Medicaid Dental Coverage Alone May Not Lower Rates of Dental Emergency Department Visits

Transcription

1 Medicaid Dental Coverage Alone May Not Lower Rates of Dental Emergency Department Visits Katie Fingar (Truven), Mark Smith (Truven), Sheryl Davies (Stanford), Kathryn MacDonald (Stanford), Carol Stocks (AHRQ), and Maria Raven (UCSF) UCSF Dental Seminar March 1, 2016

2 Acknowledgements Funding for this study came from the Agency for Healthcare Research and Quality. The views expressed herein are those of the authors and do not necessarily reflect those of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. We thank team members and federal agency staff for developing and testing conceptual models, indicators, and supporting materials for the ED Prevention Quality Indicators Agency for Healthcare Research and Quality (AHRQ): Pam Owens Carol Stocks Stanford University: Karey Shuhendler Eric Schmidt Ewen Wang Kit Delgado Ellen Schultz Lauren Riendeau Truven Health Analytics: Audrey Weiss Rosanna Coffey Bob Houchens. Marguerite Barrett (ML Barrett, Inc) Various internal expert, stakeholder, and validation panels who participated in the project We also thank Nils Nordstrand of Truven Health Analytics for analyzing the data for this sub-study, and the HCUP Partner Organizations that participated in the SEDD and SID: 2

3 BACKGROUND

4 Background Dental ED visits are rising faster than ED visits overall 1 Increased 41% from in the U.S. ED visits for all conditions rose by only 13% EDs not designed to provide definitive care for dental conditions Treat acute issues including pain and infection Over 90% of dental ED visits are later treated by a dentist 2 Rise in dental ED visits may indicate decreased access to office-based dental care Access is shaped by a number of factors including: Dental insurance coverage Dental provider supply 4

5 Dental Coverage Individuals with private insurance through employer: <40% participate in employer-sponsored dental insurance plans 3 Adults with Medicaid: Expanded coverage Dental coverage is left to each State s discretion Some States cut Medicaid dental benefits during the Recession In 2012, <50% of States provided expanded dental coverage to nondisabled, non-pregnant adults 4 No coverage Emergency coverage (e.g., extractions of diseased teeth) Limited coverage (e.g., diagnostic, preventive, and minor restorative services such as x-rays and minor fillings) Comprehensive coverage (e.g., major restorative services such as root canals and dentures) 5

6 Dental Provider Supply As of 2013, 45 million Americans were living in an area with a shortage of dental care providers 5 Particularly in rural areas 6 Dental supply is expected to decrease further as dentists retire 7 Even if Medicaid provides expanded dental coverage, most dentists do not accept Medicaid coverage The percentage of dentists who accept Medicaid has been reported to be as low as: 8 11% in Missouri 15% in Florida 20% in New York 6

7 Specific Aims Investigate the association between Medicaid dental coverage, the supply of dental providers, and use of the ED for dental conditions Examine rates of non-traumatic dental ED visits separately for Medicaid enrollees and patients with other types of or no health insurance 7

8 METHODS

9 Data Sources Healthcare Cost and Utilization Project (HCUP) 2010 State Emergency Department Databases (SEDD) 1,794 counties in 29 States Treat-and-release visits for non-traumatic dental conditions among adults aged years identified using the beta version of the ED Prevention Quality Indicator software Includes: conditions like dental caries, tooth pain, and gingivitis Excludes: conditions like wounds and broken teeth Area Health Resources Files (AHRF) Number of Medicaid enrollees by county Other county-level control variables Dental coverage through State Medicaid program from publicly available sources 3,9 9

10 Primary Dependent Variable Rate of non-traumatic dental ED visits in county Medicaid-funded rate: Numerator: Number of adult non-traumatic dental ED visits with Medicaid as the first-listed expected payer Denominator: Number of adult Medicaid enrollees in 2008, adjusted to 2010 Non-Medicaid-funded rate: Numerator: number of adult non-traumatic dental ED visits with any first-listed expected payer other than Medicaid Denominator: Census population count of adults in 2010, minus the number of adult Medicaid enrollees derived above 10

11 Primary Independent Variable Dental provider density Number of professionally active dentists per 10,000 population Dental health professional shortage areas (HPSAs) Whole-county HPSA, if all of the following are true: It is a rational area for the delivery of dental services The ratio of population to full-time-equivalent dentists is at least 5,000:1 (4,000:1 in areas with an unusual need for services) Dental services in contiguous counties are overused, distant, or inaccessible Partial HPSA If a population within the county has access barriers 11

12 Other Independent Variables Percentage of county residents: With a household income below the Federal Poverty Level With Medicaid Who were minorities (race/ethnic groups except non-hispanic Whites) Without health insurance Number of EDs in the county per 100,000 population Urban (metropolitan or micropolitan) or rural (non-core) status Census region 12

13 Analysis Multivariate Poisson regression Exp(β) can be interpreted as a rate ratio (RR) For dental provider density, the RR was calculated as the change in the rate associated with increasing the number of dentists by two per 10,000 population Separate models for: Medicaid and non-medicaid outcomes Urban and rural counties 13

