5

Expenditures and Financing for Oral Health Care

Understanding how oral health services are financed in the United States is critical to the access question. Financing for oral health care greatly influences where and whether individuals receive care. At the individual level, dental coverage and socioeconomic factors play a significant role in access to oral health care. That is, individuals who have private dental coverage or can afford care, either through private insurance or through out-of-pocket expenditures, are generally able to obtain care. On the other hand, individuals who lack dental coverage, who have minimal dental coverage, and/or those of limited financial means experience significant barriers to care. Financing also has a powerful influence on providers’ practice patterns. For example, low reimbursement by public programs, such as Medicaid and the Children’s Health Insurance Program (CHIP), are often cited as a disincentive to providers’ willingness to participate in these publicly funded programs. Finally, state and federal spending on oral health has a tremendous impact on what oral health services are available and to whom. This begins at the level of support for dental schools and continues in the form of subsidies for residency programs, reimbursement policies of public insurance programs, mandated benefits, and additional financial incentives. For example, the federal government makes considerable investments in improving the distribution of oral health care professionals in urban and rural areas while states are authorized under federal law to determine the rate of Medicaid reimbursement for oral health services provided.

This chapter provides an overview of the various sources and mechanisms of financing for oral health care in the United States and describes the



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5 Expenditures and Financing for Oral Health Care U nderstanding how oral health services are financed in the United States is critical to the access question. Financing for oral health care greatly influences where and whether individuals receive care. At the individual level, dental coverage and socioeconomic factors play a significant role in access to oral health care. That is, individuals who have private dental coverage or can afford care, either through private insur- ance or through out-of-pocket expenditures, are generally able to obtain care. On the other hand, individuals who lack dental coverage, who have minimal dental coverage, and/or those of limited financial means experi- ence significant barriers to care. Financing also has a powerful influence on providers’ practice patterns. For example, low reimbursement by public programs, such as Medicaid and the Children’s Health Insurance Program (CHIP), are often cited as a disincentive to providers’ willingness to par- ticipate in these publicly funded programs. Finally, state and federal spend- ing on oral health has a tremendous impact on what oral health services are available and to whom. This begins at the level of support for dental schools and continues in the form of subsidies for residency programs, re- imbursement policies of public insurance programs, mandated benefits, and additional financial incentives. For example, the federal government makes considerable investments in improving the distribution of oral health care professionals in urban and rural areas while states are authorized under federal law to determine the rate of Medicaid reimbursement for oral health services provided. This chapter provides an overview of the various sources and mecha- nisms of financing for oral health care in the United States and describes the 193

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194 IMPROVING ACCESS TO ORAL HEALTH CARE influences that these expenditures have on access to oral health care among vulnerable and underserved populations. OVERVIEW OF EXPENDITURES Health care costs and spending have been rapidly increasing in the United States in recent years. In 2009, overall health expenditures were $2.5 trillion, including the cost of hospital care, physician and dental ser- vices, home health care, nursing home services, prescription drugs, medical equipment and supplies, and public health direct services (CMS, 2010b). This translates to more than $8,000 per person and accounted for 17.6 percent of the national gross domestic product (CMS, 2010b). Growth in national health expenditures is expected to increase by 6.1 percent between 2009 and 2019 (CMS, 2010c). In contrast, expenditures for dental services in the United States in 2009 were $102.2 billion, approximately 5 percent of total spending on health care (CMS, 2010b). While medical and dental spending both have been rising, the growth in medical expenditures has far outpaced the growth in dental expenditures. The reported national expenditure levels undercount the total spent on improving oral health. Estimates represent only the costs associated with direct services delivered by dentists in traditional practice settings. Spending on public health initiatives (e.g., water fluoridation and public education campaigns) and oral health services delivered in medical care settings are not included in estimates of overall expenditures. For example, there are ap- proximately 3.6 million craniofacial cases (e.g., diabetes-related conditions, oral cancers, and injuries) treated in medical care settings each year, and the total costs for these treatments exceed several billion dollars (Snowden et al., 2003). Average Annual Dental Expenses In 2007, the average annual expense for individuals who had any den- tal expenses was $643 (Rohde, 2010). Individual expenses varied by age, income, race and ethnicity, and insurance status (see Figure 5-1). Annual dental expenses also varied by source of insurance. The average annual dental expense for individuals with private dental insurance was $662. Among individuals with public dental insurance (e.g., Medicaid or CHIP), the average annual dental expense was $370 (AHRQ, 2009). Individuals with higher incomes had higher annual dental expenses. The average annual dental expense for “high-income” individuals (>400 percent of the federal poverty level [FPL]) was $710. Among “poor” individuals (≤100 percent FPL), the average annual dental expense was $428 (AHRQ, 2009). This difference in expenses may reflect the ability of individuals with higher

