The impact of insurance coverage on children's dental visits and expenditures, 1996

What should we expect from Switzerland's compulsory dental insurance reform?

BACKGROUND

A vast and heated debate is arising in Switzerland as a result of some recent citizens' initiatives aimed at introducing compulsory dental health care insurance. The Grand Conseils of the Vaud, Geneva, and Neuchâtel cantons recently approved three public initiatives and their citizens are expected to vote on the proposal in 2018. The process of collecting signatures has begun in several other cantons and the discussion has now moved to a national level.

DISCUSSION

At present, there is no scientific research that can help policy-makers and citizens to understand the main economic implications of such reform. We attempt to fill this gap by analysing three critical issues: the level and determinants of unmet needs for dental care in Switzerland; the protection of vulnerable individuals; and the economic sustainability of reform.

RESULTS AND SHORT CONCLUSIONS

The results show that income is not a unique determinant of barriers to access to dental care but rather, cultural and socio-demographic factors impact the perceived level of unmet dental care needs. The reform might only partially, if at all, improve the equity of the current system. In addition, the results show that the 1% wage-based contribution that the reform promoters suggest should finance the insurance is inadequate to provide full and free dental care to Swiss residents, but is merely sufficient to guarantee basic preventive care, whereas this could be provided by dental hygienists for less.

Rural-urban differences in dental service use among children enrolled in a private dental insurance plan in Wisconsin: analysis of administrative data

BACKGROUND

Studies on rural-urban differences in dental care have primarily focused on differences in utilization rates and preventive dental services. Little is known about rural-urban differences in the use of wider range of dental procedures. This study examined patterns of preventive, restorative, endodontic, and extraction procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI).

METHODS

We analyzed DDWI enrollment and claims data for children aged 0-18 years from 2002 to 2008. We modified and used a rural and urban classification based on ZIP codes developed by the Wisconsin Area Health Education Center (AHEC). We categorized the ZIP codes into 6 AHEC categories (3 rural and 3 urban). Descriptive and multivariable analysis using generalized linear mixed models (GLMM) were used to examine the patterns of dental procedures provided to children. Tukey-Kramer adjustment was used to control for multiple comparisons.

RESULTS

Approximately, 50%, 67% and 68% of enrollees in inner-city Milwaukee, Rural 1 (less than 2500 people), and suburban-Milwaukee had at least one annual dental visit, respectively. Children in inner city-Milwaukee had the lowest utilization rates for all procedures examined, except for endodontic procedures. Compared to children from inner-city Milwaukee, children in other locations had significantly more preventive procedures. Children in Rural 1-ZIP codes had more restorative, endodontic and extraction procedures, compared to children from all other regions.

CONCLUSIONS

We found significant geographic variation in dental procedures received by children enrolled in DDWI.

Impact of chronic condition status and severity on dental utilization for Iowa Medicaid-enrolled children

BACKGROUND

Although Medicaid-enrolled children with a chronic condition (CC) may be less likely to use dental care because of factors related to their CC, dental utilization for this population is poorly understood.

OBJECTIVE

To assess the relationship between CC status and CC severity, respectively, on dental utilization for Iowa Medicaid-enrolled children.

RESEARCH DESIGN

Retrospective cohort study of Iowa Medicaid data (January 1, 2003 to December 31, 2006).

SUBJECTS

Medicaid-enrolled children aged 3 to 14 (N = 71,115) years.

MEASURES

The 3M Corporation Clinical Risk Grouping methods were used to assess CC status (no/yes) and CC severity (episodic/life-long/malignancy/complex). The outcome variable was any dental utilization in 2006. Secondary outcomes included use of diagnostic, preventive, routine restorative, or complex restorative dental care.

RESULTS

After adjusting for model covariates, Iowa Medicaid-enrolled children with a CC were significantly more likely to use each type of dental care except routine restorative care (P = 0.86) than those without a CC, although the differences in the odds were small (4%-6%). Compared with Medicaid-enrolled children with an episodic CC, children with a life-long CC were less likely to use routine restorative care (P < 0.0001), children with a malignancy were more likely to use complex restorative care (P < 0.03), and children with a complex CC were less likely to use each type of dental care except complex restorative care (P = 0.97).

CONCLUSIONS

There were differences in dental utilization for Iowa Medicaid-enrolled children by CC status and CC severity. Children with complex CCs were the least likely to use dental care. Future research efforts should seek to understand why subgroups of Medicaid-enrolled children with a CC exhibit lower dental utilization.

