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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.
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
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
Enrolled Children *Predicted Utilization
Odds Ratio (95% CI)
P-Value
Preventive ServicesSCHIPBoth plansMedicaid (ref)
26%20%15%
2.42 (2.20-2.66)1.64 (1.52-1.76)
1.00
<0.001<0.001
Restorative ServicesSCHIPBoth plansMedicaid (ref)
11%9%7%
1.75 (1.61-1.89)1.37 (1.26-1.50)
1.00
<0.001<0.001
Extraction ServicesSCHIPBoth plansMedicaid (ref)
3%2%2%
1.17 (1.02-1.36)0.93 (0.79-1.09)
1.00
0.0310.372
*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
Children with Utilization *Predicted Utilization
Odds Ratio (95% CI)
P-Value
Preventive ServicesSCHIPBoth plansMedicaid (ref)
86%82%83%
1.21 (1.08-1.36)0.93 (0.83-1.04)
1.00
0.1980.001
Restorative ServicesSCHIPBoth plansMedicaid (ref)
49%47%50%
0.94 (0.86-1.04)0.87 (0.79-0.96)
1.00
0.2100.008
Extraction ServicesSCHIPBoth plansMedicaid (ref)
10%11%17%
0.54 (0.43-0.68)0.56 (0.47-0.68)
1.00
<0.001<0.001
*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
Family Member with Active Decay
Y 61 38
N 100 62
Snacking 3+ times a day
Y 61 38
N 100 62
Suboptimal Fluoride
Y 47 29
N 114 71
Takes Bottle to Bed
Y 58 36
N 103 64
Assessment of High Risk
Y 121 75
N 40 25
Characteristic n %
Age
Mean 19 months
SD 9.5
Range 0 44
Decay
Y 31 19
N 130 81
White Spot Lesions
Y 20 13
N 139 87
Visible Plaque
Y 24 15
N 137 85
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