Disparities in Enrollment in Medicare Advantage Plans With Dental Benefits

This cross-sectional study evaluates the association of Medicare beneficiaries’ sociodemographic characteristics with having Medicare Advantage plans that cover oral health services.

Claims analysis of Medicare fee-for-service oral health care encounters, from 2019 through 2021

BACKGROUND

Many qualifying people rely on Medicare fee-for-service (FFS) for their health care insurance, although it rarely provides coverage for oral health care services. The objective of this study was to gain insights into oral health care that is being provided by all health care provider types for Medicare FFS beneficiaries.

METHODS

The authors used the Centers for Medicare & Medicaid Services Virtual Data Research Center to query 100% of Medicare FFS claims from 2019 through 2021 and identify all encounters for which there was either an oral health-related International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code or a CDT 2019-2021: Current Dental Terminology code recorded on the claim. The authors used a cross-sectional study design and calculated descriptive statistics to describe characteristics of identified oral health care encounters. The encounter level was the unit of analysis.

RESULTS

A total of 2,098,056 oral health care encounters were identified through Medicare FFS claims during the study observation period, with a lower volume observed after 2019. Nearly 98% of encounters were related to those in which oral health diagnoses were recorded (International Classification of Diseases, Tenth Revision, Clinical Modification code on claim), and non-oral health care providers primarily submitted these claims. Most encounters included beneficiaries with chronic conditions, and a roughly equal proportion included those qualifying for Medicare on the basis of age and disability.

CONCLUSIONS

Previously unreported characteristics of oral health care encounters were identified through administrative claims, providing insights into oral health care being provided to a subset of Medicare FFS beneficiaries.

PRACTICAL IMPLICATIONS

Future research and policies should focus on strengthening medical-dental integration models and expanding access to oral health care for the Medicare FFS population.

Association Between Medicaid Dental Payment Policies and Children’s Dental Visits, Oral Health, and School Absences

Question

Are increases in the ratio of Medicaid payment rates to dentist charges for an index of services associated with improvements in children’s outcomes?

Findings

This cross-sectional study used a difference-in-differences analysis to evaluate 15 738 Medicaid-enrolled and 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children’s Health. Increasing the Medicaid fee ratio was associated with significant but modest improvements in children’s dental visits and oral health and had no significant association with school absences.

Meaning

More generous Medicaid dental payment policies are associated with improvements in children’s outcomes.

Importance

Although all state Medicaid programs cover children’s dental services, less than half of publicly insured children receive recommended care.

Objective

To evaluate the association between the ratio of Medicaid payment rates to dentist charges for an index of services (fee ratio) and children’s preventive dental visits, oral health, and school absences.

Design, Setting, and Participants

In this cross-sectional study, a difference-in-differences analysis was conducted between September 2021 and April 2022 of 15 738 Medicaid-enrolled children and a control group of 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children’s Health. Exploratory subgroup analyses by sex and race and ethnicity were also performed. A 2-sided P < .05 was considered significant.

Main Outcomes and Measures

Past-year preventive dental visits (at least 1 and at least 2), parent-reported excellent oral health, and number of days absent from school (at least 4 days and at least 7 days).

Results

The Medicaid-enrolled sample included a weighted estimate of 51.20% boys and 48.80% girls (mean age, 11.24 years; Black, 21.65%; Hispanic, 37.75%; White, 31.45%). By weighted baseline estimates, 87% and 48% of Medicaid-enrolled children had at least 1 and at least 2 past-year dental visits, respectively, and 29% had parent-reported excellent oral health. Increasing the fee ratio by 1 percentage point was associated with percentage point increases of 0.18 in at least 1 dental visit (95% CI, 0.07-0.30), 0.27 in at least 2 visits (95% CI, 0.04-0.51), and 0.19 in excellent oral health (95% CI, 0.01-0.36). Increases in at least 2 visits were larger for Hispanic children than for White children. By weighted baseline estimates, 28% and 15% of Medicaid-enrolled children had at least 4 and at least 7 past-year school absences, respectively. Regression estimates for school absences were not statistically significant for the full sample but were estimated to be significantly reduced among girls.

Conclusions and Relevance

This cross-sectional study found that more generous Medicaid payment policies were associated with significant but modest increases in children’s preventive dental visits and excellent oral health. Further research is needed to understand the potential association between policies that improve access to dental care and children’s academic success.

Dental care use and other population characteristics of older Americans with self-reported chronic conditions in the health and retirement study

OBJECTIVES

To analyze relative differences in oral health care utilization, oral health, and other population characteristics of older Americans with respect to self-reported chronic conditions in the health and retirement study.

METHODS

Differences in estimated percentages of those with specific chronic conditions by selected attributes were tested for statistical significance with standardized normal Z tests and logistic regressions. All estimates were based on weighted data from 1992 to 2016 Early Release RAND HRS Longitudinal file. SE estimates for the percentages accounted for the complex sample design of the survey.

RESULTS

We establish that the strength of the associations between regular use of dental care and the absence of a chronic condition is similar in magnitude to having a college education, living in a high-income family, never smoking, not having certain functional limitations, and being under 65 years of age.