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195 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE $800 $800 $600 $600 $400 $400 $200 $200 $0 $0 < 5 years 5–17 years 18–44 years 45–64 years 65 and over ≤ 100% FPL 100–125% FPL 125–200% FPL 200–400% FPL > 400% FPL $800 $800 $600 $600 $400 $400 $200 $200 $0 $0 Hispanic White, non-Hispanic Black, non-Hispanic AI/AN/Other Asian/PI Uninsured Private insurance Public insurance FIGURE 5-1 Mean annual dental expenses by age, income, race/ethnicity, and insurance status, United States, 2007. NOTE: AI/AN = American Indians/Alaska Natives; FPL = federal poverty level; PI = Pacific Islander. SOURCE: AHRQ, 2009. incomes to pay for and use dental care. Finally, older adults (individuals 65 and over) had the highest average annual dental expenses at $776. By contrast, children and adolescents (individuals under age 18) had the lowest average annual dental expenses (AHRQ, 2009). In 2007, the source of payments for dental care (e.g., private insurance, out-of-pocket, or public insurance) varied among individuals who had any

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196 IMPROVING ACCESS TO ORAL HEALTH CARE 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% < 5 years 5–17 years 18–44 years 45–64 years 65 and over ≤ 100% FPL 100–125% FPL 125–200% FPL 200–400% FPL > 400% FPL 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Hispanic White, non-Hispanic Black, non-Hispanic AI/AN/Other Asian/PI Uninsured Private insurance Public insurance FIGURE 5-2 Percent of total annual dental expenses paid out of pocket by age, income, race/ethnicity, and insurance status, United States, 2007. NOTE: AI/AN = American Indians/Alaska Natives; FPL = federal poverty level; PI = Pacific Islander. SOURCE: AHRQ, 2009. dental expenses. For example, the percentage of annual dental expenses paid out of pocket varied by age, race and ethnicity, income, and insur- ance status (see Figure 5-2). As would be expected, uninsured individuals pay the highest percentage—nearly three quarters—of their annual dental expenses out of pocket (74.7 percent) compared to individuals with private insurance and those with public insurance (44.3 percent and 28.5 percent,

