Comparative analysis of dental procedure mix in public and private dental benefits programs

Background

There is little published research on whether public and private dental benefits plans affect the types of oral health care procedures patients receive. This study compares the dental procedure mix by age group (children, working-age adults, older adults), dental benefits type (Medicaid and Children’s Health Insurance Program, private), and level of Medicaid dental benefits by state (emergency only, limited, extensive).

Methods

The authors extracted public dental benefits claims data from the 2018 Transformed Medicaid Statistical Information System. To compare procedure mix with beneficiaries who had private dental benefits, the authors used claims data from the 2018 IBM MarketScan dental database. The authors categorized dental procedures into specific service categories and calculated the share of procedures performed within each category. They analyzed procedure mix by age, plan type (fee-for-service, managed care), and adult Medicaid benefit level.

Results

Aside from orthodontic services, the dental procedure mix among children with public and private benefits is similar. Among adults with public benefits, surgical interventions make up a higher share of dental procedures than routine preventive services.

Conclusions

Children with public benefits have a procedure mix comparable with those with private benefits. There are substantial differences in procedure mix between publicly and privately insured adults. Even in states that provide extensive dental benefits in Medicaid, those programs primarily finance invasive surgical treatment as opposed to preventive treatment.

Practical Implications

There is a need to assess best practices in publicly funded programs for children and translate those attributes to programs for adults for more equitable benefit design and care delivery across public and private insurers.

Dental insurance coverage can vary considerably by age. Nearly 90{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of children in the United States have some form of dental benefits coverage compared with 66{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of working-age adults and 34{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of older adults.

The age gap is much narrower with health care benefits; 95{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of children, 85{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of working-age adults, and 99{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of older adults have some form of coverage.

People who have dental benefits, whether private or public, are more likely than their uninsured counterparts to use oral health care.

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Among those who have dental coverage, the payment arrangements and scope of covered services tend to differ markedly in private and public benefits programs, particularly among adults.

Children’s dental coverage in Medicaid is governed by the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which guarantees preventive and restorative dental services to enrolled children younger than 21 years.

The dental services covered vary to some degree across states but tend to be relatively comprehensive and closely approximate those offered in private dental benefits plans.

There is evidence that providing adult dental benefits through Medicaid has a significant impact on access to and use of oral health care among low-income adults,

yet dental benefits are not guaranteed beyond age 20 years. Inclusion of adult dental services is optional,

and there is significant state-to-state variation in terms of what dental services are covered and which adult beneficiaries qualify.

Medicare, the medical benefits program for adults 65 years and older,

does not cover routine dental services.

Past studies have explored procedure mix among working-age adults and older adults using patient-reported data. Older adults, for instance, report using a greater share of prosthodontic services than working-age adults.

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There is a predominance of diagnostic and preventive services delivered for adults across all age and benefits groups. However, those with public benefits are more likely to have surgical services and less likely to have preventive care than their privately insured counterparts.

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Previous work examined differences in procedure mix among adults using self-reported survey data from the Medical Expenditure Panel Survey.

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There is little research on the difference in dental procedure mix between those with public and private benefits. There are a few studies that have looked at procedure mix among children insured by Medicaid and Children’s Health Insurance Program (CHIP) at the state level.

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These state-level studies indicate pediatric surgical services are trending downward, suggesting that increased oral health care use among children enrolled in Medicaid- and CHIP and the focus on preventive services may be effective in reducing the overall need for more invasive treatment.

Other studies have explored procedure mix variation for underserved populations, such as those living in rural areas or living with HIV, who were more likely to undergo surgical treatment and less likely to have had preventive oral health care.

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We used 2018 Medicaid and CHIP deidentified claims data from the Transformed Medicaid Statistical Information System (T-MSIS),

maintained by the Centers for Medicare & Medicaid Services (CMS). Since 2014, states have provided T-MSIS detailed information regarding Medicaid/CHIP enrollment, service use, and payments. As of 2018, each state, the District of Columbia, and US territories provide T-MSIS with Medicaid and CHIP claims data on a monthly basis. The T-MSIS Analytic Files, housed in the Chronic Condition Data Warehouse,

include annual demographic and eligibility tables, inpatient claims, long-term care claims, pharmacy claims, and other services (OT) claims. In 2018, there were approximately 95.1 million people enrolled in Medicaid or CHIP.

To compare Medicaid/CHIP procedure mix with private benefits, we extracted 2018 dental claims data from the IBM MarketScan dental database.