DISCUSSION

These cross-sectional findings establish the relative strength of relationships between dental care use, oral health status, and other population characteristics and eight diagnosed conditions. Further work beyond the scope of this paper is needed to confirm these results as either attributes of those with the disease or causal risk factors for the onset of the condition.

The Association Between Medicaid Adult Dental Coverage And Children's Oral Health

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.

Dental Care Use, Edentulism, and Systemic Health among Older Adults

Past research suggests there are systematic associations between oral health and chronic illness among older adults. Although causality has not yet been credibly established, periodontitis has been found to be associated with higher risk of both heart disease and stroke. We advance this literature by estimating the direct association between dental care use and systemic health using multiple waves of the 1992 to 2016 Health and Retirement Study. Through the inclusion of individual fixed effects in our regression models, we account for unobservable time-invariant characteristics of individuals that might otherwise bias estimates of the association between dental care use and health. We find statistically significant negative associations between dental care use and the number of health conditions, self-reported overall health, the incidence of heart disease, and the incidence of stroke. In particular, the use of dental care within the past 2 y is associated with a 2.7% reduction in the likelihood of being diagnosed with a heart condition and a reduction in the likelihood of a stroke diagnosis of between 5.3% and 11.6%. We also find large positive correlations between edentulism and the measures of chronic illness. Associations from models estimated separately for men and women are qualitatively similar to one another. These findings provide additional motivation for the consideration of a Medicare dental benefit.

Enrollment trends in employer-sponsored health plans that include dental benefits

BACKGROUND

In this study, the authors provide a better understanding of enrollment trends associated with dental plans embedded in private-sector, employer-sponsored insurance health plans for the years 2005, 2010, 2015, and 2018.

METHODS

Data used were from the insurance component of the Medical Expenditure Panel Survey. The authors present the number of employees enrolled in employer-sponsored insurance health plans and the percentage of these employees enrolled in health plans that include dental benefits. The authors present yearly estimates for 2005, 2010, 2015, and 2018, according to employer characteristics and state.

RESULTS

While the number of embedded dental benefit plans has decreased from approximately 14.1 million plans to slightly more than 9.3 million plans in 2018 since 2005, the percentage of enrollees in employer-sponsored insurance health plans with dental coverage has decreased from approximately 23.2% of enrollees to slightly more than 15.0%.

CONCLUSIONS

Although the percentage of embedded dental plans is decreasing, they are still an important component of the dental insurance market and are especially important to those employees who are enrolled.

PRACTICAL IMPLICATIONS

Information will provide a better understanding of the source and extent of embedded dental plans provided via private-sector employers. These plans are often less generous than stand-alone plans.

Does covering routine dental care for the Medicare population produce cost savings in Medicare? A preliminary 2-year analysis

OBJECTIVES

We estimated the association between the use of preventive dental care and medical use and expense for older persons over a 2-year period to determine if a Medicare dental benefit for routine care could result in potential cost savings in Medicare.

METHODS

We relied on 2008-2014 Medical Expenditure Panel Survey data to estimate separate logistic and lognormal ordinary least squares regressions to analyze the influence of year 1 preventive dental care on either year 1 or year 2 use and expenses for total health care, office-based care, outpatient care, inpatient stays, emergency department visits, and prescription drugs.

RESULTS

Our findings provide evidence over a 2-year period that a Medicare dental benefit for routine care could produce an increase in office-based visits and expense. We also found that older persons currently using routine dental care have healthier lifestyles and greater access to care and use of preventive medical care than current nonusers.

CONCLUSION

Our results affirm the need for a longer-term study to provide any conclusive evidence as to the ultimate impact of a Medicare dental benefit on other health care use and expenses.

The demand for preventive and restorative dental services among older adults

Many older Americans have poor access to dental care, resulting in a high prevalence of oral health problems. Because traditional Medicare does not include dental care benefits, only older Americans who are employed, have post-retirement dental benefits or spousal coverage, or enroll in certain Medicare Advantage plans are able to obtain dental care coverage. We seek to determine the extent to which poor access to dental insurance and high out-of-pocket costs affect dental service use by the elderly. Using the 2007-2015 Medical Expenditure Panel Survey and supplemental data on dental care prices, we estimate a demand system for preventive dental services and basic and major restorative services. Selection into dental and medical insurance is addressed using a correlated random effects panel data specification. Consistent with prior studies of the nonelderly population, dental service use was not sensitive to out-of-pocket prices. However, private dental insurance increased preventive service use by 25%, and dental coverage through Medicaid increased basic and major service use by 23% and 36%, respectively. The use of services was more responsive to dental insurance for women than men. These estimates suggest that a Medicare dental benefit could significantly increase dental service use by older Americans.

Diversity in the use of specialized dental services by older adults in the United States

OBJECTIVES

We estimated the use of any dental services and the use of specific types of dental services conditional on any dental use for adults 50 and over in the United States to analyze: a) disparities in the use of specialized dental services and b) whether older adults receiving routine dental care use fewer expensive specialized dental services.

