Abstract
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.
Key Words
Medicaidprocedure typepreventionclaims data
Abbreviation Key:
CDT (Code on Dental Procedures and Nomenclature), CHIP (Children’s Health Insurance Program), CMS (Centers for Medicare & Medicaid Services), EPSDT (Early and Periodic Screening, Diagnostic, and Treatment), OT (Other services), T-MSIS (Transformed Medicaid Statistical Information System)
The age gap is much narrower with health care benefits; 95{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of children, 85{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of working-age adults, and 99{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of older adults have some form of coverage.
People who have dental benefits, whether private or public, are more likely than their uninsured counterparts to use oral health care.
,
,
Among those who have dental coverage, the payment arrangements and scope of covered services tend to differ markedly in private and public benefits programs, particularly among adults.
The dental services covered vary to some degree across states but tend to be relatively comprehensive and closely approximate those offered in private dental benefits plans.
yet dental benefits are not guaranteed beyond age 20 years. Inclusion of adult dental services is optional,
and there is significant state-to-state variation in terms of what dental services are covered and which adult beneficiaries qualify.
Medicare, the medical benefits program for adults 65 years and older,
does not cover routine dental services.
,
There is a predominance of diagnostic and preventive services delivered for adults across all age and benefits groups. However, those with public benefits are more likely to have surgical services and less likely to have preventive care than their privately insured counterparts.
,
,
Previous work examined differences in procedure mix among adults using self-reported survey data from the Medical Expenditure Panel Survey.
,
,
These state-level studies indicate pediatric surgical services are trending downward, suggesting that increased oral health care use among children enrolled in Medicaid- and CHIP and the focus on preventive services may be effective in reducing the overall need for more invasive treatment.
Other studies have explored procedure mix variation for underserved populations, such as those living in rural areas or living with HIV, who were more likely to undergo surgical treatment and less likely to have had preventive oral health care.
,
In this study, we analyzed the procedure mix as it relates to dental benefits status and age. We discuss the policy implications of our findings. This study may shed light on the extent to which Medicaid adult dental benefits promote the preservation of natural dentition. We used multiple claims databases for our analysis; to our knowledge, this is the first comprehensive study using national Medicaid, CHIP, and commercial claims data to explore how procedure mix relates to benefits type. This descriptive analysis is the first step in a broader research agenda that we hope will lead to a better understanding of divergence of treatment patterns across age and benefits status.
Methods
Data sources
maintained by the Centers for Medicare & Medicaid Services (CMS). Since 2014, states have provided T-MSIS detailed information regarding Medicaid/CHIP enrollment, service use, and payments. As of 2018, each state, the District of Columbia, and US territories provide T-MSIS with Medicaid and CHIP claims data on a monthly basis. The T-MSIS Analytic Files, housed in the Chronic Condition Data Warehouse,
include annual demographic and eligibility tables, inpatient claims, long-term care claims, pharmacy claims, and other services (OT) claims. In 2018, there were approximately 95.1 million people enrolled in Medicaid or CHIP.
Medicaid and CHIP dental claims from children, working-age adults, and older adults are located in the other services claims tables. The OT claims data are split into monthly header and line tables. The header tables contain information on aggregate claim payments, claim type (fee-for-service, managed care, capitation), medical diagnoses (International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision), and dates of service. The detailed monthly line tables include the specific procedures (American Medical Association’s Current Procedural Terminology, Healthcare Common Procedure Coding System, Code on Dental Procedures and Nomenclature [CDT] codes) that occurred under a specific claim, dates of service, and procedure payments and a field for the provider designated by the National Provider Identification number. Each specific observation in the line tables contains a specific procedure code along with its date of service. A unique claim identifier links the OT header and line tables.
These data include private dental benefits claims from large employers and health plans across the United States. This administrative claims database includes data from a variety of fee-for-service, preferred provider organization, and capitated health plans. The database is a large convenience sample of the privately insured population in the United States.
In 2018, there were 10.6 million people with private dental benefits included in IBM MarketScan. On the basis of the 2018 data from the Medical Expenditure Panel Survey,
we estimated that IBM MarketScan captures approximately 6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of the private dental benefits market in the United States. Older adults represented in IBM MarketScan are likely primarily working, given that the commercial claims data come from employer-sponsored private dental plans, although some employers offer coverage to retirees. We do not have specific percentages of working and retired or not working older adults from this private claims data. Oral health-related research using IBM MarketScan dental claims data has been published widely.
