Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011) / Chapter Skim
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5 Expenditures and Financing for Oral Health Care
5 Expenditures and Financing for Oral Health Care
Pages 193-228
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From page 193... ...
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.
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In 2009, overall health expenditures were $2.5 trillion, including the cost of hospital care, physician and dental services, home health care, nursing home services, prescription drugs, medical equipment and supplies, and public health direct services (CMS, 2010b)
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. In 2007, the source of payments for dental care (e.g., private insurance, out-of-pocket, or public insurance)
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For example, the percentage of annual dental expenses paid out of pocket varied by age, race and ethnicity, income, and insurance status (see Figure 5-2)
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. By contrast, children, who are more likely to have public insurance that includes dental coverage, had the lowest percent of total annual dental expenses paid out of pocket than any other age group (23 percent)
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Dental benefits 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.
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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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Finally, the Public Policy Options committee concluded that "welldesigned 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)
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In 2006, 56 percent of all employers offered health insurance but only 35 percent offered dental coverage (Manski and Cooper, 2010)
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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.
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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)
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. As described in Chapter 3, state Medicaid programs are increasingly electing to reimburse primary medical care providers and dental hygienists for preventive oral health services, including the application of fluoride varnish, performing oral examinations, and providing anticipatory guidance (AAP, 2010; ADHA, 2010)
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The Children's Health Insurance Program Reauthorization Act (CHIPRA) enacted in February 2009 requires all states to provide dental coverage under CHIP, including "coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions."1 States can meet this requirement in separate CHIP programs by providing dental coverage equivalent to one of three benchmark dental benefit packages: (1)
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adults and children who lack dental coverage. Furthermore, final negotiated rates depend on individual agreements; the larger the size of the insurer, the deeper discounts they may be able to negotiate.
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Efforts to improve access through financing strategies will necessarily be multifaceted and will be one component of broader efforts to improve access. For example, studies have demonstrated that increasing reimbursement rates alone is not sufficient in improving access to care.
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208 Medicaid Medicaid Reimbursement Rates Median Reimbursement $18.00 Median Retail Fees Retail Fees Rates $33.00 Alabama $33.00 $18.00 Alaska $46.00 $38.50 Arizona $35.00 $29.50 Arkansas $32.00 $26.60 California $46.00 $15.00 Colorado $35.00 $20.80 Connecticut $37.00 $35.00 No data Delaware $35.00 recorded * District of Columbia $35.00 $35.00 Florida $35.00 $15.00 Georgia $35.00 $22.77 Hawaii $46.00 $29.12 Idaho $35.00 $17.76 Illinois $36.00 $28.00 Indiana $36.00 $22.58 Iowa $35.00 $16.63 Kansas $35.00 $21.00 Kentucky $33.00 *
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New Hampshire $37.00 $29.00 New Jersey $35.00 $37.00 New Mexico $35.00 $22.97 New York $35.00 $29.00 North Carolina $35.00 $27.01 North Dakota $35.00 $24.10 Ohio $36.00 $17.08 Oklahoma $32.00 $23.50 Oregon $46.00 $24.07 Pennsylvania $35.00 $20.00 Rhode Island $37.00 $10.00 South Carolina $35.00 $23.40 South Dakota $35.00 $34.00 Tennessee $33.00 $25.00 Texas $32.00 $29.44 Utah $35.00 $17.55 Vermont $37.00 $20.00 Virginia $35.00 $20.15 Washington $46.00 $22.44 West Virginia $35.00 $20.00 Wisconsin $36.00 $15.92 Wyoming $35.00 $32.00 $0 $5 $10 $15 $20 $25 $30 $35 $40 $45 $50 FIGURE 5-6 Median retail fees and Medicaid reimbursement rates for children's periodic oral evaluation, by state. SOURCE: Used with permission by the National Health Policy Forum, from "Oral Health Checkup: Progress in Tough Fiscal Times?
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The Centers for Medicare and Medicaid Services (CMS) has approved dental coverage in special situations that relate directly to medical needs.
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Table 5-2 provides an overview of additional public investments in oral health. Maternal and Child Health Block Grant Program Title V of the Social Security Act is a permanently authorized discretionary grant program that is viewed as a part of the oral health safety net for uninsured and underinsured women and children, including pregnant women and children with special health care needs.4 Title V authorized the creation of the Maternal and Child Health (MCH)
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Maternal and Child Health Services Block Grants (Title V) Bureau of Health Professions (BrHP)
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Early Intervention for Oral Health Programs Administration for Children and Families (ACF) Head Start Oral Health Initiative SOURCES: CDC, 2011a,b,c; Center for Oral Health, 2010; CMS, 2011a; HHS/ACF/OHS, 2011; HRSA, 2011d.
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For example, states that deem oral health as a priority have an existing source of annual funding from which to build. On the other hand, MCH block grants are a limited source of federal funds, and states may prioritize other critical maternal and child health issues over oral health.
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included numerous provisions to expand dental coverage, increase the number of oral health care professionals, and invest in oral health prevention and public health activities. Box 5-3 highlights key provisions of the ACA specifically related to dental coverage and the financing of oral health care.
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to participate in the Health Insurance Exchange. Dental Coverage in Medicare Advantage -- Requires Medicare Advan tage Plans to use rebates to pay for dental coverage and other services.
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Grants for School-based Dental Sealant Programs -- Requires that all states, territories, and Indian tribes receive grants for school-based dental sealant programs. Cooperative Agreements to Improve Oral Health Infrastructure -- Re quires the CDC to enter into cooperative agreements with states, ter ritories, and Indian tribes to improve public health infrastructure related to oral health.
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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 reimbursement is $1.75 million.
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, 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.
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, 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 additional services (such as cleanings or periodontal maintenance every 3 months) at no additional cost, based on their condition.
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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.
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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)
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2010a. Medicare dental coverage: Overview.
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Initiative: Interim results from a program to increase children's access to dental care. Journal of Rural Health 19(5)
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2005. Factors associated with comprehensive dental care following an initial emergency dental visit.
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2007. Dental use, expenses, private dental coverage, and changes, 1996 and 2004.
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2008. Dental coverage and care for low-income children: The role of Medicaid and SCHIP.
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2007. Effects of the State Children's Health Insurance Program on access to dental care and use of dental services.
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