Abstract
Background
Life 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.
Methods
The 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.
Results
Oral 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.
Conclusions
This 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 Implications
Health policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.
Key Words
Abbreviation Key:
CDT (Code on Dental Procedures and Nomenclature), ED (Emergency department), NTDC (Nontraumatic dental condition), PCP (Primary care provider)
- Nicolau B.
- Thomson W.M.
- Steele J.G.
- Allison P.J.
,
,
- Broadbent J.M.
- Zeng J.
- Foster Page L.A.
- Baker S.R.
- Ramrakha S.
- Thomson W.M.
,
- Gibson B.J.
- Kettle J.E.
- Robinson P.G.
- Walls A.
- Warren L.
Several of the structural and behavioral factors provided in these models are related to oral health care services use and oral health care spending.
- Gibson B.J.
- Kettle J.E.
- Robinson P.G.
- Walls A.
- Warren L.
,
- Peres K.G.
- Peres M.A.
- Araujo C.L.
- Menezes A.M.
- Hallal P.C.
,
- Brennan D.S.
- Spencer A.J.
,
,
- Lu H.X.
- Wong M.C.
- Lo E.C.
- McGrath C.
,
Comprehensive dental coverage is mandatory for children enrolled in Medicaid, but states can choose whether to cover dental services for adults in their Medicaid programs.
Medicaid adult dental benefits: an overview.
Coverage varies across the states and is dependent on state budgets, political dynamics, and public health infrastructure. Even with benefits, barriers to access to care may remain because dental practice operational overhead limits participation in Medicaid plans, and many practices choose not to serve patients enrolled in Medicaid.
- Gupta N.
- Yarbrough C.
- Vujicic M.
- Blatz A.
- Harrison B.
These coverage variations, along with broader social determinants of health, have wide-ranging effects, including poorer oral health and medical health and negative influences on employment.
Healthy mouths: why they matter for adults and state budgets.
Therefore, understanding the cost and structure of care over a life span can allow for a comparison with other systems affecting health, explore how changes in psychosocial structures affect use rates and care delivery costs, and provide continued exploration of how oral health care clinical environments affect quality of life.
- Dos Santos Costa F.
- Agostini B.A.
- Schuch H.S.
- Correa M.B.
- Goettems M.L.
- Demarco F.F.
Life course theory is a conceptual and theoretical orientation that explains people’s health and disease patterns using several key concepts, including life span development, human agency, timing, linked lives, and historical time and place.
The concept of life span development argues that health and disease patterns are sequential and cumulative, with experiences earlier in life influencing what happens later in life. Life course theory also argues that lives, and health outcomes, are linked on the basis of common shared experiences related to social determinants of health, access to care, clinical treatment patterns, health policy, disease states, and shared historical time and place.
Life course theory has bidirectional implications, both in how social determinants such as poverty, nutrition, housing, and transportation affect oral health
and in how oral disease can undermine people’s overall health and psychosocial and economic status. Producing and tracking healthy outcomes over the life span has become more important owing to continued changes in reimbursement structure,
improvement in medical-dental care integration,
- Mckernan C.S.
- Kuthy A.R.
- Reynolds C.J.
- Tuggle L.
- Dina G.T.
,
growth of safety net dental and oral health care models,
, ,
- Rosenbaum S.
- Paradise J.
- Markus A.R.
- et al.
improved access to data,
changing patient expectations,
Annual Dental Industry Report 2019.
and increased awareness of oral health as an operational concept.
,
,
- Glick M.
- Williams D.M.
- Kleinman D.V.
- Vujicic M.
- Watt R.G.
- Weyant R.J.
In fact, the US surgeon general announced that life span analysis will be a major component of the Surgeon General’s Report on Oral Health 2020.
- Albino J.
- Dye B.
- Ricks T.
In this article, we use a cross-sectional life span analysis, breaking out spending on oral health care and medical spending on oral health by category across each year of life (ages 0-89 years). The analysis includes claims information from both Medicaid-insured and commercially insured patients. This analysis allows a unique perspective into the pattern of spending on dental and oral health care at different stages of the life span and emphasizes the role of insurance coverage and policy environment as a key differentiator in the timing, impact, and severity of oral diseases. Using a life span analysis of oral health services and use contributes to life course health strategies and can allow stakeholders to better understand how new care models, social programs, grant spending, and changes in policy environments affect society or improve quality of life.