Association between parents' and children's use of oral health services

OBJECTIVE

Several parental factors influence children's use of oral health services. Some localized studies have shown that children's dental use patterns correlate positively with those of their parents. The objective of this study was to investigate associations between parents' and children's oral health-seeking behaviors among a representative sample of US children.

METHODS

We used the 2007 National Health Interview Survey to analyze a sample of children aged 2 to 17 years, matched with 1 parent. Using logistic regression, we examined associations between parents' and children's use of dental services and deferred dental care because of cost.

RESULTS

The sample included 6107 child-parent pairs. Overall, 77% of children and 64% of parents had a dental visit in the previous 12 months. Adjusting for sociodemographic and use variables, children were more likely to have a dental visit when their parents also had a dental visit (adjusted odds ratio: 3.36 [95% confidence interval: 2.71-4.18]), compared with children of parents who did not have a dental visit. In addition, compared with children of parents who did not defer seeking dental care, children of parents who deferred their dental care because of cost were more likely to have care deferred because of cost as well (adjusted odds ratio: 12.47 [95% confidence interval: 9.09-17.11]).

CONCLUSIONS

Parental oral health-seeking behaviors for themselves may have an important effect on oral health-seeking behaviors on behalf of their children, regardless of the child's insurance status. Comprehensive strategies to eliminate barriers that target parents and not just children may help to address children's underuse of oral health services.

Oral health outcomes in an adult dental population: the impact of payment systems

This study compared the effect of payment systems on recall visits and oral health outcomes for four patient payer groups. The authors reviewed recall audit data obtained over a 4-year period. Dental payer groups in the study population differed with respect to dental outcomes. Patients who had recall visits at 1 year or longer had worse outcomes than patients seen more frequently. A Medicaid subgroup with the greatest number of risk factors displayed improved oral health outcomes when seen on a more frequent recall schedule. Study findings suggest that, given the increased risks to maintaining oral health, patients being supported by public-funded programs would benefit from more frequent recalls. Such an emphasis would appear to provide the opportunity to improve outcomes in disadvantaged populations and increase the quality of care offered.

Private sector response to improving oral health care access

Despite vast improvements in the oral health status of the United States population over the past 50 years, disparities in oral health status continue, with certain segments of the population carrying a disproportionate disease burden. This article attempts to describe the problem, discuss various frameworks for action, illustrate some solutions developed by the private sector, and present a vision for collaborative action to improve the health of the nation. No one sector of the health care system can resolve the problem. The private sector, the public sector, and the not-for-profit community must collaborate to improve the oral health of the nation.

An audit of pattern of patients' presentation at the periodontics clinic of the university college hospital, ibadan

Objectives:

This study is aimed at assessing the various reasons why patients present at the periodontics clinic of the University College Hospital, Ibadan.

Materials and Methods:

A six months retrospective review of patients treated in the periodontics clinic of the University College Hospital, Ibadan was conducted. Case file records were retrieved and information on patients’ bio-data, occupation and their various presenting complaint during their first consultation at the clinic were reviewed. Three hundred patients were seen in the clinic during the period under review but records of four of them were incomplete and were therefore excluded from the study. The association between the gender of the patients and their various initial presenting complaints was assessed using chi-square tests, p set at (<0.05).

Results:

Records of two hundred and ninety-six patients were reviewed comprising of 150 males and 146 female (M/F, 1:1). Out of these patients, only eighty-four (28.4%) had been coming for regular check-up while the remaining 71.6% reported with various complaints. Majority (45.3%) presented with pain of which there were slightly more females than males (M/F =1:1.1). Gum bleeding and poor oral hygiene were other reasons why patients presented at the clinic. The younger age groups were noticed to be more frequent at the clinic on routine basis than the older ones during the period under review.

Conclusion:

The finding of this study further confirmed that majority of people only seek dental care to alleviate their pain. We therefore suggest that efforts should be intensified towards public enlightenment, as prevention is better and cheaper than cure.

Time to first dental visit after initially enrolling in Medicaid and S-SCHIP

BACKGROUND

Accessing dental care is a significant problem for children in Medicaid and S-SCHIP (Separate State Children's Health Insurance Program). Previous studies have indicated that the design of the Medicaid or S-SCHIP dental program can have an impact on the ability to use services.

OBJECTIVE

To evaluate the factors related to how quickly children had any dental visit and had a preventive dental visit after first enrolling in the Iowa Medicaid and S-SCHIP programs. The primary question was whether the structure of the dental plan was related to improved access to care.

