Access, Utilization & Cost Outcomes: Iowa Dental Wellness ... · Page 1 Return to TOC March 2017...

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March 2017Policy Report

University of Iowa Public Policy Center •209 South Quadrangle, Iowa City, IA 52242-1192 O - 319.335.6800 • F - 319.335.6801 • www.ppc.uiowa.edu

Susan McKernanAssistant Professor Preventive & Community Dentistry**

Elizabeth MomanyAssistant Director Health Policy Research Program Associate Research Scientist*

Aparna IngleshwarGraduate Research Assistant Health Policy Research Program*

Padmaja AyyagariAssistant Professor Health Management and Policy***

Astha SinghalAssistant Professor Department of Health Policy & Health Services Research****

Dan ShaneAssistant Professor Health Management and Policy***

Andrew GhattasGraduate Research Assistant Biostatistics*

Peter DamianoDirector* Professor, Preventive & Community Dentistry**

Access, Utilization & Cost Outcomes: Iowa Dental Wellness Plan Evaluation 2014-2016

* University of Iowa Public Policy Center** University of Iowa College of Dentistry and Dental Clinics*** University of Iowa College of Public Health**** Boston University Henry M.Goldman School of Dental Medicine

www.ppc.uiowa.edu

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ContentsMeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

EarnedBenefitStructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Provider Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Provider Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Healthy Behaviors Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Study Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Study Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

General Description of the Program . . . . . . . . . . . . . . . . . . . . . . . 12

Evaluation Plan Hypotheses and Measures . . . . . . . . . . . . . . . . . . 22

Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

EarnedBenefitStructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Member Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

AppendixA:TechnicalSpecifications . . . . . . . . . . . . . . . . . . . . . . . . 38

Appendix B: Linear and Logistic DID Results Predicting Annual (Any) Dental Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Appendix C: Linear and Logistic Regression Results Predicting Any Preventive or Diagnostic Service – . . . . . . . . . . . . . . . . . . . . . . 48

Appendix D: Effect of DWP Enrollment on Utilization of Dental Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Appendix E: Linear and Logistic Regression Results Predicting a Routine Oral Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

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MeasuresMeasure 1 Annual (any) dental visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Measure 6 First routine oral evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Measure 8 Any diagnostic or preventive dental service . . . . . . . . . . . . . . . . . . . . . .24

Measure 9 Use of ED for non-traumatic dental related treatment . . . . . . . . . . . . . . .25

Measure 12 People with diabetes: routine oral evaluation . . . . . . . . . . . . . . . . . . . . .27

Measure 21 Compare DWP member per member per month (PMPM) dental costs to those of MSP members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Measure 23 Routine oral evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Measure 37 Specialty dental utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

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FiguresFigure 1 Earned benefits through Iowa DWP . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Figure 2 Flow diagram of DWP members enrolled in May 1, 2014 tier movement by quarter May 2014 – April 2016 (n=112,983) . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Figure 3 Number of all DWP members by Tier for the first two program years . . . . . . . . . . . . . 16

Figure 4 DWP administrative denials of services by month . . . . . . . . . . . . . . . . . .21

Figure 5 Members with an annual dental visit by year . . . . . . . . . . . . . . . . . . . .22

Figure 6 Initial oral evaluations among members with ≥6 months of eligibility . . . .24

Figure 7 Members with any diagnostic or preventive service . . . . . . . . . . . . . . . .24

Figure 8 Routine oral evaluations among members with diabetes – ≥11 months of eligibility by year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Figure 9 PMPM month costs for IowaCare members, DWP members with DWP reimbursement and DWP members estimated Medicaid reimbursement . .29

Figure 10 Members who received a routine oral evaluation . . . . . . . . . . . . . . . . . .32

Figure 11 Percent of dental utilizers who received a routine oral evaluation . . . . . .33

Figure 12 Number of selected specialty services provided to DWP members in Years 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

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TablesTable 1 Member demographics by study year and program . . . . . . . . . . . . . . . .13

Table 2 Preventive services by tier and year of program . . . . . . . . . . . . . . . . . .18

Table 3 Diagnostic services by tier and year of program . . . . . . . . . . . . . . . . . . .18

Table 4 Treatment services by tier and year of program . . . . . . . . . . . . . . . . . . .19

Table 5 Rates of non-traumatic dental ED visits . . . . . . . . . . . . . . . . . . . . . . . .25

Table 6 Top 5 primary diagnosis codes for non-traumatic dental ED visits . . . . . .26

Table 7 Effect of DWP enrollment on ED visits for non-traumatic dental conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Table 8 Rates of follow-up dentist visits within 60 days after non-traumatic dental ED visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Table 9 Effect of DWP enrollment on utilization of routine oral evaluations among people with diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Table 10 Effect of DWP enrollment on cost of routine oral evaluations among people with diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Table 11 Incremental cost effectiveness ratios . . . . . . . . . . . . . . . . . . . . . . . . . .30

Table 12 Per member per month descriptive statistics . . . . . . . . . . . . . . . . . . . . .31

Table 13 Percent of members with specialty dental visits by study group and program year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Table 14 Percent of selected specialty services provided to DWP members by program year and tier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

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Executive SummaryThe Dental Wellness Plan (DWP) is the dental plan for members enrolled in the Iowa Health and Wellness Plan (IHAWP), Iowa’s version of the Medicaid expansion. The DWP was implemented on May 1, 2014 with a unique earned benefits structure intended to incentivize preventive dental care. Members are initially eligible for dental check ups and preventive care, large fillings when the decay is near the nerve, and emergency and stabilization services (Core benefits, or Tier 1), including emergency extractions and complete dentures, and they become eligible for additional covered services (Tiers 2 and 3) if they return at regular intervals for routine dental exams.

This report uses administrative data to evaluate some of the cost and utilization outcomes for the first two years of the DWP (May 2014 - April 2016). Outcomes for the DWP population are compared with adults in two traditional Medicaid State Plan (MSP) populations where appropriate: Family Medical Assistance program (FMAP) and Supplemental Security Income (SSI) to provide baseline comparisons and examine earned benefit structure effects. Analytic methods include descriptive, bivariate and multivariate comparisons. Difference-in-difference (DID) models, multivariate regression models, and incremental cost effectiveness ratios (ICERs) examine outcomes while controlling for differences between the DWP and MSP study groups.