These data include private dental benefits claims from large employers and health plans across the United States. This administrative claims database includes data from a variety of fee-for-service, preferred provider organization, and capitated health plans. The database is a large convenience sample of the privately insured population in the United States.

In 2018, there were 10.6 million people with private dental benefits included in IBM MarketScan. On the basis of the 2018 data from the Medical Expenditure Panel Survey,

we estimated that IBM MarketScan captures approximately 6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} of the private dental benefits market in the United States. Older adults represented in IBM MarketScan are likely primarily working, given that the commercial claims data come from employer-sponsored private dental plans, although some employers offer coverage to retirees. We do not have specific percentages of working and retired or not working older adults from this private claims data. Oral health-related research using IBM MarketScan dental claims data has been published widely.

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From the 2018 OT Medicaid/CHIP monthly line tables and the 2018 IBM MarketScan dental claims data, we extracted all dental procedure codes that appear in the CDT.

We followed the categorization of the CDT manual to classify dental procedures as follows: diagnostic, preventive, restorative, endodontics, periodontics, implant services and prosthodontics, oral and maxillofacial surgery, orthodontics, and adjunctive general services

(Table 1). Each line in the monthly OT Medicaid/CHIP line tables and IBM MarketScan dental claims table corresponds to a unique procedure with a quantity of 1. For calendar year 2018, we aggregated the number of procedures performed for each service category separately for public and private benefits programs. From the total number of procedures performed, we then calculated the share of procedures performed for each dental service category. We calculated dental procedure mix across all ages for those with public and private dental benefits. We also calculated procedure mix separately for children (0-20 years), working-age adults (21-64 years), and older adults (>= 65 years).

For working-age and older adults, we calculated Medicaid procedure mix in states with extensive, limited, or emergency-only dental benefits. The figure categorizes each state by its level of Medicaid adult dental benefits. Emergency-only dental benefits cover pain relief under defined situations; limited benefits cover diagnostic, preventive, and minor restorative procedures; and extensive benefits cover diagnostic, preventive, and a more comprehensive set of restorative procedures, with a per-enrollee annual maximum expenditure of at least $1,000.

All states are required to cover comprehensive dental services for children in Medicaid and CHIP through the EPDST benefit, and minimum standards for this coverage are relatively consistent across states.

Given that Medicaid/CHIP dental benefits for children are relatively standardized across states, we compared procedure mix for managed care and fee-for-service plans. We used the claim type indicator variable from the OT header table to differentiate between managed care and fee-for-service claims. This research is part of a data use agreement approved by the CMS (RSCH-2020-5563: The State of Oral Healthcare Use, Quality and Spending: Findings from Medicaid and CHIP Programs). We received institutional review board approval to conduct research based on T-MSIS Medicaid and CHIP claims.

We found substantial variation in dental procedure mix across dental benefits types and age groups (Table 2).

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Compared with children with private dental benefits, children with Medicaid/CHIP benefits had a higher share of diagnostic services (44.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 41.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and restorative services (11.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 8.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}), whereas a lower share of total services were preventive (35.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 38.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and orthodontic (1.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} versus 6.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).

Procedure mix for working-age adults also varied by state adult Medicaid dental benefit level (Table 3).

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As one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated to oral surgery declined from 22.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 9.9{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}. Still, in states with extensive adult Medicaid dental benefits, the share of total procedures allocated to oral surgery was higher than the share of total procedures that went toward oral surgery among adults with private dental benefits (2.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). Conversely, as one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated for periodontal services increased from 1.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 4.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}, which was still lower than the share among the privately insured (5.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of dental procedures that were preventive increased from 7.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with emergency-only dental benefits for adults to approximately 12.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with limited or extensive dental benefits for adults, which was still substantially lower than the share among those with private benefits (22.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of total dental procedures for restorative services for working-age adults enrolled in Medicaid increased from 7.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with emergency-only dental benefits for adults to 18.9{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with limited benefits before dropping slightly to 17.3{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in states with extensive dental benefits.

The change in procedure mix across state Medicaid dental benefit categories for older adults was similar to that of working-age adults (Table 4).

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In states with limited or extensive dental benefits for adults, the share of adjunctive general services was higher for older adults than for working-age adults. Across all benefit levels, the share of implant services and prosthodontics was higher for older adults than for working-age adults. As one progressed from states with emergency-only benefits to states with extensive dental benefits, the share of total procedures allocated to oral surgery declined from 22.8{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} to 10.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}. Among older adults, the share of Medicaid dental procedures for restorative services increased from 6.4{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in emergency-only benefits states to 12.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in limited benefits states before dropping to 9.7{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79} in extensive benefits states.