METHODS

We relied on data tabulations and estimated logistic regressions from the 2014 Medical Expenditure Panel Study to analyze the influence of various covariates such as age, race/ethnicity, education, dental insurance, income, and health status on the likelihood of a) using any dental care and b) using routine dental care (prophylaxis, examinations, bitewings, etc.) and specialized services for restorative, periodontal, oral surgery, or prosthetic dental care conditional on using any dental care.

RESULTS

We found a) lower use of specialized services among higher income, more educated, healthier, nonminority older adults and b) association between lower use of routine dental care and higher use of expensive restorative, oral surgery, and prosthetic dental services.

CONCLUSIONS

Our study identifies diversity in the use of specialized dental services among an older adult population and suggests that more widespread use of routine dental services could potentially improve oral health and limit the need for expensive specialized dental care for this population.

Projecting the Demand for Dental Care in 2040

The purpose of this study was to provide a forward-thinking assessment of the underlying factors likely to impact trends in dental care demand and the need for dental providers in 2020, 2025, and beyond. Dental workforce trends and their likely impact on the need for dentists are a function of predicted dental care demand, which will in turn be determined by the size and characteristics of our population size, economic outlook, the state of public and private dental care insurance, trends in dental care delivery, professionally determined dental care need, and population health beliefs. Projecting rates of dental care utilization far into the future is difficult because projections must be made using historical data, and established trends may not persist if there is structural change in the future. Nonetheless, when structural change occurs, it does not typically affect all aspects of the economy, so there is value in describing the likely future impact of current trends. This article was written as part of the project "Advancing Dental Education in the 21^st Century."

Projections Of Dental Care Use Through 2026: Preventive Care To Increase While Treatment Will Decline

This study provides a forward-thinking assessment of the factors likely to affect future trends in dental care in the United States. We developed a forecasting model based on historical data from the Medical Expenditure Panel Survey to determine how demographic trends and recent health care policies will affect dental care use in the future. Our forecasts suggest that the medical and dental insurance reforms instituted under the Affordable Care Act will increase rates of dental care use and the number of dental visits, with utilization rates reaching 47 percent in 2026 and the number of visits reaching 334 million, under optimistic assumptions about take-up of pediatric dental coverage. Our forecasting model also indicates that visits for preventive dental care will increase in the future, while visits for dental treatment will decline. Our forecasts can be used to infer future need for different types of dental care providers and to provide policy makers with the information needed to consider the expansion of mandates for dental benefit coverage to adult populations covered by Medicaid, Medicare, and individual and small-group plans sold on health insurance exchanges.

Differences Among Older Adults in the Types of Dental Services Used in the United States

The purpose of this article is to explore differences in the socioeconomic, demographic characteristics of older adults in the United States with respect to their use of different types of dental care services. The 2008 Health and Retirement Study (HRS) collected information about patterns of dental care use and oral health from individuals aged 55 years and older in the United States. We analyze these data and explore patterns of service use by key characteristics before modeling the relationship between service use type and those characteristics. The most commonly used service category was fillings, inlays, or bonding, reported by 43.6% of those with any utilization. Just over one third of those with any utilization reported a visit for a crown, implant, or prosthesis, and one quarter reported a gum treatment or tooth extraction. The strongest consistent predictors of use type are denture, dentate, and oral health status along with dental insurance coverage and wealth. Our results provide insights into the need for public policies to address inequalities in access to dental services among an older US population. Our findings show that lower income, less wealthy elderly with poor oral health are more likely to not use any dental services rather than using only preventive dental care, and that cost prevents most non-users who say they need dental care from going to the dentist. These results suggest a serious access problem and one that ultimately produces even worse oral health and expensive major procedures for this population in the future.

Dental Visit Utilization Procedures and Episodes of Treatment

This investigation describes the factors associated with patients' initial decisions to seek dental care, including the corresponding number of visits and the types of services received during a dental visit episode. Data came from the nationally representative Medical Expenditure Panel Survey (MEPS). Episode-specific dental visits were further classified into three categories, based on type of services received: preventive, treatment-based, or a combination. Among individuals with a visit episode, 78% of the episodes consisted of a single visit. Within an episode, as the number of visits increased, the proportion of initial visits that were of the preventive type decreased.The findings showed that the primary driver of oral healthcare utilization in the United States is preventive care. As new health policy is developed, it is hoped that prevention will remain a central focus in dentistry and that all segments of the population will be able reap its benefits.

Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice

In recent years, advocates for increasing access to medical and oral health care have argued for expanding the scope of practice of dentists and physicians. Although this idea may have merit, significant legal and other barriers stand in the way of allowing dentists to do more primary health care, physicians to do more oral health care, and both professions to collaborate. State practice acts, standards of care, and professional school curricula all support the historical separation between the 2 professions. Current laws do not contemplate working across professional boundaries, leaving providers who try vulnerable to legal penalties. Here we examine the legal, regulatory, and training barriers to dental and medical professionals performing services outside their traditional scope of practice.

The effect of dental insurance on the use of dental care for older adults: a partial identification analysis

We evaluate the impact of dental insurance on the use of dental services using a potential outcomes identification framework designed to handle uncertainty created by unknown counterfactuals-that is, the endogenous selection problem-and uncertainty about the reliability of self-reported insurance status. Using data from the health and retirement study, we estimate that utilization rates of adults older than 50 years would increase from 75% to around 80% under universal dental coverage.