The findings in this report are part of an evaluation of the DWP program being conducted by the University of Iowa Public Policy Center (PPC). This report is laid out to follow the DWP evaluation plan approved by the Iowa Medicaid Enterprise (IME) and the Centers for Medicare and Medicaid Services (CMS). It is one of a series of reports providing DWP evaluation results. Only new results are provided here. Links are provided to previous reports with results for hypotheses that have already been evaluated.

Key Findings

EnrollmentIn Year 1 of implementation, 193,941 unique individuals were enrolled at some point in the DWP program (on average, about 135,000 members in any given month). Overall there was a significant churn rate (i.e., members entering and leaving the program) during the first two years of the program. Almost half of the members who joined the DWP in May 2014 left the program within the first two years. We have no way of determining if they went on to receive other coverage or became uninsured.

Movement through the TiersVery few members matriculated through Tier 1 to reach Tier 2 or Tier 3. At the end of the second year, (April 2016) about 93% of DWP members remained in Tier 1; 3% of members were in Tier 2, and 4% were in Tier 3.

Access and UtilizationIn general, DWP members’ overall use of any dental services was low (about one in four had a dental visit) but comparable to rates seen in the MSP comparison groups. In multivariable modeling (DIDs) that adjusted for demographic characteristics and health conditions of the two populations, DWP members who were previously in the IowaCare program were found to be significantly more likely than MSP members to have had a routine oral evaluation (i.e., a dental check-up), a preventive dental visit, or a dental visit for any reason in the post-implementation period as compared to their use in the pre-implementation period. This is to be as expected given that these DWP members did not have dental coverage while in IowaCare during the pre-implementation period (Note: there were a relatively small number of IowaCare members who received emergency tooth extractions at the University of Iowa Hospital during the pre-implementation period). Modeling also suggests that the proportion of DWP members utilizing these services increases from Year 1 to Year 2, controlling for the demographics of the population.

ED UseRates of emergency department (ED) visits for non-traumatic dental conditions and routine dental exams were slightly higher in the Medicaid comparison group compared to DWP rates (approximately 15 vs. 11 per 1,000 months of eligibility, respectively). However, after adjusting for

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differences in the population characteristics, multivariable modeling found no significant differences between DWP and MSP groups in the likelihood of having an ED visit for non-traumatic dental conditions.

CostCost analyses examined average per person monthly costs in DWP compared to MSP by applying a common fee schedule (the MSP fee schedule) to services covered in each program and adjusted for the characteristics of the members in both programs. These analyses showed that isolating the effect of the earned benefit structure on costs lowers PMPM costs by nearly $5 per month. This difference is most likely due to: 1) the greater need for dental services for DWP members, even in Tier 1, and 2) the vast majority of DWP members who were ineligible for more complex dental care beyond emergency and stabilization services because they remained in Tier 1 the entire time they were in the program. These lower costs might be better considered costs “avoided” since many needed services (e.g., non emergent cavities) were never provided for the members who didn’t progress to Tier 2 and will remain a cost at some point in the future.

Earned Benefit StructureWith the earned benefits structure, it was hypothesized that rates of routine oral evaluations would be higher among DWP members. Overall, the DWP population had a rate of routine oral evaluations (20%) in between the rates seen for the FMAP and SSI Medicaid populations (16% and 22%, respectively). However, among members who had a dental visit during the year, rates of DWP members receiving an oral evaluation were slightly higher compared with MSP, which could be related to: 1) the DWP requirement for an oral evaluation in order to receive additional covered benefits, and/or, 2) the relationship that a patient makes with the dental office/staff after making an initial visit, and/or, 3) the pent-up demand for care and greater need for services among many in the DWP program.

Claims DenialsThe denial of claims submitted by dentists can be an indicator of both their knowledge of the DWP program and their ease with complying with the administrative aspects of the program. There were, on average, about 7000 claims denied by Delta Dental each month. Most of the denials seem to be related to a combination of: a) beginning a new program (i.e., documentation-related denials were the most frequent reason in year one), and b) potential misunderstanding of the earned benefits model (i.e., contractual limitations were the most frequent reason in year two).

ConclusionsThe DWP program has provided dental coverage for a large number of low income Iowa adults during its first two years. The DWP member population is very fluid, however, with half of the original members leaving within two years. This fluidity, in combination with low utilization of dental services overall, and a low rate of members receiving an oral evaluation in particular, makes the goal of the earned benefits model (i.e., more check-ups and preventive care to reduce future needs) challenging. Only a very small proportion of members ever make it to Tier 2 or Tier 3. The churn and low rates of utilization may help reduce near term program costs because few members become eligible for some of the more expensive services (e.g., crowns), however, it also leaves much oral disease untreated that could have been repaired with routine fillings to prevent more serious oral health problems and costs in the future (not necessarily to the DWP program).

Modeling analyses, controlling for the characteristics of the members in each program, indicated that the likelihood of a dental visit in the DWP population increased from Year 1 to Year 2, indicating that access to care in the DWP program improved over this time. Modeling analyses also indicated some modest costs were avoided for the DWP program, after controlling for the population characteristics of members in the DWP and MSP programs. The types of specialty services received by DWP members changed between Years 1 and 2; the number of complete dentures provided to members decreased by nearly 50%, while extractions decreased by 9%, indicating relief of pent-up demand for these services in the DWP population. Other services, including root canal therapy and restorations, or fillings, increased during Year 2, concomitant with increasing numbers of members becoming eligible for these benefits in Tiers 2 and 3. It should be remembered that, as mentioned, relatively few members matriculated from Tier 1 to Tier 2 or Tier 3 during the first two years of the program.

