Dentists Who Participate in Medicaid: Who They Are, Where They Locate, How They Practice

Low utilization of dental services among low-income individuals and racial minorities reflects pervasive inequities in U.S. health care. There is limited research determining common characteristics among dentists who participate in Medicaid or the Children's Health Insurance Program. Using detailed Medicaid claims data and a provider database, we estimate that among dentists with 100 or more pediatric Medicaid patients, 48% practice in high-poverty areas, 10% practice in rural areas, and 29% work in large practices (11 or more dentists). Among those with zero Medicaid patients, 18% practice in high-poverty areas, 4% practice in rural areas, and 11% work in large practices. We found that dentist race/ethnicity has an independent effect on Medicaid participation even when adjusting for community characteristics, meaning non-White dentists are more likely to treat Medicaid patients, regardless of the median income or racial/ethnic profile of the community.

A Closer Look at Disparities in Earnings between White and Minoritized Dentists: Income Disparities in Dentistry

OBJECTIVE

To examine the factors that account for differences in dentist earnings between White and minoritized dentists.

DATA SOURCES

We used data from the American Dental Association's Survey of dental practice, which includes information on 2001-2018 dentist net income, practice ZIP code, patient mix between private and public insurance, and dentist gender, age, and year of dental school graduation. We merged the data on dentist race and ethnicity and school of graduation from the American Dental Association masterfile. Based on practice ZIP code, we also merged the data on local area racial and ethnic composition from the American Community Survey.

STUDY DESIGN

We used a linear Blinder-Oaxaca decomposition to assess observable characteristics that explain the gap in earnings between White and minoritized dentists. To assess differences in earnings between White and minoritized dentists at different points of the income distribution, we used a re-centered influence function and estimated an unconditional quantile Blinder-Oaxaca decomposition.

DATA EXTRACTION METHODS

We extracted data for 22,086 dentists ages 25-85 who worked at least 8 weeks per year and 20 hours per week.

PRINCIPAL FINDINGS

Observable characteristics accounted for 58% of the earnings gap between White and Asian dentists, 55% of the gap between White and Hispanic dentists, and 31% of the gap between White and Black dentists. The gap in earnings between White and Asian dentists narrowed at higher quantiles of the income distribution.

CONCLUSIONS

Compared to other minoritized dentists, Black dentists have the largest earnings disparities relative to White dentists. While the level of the explained component of the disparity for Black dentists is comparable to the explained part of the disparities for other minoritized dentists, the excess percentage of the unexplained component for Black dentists accounts for the additional amount of disparity that Black dentists experienced. Persistent income disparities could discourage minoritized dentists from entering the profession.

Trends in Scope of Practice for Oral Health Care: Future Transformative Effects

KNOWLEDGE TRANSFER STATEMENT

The results of this study can help key stakeholders, such as health care facilities, educational and research institutions, insurance companies, and governmental bodies, plan future activities and policies on dental practice and education.

Trends in postgraduate dental training in the United States

OBJECTIVE

This study examines the individual, educational, and policy factors that predict dentists pursuing postgraduate dental (PGD) training.

METHODS

Individual dentist records from the 2017 American Dental Association Masterfile were linked with pre-doctoral training attributes and state-level dental policy factors. Generalized logistic models, adjusted for individual, educational, and policy factors, were used to predict: (1) attending any PGD program, and (2) primary (i.e., advanced general practice, pediatrics, or dental public health, per the Health Resources and Services Administration [HRSA]) versus specialty care.

RESULTS

The majority of new PGD residency slots (77%) were in primary care. Women held 56% of primary care slots; men held 62% of specialty slots. Individual characteristics that predicted PGD primary care training included being Black, Hispanic, Asian, or other race; being male or older age reduced the odds. Pre-doctoral school characteristics that predicted PGD primary care training included having a pre-doctoral HRSA grant, affiliation with an academic medical center, and being a historically Black college/university; being a private school or in a small metro area lowered the odds. At the policy level, the strongest predictors of attending PGD primary care training are a residency requirement in the state you currently practice in and federal graduate medical education (GME) investment per residency slot.

CONCLUSION

Pursuing PGD training is variable based on the race/ethnicity/gender of the dentist. Federal investments in pre-doctoral dental education and GME can drive equity, as they significantly increase the odds that dentists will go on to PGD training, as do state licensure requirements.

Practice patterns of postgraduate trained dentists in the United States

OBJECTIVE

Postgraduate dental (PGD) primary care training has grown significantly. This study examines the individual, educational, community, and policy factors that predict practice patterns of PGD-trained dentists.