A Research Note on Transitions in Out-of-Pocket Spending on Dental Services

OBJECTIVE

We analyze correlates of the direction and magnitude of changes in out-of-pocket (OOP) payments for dental care by older Americans over a recent 4-year period.

METHODS

We analyzed data from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of the direction and linear regression models of the amounts of OOP changes over survey periods.

RESULTS

Financial-based factors were more strongly associated with the direction and magnitude of changing self-payments for dental care than were health factors.

DISCUSSION

Findings suggested that dental coverage, income, and wealth and changes in these financial factors were more strongly correlated with the persistence of and changes in OOP payments for dental care over time than were health status and changes in health status. The sensitivity to dental coverage changes should be considered as insurance and retirement policy reforms are deliberated.

Dental use and expenditures for older uninsured Americans: the simulated impact of expanded coverage

OBJECTIVE

To determine if providing dental insurance to older Americans would close the current gaps in dental use and expenditure between insured and uninsured older Americans.

DATA SOURCES/STUDY SETTING

We used data from the 2008 Health and Retirement Survey (HRS) supplemented by data from the 2006 Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

We compared the simulated dental use and expenditures rates of newly insured persons against the corresponding rates for those previously insured.

DATA COLLECTION/EXTRACTION METHODS

The HRS is a nationally representative survey administered by the Institute for Social Research (ISR). The MEPS is a nationally representative household survey sponsored by the Agency for Healthcare Research and Quality (AHRQ).

PRINCIPAL FINDINGS

We found that expanding dental coverage to older uninsured Americans would close previous gaps in dental use and expense between uninsured and insured noninstitutionalized Americans 55 years and older.

CONCLUSIONS

Providing dental coverage to previously uninsured older adults would produce estimated monthly costs net of markups for administrative costs that comport closely to current market rates. Estimates also suggest that the total cost of providing dental coverage targeted specifically to nonusers of dental care may be less than similar costs for prior users.

Response error in reporting dental coverage by older Americans in the health and retirement study

The aim of this research was to analyze the inconsistency in responses to survey questions within the Health and Retirement Study (HRS) regarding insurance coverage of dental services. Self-reports of dental coverage in the dental services section were compared with those in the insurance section of the 2002 HRS to identify inconsistent responses. Logistic regression identified characteristics of persons reporting discrepancies and assessed the effect of measurement error on dental coverage coefficient estimates in dental utilization models. In 18% of cases, data reported in the insurance section contradicted data reported in the dental use section of the HRS by those who said insurance at least partially covered (or would have covered) their (hypothetical) dental use. Additional findings included distinct characteristics of persons with potential reporting errors and a downward bias to the regression coefficient for coverage in a dental use model without controls for inconsistent self-reports of coverage. This study offers evidence for the need to validate self-reports of dental insurance coverage among a survey population of older Americans to obtain more accurate estimates of coverage and its impact on dental utilization.

Dental care coverage and use: modeling limitations and opportunities

OBJECTIVES

We examined why older US adults without dental care coverage and use would have lower use rates if offered coverage than do those who currently have coverage.

METHODS

We used data from the 2008 Health and Retirement Study to estimate a multinomial logistic model to analyze the influence of personal characteristics in the grouping of older US adults into those with and those without dental care coverage and dental care use.

RESULTS

Compared with persons with no coverage and no dental care use, users of dental care with coverage were more likely to be younger, female, wealthier, college graduates, married, in excellent or very good health, and not missing all their permanent teeth.

CONCLUSIONS

Providing dental care coverage to uninsured older US adults without use will not necessarily result in use rates similar to those with prior coverage and use. We have offered a model using modifiable factors that may help policy planners facilitate programs to increase dental care coverage uptake and use.

Dental procedures among children age birth to 20, United States, 1999 and 2009

OBJECTIVE

To describe dental procedures received by US children and adolescents by poverty status and dental insurance coverage.

METHODS

Data for this analysis came from the 1999 and 2009 Medical Expenditure Panel Surveys. The primary outcome variable represented the types of dental procedures that were received during dental visits in the preceding year. Descriptive variables included dental insurance and poverty status. Analysis was restricted to children from birth to 20 years.

RESULTS

Overall, diagnostic (41.2 percent) and preventive (35.8 percent) procedures accounted for most of the procedures received by children from birth to 20 years of age, while restorative procedures accounted for just 5 percent. Children from low-income families received a higher proportion of restorative procedures than children in higher-income families. The proportion of diagnostic and preventive services was lower among uninsured children than among publicly insured children. Orthodontic services, on the other hand, represented a greater percentage of these procedures among uninsured children than among publicly insured children.

DISCUSSION

The vast majority of procedures received by children from birth to 20 years were diagnostic and preventive. Most children with at least one dental visit received a diagnostic or preventive service. Between 1999 and 2009, the proportion of all services received accounted for by diagnostic or preventive services increased. However, the proportion in which each type of procedure was received by children who made at least one visit who received did not change.

Patterns of older Americans' health care utilization over time

OBJECTIVES

We analyzed correlates of older Americans' continuous and transitional health care utilization over 4 years.