METHODS

Iowa Medicaid and S-SCHIP dental claims and enrollment files for FY 2001 through 2003 were used to identify children who were newly enrolled in the programs and their use of dental services. Factors related to the time to a child's first dental visit were analyzed using survival analytic techniques.

RESULTS

After 6 months in the program, between 21% and 36% of children had received their first dental visit, depending on their dental plan. This increased from 39% to 56% after 1 year. Based on the survival analysis, earlier dental utilization was related to the type of plan in which the child was enrolled as well as the child's age, race, and urban/rural location.

CONCLUSIONS

Children in the S-SCHIP 2 dental plan, which had an open provider network and paid dentists' full charges, were most likely to have had a dental visit sooner after enrollment. States looking for options to improve access to dental care in their Medicaid and S-SCHIP programs should consider contracting with dental plans with these features.

Public policy and the market for dental services

Social inequality in access to oral health care is a feature of countries with predominantly privately funded markets for dental services. Private markets for health care have inherent inefficiencies whereby sick and poor people have restricted access compared to their healthy and more affluent compatriots. In the future, access to dental care may worsen as trends in demography, disease and development come to bear on national oral healthcare systems. However, increasing public subsidies for the poor may not increase their access unless availability issues are resolved. Further, increasing public funding runs counter to policies that feature less government involvement in the economy, tax policy on private insurance premiums, tax reductions and, in some instances, free-trade agreements. We discuss these issues and provide international examples to illustrate the consequences of the differing public policies in oral health care. Subsidization of the poor by inclusion of dental care in social health insurance models appears to offer the most potential for equitable access. We further suggest that nations need to develop national systems capable of the surveillance of disease and human resources, and of the monitoring of appropriateness and efficiency of their oral healthcare delivery systems.

Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country

OBJECTIVE

To determine the factors associated with the dental health services utilization among children ages 6 to 12 in León, Nicaragua.

MATERIAL AND METHODS

A cross-sectional study was carried out in 1,400 schoolchildren. Using a questionnaire, we determined information related to utilization and independent variables in the previous year. Oral health needs were established by means of a dental examination. To identify the independent variables associated with dental health services utilization, two types of multivariate regression models were used, according to the measurement scale of the outcome variable: a) frequency of utilization as (0) none, (1) one, and (2) two or more, analyzed with the ordered logistic regression and b) the type of service utilized as (0) none, (1) preventive services, (2) curative services, and (3) both services, analyzed with the multinomial logistic regression.

RESULTS

The proportion of children who received at least one dental service in the 12 months prior to the study was 27.7 percent. The variables associated with utilization in the two models were older age, female sex, more frequent toothbrushing, positive attitude of the mother toward the child's oral health, higher socioeconomic level, and higher oral health needs.

CONCLUSION

Various predisposing, enabling, and oral health needs variables were associated with higher dental health services utilization. As in prior reports elsewhere, these results from Nicaragua confirmed that utilization inequalities exist between socioeconomic groups. The multinomial logistic regression model evidenced the association of different variables depending on the type of service used.

Characteristics of publicly insured children with high dental expenses

BACKGROUND

Dental coverage is provided for all children with Medicaid in Washington State. The goal of this study was to illuminate the characteristics of a sample of Medicaid-enrolled children with high dental expenses.

METHODS

Dental care utilization data for a 33-month period were obtained from Washington State's Medicaid database. For children, 0 to 6 years, these data were linked with a parent survey addressing oral health behaviors, knowledge, family history of caries, snacking patterns, and access to dental care. Children with dental expenses of $1,000 or more were classified as the "high-expense" group. Risk factors for the high-expense group were evaluated using multiple logistic regression.

RESULTS

345 children had at least one dental procedure including preventive and diagnostic care. Among these, 30 children (9 percent) incurred 64 percent of total dental expenses for the entire group. Parent perception of lack of dental coverage was associated with incurring high dental expenses. Children of Asian or Pacific Islander heritage were at disproportionately high risk compared to White children. Age of child and family history of caries were also associated with increased risk for high expenses.

CONCLUSIONS

Not all low-income children on Medicaid are at high risk for caries. A combination of factors, including family history of caries and parent's perception of lack of dental insurance coverage, can potentially increase a child's likelihood for high-expense dental treatment. This study highlighted a small group of children with disproportionately high dental expenses. For some, earlier knowledge of coverage may have resulted in more timely access to preventive and diagnostic care, reducing the subsequent need for expensive restorative treatment.