STUDY DESIGN

Individual dentist records from the 2017 American Dental Association Masterfile, with indicators of Medicaid participation and practice in a Federally Qualified Health Center (FQHC), were linked to postdoctoral training, community/practice location, and state policy factors. Generalized logistic models, adjusted for these factors, were used to predict PGD-trained dentists: (1a) serving Medicaid children, (1b) accepting new Medicaid patients, and (2) working in an FQHC.

RESULTS

Individual attributes that predicted serving Medicaid children included all race/gender combinations (vs. White females), and foreign-trained dentists and contractors/employees/associates (vs. practice owners). Black women are most likely to work in an FQHC. Residency attributes that predicted serving Medicaid children and working in an FQHC were Health Resources and Services Administration postdoctoral funding and being community based. Dentists practicing in rural or high-poverty communities were more likely to serve Medicaid children and work at FQHCs. States with higher levels of graduate medical education investment, higher Medicaid rates, and more generous adult dental Medicaid benefits increased the likelihood of serving Medicaid children, while states with more expansive adult dental Medicaid benefits increased the likelihood of working in an FQHC.

CONCLUSION

Federal training investment in PGD education combined with Medicaid payment and coverage policies can strongly impact access to dental care for vulnerable populations. Yet, oral health equity cannot be achieved without increasing dentist workforce diversity.

US dental health care workers' mental health during the COVID-19 pandemic

BACKGROUND

This study was designed to assess the prevalence of anxiety and depression symptoms and understand factors influencing mental health among dental health care workers (DHCWs) during the COVID-19 pandemic.

METHODS

Beginning in June 2020, 8,902 DHCWs participated monthly in an anonymous longitudinal, web-based survey (response rate, 6.7%). The Patient Health Questionnaire-4 was used to estimate rates of anxiety and depression symptoms. Changes in mental health over time and differences by demographic and practice characteristics, COVID-19 community transmission level, and COVID-19 vaccination status were tested using χ² tests and multilevel multivariable logistic regression.

RESULTS

Anxiety symptom rates peaked in November 2020 (28% of dental hygienists, 17% of dentists) and declined to 12% for both professions in May 2021. Depression symptom rates were highest in December 2020 (17% of dental hygienists, 10% of dentists) and declined to 8% in May 2021. Controlling for gender, age, race or ethnicity, and COVID-19 community transmission level, the authors found that dentists had significantly lower odds of anxiety symptoms (adjusted odds ratio [aOR], 0.82; 95% CI, 0.70 to 0.95) and depression symptoms (aOR, 0.79; 95% CI, 0.67 to 0.93) than dental hygienists. Compared with vaccinated respondents, those who were unvaccinated but planning on getting vaccinated had significantly higher rates of anxiety (aOR, 1.71; 95% CI, 1.20 to 2.44) and depression (aOR, 1.57; 95% CI, 1.07 to 2.29) symptoms.

CONCLUSIONS

DHCWs' mental health fluctuated during the pandemic. Anxiety and depression in DHCWs were associated with demographic and professional characteristics as well as perceived risk of COVID-19.

PRACTICAL IMPLICATIONS

Mental health support should be made available for DHCWs. This clinical trial was registered at ClinicalTrials.gov. The registration numbers are NCT04423770 and NCT04542915.

United States Dental Health Care Workers' Mental Health During the COVID-19 Pandemic

Purpose: The purpose of this study was to assess the prevalence of anxiety and depression symptoms and understand factors influencing mental health among dental health care workers (DHCWs) in the United States (US) during the COVID-19 pandemic.Methods: Beginning in June 2020, dentists (DDS) and dental hygienists (DH) in the US were invited to participate monthly in an anonymous, longitudinal, web-based survey. The Patient Health Questionaire-4 (PHQ-4) was used to estimate rates of anxiety and depression symptoms. Changes in mental health over time and differences by demographic and practice characteristics, COVID-19 community transmission level and COVID-19 vaccination status were tested using χ² tests and multilevel multivariable logistic regression.Results: A total of 8,902 DHCWs (DH, DDS) participated in the survey for a response rate of 6.7%. Anxiety symptom rates peaked in November 2020 (28% DH; 17% DDS) and declined to 12% for both professions in May 2021. Depression symptoms were highest in December 2020 (17% DH; 10% DDS) and declined to 8% in May 2021. Controlling for gender, age, race, ethnicity and community COVID-19 transmission levels, DDS respondents had lower odds of anxiety symptoms (aOR 0.82; 95% CI 0.70 to 0.95) and depression symptoms (aOR 0.79; 95% CI 0.67 to 0.93) than DHs. Compared to vaccinated respondents, DHCWs who were unvaccinated but were planning on getting vaccinated had significantly higher rates of anxiety (aOR 1.71; 95% CI 1.20 to 2.44) and depression symptoms (aOR 1.57; CI 1.07 to 2.29).Conclusions: The mental health status of DHCWs fluctuated during the COVID-19 pandemic. Anxiety and depression were associated with the demographic and professional characteristics of the DHCW as well as the perceived risk of COVID-19 infection. Mental health support should be made available for all DHCWs.