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197 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE respectively) (AHRQ, 2009). Older adults (individuals 65 and over) had the highest percent of total annual dental expenses paid out of pocket than any other age group (70.3 percent). By contrast, children, who are more likely to have public insurance that includes dental coverage, had the low- est percent of total annual dental expenses paid out of pocket than any other age group (23 percent). Working age adults (individuals between 18 and 64 years of age), who are more likely to have employer-based dental coverage, had lower costs than older adults (AHRQ, 2009). The lack of dental coverage in Medicare and the lack of employee-based dental cover- age translate into higher out-of-pocket dental expenses for older adults (Manski et al., 2010a). OVERVIEW OF COVERAGE Dental Coverage There is strong evidence that dental coverage is positively tied to access to and utilization of oral health care (AHRQ, 2010; Decker, 2011; Sohn et al., 2007), although whether or not this relationship is causal is not clear. For example, it may be that those with greater demand for dental care are the ones most likely to purchase dental coverage. This suggests it is not clear if more coverage leads to greater use or greater demand leads to the purchase of dental coverage (and then greater use). The tie is clear, though: In 2007, 52 percent of adults with private dental coverage had at least one dental visit, compared to 31 percent of those without private dental cover- age and 22 percent of uninsured individuals (Manski and Brown, 2010). Moreover, children who have dental coverage, through public programs (e.g., Medicaid or CHIP) or private insurance, use preventive care more routinely than their counterparts who lack coverage (Lewis et al., 2007). Studies using quasi-experimental designs to assess the impact of dental cov- erage on access and utilization indicate that, once children acquire coverage through a public program, they are significantly less likely to have unmet needs for dental care. For example, after enrolling in CHIP, unmet needs for oral health care decline among adolescents (Klein et al., 2007). Another study found that, after enrolling in CHIP, children with special health care needs had significantly improved access to a broad range of health care ser- vices, including dental care (Kenney, 2009). Overall, uninsured children are at least twice as likely as children with dental coverage to have unmet need for oral health care (Damiano et al., 2003; Feinberg et al., 2002; Fox et al., 2003; Kenney, 2007; Lave et al., 2002; McBroome et al., 2005; Mofidi et al., 2002; Szilagyi et al., 2004; Trenholm et al., 2005; Wang et al., 2007). Millions of Americans lack dental coverage. Recent data from several sources underscore this deficiency among children, adults, and older adults:

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198 IMPROVING ACCESS TO ORAL HEALTH CARE • An estimated 130 million U.S. adults and children lack dental cov- erage (based on enrollment in private dental plans) (NADP, 2009). • Over 40 percent adults ages 21–64 lack private dental coverage (see Figure 5-3) (Manski and Brown, 2010). • Approximately 70 percent of adults age 65 and older, lack any kind of dental coverage—public or private (Manski and Brown, 2007). • Over 22 percent of children ages 1–17 lack dental coverage (Liu et al., 2007). What Do Dental Plans Cover? The types of dental services covered by dental plans vary widely among private plans and between various public plans. Currently, there is no stan- dard set of essential oral health benefits. For example, one plan may include “comprehensive” care such as routine diagnostic and preventive services, X-rays, restorative services, and oral surgery, while another may cover more limited services such as emergency care only. A recent survey of employer- sponsored health plans of the benefits typically covered by employers based on data from the National Compensation Survey provides an overview of employment-based dental benefits (see Box 5-1). Some of the variation in services covered is driven by employer and consumer choice. Dental ben- efits available to employees may be based upon their employers’ selection of low-cost dental benefit packages or benefits packages that appeal to Public dental coverage, 5.0% No dental Private dental coverage, 35.5% coverage, 59.5% FIGURE 5-3 Percentage of adults 21–64 according to dental coverage status: U.S. civilian noninstitutionalized population, 2007. SOURCE: Manski and Brown, 2010.

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199 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE BOX 5-1 Summary of Employment-Based Dental Benefits A recent report from the Department of Labor on selected medical benefits provided the following summary of employment-based dental benefits based on data from the National Compensation Survey (NCS): Plans typically grouped dental services into categories, such as preven- tive services (typically exams and cleanings), basic services (typically fill- ings, dental surgery, periodontal care, and endodontic care), major services (typically crowns and prosthetics), and orthodontia. Cost sharing for dental services typically involved an annual deductible—the median was $50 per person. After meeting the deductible, dental plans often paid a percent of covered services up to a maximum annual benefit. The median percent paid by the plan was 100 percent for preventive services, 80 percent for basic services, and 50 percent for major services and orthodontia. The median an- nual maximum was $1,500; a separate maximum applicable to orthodontic services also had a median value of $1,500. SOURCE: BLS, 2011. their higher paid workers. Alternatively, consumers may purchase or select employer-based coverage (when available) that provides a range of desired benefits and/or choice of providers. The dental benefits included in public plans are determined by federal law and/or state decisions. (A discussion of what is covered in public plans is included later in the chapter.) Each of the factors described above contribute to the tremendous variation in dental coverage. How Is Dental Coverage Unique? The usual premise for buying insurance is to cover unpredictable and rare events. This is the impetus behind purchasing health care, home, and car insurance. But this logic does not neatly fit most dental care. In general, dental care does not meet the criteria for casualty insurance that “the event or expense insured against (1) is relatively rare for the individual person but occurs at known rates for groups, (2) is very costly, and (3) cannot gener- ally be controlled by the insured” (IOM, 1980). In fact, most people need or use oral health care at least annually. Dental coverage is similar to health coverage in one notable way: the availability of a significant tax subsidy has led employers to offer dental coverage. Thus, most private dental coverage is employer provided, subsi-