Methods
This includes more than 31 million Medicaid dental claims (covering 5.7 million enrollees and 1.1 million patients) and more than 45 million dental claims (covering 6.6 million enrollees and 4 million patients) from commercial insurance or Medicare supplemental plans over a life span. These data also include information on use of medical services for dental conditions, allowing us to estimate the burden on the medical system of treating oral health diseases.
This analysis is restricted to enrollees in fee-for-service reimbursement systems, as indicated by their last period of enrollment during the year. The commercial database is further restricted to those covered by both dental and medical insurance. Although dental and medical claims among patients eligible for Medicare are included in both databases, claims paid by Medicare are not included in the Medicaid database; it is likely that some claims are missing for those patients, especially those eligible for both Medicaid and Medicare.
Code on Dental Procedures and Nomenclature (CDT Code).
to ease comparison of the large data sets: preventive care and basic procedures, a category comprising procedures related to diagnostics, prevention, and less invasive intervention; and major procedures, a category comprising procedures related to disease stabilization, which are often irreversible, and more invasive interventions.
Code on Dental Procedures and Nomenclature (CDT Code).
Preventive care and basic procedures include diagnostic, imaging, preventive, and minor restoration. Major dental procedures include major restoration, endodontics, oral surgery, scaling and root planing, other periodontal treatment, prosthodontics, orthodontics, general anesthesia, other anesthesia, and adjunctive general (Table).
Source: American Dental Association.30
Dental conditions in the medical setting are defined as the range of International Classification of Diseases, Tenth Revision diagnostic codes used in the Association of State and Territorial Dental Directors’ definition of NTDCs. Spending on oral cancer is also included in this analysis and is defined as International Classification of Diseases, Tenth Revision codes C00.0 through C14.8 in either the inpatient or outpatient record. Finally, we included prescription drug costs for oral health care or for medical spending on NTDCs. We defined prescription drugs as those being prescribed for a dental condition if they occurred within 1 day of an encounter with a dental procedure or an NTDC.
Results
Figure 1A. Average per enrollee spending on oral health care, in broad categories, among those enrolled in Medicaid over the life span. B. Average per enrollee spending on oral health care, in detailed categories, among those enrolled in Medicaid over the life span.
Figure 2A. Average per enrollee spending on oral health care, in broad categories, among those enrolled in commercial insurance over the life span. B. Average per enrollee spending on oral health care, in detailed categories, among those enrolled in commercial insurance over the life span.
There were also notable differences with tooth mortality due to tooth extractions or removal. In supplemental analysis of the data, we found that people with Medicaid benefits were 5 times more likely to have a tooth extracted (CDT D7140, D7210, D7220, D7230, D7240, D7241) than those with commercial coverage, reflecting differences in reimbursement patterns and broader health inequities. In addition, adults 35 years or older enrolled in Medicaid were 4.25 times more likely to have 6 or more teeth extracted in a single year than adults enrolled in commercial insurance plans.
Discussion
- Sisko A.M.
- Keehan S.P.
- Poisal J.A.
- et al.
Our analysis revealed several key findings. For both Medicaid and commercial structures, there was an overall deficiency in oral health care use and spending during the first 4 years of life (Figures 1A and 2A). Although both commercial and Medicaid systems saw a reduction in use during the early 20s to mid-30s age groups, Medicaid saw this decline continue throughout adulthood (eFigure 1A). Spending on oral cancer began to increase in the early 40s and peaks in the early 60s age groups, with a total of $48 million spent by Medicaid and $69 million spent by commercial payers. Cumulatively, this investigation shows unequal and inequitable access and outcomes of health care.
- Tiwari T.
- Rai N.
- Brow A.
- Tranby E.P.
- Boynes S.G.
,
- Tranby E.P.
- Ohrenberger K.
- Boynes S.G.
Our analysis complements these data, illuminating the missed opportunity to engage young children in the recommended first dental visit by age 1 year.
- Maia F.B.
- de Sousa E.T.
- Sampaio F.C.
- Freitas C.H.
- Forte F.D.
,
- Börnigen D.
- Ren B.
- Pickard R.
- et al.
,
- Gaewkhiew P.
- Sabbah W.
- Bernabé E.
,
- Baghaie H.
- Kisely S.
- Forbes M.
- Sawyer E.
- Siskind D.J.
At the same time, many state Medicaid plans do not cover major restorative treatments or periodontal care, and low-income adults can have difficulty accessing even basic preventive dental services.
Medicaid adult dental benefits: an overview.
This leaves low-income adults and the dentists who treat them few options other than tooth extractions.