The 2021 report on oral health in America: Directions for the future of dental public health and the oral health care system

In the two decades between Oral Health in America: A Report of the Surgeon General and Oral Health in America: Advances and Challenges much good happened but intractable challenges persist. Inequity in oral health status, utilization, and access to care continue to negatively affect the health and economic wellbeing of Americans and their families, local, state, and federal health care systems, and American society overall. To move the nation forward, we argue that: more emphasis is needed in prevention; access to care must be improved to mitigate inequity; newer understandings of oral disease must be leveraged in the service of health and health care; the value that oral health brings to economic wellbeing must be elucidated; better policy choices must be made in all of the above; and more effective oral health care leaders in driving policy change must be trained.

Employment Patterns of Dental Hygienists in the United States During the COVID-19 Pandemic: An update

Purpose: Despite recovery in dental practices' patient volume, dentists in the United States (US) continue to report difficulties in hiring dental hygienists due to the COVID-19 pandemic. This study updates previous data on US dental hygienists' employment patterns and attitudes concerning returning to work.Methods: Licensed dental hygienists were invited to participate in monthly web-based surveys between September 2020 and August 2021. Employment questions included current and pre-pandemic work status as well as reasons for not currently working as a clinical dental hygienist. Descriptive statistics were used to describe dental hygienists' employment status and reasons for not currently working. Cross tabulation analysis included employment status and reasons for not working by age group.Results: As of August 2021, 4.9% (n=59) of the participants reported that they were not currently employed as a dental hygienist. Most reported that the reason for non-employment as a dental hygienist was voluntary (74.1%; n=43).Safety concerns for self and others were the primary reasons for not returning to work; participants also indicated retirement or that they no longer wished to practice due to the pandemic. However, the percentage of respondents citing insufficient childcare, wanting the COVID-19 vaccine but not obtaining it, and having an underlying health condition, decreased between the beginning and the conclusion of the study.Conclusion: A measurable degree of hesitancy among US dental hygienists to return to work has persisted over a year and a half into the pandemic and may continue despite some improvements in workplace safety and vaccine uptake. Future research should examine workforce levels after the pandemic resolves.

COVID-19 Vaccine Intention and Hesitancy of Dental Hygienists in the United States

Purpose: Vaccinations represent an important public health tool for mitigating dangerous diseases; nevertheless, there is concern and hesitancy regarding vaccinations including those for COVID-19. The purpose of this study was to determine the intentions and hesitancy among dental hygienists in the United States (US) toward COVID-19 vaccination.Methods: Dental hygienists in the US were surveyed from 1/4/21 to 8/16/21 regarding their intentions to get vaccinated and whether they received a COVID-19 vaccine. The vaccination questions were part of an anonymous, ongoing longitudinal web-based survey of dental hygienists' employment and infection control trends. Willingness or actual COVID-19 vaccination versus vaccine hesitancy were analyzed by differences in demographic characteristics using multivariable logistic regression and X2 and Fisher's exact tests.Results: Full COVID-19 vaccination rates in US dental hygienists rose sharply from 2/5/21 to 3/5/21 (26.0% to 53.9%) and leveled off to 75.4% by 8/30/21. The highest rates of vaccine hesitancy were among dental hygienists aged 26-39 years and those who had contracted COVID-19 during the time of the survey. The lowest vaccination hesitancy rates were seen among Non-Hispanic Asians and individuals 65+. When controlling for age, race/ethnicity, and years practiced, dental hygienists who had contracted COVID-19 had higher odds of being vaccine hesitant (adjusted Odds Ratio (aOR): 1.847, 95% Confidence Interval (CI): 1.274, 2.678). Having contracted COVID-19 was also associated with respondents changing from being hesitant to be vaccinated to being willing to be vaccinated (aOR: 4.071, 95% CI: 1.652, 10.030).Conclusion: Although vaccine acceptance is high among dental hygienists in the US, vaccine hesitancy remains an ongoing concern. Dental hygienists are key prevention specialists who should promote adherence to vaccination recommendations for the health of the public. Further education in virology, epidemiology, and vaccination education is recommended.

