortcomings in existing research on pediatric oral health care access using rigorous data and methods for identifying statistically significant disparities in oral health care access for children.MethodsThe study population included children, differentiated by insurance status (Medicaid, Children’s Health Insurance Program, private, none). The authors measured provider-level supply as the number of oral health care visits, stratified by provider type and urbanicity-rurality. The authors defined demand as the number of dental visits for children and derived demand and supply mainly from 2019 and 2020 data. Using statistical modeling, the authors evaluated where disparities in travel distance across communities or by insurance status were statistically significant.ResultsAlthough Dental Health Professional Shortage Areas are primarily rural, this study found that the proportions of rural, suburban, and urban communities identified for access interventions ranged from 24% through 66% and from 8% through 86%, respectively. For some states (Florida, Louisiana, Texas), rural and suburban communities showed a need for interventions for all children, whereas in the remaining states, the lack of Medicaid and Children’s Health Insurance Program access mainly contributed to these disparities. Variations in access disparities with respect to insurance status across states or by urbanicity-rurality were extensive, with the rate of communities identified for reducing disparities ranging from 1% through 100%.ConclusionsAll states showed a need for access interventions and for reducing disparities due to geographic location or insurance status. The sources of disparities were different across states, suggesting need for different policies and interventions across the 10 states.Practical ImplicationsThe study findings support the need for policies toward reducing disparities in oral health care access.     

Trends in use of dental care provider types and services in the United States in 2000-2016: Rural-urban comparisons

BackgroundThe authors conducted a study to assess recent trends in dental care provider mix (type of dental professionals visited) and service mix (types of dental procedures) use in the United States and to assess rural-urban disparities.MethodsData were from the 2000 through 2016 Medical Expenditure Panel Survey. The sample was limited to respondents who reported at least 1 dental visit to a dental professional in the survey year (N = 138,734 adults ≥ 18 years). The authors estimated rates of visiting 3 dental professionals and undergoing 5 dental procedures and assessed the time trends by rural-urban residence and variation within rural areas. Multiple logistic regression was used to assess the association between rural and urban residence and service and provider mix.ResultsA decreasing trend was observed in visiting a general dentist, and an increasing trend was observed in visiting a dental hygienist for both urban and rural residents (trend P values < .001). An increasing trend in having preventive procedures and a decreasing trend in having restorative and oral surgery procedures were observed only for urban residents (trend P values < .001). The combined data for 2000 through 2016 showed that rural residents were less likely to receive diagnostic services (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.72 to 0.93) and preventive services (AOR, 0.87; 95% CI, 0.78 to 0.96), and more likely to receive restorative (AOR, 1.11; 95% CI, 1.02 to 1.21) and oral surgery services (AOR, 1.23; 95% CI, 1.11 to 1.37).ConclusionsAlthough preventive dental services increased while surgical procedures decreased from 2000 through 2016 in the United States, significant oral health care disparities were found between rural and urban residents.Practical ImplicationsThese results of this study may help inform future initiatives to improve oral health in underserved communities. By understanding the types of providers visited and dental services received, US dentists will be better positioned to meet their patients’ oral health needs.     

Secular trends in dental services provided by dental therapists and dentists in Southwest Alaska

BackgroundThe goal of the study was to identify secular trends in dental service delivery between dental therapists and dentists in the Yukon-Kuskokwim Delta region of Southwest Alaska, the first area of the United States to authorize dental therapy practice.MethodsElectronic health record transactions from the Yukon-Kuskokwim Health Corporation from 2006 through 2015 (n = 27,459) were analyzed. Five types of dental services were identified using Current Dental Terminology procedure codes: diagnostic, preventive, restorative, endodontic, and oral surgery. Main outcomes were percentages of services provided by dental therapists compared with dentists and population-level preventive oral health care.ResultsThe overall number of diagnostic, preventive, and restorative services in the Yukon-Kuskokwim Delta increased. For diagnostic services, there was a 3.5% annual decrease observed for dentists and a 4.1% annual increase for dental therapists (P < .001). Similar trends were observed for restorative services. For preventive services, there was no change for dentists (P = .89) and a 4.8% annual increase for dental therapists (P < .001). Dental therapists were more likely than dentists to provide preventive care at the population level.ConclusionsDental therapists have made substantial contributions to the delivery of dental services in Alaska Native communities, particularly for population-based preventive care.Practical ImplicationsThe study’s findings indicate that there is a role for dental therapy practice in addressing poor access to oral health care in underserved communities.     