14 RESULTS

15 2.1% of all ED visits were for dental conditions; most had no health insurance or Medicaid Figure 1. Percentage of ED visits for non-traumatic dental conditions among adults aged 20 64, by first-listed expected payer, 2010 Medicare 5.9% Other 3.8% Private insurance 16.7% Medically uninsured 42.9% Medicaid 30.8% N=876,040 dental ED visits (2.1% of all ED visits) 15

16 Most dental ED visits by patients with Medicaid were in urban counties and dental shortage areas Figure 2. Percentage of ED visits for non-traumatic dental conditions among patients with Medicaid aged years, by location and dental HPSA designation, 2010 Whole county dental HPSA 17.3% Rural 7.3% Urban 92.7% Partial county dental HPSA 68.8% Nonshortage area 13.9% Location N=269,885 dental ED visits by patients with Medicaid Dental HPSA 16

17 Dental provider density was higher in urban counties and counties in States with expanded dental coverage through Medicaid Figure 3. Mean dental provider density, by State Medicaid dental coverage and location, Mean Dental Provider Density (per 10,000 residents) Urban counties (N=1,056) Rural counties (N=738) Location Emergency only or no dental coverage (N=722) Expanded dental coverage (N=1,072) Dental Coverage through Medicaid 17

18 Rates of dental ED visits by patients with Medicaid were higher in counties without expanded coverage Figure 4. Mean rate of dental ED visits paid by Medicaid, by State Medicaid dental coverage and location, Emergency only or no coverage 22.0* Expanded coverage Mean Medicaid- Funded Rate of Dental ED Visits (per 100,000 enrollees) * Urban Location Rural *P-value testing difference between mean in counties with expanded coverage <

19 In rural counties with expanded coverage, the rate of Medicaid dental ED visits decreased as dental provider density increased Figure 5. Mean rate of dental ED visits paid by Medicaid across levels of dental provider density, by State Medicaid dental coverage and location, * 23.9* 23.3* Mean Medicaid- Funded Rate of Dental ED Visits (per 100,000 enrollees) * * 13.1* 12.3* Quartile 1 (lowest) Quartile 2 Quartile 3 Dental provider density Quartile 4 (highest) 5 0 Emergency only or no coverage Urban Expanded coverage Emergency only or no coverage Rural Expanded coverage *P-value testing difference between mean in counties with the highest dental provider density (quartile 4). 19

20 Expanded coverage was not associated with lower rates of dental ED visits in areas with more dentists Figure 6. Mean rate of dental ED visits paid by Medicaid across levels of dental provider density, by State Medicaid dental coverage and location, Emergency only or no coverage Expanded coverage * 24.3* 23.3 Mean Medicaid- Funded Rate of Dental ED Visits (per 100,000 enrollees) * Quartile 1 (lowest) Quartile 2 Quartile 3 Quartile 4 (highest) Quartile of Dental Provider Density Quartile 1 (lowest) Quartile 2 Quartile 3 Quartile 4 (highest) Quartile of Dental Provider Density Urban Rural *P-value testing difference between mean in counties with expanded dental coverage through Medicaid. 20

21 In rural counties, higher dental provider density was associated with reduced rates dental ED visits by patients with Medicaid Table 1. Associations between Medicaid Dental Coverage, Dental Provider Density, and Rates of Dental ED Visits Paid by Medicaid from Multivariate Regression Models Independent Variable All Counties Dental provider density 0.96 ( ) Expanded dental coverage 0.77 ( ) Urban location 1.38 ( ) Rate Ratio (95% CI) Urban Counties 0.98 ( ) 0.75 ( ) N/A Rural Counties 0.89 ( ) 0.78 ( ) N/A Note: Models also controlled for percentage of residents that were minorities, in poverty, had Medicaid, were uninsured; the number of EDs in the county; and census region. 21

22 Non-Medicaid Models Dental provider density was not associated with fewer dental ED visits by non-medicaid patients 62 percent of these patients were uninsured 22

23 Sensitivity Analyses We could not compute standardized rates by payer AHRF did not contain counts of Medicaid enrollees by age or sex We computed age-sex standardized rates among all payers The results were similar to those using non-standardized rates We could not identify dental ED visits among patients dually enrolled in Medicaid and Medicare in most States Numerators exclude patients with Medicaid, if Medicare was listed first Denominators include dually enrolled individuals We re-ran our results including dually enrolled patients in the numerator for States with data on multiple payers The results were similar to the findings presented on previous slides 23

24 SUMMARY

25 Summary A larger supply of dentists was associated with reduced rates of dental ED visits by patients with Medicaid in rural counties There was no association in urban counties Over 90% of dental ED visits occurred in urban counties Rates of dental ED visits by patients with Medicaid were lower in counties with expanded dental coverage through the State Medicaid program Yet, this association was not significant after adjusting for other factors Approximately 8.3 million adults will be eligible for expanded dental coverage via the ACA Medicaid expansion 10 Without more dentists or alternative dental providers that will accept Medicaid this coverage expansion may not result in reduced ED use for dental conditions 25

