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Oral Health Disparities in Publicly Insured Children

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  • 1. Oral Health Disparities in Publicly Insured Children Dental Advisory Committee April 11 th , 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 Children’s 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 MCO’s
    • 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. 1.17 (1.02-1.36) 0.93 (0.79-1.09) 1.00 1.75 (1.61-1.89) 1.37 (1.26-1.50) 1.00 2.42 (2.20-2.66) 1.64 (1.52-1.76) 1.00 Odds Ratio (95% CI) 0.031 0.372 <0.001 <0.001 <0.001 <0.001 P-Value 3% 2% 2% 11% 9% 7% 26% 20% 15% *Predicted Utilization Extraction Services SCHIP Both plans Medicaid (ref) Restorative Services SCHIP Both plans Medicaid (ref) Preventive Services SCHIP Both plans Medicaid (ref) Enrolled Children
  • 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. 0.54 (0.43-0.68) 0.56 (0.47-0.68) 1.00 0.94 (0.86-1.04) 0.87 (0.79-0.96) 1.00 1.21 (1.08-1.36) 0.93 (0.83-1.04) 1.00 Odds Ratio (95% CI) <0.001 <0.001 0.210 0.008 0.198 0.001 P-Value 10% 11% 17% 49% 47% 50% 86% 82% 83% *Predicted Utilization Extraction Services SCHIP Both plans Medicaid (ref) Restorative Services SCHIP Both plans Medicaid (ref) Preventive Services SCHIP Both plans Medicaid (ref) Children with Utilization
  • 19. Predicted probabilities of dental services (preventive, restorative, and extraction) for North Carolina children (4 years of age) enrolled for 12 months. Preventive Restorative Extraction
  • 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. 25 75 64 36 71 29 62 38   62 38       Family Member with Active Decay 61 Y   100 N       Snacking 3+ times a day 61 Y 100 N Suboptimal Fluoride 47   Y 114 N Takes Bottle to Bed 58 Y 103   N Assessment of High Risk 121 Y 40 N
  • 25. 85 137 N 15 24 Y Visible Plaque       Age 19 months Mean     9.5 SD   44 0 Range   81 130 N 19 31 Y 87 139 N 13 20 Y       White Spot Lesions       Decay % n   Characteristic
  • 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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