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200 IMPROVING ACCESS TO ORAL HEALTH CARE dized through the tax system. However, dental coverage typically requires higher percentage co-payments than health insurance. The IOM report Public Policy Options for Better Dental Health (Public Policy Options) concluded that, despite the unique attributes of dental coverage, it is in the nation’s best interest to cover dental services; the reasons provided by the committee over 30 years ago remain largely the same today: • Use of oral health care is highly correlated with income, education, and occupational status. • Effective preventive measures exist. • The overall structure of dental benefit coverage does not adequately promote preventive services, often resulting in delayed treatment. Finally, the Public Policy Options committee concluded that “well- designed public and private dental health insurance would be useful for achieving important objectives in dental health and that this advantage outweighs the inapplicability of some of the traditional insurance principles to dental care benefits.” Specifically, the committee determined that dental coverage could, among other things, improve access to dental care delivery systems (IOM, 1980). Variation in Coverage Rates by Race/Ethnicity Dental coverage varies significantly by race and ethnicity (Flores and Tomany-Korman, 2008; Manski and Brown, 2007, 2008, 2010; Zuckerman et al., 2004). For example, data from the 2004 Household Component of the Medical Expenditure Panel Survey showed that among individuals of all ages, white non-Hispanics were more likely to have private dental coverage than black non-Hispanic and Hispanic individuals (who were more likely to have public dental coverage) (Manski and Brown, 2007). Data from the 2006 Health and Retirement Study showed that among older adults, non- Hispanic blacks were more likely to have dental coverage (56.8 percent) than non-Hispanic whites (46.7 percent) and Hispanics (42.4 percent) (Manski et al., 2010b). PRIVATE SOURCES OF FINANCING Dental care is financed primarily through private sources, including individual out-of-pocket payments and private coverage (see Table 5-1). For more than 50 years, these two sources have financed over 90 percent of all dental expenditures (CMS, 2010b). Americans spend billions of dollars out of pocket for dental services each year. In 2008, dental services accounted

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201 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE TABLE 5-1 National Dental Expenditures, by Source of Funds, 2003–2009 (in $ billions) Private Public Private Other Health Out-of- Health Insurance Year Total Pocket Insurance Medicare Medicaid Programs 2003 76.0 33.7 37.4 0.1 3.7 0.8 2004 81.8 36.0 40.5 0.1 4.0 0.9 2005 86.8 38.3 42.9 0.1 4.2 1.0 2006 91.4 40.3 45.1 0.1 4.4 1.1 2007 97.3 42.7 47.8 0.2 4.8 1.5 2008 102.3 44.9 49.1 0.2 5.8 1.7 2009 102.2 42.5 50.0 0.3 7.1 1.9 SOURCE: CMS, 2010b. for 22 percent of all out-of-pocket health care expenditures, ranking second only to prescription drug expenditures (BLS, 2010a). Variation in Coverage Rates by Employment and Income Variations in dental coverage have been observed by employment status and income level. For example, data from the 2008 National Health Inter- view Survey showed that the percentage of individuals with private dental coverage increased as income levels increased (Bloom and Cohen, 2010). Similarly, higher-paid workers are also more likely to have access to and participate in stand-alone dental plans (Barsky, 2004; Ford, 2009). The availability of dental coverage through one’s employer is associated with the size of the establishment; that is, the larger the number of employees overall, the greater the likelihood that stand-alone dental plans will be available to employees (Barsky, 2004; Ford, 2009). Employers can add a separate oral health product to their overall coverage package, but often they do not. In 2006, 56 percent of all employers offered health insurance but only 35 percent offered dental coverage (Manski and Cooper, 2010). Employees are more likely to be offered options for medical insurance than dental coverage, and a higher percentage of employees will take advantage of available dental benefits as compared with the percentage of employ- ees who take advantage of available medical benefits (80 percent vs. 75 percent) (BLS, 2010b). As noted earlier, with the exception of coverage of