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BackgroundOn January 1, 2014 Iowa implemented the Iowa Health and Wellness Plan (IHAWP), which expanded health coverage for low income Iowans. IHAWP replaced the previous IowaCare program, offering more covered services and a broader provider network. IowaCare provided coverage for Iowans not categorically eligible for Medicaid through any other program or waiver and with incomes not exceeding 200% FPL. IowaCare did not provide coverage for dental care, except for emergencies with coverage limited to extractions at two locations in the state. An evaluation of the IowaCare program indicated that members had significant unmet need for dental care and poor oral status.1 This evaluation, in part, led to the establishment of the Dental Wellness Plan (DWP).

The DWP began offering dental benefits to members of the IHAWP program on May 1, 2014. This report evaluates dental outcomes from the first two years of the DWP program– May 2014 through April 2016. From May 2014 through July 2016, Delta Dental of Iowa was the sole dental carrier for the DWP. As of July 2016, MCNA Dental became the second carrier to join the DWP. Both dental carriers are required to offer the same benefits, however, each carrier maintains a separate network of dental providers.

EarnedBenefitStructure

The DWP has a unique earned benefits structure to encourage preventive health care-seeking behaviors mirroring the healthy behavior incentive program found in the IHAWP. Members qualify for additional covered services when they return for regular and periodic routine dental check ups. All members are eligible for Core benefits (Tier 1) upon enrollment, which includes preventive care, emergency and stabilization services. If members return for a routine dental check up within 6-12 months of an initial dental check up, they become eligible for Enhanced services (Tier 2). After receiving a second routine dental check up within 6-12 months of the first dental check up, members become eligible for Enhanced Plus services (Tier 3). Figure 1 shows dental services covered in each tier.

The DWP tiered benefit design was based on a policy theory that in offering an ability to earn “enhanced” benefits, members and their providers would better engage in how services should ideally be utilized, particularly the incentive to receive routine check-ups and cleanings in order to earn the ability to receive more services. The theory suggested this incentive for returing to the dental office for preventive care could lead to behavior changes that would move the population into a more prevention-oriented context over the course of time, resulting in improved outcomes and a favorable bend in the cost curve. Because of the expected pent-up demand for dental care in this population, however, it was determined that those in the first Tier of services should also receive “emergency” services to provide care for pain and infection, as well as “stabilization” services for problems that were very close to becoming a serious and potentially save money if they were cared for sooner (e.g., placing a filling in a large cavity near to the nerve in the tooth rather than do a root canal and crown later). As a result, some members in Tier 1 receive the same types of services (e.g., fillings) for emergency or stabilization purposes that might be expected to be covered in Tier 2.

Provider Incentives

The DWP also includes provider incentives. First, provider reimbursement is approximately 50% higher than Medicaid. Second, there are bonuses for participating DWP dentists that reward general dentists based on the number of exams performed on members and reward specialists based on the number of unique members seen. General dentists are only eligible for this bonus if they complete an annual clinical risk assessment and accompanying online form for each new patient; providers are also reimbursed on a fee-for-service basis for conducting each risk assessment.

1 Damiano P, Bentler S, Momany E. Evaluation of the IowaCare Program: Information about the Medical Home Expansion. June 2013. UI Public Policy Center. Available at: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1080&context=ppc_health. Last accessed December 29, 2016.

http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1080&context=ppc_health

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Figure1.EarnedbenefitsthroughIowaDWP

Core(atenrollment)• Diagnostic/Preventive• Emergency• Stabilization•Large restorationsnear pulp•Acuteperiodontal•Dentures•Endodonticcare(followingpulpaldebridementandexam)

Enhanced(Afterrecall in6-12mos.)• Restorative• Non-surgicalperiodontal• Endodonticcare

Enhancedplus(After2ndrecall in6-12mos.)• Crown• Toothreplacements• Periodontalsurgery

Provider Network

As of January 2015, the DWP provider network consisted of 646 active dentists, 549 (85%) of whom were general dentists and 97 (15%) were dental specialists.2 Slightly over half (n=49) of these dental specialists were affiliated with the University of Iowa, including all six participating endodontists. The mean county dentist-to-population ratio in DWP was 4.8 general dentists per 1000 members, with provider availability of general dentists ranging from 0 to 70.2 full-time equivalents (FTEs) per county. A total of 19 out of 99 counties did not have any general dentists in private practice accepting new DWP patients.

Healthy Behaviors Program

The IHAWP was established with a Healthy Behaviors incentive program, designed to encourage the receipt of preventive care, including preventive dental care. Originally, there were no charges to participate in the IHAWP program, including the DWP. Beginning in 2015, a monthly contribution began to be required, depending on family income. There are no copayments for health care services or prescriptions. As part of this new Healthy Behaviors Program, there are no charges to IHAWP members during the first year of enrollment. Beginning in the second year, members contribute up to $10 per month. Contributions are waived for individuals who fulfill two Healthy Behavior requirements: complete a Health Risk Assessment (available online, by phone, or at some provider offices) and receive either a preventive exam conducted by a physician or a routine dental check up from a dental provider.3

2 McKernan SC, Pooley M, Kuthy RA, Momany ET, Damiano PC. Iowa Dental Wellness Plan: Evaluation of Baseline Provider network. A Policy Brief. March 2015. UI Public Policy Center.. http://ppc.uiowa.edu/sites/default/files/dwp_provider_report.pdf. Last accessed December 29, 2016.

3 Iowa Department of Human Services. April 2015. Iowa Health and Wellness Plan Healthy Behaviors Program Toolkit for Providers. April 2015. https://dhs.iowa.gov/sites/default/files/ProviderHealthyBehaviorsToolkit_April2015.pdf. Last accessed: December 29, 2016.

http://ppc.uiowa.edu/sites/default/files/dwp_provider_report.pdf

http://ppc.uiowa.edu/sites/default/files/dwp_provider_report.pdf

https://dhs.iowa.gov/sites/default/files/ProviderHealthyBehaviorsToolkit_April2015.pdf

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MethodsThis report uses administrative data, including dental claims, emergency department (ED) claims, and enrollment data, to evaluate access, utilization and cost outcomes in the first two years of the DWP program. Pre- and post-implementation comparisons are made using data from the traditional Medicaid State Plan (MSP) adult population.