Procedure mix across fee-for-service and managed care Medicaid/CHIP pediatric plans was also similar (Table 5),

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particularly with diagnostic and preventive services. Conversely, the share of dental procedures that was allocated for oral surgery was slightly higher in fee-for-service plans (3.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than for managed care plans (2.5{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). For private dental benefits plans, the share of dental services for oral surgery was similar (3.2{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}). The share of dental services for restorative services was higher for both fee-for service plans (11.6{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) and managed care plans (12.0{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}) than for private dental benefits plans (8.1{b8727dad3e87009fdf7522b8034efdb701cdc6055ba8d220b20c1758c4dd8d79}).

Another factor explaining disparities in procedure mix across dental benefits type could be the different policy approach to oral health care coverage in Medicaid for adults compared with children. The United States has a long history of treating oral health care as an essential service for children but not for working-age and older adults. More importantly, it is federally mandated that all state Medicaid and CHIP programs offer comprehensive dental services to child enrollees up to age 20 years via the EPSDT benefit. CMS grants autonomy to each Medicaid program to determine the services and associated frequencies that will meet minimum objectives for oral health among the eligible children living in their state.

As state programs have refined their benefits for children in adherence of EPSDT over time, public coverage for oral health care has grown to look remarkably similar to private coverage for children’s oral health care, with more dentist participation and greater oral health care use.

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The Patient Protection and Affordable Care Act reinforced the essentialism of children’s oral health care with the inclusion of pediatric oral health care as an essential health care benefit; the same was not done for adults.

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State Medicaid programs are scattered in terms of how they approach dental coverage for adults, and our analysis shows that the procedure mix is different according to the level of dental benefits. In states with extensive Medicaid dental benefits, there is more focus on restoring teeth rather than extracting them. As an example, Virginia has extensive benefits in place as of July 2021 that replace its previous limited benefits. The benefits cover restorative, endodontic, periodontic, and prosthodontic services in addition to diagnostic and preventive services, and there is no annual maximum expenditure for enrollees.

Most private dental plans have per-enrollee annual maximums much higher than $1,000.

Our analysis forces the question of whether extensive adult dental coverage in Medicaid is really that extensive. Even with extensive benefits coverage, there are differences in overall use and services received between adults who are publicly insured and those who are privately insured. How many state Medicaid programs with extensive dental coverage for adults pay for 2 examinations per year? And even if they do, why are so few beneficiaries availing themselves of these preventive services? Is provider network inadequacy contributing to these differences between the publicly and privately insured? Past research indicates that Medicaid reimbursement rates are, on average, less than one-half the private insurance rates for children’s services and even lower than that for private insurance for adult oral health care services.

In addition, private insurance payment rates tend to keep up with inflation whereas most Medicaid programs fail to do so.

Aspects of program design beyond coverage need to be studied, especially best practices for designing adequately funded and sustainable programs that promote provider participation and appropriate beneficiary use.

Our results suggest it is time to have a policy debate about how oral health care for adults is funded through public programs and what lessons can be learned from the EPSDT experience. EPDST is nearly 50 years old, and there is considerable evidence that income and race disparities in childrens oral health care have been narrowing steadily during this time frame.

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Is it time to consider an EPSDT-like benefit for adults? This is an important policy discussion, and given the newfound–and overdue–focus on disparities and inequities in health care, it is time to have it.

To our knowledge, this is the first comprehensive analysis based on detailed dental claims data comparing the mix of oral health care services for people with public and private benefits. Our analysis shows that the procedure mix for children with public benefits was comparable to the mix for those with private benefits. For adults, however, there were substantial differences. Namely, the procedure mix for publicly insured working-age adult and older adults skewed more toward invasive surgical services, whereas the procedure mix for those with private insurance had more routine preventive services. Our findings are consistent with the limited evidence available based on self-reported public surveys.

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In essence, public benefits programs for adults are financing downstream by paying for invasive treatment of dental disease for adults rather than preventive treatments that may avert such disease in the first place. This is true even in states with extensive dental benefits for adults enrolled in their Medicaid programs. Future studies should explore aspects of public dental program design–beyond coverage policies–that promote access to care and reduce oral disease, such as building sufficient provider networks and ensuring Medicaid programs are adequately funded.