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202 IMPROVING ACCESS TO ORAL HEALTH CARE Department of Other programs, 5% Veteran Affairs, 1% Medicare, 3% Department of Defense, 10% Children’s Health Insurance Program (Title XIX and Title XXI), 8% Medicaid (Title XIX), 73% FIGURE 5-4 Public expenditures for dental services by program, 2009. SOURCE: CMS, 2010b. rare events, dental coverage differs from the typical insurance model; thus, employer-based dental coverage might be viewed as a fringe benefit that subsidizes oral health care utilization. PUBLICLY SUBSIDIZED COVERAGE Access to dental care depends on a variety of factors; however, chief among these is having a provider available and having the ability to pay for services (either through insurance, direct out-of-pocket payments, or subsidies) (Borchgrevink et al., 2008; Fisher and Mascarenhas, 2007; GAO, 2000; Hughes et al., 2005). In 2009, public subsidies or direct payments for dental services from public programs totaled $7.4 billion or less than 1 percent of national expenditures for dental services (CMS, 2010b). The overwhelming majority (73 percent) of these public expenditures for direct services or coverage came from Medicaid (CMS, 2010b) (Figure 5-4). Medicaid and CHIP Medicaid Medicaid is a federal-state entitlement program for medical assistance to low-income children and pregnant women, persons over age 65, and those with disabilities who meet income and resource requirements; at the state’s discretion, certain persons who are considered medically needy

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203 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE based on their high medical costs may also be covered. The vast majority of state Medicaid programs now purchase at least some medical care services through contracts with managed care plans (CMS, 2009). Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service provides a comprehensive child health benefit, which re- quires states to fund well-child health care, diagnostic services, and medi- cally necessary treatment services to Medicaid-eligible children ages birth to age 21 (CMS, 2005a). Under federal EPSDT law, states must cover any Medicaid-covered (i.e., allowed under the federal Medicaid statute) service that is necessary to prevent, correct, or ameliorate a child’s physical health, which includes oral health (CMS, 2005b). Dental coverage is required for all Medicaid enrolled children under age 21 (CMS, 2011b). This is a com- prehensive benefit, including preventive, diagnostic, and treatment services. At a minimum, these services must include relief of pain and infections, restoration of teeth, and maintenance of dental health. In contrast, states are not required to provide coverage for adults. For adults, states must only cover medical and surgical services furnished by a dentist to the extent those services can be performed under state law by either a doctor of medicine or a dentist. Beyond this, states’ coverage of routine dental benefits for adults varies widely among the states, with a number of states limiting the benefit to emergency coverage (see Figure 5-5). Medicaid coverage can improve access to medical and dental care; however, health status, age, race and ethnicity, gender, routine source of dental care, amount of reimbursement, and availability of providers all factor into the impact of coverage (Dasanayake et al., 2007; Edelstein and Chinn, 2009; Jablonski et al., 2005; Johnson et al., 2005; Kenney, 2009; Pourat and Finocchio, 2010; Rowley et al., 2006; Shiboski et al., 2005; Snyder, 2009). There are variations in the patterns of utilization for pre- ventive, treatment, emergency, and specialty dental services associated with Medicaid populations compared to privately insured populations (Sweet et al., 2005). At the same time, low provider participation in the Medicaid program has a direct and generally negative impact on access to oral health care for Medicaid beneficiaries (GAO, 2009, 2010; Lewis et al., 2009; Milgrom et al., 2010; Ramírez et al., 2011; Shortridge and Moore, 2009). For example, 74 percent of pediatricians cite the lack of dentists who accept Medicaid as a “moderate to severe barrier for 0–3-year-old Medicaid-insured patients to obtain dental care” (Lewis et al., 2009). In addition, a recent study in Illinois found that a child with public dental coverage (Medicaid/CHIP) was significantly less likely to obtain an appointment for an urgent oral injury than a child with the same injury with private dental coverage (Bisgaier et al., 2011). This effect was found even among Medicaid/CHIP-enrolled practices. Increases in Medicaid reimbursement, discussed later in this