Dental attendance by insurance status among adults in Tehran, Iran

OBJECTIVE

To evaluate dental attendance among adults in Tehran, Iran in relation to their dental insurance status.

DESIGN

A cross-sectional survey based on telephone interviews.

PARTICIPANTS

1,531 adults in Tehran.

METHODS

Using a two-stage stratified random technique, 3,200 phone numbers were drawn; 1,669 were unavailable (busy, no answer, fax, line blocked). Of the 1,531 subjects answering the phone call, 224 were excluded (aged <18 years) and 221 refused to participate, leaving 1,086 subjects (83%) in the final sample. Data analysis included the Chi-square test, logistic regression and the corresponding odds ratios (OR).

RESULTS

Of the respondents (n=1,086), 57% were women, 62% were under 35 years of age, 70% had dental insurance and 52%, more women than men (p=0.03), reported having had a dental visit within the past 12 months. Dental attendance was more likely for women (OR=1.4), for those with a medium (OR=1.5) or high (OR=1.9) level of education, and for those with commercial insurance (OR=2.0).

CONCLUSION

In a country with a low dentist-population rate dental attendance is positively related not only to insurance status, but also to gender and to level of education. Accordingly, dental insurance coverage should be expanded to facilitate access to dental care.

The effect of two publicly funded insurance programs on use of dental services for young children

OBJECTIVE

The purpose of this study is to compare the use of dental services for preschool aged children enrolled in North Carolina Medicaid, a traditional program based on a fee-for-service schedule, and North Carolina Health Choice (NCHC), an State Children's Health Insurance Program (S-CHIP) dental insurance program structured similarly to private insurance.

STUDY POPULATION

All children (165,858) 1-5 years of age enrolled in Medicaid and S-CHIP (NCHC) at some time during one study year (October 1, 1999-September 30, 2000). DATA SOURCES/EXTRACTION METHODS: Medicaid and NCHC enrollment and dental claims files were obtained for individual children.

STUDY DESIGN

An observational study with a retrospective cohort design. Use of dental services for each child was measured as having at least one dental claim during the outcome period (October 1, 1999-September 30, 2000). Multivariable logistic regression models were developed to compare the effect of two differently administered insurance programs on the use of dental services, controlling for demographic, enrollment, and county characteristics.

PRINCIPLE FINDINGS

Children enrolled solely in S-CHIP (NCHC) were 1.6 times more likely (95 percent confidence intervals (CI)=1.50-1.79) to have a dental visit than those enrolled solely in Medicaid. Prediction models for children enrolled for 12 months indicated that those enrolled in S-CHIP (NCHC) had a significantly higher probability of having a dental visit (50 percent) than those enrolled in both plans (44 percent) or Medicaid only (39 percent), a trend found in all age groups.

CONCLUSIONS

The S-CHIP (NCHC) program appears to provide children with increased access to dental care compared to children in the Medicaid program.

Access to care and utilization among children: estimating the effects of public and private coverage

OBJECTIVES

We examine the relationship between health insurance coverage and children's access to and utilization of medical care. Access measures we study are having a usual source of care (USC) and lacking a USC for financial or insurance reasons. We also examine indicators for ambulatory visits, well-child visits, dental visits, emergency room use, and inpatient hospital stays.

METHODS

We pool data from the first 7 years of the Medical Expenditure Panel Survey (MEPS), 1996 to 2002. Pooling yields a large sample of children, enabling us to analyze access and utilization using simple descriptive statistics, multivariate analysis, and instrumental variables estimation (IV). IV estimation is of particular interest given the possibility of bias caused by confounding factors (such as child health or parent attitudes) and measurement error in insurance coverage. We also compare estimates from IV linear probability models to estimates from IV probit with residual inclusion.

RESULTS

As previous studies have found, public and private coverage are both associated with large increases in access and utilization. Simple mean comparisons suggest that private coverage has a larger effect than does public coverage. Differences between public and private coverage are reduced (and often reversed) when we control for other characteristics of children and their families. IV coverage effect estimates from both linear probability and residual inclusion probit models are substantially greater than conventional estimates across a wide range of access and utilization measures.

CONCLUSIONS

Despite concerns that conventional estimates overstate the impact of coverage on access and use, our results suggest that the reverse may be true. One explanation may be that conventional estimates are biased toward zero due to error in the reporting of insurance coverage. The magnitude of the coverage effects we find highlights the importance of reducing uninsurance among children.

