At the Intersection of Health, Health Care and Policy Cite this article as: Astha Singhal, Daniel J. Caplan, Michael P. Jones, Elizabeth T. Momany, Raymond A. Kuthy, Christopher T. Buresh, Robert Isman and Peter C. Damiano Eliminating Medicaid Adult Dental Coverage In California Led To Increased Dental Emergency Visits And Associated Costs Health Affairs, 34, no.5 (2015):749-756 doi: 10.1377/hlthaff.2014.1358
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/34/5/749.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
Access To Care By Astha Singhal, Daniel J. Caplan, Michael P. Jones, Elizabeth T. Momany, Raymond A. Kuthy, Christopher T. Buresh, Robert Isman, and Peter C. Damiano
10.1377/hlthaff.2014.1358 HEALTH AFFAIRS 34, NO. 5 (2015): 749–756 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Eliminating Medicaid Adult Dental Coverage In California Led To Increased Dental Emergency Visits And Associated Costs
Astha Singhal (asthasinghal@ gmail.com) is a PhD candidate in the Department of Preventive and Community Dentistry, College of Dentistry, and a research assistant at the Public Policy Center, both at the University of Iowa, in Iowa City.
Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006–11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations. ABSTRACT
O
ral health is an integral part of overall health because it has a significant impact on systemic health, quality of life, and economic productivity.1–3 Regular access to dental care is a basic factor in achieving and maintaining oral health. However, poor Americans, especially adults, face several barriers to dental care.4,5 Recent literature points to the worsening oral health status of the uninsured and Medicaid enrollees and to their declining access to dental care.4,5 Several initiatives to improve access to dental care have focused on children.6 The Affordable Care Act (ACA), for instance, includes pediatric dental benefits as a part of essential health benefits. This means that these benefits must be
Daniel J. Caplan is a professor and department executive officer in the Department of Preventive and Community Dentistry, College of Dentistry, at the University of Iowa. Michael P. Jones is a professor in the Department of Biostatistics, College of Public Health, at the University of Iowa. Elizabeth T. Momany is an associate research scientist at the Public Policy Center, University of Iowa.
covered by certain insurance plans, starting in 2014. However, dental care for adults has been largely overlooked by the ACA.7,8 State Medicaid programs also are required by law to provide dental coverage for children under the Early and Periodic Screening, Diagnosis, and Treatment program.6,9 However, states can elect not to cover dental benefits for adult enrollees.6,9 Only twelve states’ Medicaid programs provide comprehensive dental coverage for adults.6,10 Moreover, when faced with financial challenges during the recession of 2007–09, many states limited or completely eliminated Medicaid adult dental benefits.7,11,12 Hospital emergency departments (EDs) fill the role of a safety-net provider by attending to people who cannot obtain care, including denMay 2 015
34:5
Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
Raymond A. Kuthy is a professor in the Department of Preventive and Community Dentistry, College of Dentistry, at the University of Iowa. Christopher T. Buresh is an associate professor in the Department of Emergency Medicine, College of Medicine, at the University of Iowa. Robert Isman is a dental program consultant in the Medi-Cal Dental Services Division of the California Department of Health Care Services, in Sacramento.
Health Affa irs
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Access To Care
Peter C. Damiano is a professor in the Department of Preventive and Community Dentistry, College of Dentistry, and director of the Public Policy Center, both at the University of Iowa.
750
tal care, in traditional primary care settings. However, hospital EDs and emergency personnel are generally not equipped or trained to diagnose and treat dental diseases effectively. As a result, the vast majority of patients who visit an ED with a dental problem do not receive definitive dental treatment. Instead, they receive only prescriptions for painkillers, antibiotics, or both.13–15 Despite not providing definitive dental care, ED visits for dental problems are very expensive and, in the case of Medicaid enrollees, add to the state’s Medicaid expenditures.13–16 Hence, the original intent of reducing state Medicaid expenditures by limiting adult dental benefits could be partially counteracted by the additional expenses associated with increased ED visits for dental problems. Previous studies have examined the impact of limiting Medicaid adult dental benefits on rates of dental visits, as well as on the use of nontraditional sources of care. After Maryland eliminated Medicaid adult dental coverage in 1993, a statewide analysis revealed a 12 percent increase in the rate of ED visits for dental problems.17,18 Similarly, Massachusetts limited Medicaid dental coverage in 2002, which was followed by a decrease in the number of enrollees visiting a dentist and a decrease in the number of dentists participating in the Medicaid program.19 Oregon also eliminated Medicaid dental benefits for its adult expansion population in 2003, but it retained dental coverage for enrollees who met the traditional income-based federal statutory eligibility criteria.20 This policy change in Oregon provided a natural experiment with a concurrent control group. After the policy change, the group that lost dental benefits had a doubling of dental ED visits and associated expenditures and three times the odds of having an unmet dental need, relative to the group that retained dental benefits.20 Separately, a national analysis estimated that if a state provides adult dental coverage under Medicaid, the probability of its enrollees’ having an annual dental visit is 16–22 percent greater than that for enrollees in a state that does not provide dental coverage.21 In July 2009 the California Medicaid program eliminated coverage of comprehensive dental services for adult enrollees.22 All adult dental benefits were eliminated except the federally required adult dental services—which consist mainly of emergency dental procedures, such as extractions—and allowable dental procedures for pregnant women and people residing in longterm care facilities.22 This left more than three million low-income adult enrollees in California without dental coverage through Medicaid.