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218 IMPROVING ACCESS TO ORAL HEALTH CARE Enhanced Medicaid Payments North Carolina Medicaid Waiver North Carolina has developed a unique arrangement with the CMS to provide enhanced Medicaid payments to state-supported patient care facilities. These supplemental Medicaid payments have resulted in the de- velopment of a large network of 120 fixed and 16 mobile county-run dental clinics and an innovative clinical education model at a new School of Dental Medicine (SODM) at East Carolina University. As discussed in Chapter 3, this new clinical educational program is expected to significantly reduce dental access disparities in some of the poorest areas of the state. In 1997 North Carolina obtained a CMS Medicaid waiver that allows enhanced payments to state-supported facilities that provide care to Med- icaid patients. As a result: 1. Clinics bill fee-for-service for covered benefits provided to Medicaid- enrolled patients. On an annual basis, clinics determine the actual cost of providing services to Medicaid patients and submit the dif- ference between actual costs and payments to the state Medicaid program. 2. The state pays the university 64 percent of the difference between actual and reimbursed costs. The money comes from CMS and reflects the fact that CMS pays 64 percent of Medicaid program costs in North Carolina. As an example, assume the allowable cost for dental services is $2.0 million, and total reimbursement to the SODM under fee-for-service reim- bursement is $1.75 million. Thus, the unreimbursed allowable amount is $250,000. Medicaid reimburses the unreimbursed costs to the extent of the federal Medicaid participation rate which is currently 64 percent. Accord- ingly, the school receives an additional settlement of $160,000. There is usually a 12-month period between submitting and receiving the additional funds (Bailit et al., 2010). Minnesota Critical Access Dental Payment Program (CADPP) In 2001, the Minnesota legislature established the Critical Access Den- tal Payment Program (CADPP) to offer increased reimbursement (through add-on payments) to providers that care for patients enrolled in the Minne- sota Health Care Program (MHCP). MHCP provides health care coverage through three publicly funded health care programs: the Medical Assistance (MA) program, the General Assistance Medical Care (GAMC) program,

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219 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE TABLE 5-3 Minnesota Fee-for-Service Payment to Charge Ratio, 2000–2006 2000 2001 2002 2003 2004 2005 2006 CADPP providers n/a n/a 0.62 0.61 0.61 0.58 0.51 Non-CADPP providers 0.50 0.48 0.50 0.50 0.49 0.46 0.43 NOTE: n/a = not applicable. SOURCE: Morales and Reisdorf, 2008. and MinnesotaCare. While all three programs provide a dental benefit, only 44 percent of MA enrollees, 36 percent of GAMC enrollees, and 51 percent of MinnesotaCare enrollees visited a dentist in 2006 (Morales and Reisdorf, 2008). A 2008 study of the program’s impact on access showed that while a higher payment to charge ratio could be achieved with the CADPP designa- tion in fee-for-service programs (see Table 5-3), providers continued to state that they could not afford to participate in the program. The evaluation found that while the number of MHCP participants increased during the study period, the percent of continuously enrolled individuals receiving dental care remained stable while the rate of visits increased slightly. The researchers indicated a “growing concern for the creation of Medicaid dental mills” in which providers might deliver mul- tiple procedures in order to maximize profitability. Overall, the researchers concluded that As measured by the overall number of enrollees obtaining dental services, the CADPP has demonstrated that add-on payment rates have not led to an increase in dental access for MHCP enrollees. Regardless of this find- ing, the program should continue to serve as a viable means of sustaining dental practices that see high volumes of MHCP enrollees and provide high quality evidence based care. In addition, the researchers recommended further exploration into the effect of streamlining of administrative processes as well as payment rates. Enhanced Medicaid Payments and Streamlined Administration In 2000 the State of Michigan enrolled Medicaid-eligible children from 22 rural counties (increased to 59 counties in subsequent years) in a Delta Dental of Michigan plan called Healthy Kids Dental (HKD) (Eklund et al., 2003). Delta set fees (adjusted annually for inflation) for HKD children the same as for privately insured patients, used the same administrative