,
,
,
Methodology
We followed the categorization of the CDT manual to classify dental procedures as follows: diagnostic, preventive, restorative, endodontics, periodontics, implant services and prosthodontics, oral and maxillofacial surgery, orthodontics, and adjunctive general services
(Table 1). Each line in the monthly OT Medicaid/CHIP line tables and IBM MarketScan dental claims table corresponds to a unique procedure with a quantity of 1. For calendar year 2018, we aggregated the number of procedures performed for each service category separately for public and private benefits programs. From the total number of procedures performed, we then calculated the share of procedures performed for each dental service category. We calculated dental procedure mix across all ages for those with public and private dental benefits. We also calculated procedure mix separately for children (0-20 years), working-age adults (21-64 years), and older adults (>= 65 years).
Given that Medicaid/CHIP dental benefits for children are relatively standardized across states, we compared procedure mix for managed care and fee-for-service plans. We used the claim type indicator variable from the OT header table to differentiate between managed care and fee-for-service claims. This research is part of a data use agreement approved by the CMS (RSCH-2020-5563: The State of Oral Healthcare Use, Quality and Spending: Findings from Medicaid and CHIP Programs). We received institutional review board approval to conduct research based on T-MSIS Medicaid and CHIP claims.
Results
,
Compared with children with private dental benefits, children with Medicaid/CHIP benefits had a higher share of diagnostic services (44.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 41.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and restorative services (11.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 8.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}), whereas a lower share of total services were preventive (35.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 38.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and orthodontic (1.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 6.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).
+ Sum of observations totals across ages may not add the total across all ages because of missing data on age.
Working-age and older adults had a similar procedure mix in certain categories. For both age groups, those with Medicaid benefits had a substantially higher share of total services for oral surgery (? 12{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than those with private benefits (? 3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). Conversely, working-age and older adults with private dental benefits had a substantially higher share of total services for prevention (? 22{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than those with Medicaid benefits (? 12{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).
A higher share of dental services among working-age adults with Medicaid benefits went toward restorative care (17.5{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) compared with those with private benefits (14.2{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). Conversely, among older adults enrolled in Medicaid, a lower share of dental services went toward restorative procedures (10.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) compared with older adults with private dental benefits (13.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). For older adults , those enrolled in Medicaid had a substantially higher share of services go toward prosthodontics and implant services (7.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than those with private dental benefits (2.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).
,
As one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated to oral surgery declined from 22.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 9.9{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}. Still, in states with extensive adult Medicaid dental benefits, the share of total procedures allocated to oral surgery was higher than the share of total procedures that went toward oral surgery among adults with private dental benefits (2.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). Conversely, as one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated for periodontal services increased from 1.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 4.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}, which was still lower than the share among the privately insured (5.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of dental procedures that were preventive increased from 7.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with emergency-only dental benefits for adults to approximately 12.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with limited or extensive dental benefits for adults, which was still substantially lower than the share among those with private benefits (22.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of total dental procedures for restorative services for working-age adults enrolled in Medicaid increased from 7.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with emergency-only dental benefits for adults to 18.9{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with limited benefits before dropping slightly to 17.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with extensive dental benefits.
+ Data from states with no adult Medicaid dental benefits are not reported.
,
In states with limited or extensive dental benefits for adults, the share of adjunctive general services was higher for older adults than for working-age adults. Across all benefit levels, the share of implant services and prosthodontics was higher for older adults than for working-age adults. As one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated to oral surgery declined from 22.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 10.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}. Among older adults, the share of Medicaid dental procedures for restorative services increased from 6.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in emergency-only benefits states to 12.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in limited benefits states before dropping to 9.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in extensive benefits states.
+ Data from states with no adult Medicaid dental benefits are not reported.
,
particularly with diagnostic and preventive services. Conversely, the share of dental procedures that was allocated for oral surgery was slightly higher in fee-for-service plans (3.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than for managed care plans (2.5{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). For private dental benefits plans, the share of dental services for oral surgery was similar (3.2{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of dental services for restorative services was higher for both fee-for service plans (11.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and managed care plans (12.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than for private dental benefits plans (8.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).