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May 2 015
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A qualitative study reported that the policy change led to excessive burden from Medicaid adults seeking emergency dental care on dental safety-net providers—mainly private providers and county health departments—relative to their capacity. The providers strongly supported restoration of the dental benefits.23 Effective May 1, 2014, California restored partial dental benefits for adult enrollees in Medicaid, including preventive care, restorations, endodontic treatment for anterior teeth, and full dentures.24 Most studies that have examined the impact of changing coverage policies for Medicaid adult dental benefits used a simple before-and-after comparison approach, which could lead to ambiguous results.25,26 For instance, because dental ED visits are increasing nationally,5,27–30 even if a before-after comparison demonstrates an increase in dental ED visits, that increase may not be attributable to the state-specific policy change. Hence, we used an interrupted time-series analysis, one of the strongest quasi-experimental approaches,25 to examine the impact of the elimination of Medicaid adult dental coverage on ED use in California, while controlling for secular trends.We compared the costs associated with dental ED visits and Medicaid savings from dental coverage cuts, to provide an economic context to our results. We also examined whether the impact of this policy change differed across subpopulations within adult enrollees in California Medicaid.
Study Data And Methods Data Source We used data from the State Emergency Department Databases, which capture all visits to hospital-affiliated EDs that do not result in a hospital admission. The databases are part of the Healthcare Cost and Utilization Project, which was developed through a federal-stateindustry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ). Data for California were obtained from AHRQ for six years, from 2006 to 2011. Medicaid enrollment and reimbursement data were obtained from the California Department of Health Care Services. Study Design We used an interrupted timeseries study design with control outcome variables. Interrupted time series consist of a string of equally spaced observations interrupted by an intervention. This design is robust despite the lack of randomization, because multiple pre- and post-intervention observations allow the detection of and accounting for time trends that are unrelated to the intervention. Control outcomes are outcomes that are ex-
Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
pected not to be affected by the intervention under examination but that would be affected by secular changes, such as an economic recession. Using control outcomes allowed us to minimize threats to internal validity, such as history and maturation—that is, extraneous events and changes over time that could affect our results.31,32 Study Population And Variable The target population of this study consisted of people age twenty-one or older who were enrolled in Medicaid as “Medi-Cal certified eligibles”33 at any time during the study period (2006–11). The main outcome variable was the number of ED visits per month with a primary diagnosis of dental disease per 100,000 Medicaid adult enrollees. The main explanatory factor was the policy change of the elimination of Medicaid adult dental coverage in July 2009 (the forty-third month of our observations). The control outcome variables were rates of ED visits per month per 100,000 enrollees with a primary diagnosis of one of the following ambulatory care–sensitive conditions: asthma, headache, abdominal pain, diabetes, and back pain. ED visits due to dental problems or control outcome conditions were identified using the primary diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes listed in online Appendix Exhibit 1.34 Ambulatory care–sensitive conditions were chosen as control outcomes on the assumption that, similar to patients with dental problems, patients suffering from these ideally should not be seen in the ED. Asthma has been used as a comparison condition in the past when examining trends in dental ED visits over time.30 Using several comparison conditions helped ensure that there were no global changes in Medicaid policy or in the health care environment in California that would have affected ED visits for multiple health conditions. Analytic Methodology Segmented linear regression was used to examine whether the policy change led to a change in the intercept or slope of the rate of ED visits for dental problems or other control outcome variables, when the dental coverage was eliminated. An intercept change would indicate an immediate impact. A slope change after the policy change would indicate a gradual impact on the rate of ED visits. Segmented linear regression was also used to examine whether the policy had differential effects on subgroups of Medicaid adult enrollees based on patient age, sex, race/ethnicity, and location. Models were tested for the presence of seasonality, autocorrelation, and a structural break. They were appropriately adjusted, as described in the Appendix.34
Statistical significance was set at p
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/34/5/749.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2015 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
Access To Care By Astha Singhal, Daniel J. Caplan, Michael P. Jones, Elizabeth T. Momany, Raymond A. Kuthy, Christopher T. Buresh, Robert Isman, and Peter C. Damiano
10.1377/hlthaff.2014.1358 HEALTH AFFAIRS 34, NO. 5 (2015): 749–756 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Eliminating Medicaid Adult Dental Coverage In California Led To Increased Dental Emergency Visits And Associated Costs
Astha Singhal (asthasinghal@ gmail.com) is a PhD candidate in the Department of Preventive and Community Dentistry, College of Dentistry, and a research assistant at the Public Policy Center, both at the University of Iowa, in Iowa City.
Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006–11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations. ABSTRACT
O
ral health is an integral part of overall health because it has a significant impact on systemic health, quality of life, and economic productivity.1–3 Regular access to dental care is a basic factor in achieving and maintaining oral health. However, poor Americans, especially adults, face several barriers to dental care.4,5 Recent literature points to the worsening oral health status of the uninsured and Medicaid enrollees and to their declining access to dental care.4,5 Several initiatives to improve access to dental care have focused on children.6 The Affordable Care Act (ACA), for instance, includes pediatric dental benefits as a part of essential health benefits. This means that these benefits must be
Daniel J. Caplan is a professor and department executive officer in the Department of Preventive and Community Dentistry, College of Dentistry, at the University of Iowa. Michael P. Jones is a professor in the Department of Biostatistics, College of Public Health, at the University of Iowa. Elizabeth T. Momany is an associate research scientist at the Public Policy Center, University of Iowa.
covered by certain insurance plans, starting in 2014. However, dental care for adults has been largely overlooked by the ACA.7,8 State Medicaid programs also are required by law to provide dental coverage for children under the Early and Periodic Screening, Diagnosis, and Treatment program.6,9 However, states can elect not to cover dental benefits for adult enrollees.6,9 Only twelve states’ Medicaid programs provide comprehensive dental coverage for adults.6,10 Moreover, when faced with financial challenges during the recession of 2007–09, many states limited or completely eliminated Medicaid adult dental benefits.7,11,12 Hospital emergency departments (EDs) fill the role of a safety-net provider by attending to people who cannot obtain care, including denMay 2 015
34:5
Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
Raymond A. Kuthy is a professor in the Department of Preventive and Community Dentistry, College of Dentistry, at the University of Iowa. Christopher T. Buresh is an associate professor in the Department of Emergency Medicine, College of Medicine, at the University of Iowa. Robert Isman is a dental program consultant in the Medi-Cal Dental Services Division of the California Department of Health Care Services, in Sacramento.
Health Affa irs
74 9
Access To Care
Peter C. Damiano is a professor in the Department of Preventive and Community Dentistry, College of Dentistry, and director of the Public Policy Center, both at the University of Iowa.
750
tal care, in traditional primary care settings. However, hospital EDs and emergency personnel are generally not equipped or trained to diagnose and treat dental diseases effectively. As a result, the vast majority of patients who visit an ED with a dental problem do not receive definitive dental treatment. Instead, they receive only prescriptions for painkillers, antibiotics, or both.13–15 Despite not providing definitive dental care, ED visits for dental problems are very expensive and, in the case of Medicaid enrollees, add to the state’s Medicaid expenditures.13–16 Hence, the original intent of reducing state Medicaid expenditures by limiting adult dental benefits could be partially counteracted by the additional expenses associated with increased ED visits for dental problems. Previous studies have examined the impact of limiting Medicaid adult dental benefits on rates of dental visits, as well as on the use of nontraditional sources of care. After Maryland eliminated Medicaid adult dental coverage in 1993, a statewide analysis revealed a 12 percent increase in the rate of ED visits for dental problems.17,18 Similarly, Massachusetts limited Medicaid dental coverage in 2002, which was followed by a decrease in the number of enrollees visiting a dentist and a decrease in the number of dentists participating in the Medicaid program.19 Oregon also eliminated Medicaid dental benefits for its adult expansion population in 2003, but it retained dental coverage for enrollees who met the traditional income-based federal statutory eligibility criteria.20 This policy change in Oregon provided a natural experiment with a concurrent control group. After the policy change, the group that lost dental benefits had a doubling of dental ED visits and associated expenditures and three times the odds of having an unmet dental need, relative to the group that retained dental benefits.20 Separately, a national analysis estimated that if a state provides adult dental coverage under Medicaid, the probability of its enrollees’ having an annual dental visit is 16–22 percent greater than that for enrollees in a state that does not provide dental coverage.21 In July 2009 the California Medicaid program eliminated coverage of comprehensive dental services for adult enrollees.22 All adult dental benefits were eliminated except the federally required adult dental services—which consist mainly of emergency dental procedures, such as extractions—and allowable dental procedures for pregnant women and people residing in longterm care facilities.22 This left more than three million low-income adult enrollees in California without dental coverage through Medicaid.