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220 IMPROVING ACCESS TO ORAL HEALTH CARE processes for filing claims, and so forth, but did not charge patients any out-of-pocket expenses. In 5 years (2005), HKD utilization rates for those enrolled for 12 months increased to 53 percent, compared to the traditional Medicaid program (35 percent), but they were not as high as the privately insured (64 percent) (Eklund et al., 2003). The existing dental workforce was able to provide care to another 100,000 children (200,000 eligible). Streamlined Administration and Supportive Activities A recent CMS report features state-level efforts to improve the provision of Medicaid dental services through innovative practices (CMS, 2011a). For example, in Alabama, outreach to increase provider participation includes on-site assistance to dentists in completing Medicaid application forms; Maryland uses electronic funds transfer to improve the timeliness of reim- bursement to providers; and Maryland and Virginia use a single contractor to administer their dental programs to reduce the paperwork providers and their office staff must complete; and Virginia reduced the prior authorizations needed for dental services (CMS, 2011a). The CMS report notes “states and providers interviewed say that these simplifications are extremely important to maintaining and increasing provider participation” (CMS, 2011a). Integrating Medical and Oral Health Coverage In Massachusetts, Blue Cross Blue Shield (BCBSMA) provides inte- grated medical and oral health coverage with the aim of improving overall health outcomes and removing cost barriers to oral health care among its vulnerable beneficiaries. Beneficiaries with diabetes, coronary artery disease (CAD), oral cancer, and women who are pregnant that have both medical and dental coverage are automatically enrolled in a program that provides “enhanced dental benefits.” These individuals are eligible to receive ad- ditional services (such as cleanings or periodontal maintenance every 3 months) at no additional cost, based on their condition. According to BCBSMA claims data, this approach has lowered medical costs among participants with diabetes and CAD. For example, BCBSMA claims data from 2007 showed that beneficiaries with CAD and diabetes who received periodontal services had lower overall monthly costs than those who received no dental care or preventive dental services alone (Lewando, 2010). BCBSMA claims data from 2009 showed that ben- eficiaries with CAD and diabetes who received dental prophylaxis and/ or periodontal treatment had lower per-member-per-month medical costs than beneficiaries who did not receive treatment ($487 and $67, respec- tively) (Lewando, 2010). While this approach is not specifically designed to increase access, it is an example of an innovative cost-savings strategy