* CHIP: Children’s Health Insurance Program.
? Procedure mix from claims for which the claim type is not fee-for-service or managed care is not reported.
Discussion
In this analysis, we found that dental procedure mix among children with public and private benefits is more similar than among adults. Among adults, surgical interventions make up a higher share of procedures among publicly insured adults, and routine preventive services make up a higher share of procedures among privately insured adults. Even in states offering extensive dental benefits for adults enrolled in their Medicaid program, the share of procedures allocated to oral surgery is higher than the share for privately insured adults.
There are several factors that could explain our results. There could be important differences in the risk of developing dental disease and the acuity of oral health care need between patients with private and public dental benefits. If oral health care needs are higher among Medicaid populations than privately insured populations, this would translate into differences in procedure mix. But why would this be the case for working-age and older adults and not children? Ideally, we would control for underlying acuity of oral health care needs with diagnostic data, but such data are not collected routinely in oral health care claims. It also could be the case that underlying oral health care needs might be similar between publicly and privately insured populations, but oral health care-seeking behavior or access to oral health care might differ. This could translate to patients with public benefits seeking oral health care only for acute, symptomatic issues compared with patients with private benefits seeking oral health care for routine prevention. Again, this is not something we can measure or control for in our data.
As state programs have refined their benefits for children in adherence of EPSDT over time, public coverage for oral health care has grown to look remarkably similar to private coverage for children’s oral health care, with more dentist participation and greater oral health care use.
,
,
,
,
State Medicaid programs are scattered in terms of how they approach dental coverage for adults, and our analysis shows that the procedure mix is different according to the level of dental benefits. In states with extensive Medicaid dental benefits, there is more focus on restoring teeth rather than extracting them. As an example, Virginia has extensive benefits in place as of July 2021 that replace its previous limited benefits. The benefits cover restorative, endodontic, periodontic, and prosthodontic services in addition to diagnostic and preventive services, and there is no annual maximum expenditure for enrollees.
Most private dental plans have per-enrollee annual maximums much higher than $1,000.
In addition, private insurance payment rates tend to keep up with inflation whereas most Medicaid programs fail to do so.
Aspects of program design beyond coverage need to be studied, especially best practices for designing adequately funded and sustainable programs that promote provider participation and appropriate beneficiary use.
,
Is it time to consider an EPSDT-like benefit for adults? This is an important policy discussion, and given the newfound–and overdue–focus on disparities and inequities in health care, it is time to have it.
Conclusions
,
In essence, public benefits programs for adults are financing downstream by paying for invasive treatment of dental disease for adults rather than preventive treatments that may avert such disease in the first place. This is true even in states with extensive dental benefits for adults enrolled in their Medicaid programs. Future studies should explore aspects of public dental program design–beyond coverage policies–that promote access to care and reduce oral disease, such as building sufficient provider networks and ensuring Medicaid programs are adequately funded.
References
Dental benefits coverage in the U.S. Health Policy Institute Infographic. November 2017.
Date accessed: February 16, 2021
Health insurance coverage: early release of estimates from the National Health Interview Survey, 2019. National Center for Health Statistics. September 2020.
Date accessed: February 16, 2021
A decade in dental care utilization among adults and children (2001-2010).
Health Serv Res. 2014; 49: 460-480
The demand for preventive and restorative dental services.
Health Econ. 2014; 23: 14-32
Medicaid adult dental benefits increase use of dental care, but impact of expansion on dental services use was mixed.
Health Aff. 2017; 36: 723-732
Early and periodic screening, diagnostic and treatment. Centers for Medicare & Medicaid Services.
Date accessed: February 16, 2021
The impact of Medicaid insurance coverage on dental service use.
J Health Econ. 2011; 30: 1020-1031
Mandatory and optional Medicaid benefits. Centers for Medicare & Medicaid Services.
Date accessed: February 16, 2021
Medicaid adult dental benefits: an overview. September 2019.
Date accessed: February 16, 2021
Medicare program: general information. January 2021.
Date accessed: February 16, 2021
Dental services. Centers for Medicare & Medicaid Services.
Date accessed: February 16, 2021
Dental service mix among working-age adults in the United States, 1999 and 2009.