Infection Prevention and Control Practices of Dental Hygienists in the United States During the COVID-19 Pandemic: A longitudinal study

Purpose: The SARS-CoV-2 virus continues to mutate, and the COVID-19 pandemic remains a global health crisis. The purpose of this longitudinal study was to continue to analyze the use of infection prevention and control practices (IPC) and personal protective equipment (PPE) by dental hygienists in the United States (US) during the COVID-19 pandemic.Methods: Web-based surveys on COVID-19 related health, IPC, and PPE were administered monthly to a panel of US licensed dental hygienists (n=6,976) from September 2020 to August 2021. Trends over time and predictors of IPC and PPE use were estimated using Stata 17.0 xt commands and multilevel multivariable logistic regression. Linear regression modeling for trends in time and tests for changes in trends were conducted (Joinpoint Regression Program, Version 4.9.0.0).Results: Almost all practicing dental hygienists (99.9%, 14,926 observations) reported COVID-19 specific IPC in place at their primary dental practice. Consistently >96% of dental hygienists reported operatory disinfection and staff masking over the study period. Patient face masking and physical protections such as barriers or air filtration increased in use over time, then declined in spring 2021. Screening or interviewing patients before appointments, checking patient temperatures before treatment, checking staff temperatures at shift start, disinfecting frequently touched surfaces, and encouraging distance between patients were reported by >85% of respondents until March 2021, at which point significant decreases were observed. Wearing a mask or respirator and eye protection during patient care consistently rose over time from September 2020 (77.1%) to August 2021 (81.4%). Always wearing a N95 or equivalently protective respirators during aerosol generating procedures peaked in 2/2021 and declined thereafter. Dental practice setting, supply of respirators, COVID-19 vaccination, and COVID-19 community transmission level were significantly associated with IPC and PPE use.Conclusion: Most US dental hygienists reported always wearing masks and eye protection during patient care and a variety of IPC types have been instituted to reduce the risk of COVID-19 transmission in dental practice settings. However, the use of N95 or equivalent respirators and some additional IPC methods declined during 2021.

Time for Dental Care to Be Considered Essential in US Health Care Policy

Training, service delivery, and financing are done separately in dentistry and general health care, which has influenced reimbursement structures, access to services, and outcomes. This article considers how medical and dental separation exacerbates health inequity and canvasses data demonstrating that oral health and dental services are the least affordable health services. This article also proposes how dental and general medical care coverage can be meaningfully integrated through better health policy to motivate health equity.

Employment Patterns of Dental Hygienists in the United States During the COVID-19 Pandemic

Purpose: The COVID-19 pandemic has led to drops in patient volume and staffing in dental practices in the United States (US). This study aimed to provide insights on dental hygienists' employment patterns as well as their attitudes toward working as dental hygienists during a pandemic.Methods: Licensed dental hygienists were invited to participate in a web-based 30-question survey between September 29 and October 8, 2020. Employment questions included current and pre-pandemic work status, reasons for not currently working as a dental hygienist, and estimated levels of personal protective equipment (PPE) in the primary work location. All statistical analysis was conducted in Qualtrics Core XM; cross tabulation was used to examine dental hygienist working patterns and attitudes by age, practice PPE supply, and other factors.Results: The COVID-19 pandemic has led to an estimated 8% reduction in dental hygienist employment. The majority (59.1%, n=205) of this reduction is voluntary, with the main reason being general concerns over COVID-19 (48.3%, n=100). Other reasons include issues surrounding childcare and concerns over safety measures in the workplace. Dental hygienists aged 65 and older were most likely to have left the workforce voluntarily. More than half of respondents reported that their work locations had more than a two-week supply of most PPE items, although about 10% did not know supply levels. Dental hygienists working in settings with lower supplies of PPE were more concerned with COVID-19 transmission risk to themselves or to patients.Conclusion: COVID-19 has led to a reduction in the dental hygienist workforce that is likely to persist until the pandemic passes.The dental hygienist labor market has tightened and employers may continue to experience difficulties in filling vacant dental hygienist positions until the pandemic subsides. There is also likely to be a longer term, yet smaller, impact on dental hygiene employment levels.

COVID-19 Prevalence and Related Practices among Dental Hygienists in the United States

Purpose: Throughout the COVID-19 pandemic, health care professionals have been challenged to provide appropriate preventive and therapeutic measures while using precautions to minimize disease transmission. The purpose of this study was to estimate the prevalence of COVID-19 among United States (US) dental hygienists, describe infection prevention and control procedures and any associated trends in mental health.Methods: Registered dental hygienists (RDHs) licensed in the US were invited to participate in a 30-question web-based survey. COVID-19 infection items included probable and confirmed results, COVID-19 related symptoms experienced in the last month, and level of concern about COVID-19 transmission to patients and themselves. The validated Patient Health Questionnaire 4 screened respondents for depression or anxiety. Personal protective equipment (PPE) use when treating patients was assessed. The research protocol and survey were approved by the American Dental Association IRB and registered at clinicaltrials.gov (NCT04542915). Kruskal-Wallis and X² tests were used to test for associations between PPE use, PPE supply, mental health symptoms, and concern about COVID-19 transmission.Results: As of October 8, 2020, a total of 4,776 dental hygienists from all 50 states and Puerto Rico participated in the study. Respondents reported elevated symptoms of anxiety and depression. Of the respondents, 3.1% (n=149) had ever tested positive or been diagnosed with COVID-19. The majority of respondents (99.1%; n=3,328) who practiced dental hygiene reported their primary dental practice had enhanced infection prevention or control efforts in response to the pandemic. PPE use was significantly associated with years of experience as a dental hygienist, level of concern about COVID-19, and level of PPE supplies available (p-values<0.01), but not type of dental practice (p-value 0.1).Conclusion: As of October 2020, the estimated prevalence rate of dental hygienists in the US having had COVID-19 was low. There is a need for further support for dental hygienists' use of PPE and mental health.