Persistent but narrowing oral health care inequalities in Canada from 2001 through 2016

BackgroundSimilar to the United States, inequality in oral health care use is longstanding in Canada. It remains unclear whether this inequality is improving or worsening. In this study, the authors report on income-related inequality in dental visits in Canada and across its provinces over time and interprovincial inequality in dental visits among Canadian provinces.MethodsThe authors used 7 nationally representative health surveys of the Canadian population and collected data from 2001 through 2016. The magnitude of income-related inequality was measured using the slope index of inequality and relative index of inequality. Interprovincial inequality was examined using a number of indexes including the Theil index.ResultsIncome-related inequality in dental visits was present in all survey years, with people in higher income groups reporting higher dental visit prevalence rates. However, results from the slope index of inequality and relative index of inequality showed a steady decline, meaning there was a decrease in the magnitude of inequality over time. Absolute and relative inequality decreased by 7.2% and 22.9% from 2000 through 2016, respectively. A similar decline was observed across most Canadian provinces. Interprovincial differences in dental visits also decreased over time.ConclusionsThere appears to be persistent but narrowing income-related inequality in dental visits in Canada and across its provinces over time. In addition, it appears that Canadian provinces are becoming more equal in terms of dental services use.Practical ImplicationsNarrowing income-related inequality in dental visits in Canada is promising, suggesting a more equal distribution of dental visits. However, unequal use of dental services remains an issue affecting the Canadian population.     

Were Patient Protection and Affordable Care Act spillover gains to private dental coverage for dependents widely shared?: An analysis using Medical Expenditure Panel Survey data

BackgroundThe dependent coverage mandate policy of the Patient Protection and Affordable Care Act led to spillover increases in private dental coverage among affected young adults. The authors investigate whether such gains were widely shared across racial or ethnic groups and shared across income levels. The authors further explore the relationship between dental coverage and dental services use stratified by race or ethnicity and income using the mandate as a natural experiment.MethodsUsing nationally representative Medical Expenditure Panel Survey data from 2006 through 2015, the authors used a difference-in-difference regression approach comparing changes in private dental coverage and dental services use for 19- through 25-year-olds affected by the policy with those for unaffected 27- through 30-year-olds. The authors stratified the model by race or ethnicity and income to understand potential differences in the effects of the mandate across these groups.ResultsThe authors found significant increases in private dental coverage across all racial or ethnic groups as well as across higher- and lower-income young adults. However, despite notable increases in private dental coverage, the authors found little evidence of any overall effects on dental services use. The authors did find evidence suggesting an increased relative likelihood of dental visits for 19- through 25-year-old non-Hispanic blacks compared with slightly older non-Hispanic blacks.ConclusionsThe spillover effect of the dependent coverage mandate on private dental coverage was widely shared across racial or ethnic groups and across income levels.Practical ImplicationsAmong young adults aged 19 through 25 years, increases in private dental coverage may not be enough on its own to increase the use of preventive dental services and ultimately lead to improved oral health.     

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits

BackgroundThe goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance’s adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults.MethodsMedicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity.ResultsAdult Medicaid enrollees’ ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%.ConclusionsTesting revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit.Practical ImplicationsAdoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.     

Frequency and pattern of outpatient dental visits during the COVID-19 pandemic at hospital and community clinics

