Oral Health Disparities in Publicly Insured Children

Dental Advisory Committee

April 11th, 2008

Tegwyn H. Brickhouse DDS PhD

Department of Pediatric Dentistry

VCU School of Dentistry

Grant

• NIH Career Transition Award (K22)• From the National Institutes of Dental and Craniofacial Research• Supports young investigators in their early career • Experience guides them to become a independent scientist • Future grants

Oral Health Disparities

• Dental caries is the most common chronic disease of childhood, affecting 58% of all children.

• Untreated dental caries has been identified as the most prevalent unmet health need in US children.

• Disparities exist among children with 25% suffering 80% of all tooth decay.

• Dental disease disproportionately affects children younger then 6, from lower socioeconomic backgrounds.

SGR on Oral Health May, 2000

Health Coverage for Children

• Employer/Private Insurance 60%

– 47 million children

• Medicaid/SCHIP 28%

– 22 million children

• Uninsured 12%

– Over 9.4 million

60%

12%

28%

Uninsured

Medicaid/SCHIP

Private

Kaiser Commission on Medicaid and the Uninsured September, 2007

Background

• Publicly Financed Health Plans Providing Dental Services

• Medicaid– A joint federal-state-county program established in 1965 to

provide health insurance to low-income populations

• State Children’s Health Insurance Program (SCHIP)– A joint federal-state program established in 1997 to provide

coverage to low-income uninsured children who are not eligible for Medicaid.

Grant Objectives

• Examine the structure of public dental insurance programs and patterns of Enrollment in publicly insured children.

• Examine the Process of dental care (utilization, mix of services) and dental health status Outcomes (tooth loss, caries-related treatments).

• Compare dental treatment with of general anesthesia versus the conventional dental delivery system for preschool-aged children

• Implement a project that examines outcomes for case management of infant oral health in a medical setting.

Effects of Public Insurance on Access to Dental Services

• Cohort of Publicly Insured Children • Enrollment and Claims data from 2002-2005• Children 0-18 years of age• Two State Programs (Virginia and North Carolina)

– Similar size– Similar population distribution– Similar geography

Analytical File Construction

• Claim summaries of utilization• Provider-Level summaries• Individual Child-level files

– linked enrollment and claims across time periods.

Analytical File Creation Child-Level File

Provider Characteristics

Enrollment Claims

Child

Enrollment Patterns of Publicly Insured Children

• Measures that characterize enrollment in public programs

• Length of Enrollment (duration)– Heterogeneous populations

• Patterns of Enrollment (continuity)– yearly and age determinations– gaps

Impacts of Enrollment

• Impact on eligibility for dental services– Age and aid categories of eligibility determination

• Enrollees are approximately 10% SCHIP, 90% Medicaid• 75% of children were enrolled with one MCO provider• 20% enrolled with 2 MCO’s • 5% enrolled with 3+• Impact on provider acceptance

– Real-time eligibility determination (on-line, swipe methods)

Enrollment

• Over the 3 year period, children were enrolled a mean number of 436 days, median of 365 days.

• The mean age of enrolled children is 5 years.

• 12.5% had no gaps in enrollment

• 50% has one gap in enrollment

• 37.5% had 2+ gaps in enrollment

• Few studies have examined the relationship of enrollment patterns and utilization.

Outcomes

• Dental Visits– Utilization of dental services measured by at least one paid

claim.– Annual Dental Visit (NCQA standards)– Performance Measures of Dental Services– Which children utilize services/benefit most

• Age• Geography• Income

Outcomes

• Performance Measures of Dental Services– Preventive services – Restorative services– Tooth Loss (receipt of one or more extraction services)

• Dental Home– 2 visits to same practice/same year

North Carolina Claims Data

Medicaid versus Separate SCHIP Program

0 1 2 3 4 5 6 7 8 9 10 11 120.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

BothHealth Choice onlyMedicaid onlyEnrollment category

Months enrolled

Prob

abili

ty o

f vis

it (

± 95

% C

I)