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221 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE targeted at vulnerable populations. Furthermore, it supports the commit- tee’s guiding principles that oral health care is an essential component of comprehensive health care and that oral health promotion and disease prevention are essential to any strategies aimed at improving access to care. LIMITATIONS As described in Chapter 1, the committee encountered considerable shortcomings in the research on expenditures and financing for oral health care during its review of the evidence. The committee made every effort to include the most up-to-date research published in peer-reviewed journals on these subjects. On the surface, it may appear that some of the refer- ences are dated. However, the committee determined that, in some cases, the strongest evidence on oral health financing and coverage was found in studies that have not been replicated in recent years. In other cases, newer data have been collected (through surveys such as NHANES and MEPS), but they have not been fully analyzed. Because the committee was not equipped to or charged with analyzing these data, it has cited the most current published analyses. In addition to the lack of recent data in key areas, the committee was constrained by the somewhat limited analyses of data that exist on oral health coverage and financing. In general, the committee found few studies that provide detailed analyses of oral health financing by specific variables of interest or that analyzed complex relationships. For example, analyses of the different categories of dental coverage by subpopulations would provide a more complete picture of the impact of coverage on access and utilization and move beyond simple comparisons. In lieu of more detailed analyses, the committee relied on the strongest evidence available in the literature. Finally, by reviewing and synthesizing the evidence, this chapter under- scores the overall deficiencies in research on oral health financing. The com- mittee hopes that this examination will help generate additional research questions and provide direction for future research. FINDINGS AND CONCLUSIONS The committee noted the following findings and conclusions: • Financing for oral health care greatly influences where and whether individuals receive care. • Per capita out-of-pocket spending for dental services is proportion- ally much greater than for medical services. • Dental coverage is positively tied to access to and utilization of oral health care.

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222 IMPROVING ACCESS TO ORAL HEALTH CARE • Comprehensive dental benefits are federally required for all Medicaid-enrolled children, and all states are required to provide comparable dental coverage to children enrolled in CHIP. • However, access to dental care continues to be a problem for chil- dren in Medicaid and CHIP. • Medicaid benefits are not required for adults in every state, and among those states that offer dental coverage for adult Medicaid recipients, the benefits are typically limited to emergency coverage. • Medicaid cannot properly address access to oral health services if it excludes oral health benefits. • Low provider participation in the Medicaid program has a direct and generally negative impact on access to dental care for Medicaid beneficiaries. • Medicare does not cover routine checkups, cleanings, fillings, or dentures for older adults. • The federal government and states make considerable investments in dental coverage (e.g., Medicaid and CHIP), oral health services, infrastructure, and research. These investments, however, are insuf- ficient in providing dental coverage and improving access to care for vulnerable and underserved populations. REFERENCES AAP (American Academy of Pediatrics). 2010. Fluoride information by state. http://www.aap. org/commpeds/dochs/oralhealth/fluoride.cfm (accessed March 15, 2011). ADA (American Dental Association). 2004. State and community models for improving access to dental care for the underserved—a white paper. Chicago, IL. ADHA (American Dental Hygienists’ Association). 2010. States which directly reimburse dental hygienists for services under the Medicaid program. http://www.adha.org/ governmental_affairs/downloads/medicaid.pdf (accessed March 12, 2011). AHRQ (Agency for Healthcare Research and Quality). 2009. Dental services—Mean and median expenses per person with expense and distribution of expenses by source of payment: United States, 2007. http://www.meps.ahrq.gov/ (accessed March 15, 2011). AHRQ. 2010. 2009 National healthcare disparities report. Rockville, MD: U.S. Department of Health and Human Services. Association of Maternal and Child Health Programs. 2011. State profile: Iowa maternal and child health block grant 2011. http://www.amchp.org/Advocacy/BLOCK-GRANT/ 2011PROFILES/Iowa.pdf (accessed March 16, 2011). ASTDD (Association of State and Territorial Dental Directors). 2010. Synopses of state dental public health programs: Data for FY 2008-2009. http://www.astdd.org/docs/ StateSynopsisReport2010SUMMARY.pdf (accessed April 5, 2011). ASTDD. 2011. Best practice approach reports. http://www.astdd.org/best-practice-approach- reports (accessed March 17, 2011). Bailit, H., J. D’Adamo, and T. Beazoglou. 2010 (unpublished). Report to the Oral Health Ac- cess Committee: State case studies: Improving access to dental care for the underserved. Barsky, C. B. 2004. Incidence benefits measures in the national compensation survey. Monthly Labor Review 127(8):21-28.

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