Study Period

This report examines outcomes in the DWP during the first two program years (Years 1 and 2), from May 1, 2014 to April 30, 2016. Outcomes from the 12 months preceding implementation of DWP provide baseline comparisons (Year 0).

Year 0 May 2013 through April 2014



The study period for ED outcomes is slightly modified from the above. Post-implementation outcomes are limited to May 2014 through September 2015 due to changes in medical coding; ICD-10 codes replaced ICD-9 terminology on October 1, 2015. The pre-implementation comparison study period for ED outcomes covers November 2012 through April 2014, resulting in time periods of more equivalent duration.

Study Populations

DWP outcomes are compared with outcomes among adults aged 19-64 years enrolled in the traditional Medicaid State Plan (MSP). The MSP comparison group includes members aged 19-64 years. Most outcomes limit the comparison group to individuals enrolled in the Family Medical Assistance Program (FMAP) and Supplemental Security Income (SSI). For ED outcomes, the MSP comparison group is limited to FMAP members. Unless otherwise specified, outcomes are assessed for members with any length of eligibility during the study year.

Research Design

This evaluation provides univariate and bivariate analyses to compare characteristics of DWP members with the comparison groups in the MSP. Simple rate comparisons are calculated for population-based demographic and utilization outcomes.

Difference-in-Difference AnalysisWe utilize difference-in-difference (DID) modelling throughout the report to determine whether DWP members are more likely than MSP members to obtain services. DID modelling takes advantage of the natural experiment occurring with program implementation. The data for the study group and comparison group are modelled before program implementation and then after implementation. Any difference between the two groups appearing after implementation that did not occur before implementation is considered a program effect, with adjustments for the controls including, but not limited to, age, gender, and disease state. We would anticipate that when comparing DWP members to FMAP members there will be a significant increase in all types of dental utilization among DWP members because MSP members had access to dental care before implementation of DWP, but DWP members did not.

The DID models used in this report adjust for variation in time (over year), demographic characteristics (age, sex, race, length of eligibility, and county or residence) and health conditions (diabetes, coronary artery disease, obesity, hypertension, acute myocardial infarction, mental health indicator, and substance abuse). All of these factors may contribute to differences in dental service utilization and program enrollment.

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Linear Regression AnalysisWe used a statistical technique called linear regression modeling to estimate the impact of enrollment in the Iowa Dental Wellness Plan (DWP) on cost to the Medicaid program while controlling for the different characteristics of each population. The dependent variable is the mean dollar value of Medicaid reimbursement applied to each dental procedure for DWP members and the actual Medicaid reimbursement for MSP members. Costs are adjusted for inflation using the Consumer Price Index from the Bureau of Labor Statistics. The index year is set to 2016. The regression model compared DWP members to MSP members, adjusting for the following covariates: age, sex, race, county of residence, month of claim, year of claim, and indicators for several health conditions. These health conditions included mental health, substance abuse, asthma, diabetes, coronary artery disease, obesity, hypertension, Parkinson’ or multiple sclerosis, COPD or emphysema, renal disease, chronic kidney disease, acute myocardial infarction, dementia, developmental delay, depression, mental retardation, schizophrenia, mood disorder, anxiety and a major cancer.

The county of residence (fixed effects) adjusts for geographical variation in costs and access to dental care services. Month of claim (fixed effects) account for seasonal effects and year of claims (fixed effects) account for time trends. The health indicators account for health differences between the DWP and MSP members which may be correlated with dental care use and costs. Standard errors are clustered at the individual level to account for within-person correlations.

Costs are adjusted for inflation using the Consumer Price Index from the Bureau of Labor Statistics. The index year is 2016. For these analyses, preventive dental services are restricted to D1000-1360; radiographic services are excluded since they are not strictly preventive. Diagnostic dental services are restricted to routine oral evaluations (D0120, D0150, D0180) and caries risk assessments (D0601-0603).

We use linear regression models to estimate the impact of enrollment in the DWP on utilization of dental care services. We examine utilization of three dental care services: annual dental exam, preventive visit and ER visit for dental related diagnoses. We also examine the total number of visits for any purpose (examinations or preventive care but excluding ER visits). Similar to the cost analysis, we compare DWP members to MSP members. All regressions include the same set of covariates used in the cost analysis and standard errors were clustered at the individual level.

Incremental Cost Effectiveness Ratios (ICERs)The incremental cost effectiveness ratio or ICER is defined as the difference in cost between two competing strategies divided by the difference in an outcome of interest, ideally directly tied to patient health. This ratio is used to evaluate the best use of health care resources. A positive ICER is interpreted as the additional investment necessary to improve a health outcome by a specific increment4. ICERs are the ratio of the impact of DWP enrollment on costs (numerator) to the impact of DWP enrollment on effectiveness (denominator). The impact of DWP enrollment on costs and effectiveness are obtained from the regression models described above. We construct separate ICERs for each measure of effectiveness: annual visits, preventive visits and ER visits.

Measure specificationsAppendix A provides technical specifications for all measures.

ResultsFollowing a general description of program experiences during the first two years, results are organized by the research questions and hypotheses as outlined in the original evaluation proposal.

4 Muennig, P, Bounthavong, M. Cost-Effectiveness Analysis in Health: A Practical Approach, 3rd Edition (Jossey-Bass 2016)

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General Description of the Program

DWP member demographicsDescriptive statistics for DWP members and the comparison group of MSP members are shown in Table 1; this table presents demographic characteristics of individuals with at least 1 month of eligibility during each study year. In Year 1 of implementation, 193,941 unique individuals were enrolled at some point in the DWP program, with 71,009 people eligible for at least 11 months during the year. DWP members tended to be younger than SSI members but older than FMAP members, more likely to be male than FMAP members and nearly as likely to be male as the SSI population. In addition, DWP members were more likely to be white.