Developing a Standard Set of Patient-centred Outcomes for Adult Oral Health - An International, Cross-disciplinary Consensus

Objective

To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health.

Materials and methods

An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers.

Results

The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered.

Conclusion

In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

Estimating COVID-19 prevalence and infection control practices among US dentists

BACKGROUND

Understanding the risks associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during oral health care delivery and assessing mitigation strategies for dental offices are critical to improving patient safety and access to oral health care.

METHODS

The authors invited licensed US dentists practicing primarily in private practice or public health to participate in a web-based survey in June 2020. Dentists from every US state (n = 2,195) answered questions about COVID-19-associated symptoms, SARS-CoV-2 infection, mental and physical health conditions, and infection control procedures used in their primary dental practices.

RESULTS

Most of the dentists (82.2%) were asymptomatic for 1 month before administration of the survey; 16.6% reported being tested for SARS-CoV-2; and 3.7%, 2.7%, and 0% tested positive via respiratory, blood, and salivary samples, respectively. Among those not tested, 0.3% received a probable COVID-19 diagnosis from a physician. In all, 20 of the 2,195 respondents had been infected with SARS-CoV-2; weighted according to age and location to approximate all US dentists, 0.9% (95% confidence interval, 0.5 to 1.5) had confirmed or probable COVID-19. Dentists reported symptoms of depression (8.6%) and anxiety (19.5%). Enhanced infection control procedures were implemented in 99.7% of dentists' primary practices, most commonly disinfection, COVID-19 screening, social distancing, and wearing face masks. Most practicing dentists (72.8%) used personal protective equipment according to interim guidance from the Centers for Disease Control and Prevention.

CONCLUSIONS

COVID-19 prevalence and testing positivity rates were low among practicing US dentists. This indicates that the current infection control recommendations may be sufficient to prevent infection in dental settings.

PRACTICAL IMPLICATIONS

Dentists have enhanced their infection control practices in response to COVID-19 and may benefit from greater availability of personal protective equipment. ClinicalTrials.gov: NCT04423770.

Advancing oral health policy through persuasive messaging and effective research measures

Oral health is often excluded from broad health policy discussions, addressed only in a policy silo. There is a paucity of research to guide policymaking as it relates to oral health. In response, AcademyHealth's Oral Health Interest Group organized a meeting during the 2019 AcademyHealth Annual Research Meeting to promote transdisciplinary dialog on the current state of oral health policy and the steps necessary to improve the oral health of Americans. This article summarizes the two main themes that emerged from the proceedings of the Oral Health Interest Group meeting: a) recommendations for advocating the inclusion of oral health in policy discussions and b) critical research topics and measures needed for effective oral health policies in the future.

The association of dental education with pediatric Medicaid participation

PURPOSE

This study examines whether characteristics of dental education, practice characteristics and state Medicaid policies are associated with dentists' pediatric Medicaid participation.

METHODS

Cross-sectional analysis of data about dentists' Medicaid participation in 2016, based on current practice characteristics and characteristics of dental schools they attended 5 to 10 years earlier. We analyze data about 22,500 general and pediatric dentists, drawn from the American Dental Association's Masterfile for 2016 and its dental school survey for 2009-10. The primary outcome is whether dentists participated in Medicaid-enrolled to accept Medicaid patients and payments-in at least 1 of their practice sites in 2016.

RESULTS

A majority (55%) of dentists accepted Medicaid in at least 1 practice site, while a quarter (24%) accepted Medicaid in all their sites. Dentists who attended schools with higher tuition rates were less likely to serve Medicaid patients at any site several years later (adjusted odds ratio [AOR] = .761). Dental schools' receipt of grants that encourage community-based training were associated with increased Medicaid participation at all sites (AOR = 1.22). Those practicing in rural areas also had higher Medicaid participation (AOR = 2.62). A 10% increase in Medicaid reimbursement rates was associated with increased Medicaid participation at any site (AOR = 1.24).

