Oral Health Disparities in Publicly Insured Children

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Oral Health Disparities in Publicly Insured
Children

• Dental Advisory Committee
• April 11th, 2008
• Tegwyn H. Brickhouse DDS PhD
• Department of Pediatric Dentistry
• VCU School of Dentistry

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Grant

• NIH Career Transition Award (K22)
• From the National Institutes of Dental and
  Craniofacial Research
• Supports young investigators in their early
  career
• Experience guides them to become a independent
  scientist
• Future grants

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Oral Health Disparities

• Dental caries is the most common chronic disease
  of childhood, affecting 58 of all children.
• Untreated dental caries has been identified as
  the most prevalent unmet health need in US
  children.

• Disparities exist among children with 25
  suffering 80 of all tooth decay.
• Dental disease disproportionately affects
  children younger then 6, from lower socioeconomic
  backgrounds.

SGR on Oral Health May, 2000
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Health Coverage for Children

• Employer/Private Insurance 60
• 47 million children
• Medicaid/SCHIP 28
• 22 million children
• Uninsured 12
• Over 9.4 million

Kaiser Commission on Medicaid and the Uninsured
September, 2007
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Background

• Publicly Financed Health Plans Providing Dental
  Services
• Medicaid
• A joint federal-state-county program established
  in 1965 to provide health insurance to low-income
  populations
• State Childrens Health Insurance Program (SCHIP)
• A joint federal-state program established in 1997
  to provide coverage to low-income uninsured
  children who are not eligible for Medicaid.

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Grant Objectives

• Examine the structure of public dental insurance
  programs and patterns of Enrollment in publicly
  insured children.
• Examine the Process of dental care (utilization,
  mix of services) and dental health status
  Outcomes (tooth loss, caries-related treatments).
• Compare dental treatment with of general
  anesthesia versus the conventional dental
  delivery system for preschool-aged children
• Implement a project that examines outcomes for
  case management of infant oral health in a
  medical setting.

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Effects of Public Insurance on Access to Dental
Services

• Cohort of Publicly Insured Children
• Enrollment and Claims data from 2002-2005
• Children 0-18 years of age
• Two State Programs (Virginia and North Carolina)
• Similar size
• Similar population distribution
• Similar geography

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Analytical File Construction

• Claim summaries of utilization
• Provider-Level summaries
• Individual Child-level files
• linked enrollment and claims across time periods.

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Analytical File Creation Child-Level File
Provider Characteristics
Enrollment
Claims
Child
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Enrollment Patterns of Publicly Insured Children

• Measures that characterize enrollment in public
  programs
• Length of Enrollment (duration)
• Heterogeneous populations
• Patterns of Enrollment (continuity)
• yearly and age determinations
• gaps

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Impacts of Enrollment

• Impact on eligibility for dental services
• Age and aid categories of eligibility
  determination
• Enrollees are approximately 10 SCHIP, 90
  Medicaid
• 75 of children were enrolled with one MCO
  provider
• 20 enrolled with 2 MCOs
• 5 enrolled with 3
• Impact on provider acceptance
• Real-time eligibility determination (on-line,
  swipe methods)

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Enrollment

• Over the 3 year period, children were enrolled a
  mean number of 436 days, median of 365 days.
• The mean age of enrolled children is 5 years.
• 12.5 had no gaps in enrollment
• 50 has one gap in enrollment
• 37.5 had 2 gaps in enrollment
• Few studies have examined the relationship of
  enrollment patterns and utilization.

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Outcomes

• Dental Visits
• Utilization of dental services measured by at
  least one paid claim.
• Annual Dental Visit (NCQA standards)
• Performance Measures of Dental Services
• Which children utilize services/benefit most
• Age
• Geography
• Income

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Outcomes

• Performance Measures of Dental Services
• Preventive services
• Restorative services
• Tooth Loss (receipt of one or more extraction
  services)
• Dental Home
• 2 visits to same practice/same year

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North Carolina Claims Data
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Medicaid versus Separate SCHIP Program
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Mix of Services for all Children
Likelihood of having a dental service compared
to Medicaid (ref), controlling for enrollment
characteristics, age, race, and county-level
indicators.
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Mix of Services for Children Accessing Dental Care
Likelihood of having a dental service compared
to Medicaid (ref), controlling for enrollment
characteristics, age, race, and county-level
indicators.
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Preventive
Restorative
Extraction
Predicted probabilities of dental services
(preventive, restorative, and extraction) for
North Carolina children (4 years of age) enrolled
for 12 months.
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Virginia Claims Data

• 62 of dental claims were MCO
• 38 of dental claims were FFS
• Mean age for children with claims was 9 years of
  age.

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Mix of Services

• 32 Diagnostic Services
• 40 Preventive Services
• 18 Restorative Services
• 5 Extraction Services
• 1.5 Orthodontic Services

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Infant Oral Health Project

• Preventive oral health services consist of
• knee to knee oral screening and risk
  assessment
• Fluoride varnish
• oral health education for caregivers
• referral to a pediatric dental clinic.

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Infant Assessment

• 19 of children had signs of dental caries
• 12.5 having white-spot lesions
• 75 were categorized as high risk and referred
  for a dental visit
• 80 of children received a fluoride varnish
  treatment

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High-Risk Children

• 6-months post-enrollment, 9 of children had made
  a dental visit to VCU.
• Children with visible plaque were more likely to
  have decay at baseline.
• 400 Children enrolled in the VCU Bright Smiles
  Program
• Examine the prevalence of dental claims for
  enrolled children versus a random sample of
  Medicaid children 0-3 years of age.

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Future Studies

• Provider Measures
• Participation in programs
• Level of activity
• Types of Services
• Response to program changes
• Program structure
• Fee increases

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State Program Reform

• Single Vendor Carve Out
• Pre-Post Design

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Questions?

• Many Thanks to DMAS
• Sandra Brown
• James Starkey
• Lisa Bilik
• Pat Finnerty