METHODS

We analyzed data for civilian, noninstitutionalized US individuals older than 50 years from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of persistent and intermittent use of physician, inpatient hospital, home health, and outpatient surgery over the 2004-2008 survey periods.

RESULTS

Individuals with worse or worsening health were more likely to persistently use medical care and transition into care and not transition out of care over time. Financial variables were less often significant and, when significant, were often in an unexpected direction.

CONCLUSIONS

Older individuals' health and changes in health are more strongly correlated with persistence of and changes in care-seeking behavior over time than are financial status and changes in financial status. The more pronounced sensitivity to health status and changes in health are important considerations in insurance and retirement policy reforms.

Dental usage under changing economic conditions

OBJECTIVE

The purpose of this article is to examine the relationship between changes in household finances (wealth and income) and changes in dental utilization at the onset of the recent recession in a population of older Americans.

METHODS

Data from the Health and Retirement Study (HRS) were analyzed for U.S. individuals aged 51 years and older during the 2006 and 2008 waves of the HRS. We estimated logistic models of (a) starting and (b) stopping dental use between 2006 and 2008 survey periods as a function of changes in household wealth and income, controlling for other potentially confounding covariates.

RESULTS

We found that only when household wealth falls by 50 percent or more were older adults less likely to seek dental care. Changes in household income and other changes in household wealth were not associated with changes in dental utilization among this population.

CONCLUSIONS

Older Americans' dental care utilization appeared to be fairly resilient to changes in household finances; only when wealth fell by 50 percent or more did individuals decrease dental use. This finding might extend to other health-care services that are preventive, routine, and relatively inexpensive.

Wealth effect and dental care utilization in the United States

OBJECTIVE

The purpose of this article is to examine the relationship of wealth and income and the relative impact of each on dental utilization in a population of older Americans, using data from the Health and Retirement Study (HRS).

METHODS

Data from the HRS were analyzed for US individuals aged 51 years and older during the 2008 wave of the HRS. The primary focus of the analysis is the relationship between wealth, income, and dental utilization. We estimate a multivariable model of dental use controlling for wealth, income, and other potentially confounding covariates.

RESULTS

We find that both wealth and income each have a strong and independent positive effect on dental care use of older Americans (P < 0.05). A test of the interaction between income and wealth in our model failed to show that the impact on dental care utilization as wealth increases depends on a person's income level or, alternatively, that the impact on dental use as income increases depends on a person's household wealth status (P > 0.05).

CONCLUSIONS

Relative to those living in the wealthiest US households, the likelihood of utilizing dental care appears to decrease with a decline in wealth. The likelihood of utilizing dental care also appears to decrease with a decline in income as well.

Health literacy impact on patient-provider interactions involving the treatment of dental problems

Health literacy-related problems can interfere with effective doctor-patient communication and effective patient care. This study examined several health literacy-related markers for patients seeking treatment in hospital emergency departments and physician and dentist offices for dental problems and injuries. Participants consisted of low-income white, black, and Hispanic adults who had experienced a dental problem or injury during the previous twelve months and who visited a hospital emergency department, physician, or dentist for treatment. A stratified random sample of Maryland households participated in a cross- sectional telephone survey. Interviews were completed with 94.8 percent of 423 eligible individuals. Multivariable logistic regression analyses were performed. Only 10.0 percent of the respondents expressed a difficulty understanding what they were told by the health provider, while 4.9 percent expressed a difficulty understanding the dental or medical forms they were asked to complete and 6.9 percent reported that they had difficulty getting the health provider to understand their dental problem or injury. Logistic regression analysis found that males and Hispanics were significantly (p<0.05) more likely to experience health literacy-related problems. In general, respondents did not express health literacy-related problems. Additional research is needed to identify health literacy-related barriers to effective patient-provider communication.

The influence of changes in dental care coverage on dental care utilization among retirees and near-retirees in the United States, 2004-2006

OBJECTIVES

We examined dental care utilization transition dynamics between 2004 and 2006 in the context of changing dental coverage status.

METHODS

We used data from the Health and Retirement Study for persons aged 51 years and older to estimate a multivariable model of dental care use transitions with controls for dental coverage and retirement transitions and other potentially confounding covariates.

RESULTS

We found that Americans aged 51 years and older who lost dental coverage between the 2004 and 2006 survey periods were more likely to stop dental care use between periods, and those who gained coverage were more likely to start dental care use between periods, than those without coverage in both periods.

CONCLUSIONS

Dental coverage transitions and status have a strong effect on transitions in dental care use. Given that retirement is a time when many experience a loss of dental coverage, older adults may be at risk for sporadic dental care and even stopping use, leading to worse dental and potentially overall health.

The influence of comorbidity and other health measures on dental and medical care use among Medicare beneficiaries 2002

OBJECTIVE

To assess the impact of comorbidity and other health measures on the use of dental and medical care services among the community-based Medicare population with data from the 2002 Medicare Current Beneficiary Survey.