J Pub Health Dent. 2014; 74: 102-109
Dental service mix among older adults aged 65 and over, United States, 1999 and 2009.
J Pub Health Dent. 2014; 74: 219-226
Dental service trends for older U.S. adults, 1998-2006.
Spec Care Dentist. 2012; 32: 42-48
Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid.
JADA. 2015; 146: 52-60
Assessing patterns of restorative and preventive care among children enrolled in Medicaid, by type of dental care provider.
JADA. 2009; 140: 886-894
Trends in use of dental care provider types and services in the United States in 2000-2016: rural-urban comparisons.
JADA. 2020; 151: 596-606
Do regular dental visits affect the oral health care provided to people with HIV?.
JADA. 2002; 133: 1343-1350
Transformed Medicaid Statistical Information System (T-MSIS). Centers for Medicare & Medicaid Services. January 2021.
Date accessed: February 16, 2021
Chronic conditions data warehouse.
Date accessed: February 1, 2021
IBM MarketScan Research Databases for life sciences researchers.
IBM Corporation,
2020
Date accessed: February 2, 2021
MEPS HC-209: 2018 Full Year Consolidated Data File.
Agency for Healthcare Research and Quality,
August 2020
Date accessed: February 2, 2021
The relationship between periodontal interventions and healthcare costs and utilization. Evidence from an integrated dental, medical and pharmacy commercial claims database.
Health Econ. 2017; 26: 519-527
Pricing in commercial dental insurance and provider markets.
Health Serv Res. 2021; 56: 25-35
Multiple opioid prescriptions among privately insured dental patients in the United States: evidence from claims data.
JADA. 2018; 149: 619-627
Opioid prescribing practices from 2010 through 2015 among dentists in the United States. What do claims data tell us?.
JADA. 2018; 149: 237-245
CDT 2020. Code on Dental Procedures and Nomenclature.
2020
Date accessed: February 1, 2021
State Medicaid early and periodic screening, diagnosis, and treatment guidelines: adherence to professionally recommended best oral health practices.
JADA. 2013; 144: 297-305
Keep kids smiling: promoting oral health through the Medicaid benefit for children and adolescents. September 2013.
Date accessed: February 16, 2021
Michigan Medicaid’s Healthy Kids dental program: an assessment of the first 12 months.
JADA. 2003; 134: 1509-1515
Medicaid meets its equal access requirement for dental care, but oral health disparities remain.
Health Aff. 2016; 35: 2259-2267
Obamacare, Trumpcare, and your mouth. Health Affairs Blog. January 2017.
Date accessed: February 16, 2021
Health benefits and coverage. What marketplace health insurance plans cover. Centers for Medicare & Medicaid Services. Accessed February 16,2021.
https://www.healthcare.gov/coverage/what-marketplace-plans-cover/
Adult dental benefit frequently asked questions.
Date accessed: May 4, 2021
2020 State of the Dental Benefits Market. National Association of Dental Plans,
2020
A ten-year, state-by-state, analysis of Medicaid fee-for-service reimbursement rates for dental care services.
Health Policy Institute Research Brief,
October 2014
Date accessed: May 4, 2021
Are Medicaid and private dental insurance payment rates for pediatric dental care services keeping up with inflation?.
Health Policy Institute Research Brief. December 2015;
Date accessed: May 4, 2021
Children’s oral health: progress, policy development, and priorities for continued improvement.
Health Aff. 2020; 39: 1762-1769
Biography
Dr. Nasseh is a health economist, Health Policy Institute, American Dental Association, Chicago, IL.
Dr. Fosse is a senior health policy analyst, Health Policy Institute, American Dental Association, Chicago, IL.
Dr. Vujicic is a chief economist and vice president, Health Policy Institute, American Dental Association, Chicago, IL.
Article Info
Publication History
Published online: October 03, 2021
Accepted:
July 21,
2021
Received in revised form:
July 21,
2021
Received:
March 5,
2021
Publication stage
In Press Corrected Proof
Footnotes
Disclosure. None of the authors reported any disclosures.
Identification
DOI: https://doi.org/10.1016/j.adaj.2021.07.024
Copyright
(C) 2021 American Dental Association. All rights reserved.
ScienceDirect
Access this article on ScienceDirect