CONCLUSIONS

Dental school practices and state Medicaid policies are associated with whether dentists care for Medicaid patients. Changes in dental school or Medicaid policies, such as higher reimbursement rates, could help encourage more dentists to accept Medicaid patients, thereby increasing access to care.

Pricing in commercial dental insurance and provider markets

Objective

To examine the impact of commercial dental insurer and provider concentration on dentist reimbursement.

Data Sources

We utilized provider data from the American Dental Association, reimbursement data from IBM Watson MarketScan^® Commercial Research Databases, submitted billed charges from FAIR Health^®, dental insurance market concentration data from FAIR Health^®, and county‐level demographic and economic data from the Area Health Resources File and the Council for Community and Economic Research.

Study Design

We used the Herfindahl‐Hirschman Index to separately measure commercial dental insurance concentration and dentist concentration. We studied the effect of provider and insurance concentration on dentist reimbursement. Using two‐stage least squares, we accounted for potential endogeneity in dental insurer and provider concentration.

Principal Findings

Across the dental procedures we examined, a 10 percent increase in dental insurance concentration is associated with a 1.95 percent (P‐value = .033) reduction in gross payments to dentists. Conversely, a 10 percent increase in dentist concentration is associated with a more modest 0.71 percent (P‐value = .024) increase in gross payments. A 10 percent increase in dental insurance concentration is associated with a 1.16 percentage point (P‐value = .016) decline in the allowed‐to‐list price ratio, while a 10 percent increase in dentist concentration is associated with a 0.56 percentage point (P‐value = .001) increase in the allowed‐to‐list price ratio. Similar patterns were found across dental procedure subcategories.

Conclusions

Dental provider markets are substantially less concentrated than insurance markets, which may limit the ability of dentists to garner higher reimbursement.

COVID-19 Has Clarified 2 Foundational Policy Questions in Dentistry

Before the COVID-19 pandemic, health policy debates about the importance of oral health and dental care were intensifying around the world. These debates were invariably complex and muddled by political, professional, and commercial interests. Although, in broad terms, 2 foundational questions have tended to undergird debates on how dental care should be addressed in health policy. These are: who should receive the support of governments, and what constitutes essential or medically necessary dental care? In our view, the COVID-19 pandemic has provided a stark social and policy context that has radically clarified both questions.

Knowledge Transfer Statement:

This commentary can be used by governments, regulators, professional groups, and other stakeholders in their considerations of what constitutes essential or medically necessary dental care and how to best allocate dental care resources.

Consolidation in the dental industry: a closer look at dental payers and providers

We examine the effect of commercial dental insurance concentration on the size of dental practices, the decision of dentists to own a practice, and the choice of dentists to work at a dental management service organization-a type of corporate group practice that has become more prevalent in the United States in recent years. Using 2013-2015 dentist-level data from the American Dental Association, county-level data on firms and employment from the United States Census, and commercial dental insurance market concentration data from FAIR Health^®, we find a modest effect of dental insurance market concentration on the size of dental practices. We also find that a higher level of commercial dental insurance market concentration is associated with a dentist's decision not to own a practice. There is inconclusive evidence that higher levels of dental insurance market concentration impact a dentist's decision to affiliate with a dental management service organization. Overall, our findings imply that dentists consolidate in response to increases in concentration among commercial dental insurers.

Opioid prescribing practices from 2010 through 2015 among dentists in the United States: What do claims data tell us?

BACKGROUND

Dentists wrote 6.4% of all opioid prescriptions in the United States in 2012. The purpose of this study was to examine opioid prescription rates, dosage of opioids prescribed, type of opioid drug prescribed, and type of dental visit at which dentists prescribe opioids.

METHODS

The authors used the 2010 through 2015 Truven Health Marketscan Research databases and the Prescription Drug Monitoring Program (PDMP) Training and Technical Assistance Center conversion data set. The authors conducted descriptive analyses for days' supply, quantity prescribed, and daily morphine milligram equivalent dose.

RESULTS

The opioid prescription rate per 1,000 dental patients increased from 130.58 in 2010 to 147.44 in 2015. Approximately 68.41% of all opioids prescribed were during surgical dental visits and approximately 31.10% during nonsurgical dental visits. During nonsurgical dental visits at which dentists prescribed an opioid, most of the procedures were restorative.

CONCLUSIONS

Among a population of dental patients with private insurance, opioid prescribing rates in the United States increased slightly from 2010 to 2015. The largest increase was among 11- through 18-year-olds. Almost one-third of opioid prescriptions written by dentists were associated with nonsurgical dental visits.

PRACTICAL IMPLICATIONS

Use of PDMP resources and use of nonopioid analgesics could help reduce the number of opioid prescriptions in dentistry.