METHODS

A comorbidity index is the main independent variable of our study. It includes oral cancer as a comorbidity condition and was developed from Medicare claims data. The two outcome variables indicate whether a beneficiary had a dental visit during the year and whether the beneficiary had an inpatient hospital stay during the year. Logistic regressions estimated the relationship between the outcome variables and comorbidity after controlling for other explanatory variables.

RESULTS

High scores on the comorbidity index, high numbers of self-reported physical limitations, and fair or poor self-reported health status were correlated with higher hospital use and lower dental care utilization. Similar results were found for types of medical care including medical provider visits, outpatient care, and prescription drugs. A multiple imputation technique was used for the approximate 20 percent of the sample with missing claims, but the resulting comorbidity index performed no differently than the index constructed without imputation.

CONCLUSIONS

Comorbidities and other health status measures are theorized to play either a predisposing or need role in determining health care utilization. The study's findings confirm the dominant role of these measures as predisposing factors limiting access to dental care for Medicare beneficiaries and as need factors producing higher levels of inpatient hospital and other medical care for Medicare beneficiaries.

Dental care expenditures and retirement

OBJECTIVES

To examine the relationship of dental care coverage, retirement, and out-of-pocket (OOP) dental expenditures in an aging population, using data from the Health and Retirement Study (HRS).

METHODS

We estimate OOP dental expenditures among individuals who have dental utilization as a function of dental care coverage status, retirement, and individual and household characteristics. We also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

Overall, mean OOP dental expenditures among those with any spending were substantially larger for those without coverage than for those with coverage. However, controlling for coverage shows that there is little difference in spending by retirement status.

CONCLUSIONS

Although having dental coverage is a key determinant of the level of OOP expenditures on dental care; spending is higher among those without coverage than those who have dental insurance. We also found that while retirement has no independent effect on OOP dental expenditures once controlling for coverage, dental coverage rates are much lower among retirees.

Investing in preventive dental care for the Medicare population: a preliminary analysis

OBJECTIVES

We estimated the use of preventive dental care services by the US Medicare population, and we assessed whether money spent on preventive dental care resulted in less money being spent on expensive nonpreventive procedures.

METHODS

We used data from the 2002 Medicare Current Beneficiary Survey to estimate a multinomial logistic model to analyze the influence of predisposing, enabling, and need variables in identifying those beneficiaries who used preventive dental care, only nonpreventive dental care, or no dental care in a multiple-variable context. We used regression models with similar controls to estimate the influence of preventive care on the utilization and cost of nonpreventive dental care and all dental care.

RESULTS

Our analyses showed that beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems.

CONCLUSIONS

Adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.

Dental care utilization and retirement

OBJECTIVE

The authors examine the relationship of dental care coverage, retirement, and utilization in an aging population using data from the Health and Retirement Study (HRS).

METHODS

The authors estimate dental care use as a function of dental care coverage status, retirement, and individual and household characteristics. They also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

The authors show that that the loss of income and dental coverage associated with retirement may lead to lower use rates but this effect may be offset by other unobserved aspects of retirement including more available free time leading to an overall higher use rate.

CONCLUSIONS

The authors conclude from this study that full retirement accompanied by reduced income and dental insurance coverage produces lower utilization of dental services. However, they also show that retirement acts as an independent variable, whereas income, coverage, and free time (unobserved) act as intervening variables.

Dental care coverage and retirement

OBJECTIVES

To examine the convergence of an aging population and a decreased availability of dental care coverage using data from the Health and Retirement Study (HRS).

METHODS

We calculate national estimates of the number and characteristics of those persons age 51 years and above covered by dental insurance by labor force, retirement status, and source of coverage. We also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

We show that being in the labor force is a strong predictor of having dental coverage. For older retired adults not in the labor force, the only source for dental coverage is either a postretirement health benefit or spousal coverage.

CONCLUSIONS

Dental care, generally not covered in Medicare, is an important factor in the decision to seek dental care. It is important to understand the relationship between retirement and dental coverage in order to identify the best ways of improving oral health and access to care among older Americans.

Comparison of patient centeredness of visits to emergency departments, physicians, and dentists for dental problems and injuries

BACKGROUND

Patient-centered care has a positive impact on patient health status. This report compares patient assessments of patient centeredness during treatment in hospital emergency departments (EDs) and physician and dentist offices for dental problems and injuries.

RESEARCH DESIGN

Participants included low-income White, Black, and Hispanic adults who had experienced a dental problem or injury during the previous 12 months and who visited an emergency department, physician, or dentist for treatment. A stratified random sample of Maryland households participated in a cross-sectional telephone survey. Interviews were completed with 94.8% (401/423) of eligible individuals. Multivariable logistic regression analyses were performed.

RESULTS

The measure of predictive power, the pseudo-R2s, calculated for the logistic regression models ranged from 12% to 18% for the analyses of responses to the measures of patient centeredness (satisfaction with treatment, careful listening, thorough explaining, spending enough time, and treated with courtesy and respect). EDs were less likely than dentists to treat patients with great courtesy and respect.

CONCLUSIONS

Further research is needed to identify factors that support patient-centered care.

Dental care coverage transitions

OBJECTIVE

To examine dental insurance transition dynamics in the context of changing employment and retirement status.

