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Oral Health Disparities in Publicly Insured Children

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Title: Oral Health Disparities in Publicly Insured Children


1
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

2
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

3
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
4
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
5
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.

6
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.

7
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

8
Analytical File Construction
  • Claim summaries of utilization
  • Provider-Level summaries
  • Individual Child-level files
  • linked enrollment and claims across time periods.

9
Analytical File Creation Child-Level File
Provider Characteristics
Enrollment
Claims
Child
10
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

11
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)

12
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.

13
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

14
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

15
North Carolina Claims Data
16
Medicaid versus Separate SCHIP Program
17
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.
18
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.
19
Preventive
Restorative
Extraction
Predicted probabilities of dental services
(preventive, restorative, and extraction) for
North Carolina children (4 years of age) enrolled
for 12 months.
20
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.

21
Mix of Services
  • 32 Diagnostic Services
  • 40 Preventive Services
  • 18 Restorative Services
  • 5 Extraction Services
  • 1.5 Orthodontic Services

22
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.

23
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

24
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25
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26
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.

27
Future Studies
  • Provider Measures
  • Participation in programs
  • Level of activity
  • Types of Services
  • Response to program changes
  • Program structure
  • Fee increases

28
State Program Reform
  • Single Vendor Carve Out
  • Pre-Post Design

29
Questions?
  • Many Thanks to DMAS
  • Sandra Brown
  • James Starkey
  • Lisa Bilik
  • Pat Finnerty
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