Access to primary and dental care among adults newly enrolled in Medicaid

OBJECTIVES

Adequate access to primary and dental care is essential for population health, and some state Medicaid programs have expanded insurance coverage for both. However, there are few data on new Medicaid enrollees' ability to access services. We examined the relationship between provider supply and enrollees' identification of usual sources of care.

STUDY DESIGN

Between November 2015 and February 2016, we surveyed low-income adults newly insured through Medicaid in Philadelphia, Pennsylvania, to determine if they had a usual source of care. Additionally, we used geospatial methods to calculate adult population per provider ratios by Census tract for primary and dental care providers who accepted Medicaid patients, then identified low-supply clusters.

METHODS

We used multivariable logistic regression models to describe the odds of identifying usual sources of care based on being in low- or high-supply clusters, adjusting for patient demographics.

RESULTS

Of 1000 contacted individuals, 312 completed the survey. Among respondents, 168 were previously uninsured and newly enrolled in Medicaid; 66.7% of this group identified a usual primary care provider and 42.3% identified a usual dental care provider. In adjusted analyses, individuals living in low- and high-supply areas had similar likelihoods of identifying a usual source of primary or dental care.

CONCLUSIONS

Many new Medicaid enrollees did not have usual sources of primary or dental care, regardless of nearby provider supply. Efforts to understand what improves access or engagement in healthcare among Medicaid enrollees are critical after low-income adults gain insurance.

Earnings of Employed and Self-employed US Health Care Professionals, 2001 to 2015

IMPORTANCE

Over the last 15 years, the health care practitioner landscape has changed significantly. Fewer practitioners are self-employed and more are employed by for-profit or nonprofit organizations. These shifts can have an impact on annual labor earnings.

OBJECTIVES

To examine trends in self-employment and employment and to assess the gap in annual labor earnings between self-employed and employed US health care professionals from 2001 to 2015.

DESIGN, SETTING, AND PARTICIPANTS

Survey study in which data on employment type (self-employed, employed by private sector, or employed by government) and annual labor earnings for 50 states and the District of Columbia were extracted from the 2001 to 2015 American Community Survey. The analyses were restricted to 175 714 self-identified dentists, physicians, pharmacists, optometrists, podiatrists, chiropractors, and physical therapists aged 30 years and older who worked at least 40 weeks per year and 20 hours per week. Controlling for age, sex, race/ethnicity, year, and state of residence, median regression models were used to measure the gap in annual labor earnings between self-employed and employed health care professionals.

MAIN OUTCOMES AND MEASURES

Annual labor earnings, defined as the sum of self-employment and wages or salary income.

RESULTS

Our sample of 175 714 respondents included 99 077 physicians, 20 008 dentists, 26 143 pharmacists, 4238 optometrists, 6076 chiropractors, 1164 podiatrists, and 19 008 physical therapists. The weighted percentage of self-employed physicians decreased from 35.2% (95% CI, 34.4%-36.1%; 6807 of 18 726 physicians) in 2001 through 2005 to 24.7% (95% CI, 24.2%-25.2%; 10 974 of 41 205 physicians) in 2011 through 2015. The percentage of self-employed dentists decreased from 73.0% (95% CI, 71.2%-74.8%; 3117 of 4153 dentists) in 2001 through 2005 to 65.1% (95% CI, 63.7%-66.4%; 5260 of 7820 dentists) in 2011 through 2015. Among physicians, the regression-adjusted earnings gap reversed from $19 679 (95% CI, $14 431-$24 927; P < .001) during 2001 through 2005 to -$10 623 (95% CI, -$14 547 to -$6699; P < .001) during 2011 through 2015. Among dentists, the regression-adjusted earnings gap narrowed from $30 448 (95% CI, $23 040-$37 855; P < .001) during 2001 through 2005 to $21 291 (95% CI, $15 723-$26 859; P < .001) during 2011 through 2015. From 2001 to 2015 the earnings gap also reversed among pharmacists, optometrists, and podiatrists. The regression-adjusted earnings gap narrowed among chiropractors and physical therapists.

CONCLUSIONS AND RELEVANCE

Since 2001, the percentage of health care professionals who are self-employed declined, and the gap in earnings between self-employed and employed health care professionals narrowed.

The impact of the affordable care act's Medicaid expansion on dental care use through 2016

OBJECTIVE

To examine the impact of the Affordable Care Act on dental care use among low-income adults ages 21-64.

METHODS

Our analysis uses national survey data from the 2010-2016 Gallup Wellbeing-Index. We use a differences-in-differences analysis to assess changes since the end of 2013 in dental care use among low-income adults. We compare changes in states that expanded Medicaid and offer adult Medicaid dental benefits versus changes in other states.

RESULTS

Relative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased 3-6 percentage points in 2016.