STUDY DESIGN

Data from the Health and Retirement Study (HRS) were analyzed for individuals 51 years and older between the 2004 and 2006 waves of the HRS.

METHODS

The primary focus of the analysis is the relationship between retirement and transitions in dental care coverage. We calculate and present bivariate relationships between dental coverage and retirement status transitions over time and estimate a multivariable model of dental coverage controlling for retirement and other potentially confounding covariates.

RESULTS

Older adults are likely to lose their dental coverage on entering retirement compared with those who remain in the labor force between waves of the HRS. While more than half of those persons in the youngest group (51-64 years) were covered over this entire period, two-thirds of those in the oldest group (>or=75 years) were without coverage over the same period. We observe a high percentage of older persons flowing into and out of dental coverage over the period of our study, similar to flows into and out of poverty.

CONCLUSIONS

Dental insurance is an important factor in the decision to seek dental care. Yet, no dental coverage is provided by Medicare, which provides medical insurance for almost all Americans 65 years and older. This loss of coverage could lead to distortions in the timing of when to seek care, ultimately leading to worse oral and overall health.

Toothache pain: behavioral impact and self-care strategies

A computer-assisted telephone interview in Maryland of adults who had low income and were Hispanic, Black, and White and who had experienced a toothache during the previous 12 months was conducted. Respondents reported a high prevalence of toothaches, with 44.3% having experienced more than five toothaches during the preceding 10 years. Pain intensity associated with the most recent toothache was high with 45.1% of the respondents reporting the highest pain possible. Pain interfered with many aspects of normal functioning. Self-care strategies generally took precedence over professional health services. Pain sufferers used a combination of self-care and formal care strategies. Initial strategies most often focused on nonprescription medicines(home remedies and prayer. The majority of respondents ultimately sought pain relief from a dentist. We identified a number of significant differences in the strategies used across racial/ethnic groups.

Public programs, insurance, and dental access

Disparities remain among the United States population with regard to who receives dental treatment. This article assesses current programs designed to provide dental insurance coverage. This assessment examines person-level use and expenditures as a function of preferences, price, and the use of third-party coverage.

Low-income and minority patient satisfaction with visits to emergency departments and physician offices for dental problems

OBJECTIVES

Individuals lacking access to dentists may use hospital emergency departments (EDs) or physicians (MDs) for the management of their dental problems. This study examined visits by minority and low-income individuals to physicians and hospital emergency departments for the treatment of dental problems with the goal of exploring the nature of treatment provided and patient satisfaction with the care received.

METHODS

Eight focus group sessions were conducted with 53 participants drawn from low-income White, Black, and Hispanic adults who had experienced a dental problem and who had sought MD/ED care at least once during the previous 12 months.

RESULTS

Toothache pain or more generalized jaw/face pain was the most frequent oral problem resulting in MD/ED visits. Pain severity was the principle reason for seeking care from MDs/EDs, with financial barriers most often mentioned as the reason for not seeking care from dentists. Expectations of MD/ED visits were generally consistent with care received; most participants limited their expectations to the provision of antibiotics or pain medication. Nearly all of the participants thought they would eventually need to see a dentist for resolution of their dental problem.

CONCLUSIONS

Poor/minority individuals seek relief from oral pain through MDs/ EDs while recognizing that such care is not definitive.

Dental care use: does dental insurance truly make a difference in the US?

OBJECTIVE

Having medical insurance with or without coverage for dental care has been shown to be associated with an increase in dental use. The purpose of this study is to provide information that will help describe this behavior.

METHOD

We isolate the independent effect of health insurance on the likelihood of a dental visit by analyzing Medical Expenditure Panel Survey (MEPS) data.

RESULTS

Data show that persons with private medical coverage, controlling for dental coverage and other socioeconomic and demographic factors, are more likely to have a dental visit than persons without private medical coverage. Having medical insurance with or without coverage for dental care is associated with an increased likelihood of having a dental visit. These data suggest a more complex role for dental insurance beyond that of traditional insurance motivation.

CONCLUSIONS

These data suggest that programmes designed to improve dental access with added dental coverage may not be sufficient to remedy access deficiencies and may offer only modest extra incentives to use dental services over and above medical insurance.

The dental care of U.S. children

BACKGROUND

Improvements in oral health care services have not reached evenly across every segment of American society. The authors examine the role of nondentist practitioners in referring child patients for dental care by analyzing data from the 2003 Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.

METHODS

The authors provide national estimates of the percentage of the civilian noninstitutionalized population of the United States aged 2 through 17 years who had a dental visit, who had a dental checkup and who received advice from a nondentist health care provider to have a dental checkup.

RESULTS

Overall, 38 percent of all poor, near-poor or low-income children and 60 percent of all middle- or high-income children aged 2 through 17 years reported having had a dental checkup during 2003. The authors observed no significant differences between poor, near-poor and low-income children and higher-income children in terms of having been advised by a nondentist health care provider to have a dental checkup.

CONCLUSION

Although income may not predict the likelihood of patients' receiving advice from a nondentist health care provider to have a dental checkup, children from families with higher levels of income were more likely to seek dental care than were children from families with lower levels of income. Practice Implications. Efforts to increase access to dental care should aim to maximize the benefit of advice provided by nondentist health care practitioners to receive a dental checkup, so that children from families with limited income are as likely to receive a dental checkup as are children from families with higher levels of income.