BackgroundThe authors aimed to measure the frequency of dental visits before and during the COVID-19 pandemic and to evaluate whether dental visits can be predicted from demographic characteristics, socioeconomic status, oral problem diagnoses, and dental service providers.MethodsParticipants for this retrospective study were patients visiting dental care providers at hospital- and community-based outpatient clinics in Alberta, Canada. Data were retrieved from electronic databases from March 12, 2020, through September 30, 2020, and from the same period for 2018 and 2019. The COVID-19 lockdown was declared for March 12 through May 14, 2020. Data were analyzed using analysis of variance test and multiple logistic regression at α = 0.05.ResultsFrom a total of 14,319 dental visits, 5,671, 5,036, and 3,612 visits occurred in 2018, 2019, and 2020, respectively. The mean (standard deviation) frequency of daily visits was 36.69 (15.64), 32.09 (15.51), and 24.24 (14.78), respectively. Despite the overall decrease, the frequency of visits for infections, salivary problems, and temporomandibular disorders increased during the COVID-19 pandemic in 2020. Dental visits during the pandemic were associated with more complicated oral diagnoses and dental services as well as higher economic status.ConclusionsDuring the COVID-19 pandemic, the frequency of dental visits decreased specifically during lockdown. Patients with complicated problems requiring urgent treatments mainly visited dental clinics. Reduced access to care was observed primarily among socially disadvantaged groups.Practical ImplicationsAlthough guidelines and related recommendations have been effective in restoring the compromised dental system during the COVID-19 pandemic, additional modifications are needed to promote in-person visits to improve the oral health status of patients.     

Periodontal treatment associated with decreased diabetes mellitus–related treatment costs: An analysis of dental and medical claims data

BackgroundDiabetes mellitus (DM) and periodontal disease have a suggested bidirectional relationship. Researchers have reported decreases in DM-related health care costs after periodontal treatment. The authors examined the relationship between periodontal disease treatment and DM health care costs in commercial insurance and Medicaid claims data.MethodsThis study of IBM MarketScan commercial insurance and Medicaid databases included overall outpatient, inpatient, and drug costs for patients with DM. The authors examined associations between overall health care costs per patient in 2019 according to use of periodontal services from 2017 through 2018 using generalized linear modeling. The average treatment effect on treated was calculated by means of propensity score matching using a logistic model for periodontal treatment on covariates.ResultsFor commercial insurance enrollees, periodontal treatment was associated with reduced overall health care costs of 12% compared with no treatment ($13,915 vs $15,739; average treatment effect on treated, –$2,498.20; 95% CI, –$3,057.21 to –$1,939.19; P < .001). In the Medicaid cohort, periodontal treatment was associated with a 14% decrease in costs compared with patients with DM without treatment ($14,796 vs $17,181; average treatment effect on treated, –$2,917.84; 95% CI, –$3,354.48 to –$2,480.76; P < .001). There were no significant differences in inpatient costs (commercial insurance) or drug costs (Medicaid).ConclusionsUndergoing periodontal treatment is associated with reduced overall and outpatient health care costs for patients with DM in Medicaid and commercial insurance claims data. There were no significant differences in inpatient costs for commercial insurance enrollees or in drug costs for Medicaid beneficiaries.Practical ImplicationsA healthy mouth can play a key role in DM management. Expanding Medicaid benefits to include comprehensive periodontal treatment has the potential to reduce health care costs for patients with DM.     

Impact of a Medicaid policy on preventive oral health services for children with intellectual disabilities,developmental disabilities,or both

BackgroundIntegrating preventive oral health services (POHS) into medical offices may ease access to care for children with intellectual and developmental disabilities (IDD). The authors examined the impact of state policies allowing delivery of POHS in medical offices on receipt of POHS among Medicaid enrollees with IDD.MethodsThe authors used 2006 through 2014 Medicaid data for children with IDD aged 6 months through 5 years from 38 states. IDD were defined using 14 condition codes from Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse. The length of the state’s medical POHS policy (no policy, < 1 year, 1 year, 2 years, 3 years, or ≥ 4 years) was interacted with an indicator that the child was younger than 3 years. The authors used logistic regression models to estimate the likelihood that a child received POHS in a medical office or in a medical or dental office in a given year.ResultsAmong 447,918 children with IDD, 1.6% received POHS in medical offices. Children younger than 3 years in states with longer-enacted policies had higher rates of receiving POHS. For example, the predicted probability of receiving POHS was 40.6% (95% confidence interval, 36.3% to 44.9%) for children younger than 3 years in states with a medical POHS policy for more than 4 years compared with 30.6% (95% confidence interval, 27.8% to 33.5%) for children in states without a policy.ConclusionsState Medicaid policies allowing delivery of POHS in medical offices increased receipt of POHS among Medicaid-enrolled children with IDD who were younger than 3 years.Practical ImplicationsFew children with IDD receive POHS in any setting. Efforts are needed to reduce barriers to POHS for publicly insured children with IDD.     