Because most low-income adults lack affordable access to preventive dental services, localized oral disease can begin and advance to more extensive and more acute conditions. This leaves these adults with few, if any, options other than visiting hospital EDs, a decision that may well be reflected by the higher rates of such visits among Medicaid-enrolled adults, starting in their 20s and continuing through their 50s, as seen in our analysis. This strongly suggests that many adults who lack the coverage to secure care eventually do become patients, albeit with oral conditions that are more acute and costly to treat.
It is unclear the degree to which the observed oral cancer prevalence is shaped by the relatively low dental care use rates among Medicaid-enrolled adults. Better access to regular preventive oral health care throughout the adulthood years could have provided opportunities for education, anticipatory guidance on behaviors and risk factors, and earlier diagnosis. In addition, the use of human papillomavirus vaccinations is still not widespread, limiting the ability to determine what impact its administration is having on overall incidence or prevalence.
- Patrick D.L.
- Lee R.S.Y.
- Nucci M.
- Grembowski D.
- Jolles C.Z.
- Milgrom P.
,
,
,
,
- Borrell L.N.
- Taylor G.W.
- Borgnakke W.S.
- Woolfolk M.W.
- Nyquist L.V.
The use and spending design of both commercial and Medicaid dental insurance is shaped by financial incentives that create business and care models influenced by revenue collection, risk pooling, purchasing, and the lack of social empathy.
The cumulative effect has produced a focus on finding or awaiting disease advancement as opposed to optimizing prevention and health and rewarding lack of disease.
Some limitations should be considered when interpreting the results of this analysis. The first is that these are cross-sectional data based on 2018 claims only, which do not capture changes over time that may be evident through longitudinal analyses. Another weakness is that claims paid by Medicare are not included in the Medicaid database, making it possible that some claims are missing for those patients, especially those who are eligible for both Medicare and Medicaid. Furthermore, Medicaid is administered at the state level, with significant variability in both pediatric and adult coverage (with relatively few states providing extensive adult oral health care coverage), and the results presented may not be generalizable to all states and plans. Finally, people who pay 100% of their dental expenses out of pocket (the self-pay population), as well as those who may have received dental services at free clinics or via charity care, are not present in the analysis
Future analysis should examine operating pathway variations through oral health and medical systems to show how inequalities in care at 1 point in time influence trajectories of care and systemic outcomes. A deeper understanding of variations of these patient pathways over a life span can allow researchers, payers, funders, and care teams to better understand how new care models, social programs, grant spending, and changes in political and socioeconomic environments affect society or quality of life.
Conclusions
Life span data could also positively inform programmatic strategies, such as medical-dental integration, and clinical practices, such as disease prevention and management.
Supplemental Data
eFigure 1A. Utilization rate of oral health care over the life span among Medicaid-insured and commercially insured populations in 2018. B. Utilization rate of hospital outpatient and emergency departments for oral health care among Medicaid- and commercial-insured populations in 2018. C. Utilization rate of hospital inpatient and incidence of oral cancer among Medicaid-insured and commercially insured populations in 2018.
eFigure 2A. Average per enrollee payment to dental provider. B. Average per enrollee cost using usual, customary, and reasonable fee schedule. C. Average per patient payment to dental provider.
eFigure 2A. Average per enrollee payment to dental provider. B. Average per enrollee cost using usual, customary, and reasonable fee schedule. C. Average per patient payment to dental provider.
eTable 1Average spending on oral health care in Medicaid, by age and type, 2018.
eTable2Average spending on oral health care in commercial insurance, by age and type, 2018.
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Biography
Dr. Tranby is a manager, Data and Impact, CareQuest Institute for Oral Health, Boston, MA.
Dr. Frantsve-Hawley is the director, Analytics and Evaluation, CareQuest Institute for Oral Health, Boston, MA.
Dr. Minter-Jordan is the chief executive officer, CareQuest Institute for Oral Health, Boston, MA.
Dr. Thommes is the vice president, Clinical Management, CareQuest, Boston, MA.
Mr. Jacob is a communications consultant, CareQuest Institute for Oral Health, Boston, MA.
Dr. Monopoli is the vice president, Grant Strategy, CareQuest Institute for Oral Health, Boston, MA.
Mr. Okunev was a biostatistician, CareQuest Institute for Oral Health, Boston MA, when the work described in this article was conducted. He now is a senior statistical programmer, Health Data Analytics Institute, Dedham, MA.
Dr. Boynes is the vice president, Health Improvement, CareQuest Institute for Oral Health, Boston, MA.
Article Info
Publication History
Published online: November 09, 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.2021.07.028
Copyright
© 2021 American Dental Association.
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