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Table 1. Member demographics by study year and program

Pre- implementation

Post-implementation

Year 0 Year 1 Year 2May 2013 – April 2014

May 2014 – April 2015 May 2015 – April 2016

FMAP SSI FMAP SSI DWP FMAP SSI DWP

Members eligible≥1month

75,602 38,843 59,591 35,517 193,941 56,674 35,364 211,012

Age

19-20 years 5% 4% 4% 3% 6% 2% 1% 3%

21-24 years 16% 8% 15% 8% 13% 14% 8% 14%

25-34 years 44% 17% 45% 18% 28% 45% 19% 30%

35-44 years 26% 17% 27% 17% 20% 28% 17% 21%

45-54 years 8% 27% 8% 26% 19% 9% 25% 18%

55-64 years 1% 27% 1% 28% 14% 2% 30% 14%

Sex

Female 75% 53% 77% 53% 53% 78% 53% 54%

Male 25% 47% 23% 47% 47% 22% 47% 46%

Race

White 63% 65% 63% 65% 65% 62% 64% 66%

Black 11% 10% 11% 10% 8% 12% 10% 8%

Native American

2% 1% 2% 1% 1% 2% 1% 1%

Asian 2% 0% 2% 0% 2% 2% 1% 2%

Hispanic 4% 1% 5% 1% 4% 5% 1% 4%

Pacific Islander

0% 0% 1% 0% 1% 1% 0% 1%

Multi-racial Hispanic

1% 1% 1% 1% 1% 2% 1% 1%

Multi-racial Other

1% 0% 1% 0% 1% 1% 0% 1%

Unknown 16% 22% 14% 22% 17% 13% 22% 16%

Members eligible≥11months

24,181 29,642 25,363 30,395 71,009 24,838 29,861 88,599

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DWP Member Churn and Movement through the Tiers To better understand the movement of DWP members through the three tiers over the first two years of the program and the churn of members from the program (i.e., remaining in the program, moving out of the program to another public option, or moving out and lost to follow-up), we plot the trajectories of the initial cohort of 112,983 members who enrolled at the start of the DWP on May 1, 2014. The flow diagram below (Figure 2) visually depicts the churn in DWP members’ enrollment status within the program by quarter as well as the proportion of members who completed a recall exam and qualified for progression to the next level of services (Tier 2 and Tier 3). Clicking on the image navigates to an online version of this figure with interactive features that allow the user to examine the number of individuals in any given category.w

After the first three months of the program (Quarter 1), 11,091 members had left the DWP program entirely (the gray “Out” category) and no members could be eligible for Tier 2 because they had to wait at least 6 months to progress. Between Quarters 2 and 3, 1,108 individuals entered Tier 2 because they had returned for a second routine oral evaluation since joining the DWP. Flow lines indicate where individuals moved to a higher or lower tier, and left or re-entered the program.

Overall, there was a significant churn rate of members during the first two years of the program (Quarters 1-8). Almost half (45%) of the members who joined the DWP in May 2014 left the program within the first two years. Approximately one-third of the original cohort remained in Tier 1 (n=40,307), significantly affecting their ability to receive routine restorative care or other treatment services. Approximately 3% of members made it to Tier 2 (n=3,414), and 4% moved through Tier 2 to Tier 3 (n=4,296). There were also some members who gained Tier 2 or Tier 3 but then did not continue to return for a routine dental check up within 12 months and thus returned to Tier 1.

New members enrolled in the DWP as other members dropped out during this time period such that the total number of members in the DWP rose over the first two years from 112,983 to 138,496. Figure 3 shows the monthly enrollment in DWP by tier. The members in Tier 2 reached a peak membership of 9,877 in October 2015 and then fell slightly to 8,778 by April 2016. At the same time, the number of members in Tier 3 continued to grow from April 2015 through April 2016 from 6 to 7,750. Overall, it is clear that a significant proportion of members did not advance past Tier 1 and, among those that did, few advanced to Tier 3.

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Figure 2. Flow diagram of DWP members enrolled in May 1, 2014 tier movement by quarter May 2014 – April 2016 (n=112,983)

http://ppc.uiowa.edu/dwp/flow

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Figure 3. Number of all DWP members by Tier for the first two program years

0

20000

40000

60000

80000

100000

120000

140000

160000

May-14

Jun-14

Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-1

5

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

Tier1 Tier2 Tier3

Use of Services by DWP Members by Tier Tables 2, 3 and 4 show the number of members enrolled at any point during the first and second years of the DWP program and the number and proportion of each type of dental service received by members while in each of the three tiers during those two years. Unlike the previous graphic, these numbers are for all members enrolled at any point during the first two years, not just those who initially enrolled when the program began. This provides a better sense of the volume of services provided during the first two years of the DWP.

During year one, 85% of the services were provided to the 95% of members who were in Tier 1. The most common dental services provided to DWP members while in Tier 1 during the first year were: 1) dental x-rays (radiology–63,951-22%), 2) tooth extractions (58,157–20%), 3) dental check-ups (oral evaluations–38,053-13%), 4) dental fillings (restorative–25,309-9%), 5) dental cleanings (prophylaxis–25,008-8%), 6) clinical risk assessments (20,673-7%). The tooth extractions and dental fillings were provided under the DWP’s provision allowing “emergency and stabilization” services to members in Tier 1 to reduce pain and help prevent higher cost care by providing some care sooner (e.g., placing a filling in a large cavity near to the nerve in the tooth rather than do a root canal and crown later).

In comparison to members in Tier 1, there was an expected change in the mix of services provided to members in Tier 2. The volume of services was also much less for those in Tier 2 due to the relatively few members who progressed to Tier 2. The most common services provided for members in Tier 2 during Year 1 included: 1) dental fillings (restorative–14,367-31%), 2) dental check-ups (oral evaluations–6,620-20%), 3) dental cleanings (prophylaxis–6,620-14%), 4) gum disease treatment (periodontal maintenance –4,010-9%), 5) dental x-rays (radiology–3,514-8%), 6) tooth extractions (2,820–6%). Thus, the proportion of services specifically designed to be provided in Tier 2 (e.g, dental fillings) services increased since they had only been allowed for emergency and stabilization purposes to members in Tier 1. Dental fillings were the most common service (31% of all services) for people in Tier 2 as compared to Tier 1 when fillings were 9% of all services to members in Tier 1 during the first year of the program. There was also significantly more care for gum disease (i.e., scaling and root planing) for people in Tier 2.