The pediatric dental workforce in 2016 and beyond

BackgroundChildhood caries is a major oral and general health problem, particularly in certain populations. In this study, the authors aimed to evaluate the adequacy of the supply of pediatric dentists.MethodsThe authors collected baseline practice information from 2,546 pediatric dentists through an online survey (39.1% response rate) in 2017. The authors used a workforce simulation model by using data from the survey and other sources to produce estimates under several scenarios to anticipate future supply and demand for pediatric dentists.ResultsIf production of new pediatric dentists and use and delivery of oral health care continue at current rates, the pediatric dentist supply will increase by 4,030 full-time equivalent (FTE) dentists by 2030, whereas demand will increase by 140 FTE dentists by 2030. Supply growth was higher under hypothetical scenarios with an increased number of graduates (4,690 FTEs) and delayed retirement (4,320 FTEs). If children who are underserved experience greater access to care or if pediatric dentists provide a larger portion of services for children, demand could grow by 2,100 FTE dentists or by 10,470 FTE dentists, respectively.ConclusionsThe study results suggest that the supply of pediatric dentists is growing more rapidly than is the demand. Growth in demand could increase if pediatric dentists captured a larger share of pediatric dental services or if children who are underserved had oral health care use patterns similar to those of the population with fewer access barriers.Practical ImplicationsIt is important to encourage policy changes to reduce barriers to accessing oral health care, to continue pediatric dentists’ participation with Medicaid programs, and to urge early dental services for children.     

Oral health and oral health care use among able-bodied adults enrolled in Medicaid in Kentucky after Medicaid expansion: A mixed methods study

BackgroundOral health care use remains low among adult Medicaid recipients, despite the Patient Protection and Affordable Care Act’s expansion increasing access to care in many states. It remains unclear the extent to which low use reflects either low demand for care or barriers to accessing care. The authors aimed to examine factors associated with low oral health care use among adults enrolled in Medicaid.MethodsThe authors conducted a survey from May through September 2018 among able-bodied (n = 9,363) Medicaid recipients who were aged 19 through 65 years and nondisabled childless adults in Kentucky. The survey included questions on perceived oral health care use. Semistructured interviews were also conducted from May through November 2018 among a subset of participants (n = 127).ResultsMore than one-third (37.8%) of respondents reported fair or poor oral health, compared with 26.2% who reported fair or poor physical health. Although 47.6% of respondents indicated needing oral health care in the past 6 months, only one-half of this group reported receiving all of the care they needed. Self-reported barriers included lack of coverage for needed services and lack of access to care (for example, low provider availability and transportation difficulties).ConclusionsLow rates of oral health care use can be attributed to a subset of the study population having low demand and another subset facing barriers to accessing care. Although Medicaid-covered services might be adequate for beneficiaries with good oral health, those with advanced dental diseases and a history of irregular care might benefit from coverage for more extensive restorative services.Practical ImplicationsThese results can inform dentists and policy makers about how to design effective interventions and policies to improve oral health care use and oral health outcomes.     

A cross-sectional analysis of oral health care spending over the life span in commercial- and Medicaid-insured populations

BackgroundLife course theory creates a better framework to understand how oral health care needs and challenges align with specific phases of the life span, care models, social programs, and changes in policy.MethodsThe authors obtained data from the 2018 IBM Watson Multi-State Medicaid MarketScan Database (31 million claims) and the 2018 IBM Watson Dental Commercial and Medicare Supplemental Claims Database (45 million claims). The authors conducted analysis comparing per enrollee spending on fee-for-service dental claims and medical spending on oral health care for patients from ages 0 through 89 years.ResultsOral health care use rate and spending are lower during the first 4 years of life and in young adulthood than in other periods of life. Stark differences in the timing, impact, and severity of caries, periodontal disease, and oral cancer are seen between those enrolled in Medicaid and commercial dental plans. Early childhood caries and oral cancer occur more frequently and at younger ages in Medicaid populations.ConclusionsThis life span analysis of the US multipayer oral health care system shows the complexities of the current dental service environment and a lack of equitable access to oral health care.Practical ImplicationsHealth policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.