26 Why might dental supply and coverage not lead to less ED use? Constraint in the supply of dentists who accept Medicaid Dentists in urban areas are less likely to accept Medicaid 11,12 Other service options for dental care, such as Federally Qualified Health Centers (FQHCs) 1,200 FQHCs in the U.S % of centers provide dental care, but many sites do not 14 FQHCs serve an estimated 16% of Medicaid population 15 Continued pattern of ED use despite having insurance, which has been observed for medical care 16 Difficulty reaching a provider during normal business hours 26

27 Approaches to reducing ED use for dental conditions Pilot programs have shown promise 17,18 Waived or reduced fees for low-income individuals Immediate referral to a dentist Tele-health Mid-level providers and trainees May prove challenging when implemented on a large scale, as these approaches involve charity care or grant funding May need to alter the way dental care is paid for and provided in U.S. Dental care must be viewed not as an optional add-on, but as an integral part of overall health 27

28 GROUP DISCUSSION

29 Media coverage and reader response Medicaid recipients continue to use ED for dental work, even with coverage 1 Oversimplification may lead some readers to think Medicaid coverage is not effective, when in fact it is a necessary first step Misses key point that most dentists don t accept Medicaid insurance However, coverage does not equal access 1. California HealthLine:

30 Reader response (continued) Given the cross-sectional nature, it is impossible to ascertain the temporal sequence and effect of Medicaid coverage of dental services and the provider availability on each other It is possible that provider availability (more accurately, density of dentists who accept Medicaid) is an intermediate variable on the causal path from Medicaid adult dental coverage policy to ED use for dental problems as outcome If we examine the impact of the policy on ED visits after adjusting for the variables through which such impact manifests, we can expect to not find significance, like the study did. Local dental resources after policy Existing local dental resources before policy (e.g., number of nearby dentists) State Medicaid policies Dental ED visits

31 References 1. Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to Am J Public Health. 2012;102(11):e Cohen LA, Bonito AJ, Eicheldinger C, Manski RJ, Macek MD, Edwards RR, et al. Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries. J Public Health Dent. 2011;71(1): McGuinn-Shapiro M. Medicaid coverage of adult dental services. State Health Policy Monitor [serial on the Internet]. Portland (ME): National Academy for State Health Policy; 2008 Oct [cited 2015 Jun 15]. Available from: 4. Henry J. Kaiser Family Foundation. Medicaid benefits: dental services [Internet]. Menlo Park (CA): KFF; [cited 2015 Jun 15]. Available from: 5. Health Resources and Services Administration. Designated Health Professional Shortage Areas (HPSA) statistics [Internet]. Rockville (MD): HRSA; 2013 Jan [cited 2015 Jun??]. Available from: 6. Skillman SM, Doescher MP, Mouradian WE, Brunson DK. The challenge to delivering oral health services in rural America. J Public Health Dent. 2010;70(Suppl 1):S American Dental Association. Distribution of dentists in the United States by region and state, 2009 [Internet]. Chicago (IL): ADA; 2011 Apr [cited 2015 Jun 15]. Available from: 8. Pew Charitable Trusts. In search of dental care: two types of dentist shortages limit children s access to care [Internet]. Philadelphia (PA): The Trusts; 2013 Jun [cited 2015 Jun 15]. (Issue Brief). Available from: 9. Henry J. Kaiser Family Foundation. Medicaid benefits: dental services [Internet]. Menlo Park (CA): KFF; [cited 2015 Jun 15]. Available from: Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion [Internet]. Chicago (IL): American Dental Association; 2014 Feb [cited 2015 Jun 15]. (Research Brief). Available from: Morris PJ, Freed JR, Nguyen A, Duperon DE, Freed BA, Dickmeyer J. Pediatric dentists participation in the California Medicaid program. Pediatr Dent. 2004;26(1): Lang PA, Weintraub JA. Comparison of Medicaid and non-medicaid dental providers. J Public Health Dent. 1986;46(4): Henry J. Kaiser Family Foundation. Number of Federally-Funded Federally Qualified Health Centers [Internet]. Menlo Park (CA): KFF; [cited 2015 Jun 17]. Available from: Jones E, Shi L, Hayashi AS, Sharma R, Daly C, Ngo-Metzger Q. Access to oral health care: the role of federally qualified health centers in addressing disparities and expanding access. Am J Public Health. 2013;103(3): Russell L. Federally qualified health centers: are they effective? [Internet]. Ann Arbor (MI): Center for Healthcare Research and Transformation; 2013 Jul 23 [cited 2015 Jun 15]. Available from: Long SK, Stockley K. Emergency department visits in Massachusetts: who uses emergency care and Why? [Internet]. Washington (DC): Urban Institute; 2009 Sep [cited 2015 Jun 15]. (Policy Brief). Available from: McCormick AP, Abubaker AO, Laskin DM, Gonzales MS, Garland S. Reducing the burden of dental patients on the busy hospital emergency department. J Oral Maxillofac Surg. 2013;71(3): Pew Charitable Trusts. Expanding the dental team: increasing access to care in public settings [Internet]. Philadelphia (PA): The Trusts; 2014 Jun [cited 2015 Jun 15]. Available from: 31

32 THANK YOU! QUESTIONS?