The patterns for services received in Tier 1 and Tier 2 during the second year of the program were very similar to those in year one.

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In Tier 3 (second year only), there were just under 56,000 services provided to almost 9,000 members. Dental check-ups (oral evaluations-10,948–20%), x-rays (radiology-10,700–19%) and cleanings (prophylaxis-8715–16%) were the most common procedures. Single crowns, a relatively expensive procedure, increased to 4% (2,342) of all services in Tier 3. Dental fillings (7,442–13%) and gum disease treatment (708–1%) represented a smaller proportion of services than they did for members in Tier 2.

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Table 2. Preventive services by tier and year of program

Year 1 Year 2Tier 1 Tier 2 Tier 1 Tier 2 Tier 3

Total services

performed

Total persons enrolled

Total ser-vices per-

formed



formed



formed



formed


All Services/Members

296,849 183,710 45,817 9,215 244,102 191,069 83,916 21,969 55,903 8,934

Preventive Prophylaxis n

%25,008

8%

24,549

13%

6,620

14%

6,617

72%

19,892

8%

19,713

10%

10,385

12%

10,315

47%

8,715

16%

6,796

76%Fluoride n

%14,336

5%

14,318

8%

933

2%

933

10%

11,942

5%

11,941

6%

1,998

2%

1,998

9%

3,596

6%

3,596

40%Other Pre-ventive

n%

9645

3%

9645

5%

636

1%

636

7%

7924

3%

7923

4%

812

1%

812

4%

364

1%

364

4%

Table 3. Diagnostic services by tier and year of program

Year 1 Year 2Tier 1 Tier 2 Tier 1 Tier 2 Tier 3


formed



formed



formed



formed



formed


All Services/Members

296,849 183,710 45,817 9,215 244,102 191,069 83,916 21,969 55,903 8,934

DiagnosticOral Evalu-ation

n%

38,053

13%

36,761

20%

9,039

20%

8,917

97%

29,464

12%

28,704

15%

13,735

16%

13,519

62%

10,948

20%

8,52295%

Caries Risk Assessment

n%

20,673

7%

20,614

11%

941

2%

939

10%

16,486

7%

16,308

9%

3,838

5%

3,808

17%

4,656

8%

4,079

46%

Radiology n%

63,951

22%

40,153

22%

3,514

8%

2,541

28%

50,670

21%

32,296

17%

8,19410%

5,560

25%

10,700

19%

6,419

72%

Other Diag-nostic

n%

18,197

6%

14,690

8%

611

1%

549

6%

15,1016%

12,685

7%

1,932

2%

1,693

8%

880

2%

748

8%

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Table 4. Treatment services by tier and year of program

Year 1 Year 2

Tier 1 Tier 2 Tier 1 Tier 2 Tier 3

Total services

per-formed


Total services

per-formed


Total services

per-formed


Total services

per-formed


Total services

per-formed


All Services/Mem-bers

296,849 183,710 45,817 9,215 244,102 191,069 83,916 21,969 55,903 8,934

Restorative n%

25,309

9%

11,021

6%

14,367

31%

4,183

45%

25,492

10%

10,629

6%

25,410

30%

7,605

35%

7,442

13%

3,110

35%Endodontic n

%5,073

2%

3,301

2%

492

1%

352

4%

4,349

2%

3,020

2%

1,116

1%

800

4%

466

1%

329

4%PeriodontalScaling/root planing

n%

927

<1%

329

<1%

4,010

9%

1,220

13%

631

<1%

234

<1%

6,400

8%

2,044

9%

708

1%

247

3%Periodontal maintenance

n%

416

<1%

391

<1%

347

1%

333

4%

438

<1%

395

<1%

1,091

1%

994

5%

1,720

3%

1,114

12%Full mouth debridement

n%

2,767

1%

2,767

2%

20

<1%

20

<1%

2,157

1%

2157

1%

79

<1%

79

<1%

14

<1%

14

<1%ProsthodonticComplete dentures

n%

4,209

1%

2,603

1%

237

1%

174

2%

3,279

1%

2,034

1%

519

1%

353

2%

143

<1%

112

1%Removable partial den-tures

n%

1

<1%

1

<1%

1

<1%

1

<1%

12

<1%

9

<1%

2

<1%

2

<1%

559

1%

449

5%

Interim den-tures

n%

1,812

1%

1,507

1%

184

<1%

161

2%

1,507

1%

1,271

1%

390

<1%

331

2%

50

<1%

42

<1%Single crowns n

%78

<1%

50

<1%

199

<1%

158

2%

88

<1%

59

<1%

510

1%

368

2%

2,342

4%

1,366

15%Extractions n

%58,157

20%

14,559

8%

2,820

6%

859

9%

47,773

20%

12,197

6%

5,771

7%

1,898

9%

1,742

3%

653

7%General anes-thesia

n%

2,111

1%

1,987

1%

123

<1%

119

1%

1,310

1%

1,277

1%

273

<1%

269

1%

52

<1%

50

1%Other treat-ment services

n%

6,126

2%

3,386

2%

723

2%

430

5%

5,587

2%

3,243

2%

1,461

2%

991

5%

806

1%

494

6%

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Administrative denials of services The services provided to DWP members, and payment to dentists, are affected by Delta Dental of Iowa’s review process to determine if submitted claims meet the DWP’s programmatic requirements. Figure 4 shows that in the DWP’s first nine months, most denials were due to documentation-related issues, which might be expected for a new program. The largest proportion of denials then shifted to being related to what is covered by the program (contractual limitations), many of these are likely related to the DWP’s earned benefit model. The higher number of denials due to contractual limitations may be due to the fact that relatively few DWP members matriculated to Tier 2 and Tier 3, and dentists were providing services for which members were not yet eligible, such as routine fillings. The number of denials may also be an indicator of both provider understanding of the program and the potential for provider frustration due to what they might interpret as administrative burden.