The Effect of Rural Residence on Dental Unmet Need for Children With Special Health Care Needs

BACKGROUND

Unmet need for dental care is the most prevalent unmet health care need among children with special health care needs (CSHCN), even though these children are at a greater risk for dental problems. The combination of rural residence and special health care needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs.

OBJECTIVE

To examine the effects of rural residence on unmet dental need for CSHCN.

METHODS

We use the nationally representative National Survey of CSHCN Needs. We performed logistic regression to estimate the independent effects of rural residence on the likelihood of having an unmet dental need, using a measure of unmet need based on professional society recommendations and a measure based on parental report.

RESULTS

Using either of the measures, a substantial percentage of CSHCN do not receive all needed dental care. Rural CSHCN are more likely to forgo needed dental care than their urban counterparts. Our results suggest that rural CSHCN have unmet needs for dental care due to both difficulty accessing care and because their parents do not recognize a need.

CONCLUSION

Traditional access barriers for rural children, such as inadequate provider supply and lack of insurance, may increase unmet needs both directly and indirectly, through their effects on parents' perceptions of need. Reducing unmet needs for dental care in rural children with special needs will require addressing both access issues and parents' understanding of dental care need.

The impact of SCHIP on insurance coverage of children

In this paper we use the Medical Expenditure Panel Survey between 1996 and 2002 to investigate the impact of the State Children's Health Insurance Program (SCHIP) on insurance coverage for children. We explore a range of alternative estimation strategies, including instrumental variables and difference-in-trends models. We find that SCHIP had a significant impact in decreasing uninsurance and increasing public insurance for both children targeted by SCHIP and those eligible for Medicaid. With respect to changes in private coverage our results are less conclusive: some specifications resulted in no significant effect of SCHIP on private insurance coverage, while others showed significant decreases in private insurance. Associated estimates of SCHIP crowd-out had wide confidence intervals and were sensitive to estimation strategy.

Dental care use and self-reported dental problems in relation to pregnancy

OBJECTIVES

We examined the relationships between risk factors amenable to intervention and the likelihood of dental care use during pregnancy.

METHODS

We used data from the Washington State Department of Health's Pregnancy Risk Assessment Monitoring System.

RESULTS

Of the women surveyed, 58% reported no dental care during their pregnancy. Among women with no dental problems, those not receiving dental care were at markedly increased risk of having received no counseling on oral health care, being overweight, and using tobacco. Among women who received dental care, those with dental problems were more likely to have lower incomes and Medicaid coverage than those without dental problems.

CONCLUSIONS

There is a need for enhanced education and training of maternity care providers concerning oral health in pregnancy.

Who shall care for the children of the poor and uninsured? Pediatric dentistry in the United States

Although Medicaid was established at least in part to help alleviate dental problems for children of the indigent, the program has not been particularly successful. Some possible solutions to the problem of disparities in access to pediatric dental care are suggested, including access and workforce approaches. Whatever approaches are undertaken, cost-benefit analyses should be done to demonstrate economic value.

Access to dental care services for Medicaid children: variations by urban/rural categories in Illinois

Poor oral health status and limited access to dental care have been recognized as problems for children from Medicaid and low-income families. However, little is known about dental access for Medicaid-enrolled children in rural areas. This study examines differences between rural and urban counties in dental utilization rates of Illinois children enrolled in either Medicaid or the Children's Health Insurance Program. How the overall dentist supply, the dentist Medicaid participation rate, and county level sociodemographic factors relate to Medicaid dental utilization are examined. Illinois counties were aggregated into four urban/rural categories. Descriptive analysis showed lower utilization rates in the rural categories (25 and 27%) compared with the metropolitan categories (35 and 31%). Rural areas had a substantially lower supply of dentists, and consequently a lower supply of dentists participating in Medicaid, despite the substantially higher Medicaid participation rate of dentists in the rural categories (45 and 51%) than in the metropolitan categories (22 and 32%). However, regression results indicated no significant relationship between the rate of utilization of Medicaid-enrolled children and rural status after controlling for several dental supply and population factors. The most important factors relating to Medicaid-enrolled children's dental utilization, regardless of urban or rural status, were the proportion of children enrolled in Medicaid and the participating dentist to population ratio. Without the high participation rate of dentists in rural areas, access to oral health care for rural children enrolled in Medicaid would have been worse. Policy makers should focus on maintaining high rural dentist participation rates as well as addressing future supply problems that may exacerbate difficulties with access in rural areas.