Mix of Services for all Children

1.17 (1.02-1.36)0.93 (0.79-1.09)

1.00

1.75 (1.61-1.89)1.37 (1.26-1.50)

1.00

2.42 (2.20-2.66)1.64 (1.52-1.76)

1.00

Odds Ratio (95% CI)

0.0310.372

<0.001<0.001

<0.001<0.001

P-Value

3%2%2%

11%9%7%

26%20%15%

*Predicted Utilization

Extraction ServicesSCHIPBoth plansMedicaid (ref)

Restorative ServicesSCHIPBoth plansMedicaid (ref)

Preventive ServicesSCHIPBoth plansMedicaid (ref)

Enrolled Children

*Likelihood of having a dental service compared to Medicaid (ref), controlling for enrollment characteristics, age, race, and county-level indicators.

Mix of Services for Children Accessing Dental Care

0.54 (0.43-0.68)0.56 (0.47-0.68)

1.00

0.94 (0.86-1.04)0.87 (0.79-0.96)

1.00

1.21 (1.08-1.36)0.93 (0.83-1.04)

1.00

Odds Ratio (95% CI)

<0.001<0.001

0.2100.008

0.1980.001

P-Value

10%11%17%

49%47%50%

86%82%83%

*Predicted Utilization

Extraction ServicesSCHIPBoth plansMedicaid (ref)

Restorative ServicesSCHIPBoth plansMedicaid (ref)

Preventive ServicesSCHIPBoth plansMedicaid (ref)

Children with Utilization

*Likelihood of having a dental service compared to Medicaid (ref), controlling for enrollment characteristics, age, race, and county-level indicators.

Mix of Dental Services for Children with Utilization

Medicaid SCHIP Both Medicaid SCHIP Both Medicaid SCHIP Both0

10

20

30

40

50

60

70

80

90 MedicaidSCHIPBoth

% R

ecei

vin

g S

ervi

ce

Predicted probabilities of dental services (preventive, restorative, and extraction) for North Carolina children (4 years of age) enrolled for 12 months.

Preventive

Restorative

Extraction

Virginia Claims Data

• 62% of dental claims were MCO• 38% of dental claims were FFS• Mean age for children with claims was 9 years of age.

Mix of Services

• 32% Diagnostic Services• 40% Preventive Services• 18% Restorative Services• 5% Extraction Services• 1.5 % Orthodontic Services

Infant Oral Health Project

• Preventive oral health services consist of – knee to knee oral screening and risk

assessment – Fluoride varnish– oral health education for caregivers – referral to a pediatric dental clinic.

Infant Assessment

• 19% of children had signs of dental caries• 12.5% having white-spot lesions• 75% were categorized as ‘high’ risk and referred for a dental visit• 80% of children received a fluoride varnish treatment

25

75

64

36

71

29

62

38

62

38

Family Member with Active Decay

61Y

100N

Snacking 3+ times a day

61Y

100N

Suboptimal Fluoride

47 Y

114N

Takes Bottle to Bed

58Y

103 N

Assessment of High Risk

121Y

40N

85137N

1524Y

Visible Plaque

Age

19 monthsMean

9.5SD

440Range

81130N

1931Y

87139N

1320Y

White Spot Lesions

Decay

% n Characteristic

High-Risk Children

• 6-months post-enrollment, 9% of children had made a dental visit to VCU.

• Children with visible plaque were more likely to have decay at baseline.

• 400+ Children enrolled in the VCU Bright Smiles Program• Examine the prevalence of dental claims for enrolled children

versus a random sample of Medicaid children 0-3 years of age.

Future Studies

• Provider Measures– Participation in programs– Level of activity– Types of Services– Response to program

changes• Program structure • Fee increases

State Program Reform

• Single Vendor Carve Out• Pre-Post Design

Questions?

• Many Thanks to DMAS• Sandra Brown• James Starkey• Lisa Bilik• Pat Finnerty