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Figure 4. DWP administrative denials of services by month

0

500

1,000

1,500

2,000

2,500

3,000

3,500

May

June July

August

September

October

November

December

January

February

March

April

May

June July

August

September

October

November

December

January

February

March

April

2014 2015 2016

Documentationrelateddenials

ContractualLimitations

Duplicateservicerelateddenials

Prior-authorizationrelateddenials

Coverage/Network relateddenials

Other

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Evaluation Plan Hypotheses and Measures

The following outcomes are presented in this report in the order that they were in the DWP evaluation plan developed by the PPC and approved by the IME and CMS. As mentioned, some of the outcomes measures in the evaluation plan have been previously reported; URL links are provided to these reports.

Access to Care

Research Question 1 – What are the effects of DWP on member access to care?

Hypothesis 1.1 DWP members will have equal or greater access to dental care.

Measure 1 Annual (any) dental visit

1A Percent of members who had an annual (any) dental visit

Measure 1 hypothesizes that DWP members have equal or greater access to dental care as measured by having an annual dental visit, defined as receiving any service provided by a dentist. This definition conforms to HEDIS specifications for an annual dental visit. The proportion of all DWP members with an annual dental visit was 23.3% during Year 1 and 24.2% during Year 2 (Figure 5). The SSI population had the highest rates of annual dental visits, with 32-33% of members having a dental visit during each study year. FMAP members were less likely to have had a dental visit than SSI members, with rates slightly higher than DWP members. Overall, DWP members were not more likely to have had an annual dental visit.

Figure 5. Members with an annual dental visit by year

Year0 Year1 Year2FMAP 25.6% 26.7% 27.4%

SSI 31.7% 33.3% 32.9%

DWP 23.3% 24.2%

0%

20%

40%

60%

80%

100%

FMAP

SSI

DWP

1B Whether members received an annual (any) dental visit Difference-In-Difference (DID) regression model

Whereas Measure 1A provided overall descriptive information about the proportion of DWP and MSP members who had an annual dental visit, Measure 1B uses difference-in-difference (DID) regression to control for differences between these two populations to determine if the likelihood of receiving a service increased as compared to the pre-implementation period.

Three outcomes measures were modelled using DID regression techniques: 1) the receipt of an annual dental visit (Measure 1), 2) the receipt of a preventive visit (Measure 8), and 3) the receipt of any dental services.

The study population included 410,325 Medicaid/DWP members with coverage through the FMAP,

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SSI, IowaCare and DWP. The model is designed to compare member experiences in the pre-implementation year (Year 0) to member experiences post-DWP implementation, in Years 1 and 2. Members were included if they had coverage through the same Medicaid program (FMAP, SSI) in the pre-implementation period and one or both of the program years. DWP members were included only if they had previously been enrolled in IowaCare during Year 0 and were enrolled in DWP during Years 1 and 2. This reduced the study population to 85,068. Modeling was done at the yearly level.

The models adjusted for the following variables in order to control for differences that may affect utilization of dental care: age at the end of the study year, race, percent poverty as reported in the enrollment files, county urbanicity, number of months in Medicaid, sex, number of program months with reduced spending such as family planning or the Medicaid Buy-in, indicator that member qualifies for institutional level of care (usually in Home and Community Based Waiver program), indicator whether the person was newly eligible for dental services in the study year, DWP by time interaction, indicators to control for Year 1 and Year 2 effects, indicators of months when members were newly eligible, and program indicators. The indicators to control for Year 1 and Year 2 effects are the DID terms.

The models also adjusted for chronic conditions with indicators of whether an individual received a diagnosis for any of the following during the study period: diabetes, mental health, substance abuse, obesity, and heart disease. The modelling was done using both logistic Generalized Estimating Equation (GEE) and linear GEE for robustness. Complete results are provided in Appendices B-D.

The logistic regression fit for the three outcome measures indicated large positive and statistically significant differences for both Years 1 and 2. The DID estimates for whether a member had an annual dental visit are 1.14 and 1.23 for Years 1 and 2, respectively (Appendix B). This corresponds to a 3.13 and 3.42 multiplicative increase in the odds of having a dental visit for Years 1 and 2, respectively as compared to the pre-implementation period (when they did not have dental coverage). DWP members were 3.13 times more likely than FMAP members to have a visit in Year 1 and 3.42 times more likely in Year 2 to have a visit than FMAP members as compared to the pre-implementation period. The Year 1 result is not surprising, given the lack of dental coverage in Year 0, however, the continued increase in likelihood of a visit in Year 2 indicates that the DWP program continues to improve access to care.

Note: Measures 2 through 5 evaluate DWP member experiences. Results from the Year 1 are available at http://ppc.uiowa.edu/publications/evaluation-dental-wellness-plan-member-experiences-first-year

Hypothesis 1.2 DWP members will be more likely to receive preventive dental care.

Measure 6 First routine oral evaluation

6APercentofmemberswhohavearoutineoralevaluationwithintheirfirst6-12 months in the program

Measure 6 hypothesizes that DWP members are more likely to receive preventive dental care, as measured by rates of initial routine oral evaluations (D0120, D0150, and D0180) for members with at least 6 months of enrollment during the program year. This measure uses the Dental Quality Alliance (DQA) technical specifications for length of enrollment and the DWP requirements for routine oral evaluations (i.e., evaluations that qualify for Earned Benefits). Note: this measure differs from Measure 23 in that Measure 23 does not apply a requirement for length of enrollment. These routine oral evaluations are differentiated from limited oral evaluations (D0140), which are problem-focused and typically provided to patients presenting with “a specific problem and/or dental emergencies, trauma, acute infections, etc.”5

During Year 1, one quarter of DWP members with at least 6 months of enrollment had an initial oral evaluation within their first 6-12 months in the program (Figure 6). This number decreased to 18% in Year 2. Rates of oral evaluations are lowest in the SSI population in Year 0 and Year 1, with the FMAP group having only slightly higher rates of dental exams. SSI and FMAP groups have similar rates of oral evaluations in Year 2. Overall, newly enrolled DWP members were slightly more likely to have an oral evaluation within 6-12 months of joining the program. The general time trend for this

5 CDT 2015. Dental Procedure Codes. 2014. American Dental Association; Chicago, IL.

http://ppc.uiowa.edu/publications/evaluation-dental-wellness-plan-member-experiences-first-year

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measure shows routine evaluations slightly decreasing for the FMAP population, slightly increasing for the SSI population, and decreasing for the DWP population.