The supply of dentists and access to care in rural Kansas

CONTEXT

Rural deficits in dental care and oral health are well documented and are typically attributed to the low number of dentists practicing in rural areas, but the relationships between rural residence, dental supply, and access to care have not been firmly established, impeding the development of effective public policy.

PURPOSE

The purpose of this study is to develop a conceptual framework for observed variations in dental supply, oral health, and access to dental care in rural versus nonrural areas, and to test key empirical implications of this framework (eg, whether lower levels of utilization are associated with the lack of dentists and/or other aspects of residence in a rural area).

METHODS

This study employs descriptive statistics, bivariate analyses, and multiple logistic regression to describe the relationship between oral health, access to care, and the supply of dentists in rural versus nonrural populations. Data analyzed includes Kansas' dental licensure records and the 2002 Behavioral Risk Factor Surveillance System.

FINDINGS

Bivariate results confirm that dental supply, access to care, and oral health are lower for populations living in rural areas. Multivariate models indicate that dentist supply has a positive and independent association with utilization, but that rurality is not associated with utilization and oral health after controlling for demographics and dentist supply.

CONCLUSIONS

Findings are consistent with a conceptual framework linking the geography of rural residence, individual preferences for services such as dental care, and the financial disincentives for dentists to locate in rural areas.

Coping with toothache pain: a qualitative study of low-income persons and minorities

OBJECTIVES

This study examined the behavioral impact of toothache pain as well as self-care strategies for pain relief among minority and low-income individuals.

METHODS

Eight focus group sessions were conducted with 66 participants drawn from low-income non-Hispanic White, non-Hispanic Black, and Hispanic adults over the age of 20 who had experienced a toothache during the previous 12-month period and who had utilized self-care or care from a nondentist.

RESULTS

Toothache pain was described as intense, throbbing, miserable, or unbearable. Focus group participants indicated that toothache pain affected their ability to perform normal activities, such as their job, housework, social activities, sleeping, talking, and eating, as well as making them depressed and affecting their social interactions. Numerous prescription and nonprescription medications as well as home remedies and self-care strategies were used for pain relief, although these were generally of limited and uncertain benefit. While receiving care at a dental office was the most preferable option for care, most participants reported multiple barriers, including the cost of dental care that resulted in long delays in seeking dental care. The main reason for eventually seeking dental care was the severity of the pain.

CONCLUSIONS

Although removing financial barriers alone may not lead to preventive dental visits, it would facilitate more timely visits to dentists to treat toothache pain.

Dentist-prescribed drugs and the patients receiving them

BACKGROUND

Outpatient prescription drugs continue to play an ever-increasing role in health care delivery in the United States. This paper focuses on the drugs prescribed by dentists and the patients who receive those drugs.

METHODS

The authors analyzed data from the 2001 Medical Expenditure Panel Survey (MEPS) for the U.S. community-based population. They developed estimates of the total market for prescription drugs related to a dental visit in terms of total number of prescriptions, total expenditures, and sources of payment. Also included are breakdowns by the type of dentist and the therapeutic class of drug prescribed. They also present a model that identifies the patient characteristics that best predict the likelihood of receiving a dental visit related prescription drug.

RESULTS

Dental patients who were 18 years and older, African American patients, patients whose education level was less than a college degree, patients whose dental visit frequency was less than twice a year, and patients without medical insurance were most likely to report a prescription drug.

CONCLUSION

Respondents' socioeconomic background and other demographic factors were related to the likelihood of receiving a prescription drug related to a dental visit. Patient age was related to the therapeutic class of the drug prescribed.

PRACTICE IMPLICATIONS

Patients with fewer than two dental visits per year were more likely to report a dental prescription than patients with at least two visits per year.

Visits to non-dentist health care providers for dental problems

BACKGROUND AND OBJECTIVES

Although poor and minority adults experience greater levels of dental disease, they frequently face cost and other system-level barriers to obtaining dental care. These individuals may be forced to use physicians or hospital emergency rooms for the treatment of dental problems. This study was conducted to gain a better understanding of the role that non-dentist health care providers play in providing access to oral health care services.

METHODS

Dental conditions and dental condition-related visits to non-dentist health care providers during 2001 for the US civilian noninstitutionalized population were analyzed using data from the Household Component of the Medical Expenditure Panel Survey.

RESULTS

During 2001, approximately 3.1% of the US population experienced at least one dental problem reported outside of the traditional office-based dental delivery system. Of these, approximately 2.7% received care in a hospital emergency room setting while 7.0% received care in other medical settings. A majority (68.1%) had contact with the formal health care system via a prescription associated with their identified dental problem. Approximately 22.5% did not seek any formal treatment for their problem. Overall, low-income individuals were more likely not to seek formal care than were middle/high-income individuals (32.5% versus 19.7%).

CONCLUSIONS

Individuals not using traditional sources of dental care appear to have greater access to physician offices and other medical settings than to hospital emergency rooms for the treatment of dental problems.