CONCLUSIONS

In Medicaid expansion states with adult dental benefits, evidence suggests that low-income adults have greater access to dental care.

The Relationship between Periodontal Interventions and Healthcare Costs and Utilization. Evidence from an Integrated Dental, Medical, and Pharmacy Commercial Claims Database

Periodontal disease has been linked to poor glycemic control among individuals with type 2 diabetes. Using integrated dental, medical, and pharmacy commercial claims from Truven MarketScan® Research Databases, we implement inverse probability weighting and doubly robust methods to estimate a relationship between a periodontal intervention and healthcare costs and utilization. Among individuals newly diagnosed with type 2 diabetes, we find that a periodontal intervention is associated with lower total healthcare costs (-$1799), lower total medical costs excluding pharmacy costs (-$1577), and lower total type 2 diabetes-related healthcare costs (-$408). © 2016 The Authors. Health Economics Published by John Wiley & Sons Ltd.

Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace

OBJECTIVE

To estimate premium and out-of-pocket costs for child dental care services under various dental coverage options offered within the federally facilitated marketplace.

STUDY DESIGN

We estimated premium and out-of-pocket costs for child dental care services for 12 patient profiles, which vary by dental care use and spending. We did this for 1039 medical plans that include child dental coverage, 2703 medical plans that do not include child dental coverage, and 583 stand-alone dental plans for the 2015 plan year. Our analysis is based on plan data from the Center for Consumer Information and Insurance Oversight and Data.HealthCare.Gov.

RESULTS

On average, expected total financial outlays for child dental care services were lower when dental coverage was embedded within a medical plan compared with the alternative of a stand-alone dental plan. The difference, however, in average expected out-of-pocket spending varied significantly for our 12 patient profiles. Older children who are very high users of dental care, for example, have lower expected out-of-pocket costs under a stand-alone dental plan. For the vast majority of other age groups and dental care use profiles, the reverse holds.

CONCLUSIONS

Our results show that embedding dental coverage within medical plans, on average, results in lower total financial outlays for child beneficiaries. Although our results are specific to the federally facilitated marketplace, they hold lessons for both state-based marketplaces and the general private health insurance and dental benefits market, as well.

The effect of education debt on dentists' career decisions

BACKGROUND

The purpose of the study was to determine whether there is an association between the amount of education debt on completing dental school (initial debt) and certain career decisions.

METHODS

The authors surveyed 1,842 practicing dentists who completed dental school between 1996 and 2011 to ascertain their initial education debt, the balance on their debt in 2013, and a variety of specialization and practice decisions made during their careers. Data also included demographic characteristics and parental income and education levels.

RESULTS

Dentists with higher initial debt were less likely to specialize and more likely to enter private practice, accept high-paying jobs on graduation, and work longer hours. Choice of employment setting, practice ownership, and whether to provide Medicaid and charity care were associated with dentists' sexes and races but not debt.

CONCLUSIONS

High debt levels influenced some career decisions, but the magnitude of these effects was small compared with the effects of demographic characteristics, including race and sex, on career choices.

PRACTICAL IMPLICATIONS

Policy makers concerned about the influence of student debt on the professional decisions of dental school graduates should recognize that students' demographic characteristics may be more powerful in driving career choices.

The impact of out-of-pocket payments for dental care on household finances in low and middle income countries

BACKGROUND

Dental care is extremely costly and beyond most people means in developing countries. The primary aim of this study was to determine the impact of out-of-pocket payments for dental care on household finances in 40 low and middle income countries. A second aim was to compare the burden of payments for dental care with that for other health services.

METHODS

We used data from 174,257 adults, aged 18 years and above, who reported their total and itemized household expenditure in the past four weeks as part of the World Health Surveys. The financial burden on households was measured using the catastrophic health expenditure (CHE) and impoverishment approaches. A household was classified as facing CHE if it spent 40% or more of its capacity to pay, and as facing impoverishment if it fell below the country-specific poverty line after spending on health care was subtracted from household expenditure. The odds of experiencing CHE and impoverishment due to expenditure on dental care were estimated from two-level logistic regression models, controlling for various individual- and country-level covariates.

RESULTS

Households that paid for dental care had 1.88 (95% Confidence Interval: 1.78-1.99) greater odds of incurring CHE and 1.65 (95% CI: 1.52-1.80) greater odds of facing impoverishment, after adjustment for covariates. Furthermore, the impact of paying for dental care was lower than that for medications or drugs, inpatient care, outpatient care and laboratory tests but similar to that of health care products, traditional medicine and other health services.

CONCLUSION

Households with recent dental care spending were more likely to use a large portion of their disposable income and fall below the poverty line. Policy makers ought to consider including dental care as part of universal health care and advocate for the inclusion of dental care coverage in health insurance packages.