Health A ffairs
May 2 015
34:5
A qualitative study reported that the policy change led to excessive burden from Medicaid adults seeking emergency dental care on dental safety-net providers—mainly private providers and county health departments—relative to their capacity. The providers strongly supported restoration of the dental benefits.23 Effective May 1, 2014, California restored partial dental benefits for adult enrollees in Medicaid, including preventive care, restorations, endodontic treatment for anterior teeth, and full dentures.24 Most studies that have examined the impact of changing coverage policies for Medicaid adult dental benefits used a simple before-and-after comparison approach, which could lead to ambiguous results.25,26 For instance, because dental ED visits are increasing nationally,5,27–30 even if a before-after comparison demonstrates an increase in dental ED visits, that increase may not be attributable to the state-specific policy change. Hence, we used an interrupted time-series analysis, one of the strongest quasi-experimental approaches,25 to examine the impact of the elimination of Medicaid adult dental coverage on ED use in California, while controlling for secular trends.We compared the costs associated with dental ED visits and Medicaid savings from dental coverage cuts, to provide an economic context to our results. We also examined whether the impact of this policy change differed across subpopulations within adult enrollees in California Medicaid.
Study Data And Methods Data Source We used data from the State Emergency Department Databases, which capture all visits to hospital-affiliated EDs that do not result in a hospital admission. The databases are part of the Healthcare Cost and Utilization Project, which was developed through a federal-stateindustry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ). Data for California were obtained from AHRQ for six years, from 2006 to 2011. Medicaid enrollment and reimbursement data were obtained from the California Department of Health Care Services. Study Design We used an interrupted timeseries study design with control outcome variables. Interrupted time series consist of a string of equally spaced observations interrupted by an intervention. This design is robust despite the lack of randomization, because multiple pre- and post-intervention observations allow the detection of and accounting for time trends that are unrelated to the intervention. Control outcomes are outcomes that are ex-
Downloaded from content.healthaffairs.org by Health Affairs on June 1, 2015 at NYU LANGONE MED CTR SCHOOL OF MEDICINE
pected not to be affected by the intervention under examination but that would be affected by secular changes, such as an economic recession. Using control outcomes allowed us to minimize threats to internal validity, such as history and maturation—that is, extraneous events and changes over time that could affect our results.31,32 Study Population And Variable The target population of this study consisted of people age twenty-one or older who were enrolled in Medicaid as “Medi-Cal certified eligibles”33 at any time during the study period (2006–11). The main outcome variable was the number of ED visits per month with a primary diagnosis of dental disease per 100,000 Medicaid adult enrollees. The main explanatory factor was the policy change of the elimination of Medicaid adult dental coverage in July 2009 (the forty-third month of our observations). The control outcome variables were rates of ED visits per month per 100,000 enrollees with a primary diagnosis of one of the following ambulatory care–sensitive conditions: asthma, headache, abdominal pain, diabetes, and back pain. ED visits due to dental problems or control outcome conditions were identified using the primary diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes listed in online Appendix Exhibit 1.34 Ambulatory care–sensitive conditions were chosen as control outcomes on the assumption that, similar to patients with dental problems, patients suffering from these ideally should not be seen in the ED. Asthma has been used as a comparison condition in the past when examining trends in dental ED visits over time.30 Using several comparison conditions helped ensure that there were no global changes in Medicaid policy or in the health care environment in California that would have affected ED visits for multiple health conditions. Analytic Methodology Segmented linear regression was used to examine whether the policy change led to a change in the intercept or slope of the rate of ED visits for dental problems or other control outcome variables, when the dental coverage was eliminated. An intercept change would indicate an immediate impact. A slope change after the policy change would indicate a gradual impact on the rate of ED visits. Segmented linear regression was also used to examine whether the policy had differential effects on subgroups of Medicaid adult enrollees based on patient age, sex, race/ethnicity, and location. Models were tested for the presence of seasonality, autocorrelation, and a structural break. They were appropriately adjusted, as described in the Appendix.34
Statistical significance was set at p