Figure 6. Initial oral evaluations among members with ≥6 months of eligibility


SSI 11.2% 14.3% 15.0%

DWP 25.4% 18.2%

0%

20%

40%

60%

80%

100%

FMAP

SSI

DWP

Note: Protocol for Measure 7 (second preventive dental recall exam) is being developed for the final report.

Measure 8 Any diagnostic or preventive dental service

Percent of members who receive any diagnostic or preventive dental service

Measure 8 hypothesized that DWP members would be more likely to receive diagnostic or preventive dental care. Diagnostic dental services (D0100-0999) include services such as oral evaluations, diagnostic imaging, and other tests or examinations. Preventive dental services (D1000-1999) include prophylaxis (i.e. dental cleanings), in-office fluoride treatments, dental sealants, and healthy behavior counseling (e.g., tobacco prevention and cessation services).

In Years 1 and 2, 23% of DWP members with at least 1 month of eligibility received any preventive or diagnostic dental service (Table 8). These rates are comparable to those seen in the FMAP population, and slightly lower than rates seen in the SSI population, where 27-28% of eligible individuals received preventive or diagnostic dental services in each year. The time trend for this measure was stable over the study period.

Figure 7. Members with any diagnostic or preventive service


SSI 27.1% 28.0% 27.6%

DWP 23.0% 22.9%

0%

20%

40%

60%

80%

100%

FMAP

SSI

DWP

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Having any preventive or diagnostic visit-controlling for population characteristicsThis analysis was not originally included in the evaluation plan; however, additional DID analyses are provided to estimate odds of receiving any preventive or diagnostic dental care. See model specifications in results section for Measure 1B. For this measure, preventive dental services are limited to D1000-1360; radiographic services are excluded since they are not strictly preventive. Diagnostic dental services are restricted to routine oral evaluations (D0120, D0150, D0180) and caries risk assessments (D0601-0603).

The estimates for having any preventive or diagnostic care after controlling for population differences using DID techniques were 2.38 and 2.42 for Years 1 and 2, respectively (Appendix C). This corresponds to a 10.80 and 11.25 multiplicative increase in the odds of receiving preventive or diagnostic dental care. This indicates that DWP members were nearly 11 times more likely to have a preventive or diagnostic visit during Year 1 than FMAP members. This effect does not increase measurably for Year 2.

Hypothesis 1.3 DWP members will have equal or greater access to care, resulting in equal or lower use of emergency department (ED) services for non-traumaticdentalcarewithineachearnedbenefittier.

Measure 9 Use of ED for non-traumatic dental related treatment

9A Percent of members who were seen for non-traumatic dental reasons in an ED for1,2,or3ormorevisitsperyearwhilecontrollingfortheearnedbenefittier

Measure 9 hypothesizes that DWP members utilize ED services for non-traumatic dental care at equal or lower rates compared to the traditional Medicaid populations.

Table 5 provides the rates of ED utilization for oral health-related primary diagnoses. Note that this measure uses 18-month pre- and post-implementation time periods. In the 18-month pre-implementation period, FMAP members had 15.74 ED visits per 1,000 months of eligibility. Post-implementation, FMAP members had 14.94 ED visits per 1,000 months and DWP members had 10.95 ED visits per 1,000 months of eligibility.

For both FMAP and DWP populations, ED visit rates are higher in the 19-44 year age group compared to 45-64 year olds. Across both age groups, FMAP members show a 5% decline in the number of ED visits from pre-implementation period to post-implementation period. Lack of data on ED visits for DWP members in the pre-implementation period precludes comparisons across time. However, during the initial post-implementation period, DWP members have lower rates of ED visits for non-traumatic dental conditions.

Table 5. Rates of non-traumatic dental ED visits

Pre-implementation Post-implementationNovember 2012 –

April 2014May 2014 – September 2015

FMAP FMAP DWP19-44 years of ageEligible months 74,027 74,085 143,031Number of visits 2,509 2,376 3,028Visits/1000 months 33 .89 32 .07 21 .17% change -5%

45-64 years of ageEligible months 10,925 11,041 66,685Number of visits 172 165 730Visits/1000 months 15 .74 14 .94 10 .95% change -5%

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Table 6 shows the top five diagnoses for non-traumatic dental conditions by study group and year. Interestingly, across time and in both groups, the top five diagnoses and their respective rankings remain unchanged. Unspecified disorder of teeth and supporting structures (ICD-9 525.9) accounted for nearly 50% of oral-health related ED visits.

Table 6. Top 5 primary diagnosis codes for non-traumatic dental ED visits

Pre-implementa-tion

Post-implementation

November 2012 – April 2014

May 2014 –September 2015

FMAP FMAP DWPDescription ICD-9

codeNumber

%Rank Number

%Number

%Rank

Unspecifieddisorderofteeth and supporting structures

525 .9 1,315

49%

1 1,314

52%

1,818

48%

1

Dental caries, unspec-ified

521 .00 500

19%

2 405

16%

662

18%

2

Periapical abscess without sinus

522 .5 336

13%

3 348

14%

598

16%

3

Acute apical periodonti-tis of pulpal origin

522 .4 113

4%

4 94

4%

151

4%

4

Otherandunspecifieddiseases of oral soft tissues

528 .9 63

2%

5 91

4%

127

3%

5

Table 7 shows results from a linear regression model estimating the impact of enrollment in DWP on utilization of ED services for non-traumatic dental conditions after controlling for characteristics of the Medicaid and DWP populations. The regression model compares DWP members to MSP members, adjusting for: age, sex, county (fixed effects), month (fixed effects), year (fixed effects), and several health conditions.

After controlling for these characteristics, there is no statistically significant difference in the number of ED visits between the two groups. Characteristics, other than DWP or Medicaid, that are related to having an ED visit for a non-traumatic dental condition are being younger, male, and having a variety of chronic health conditions such as a substance use, mental health or developmental diagnoses, having asthma, being obese, having COPD, renal failure, or several types of heart conditions. See Appendix D for linear regression results predicting dental utilization for the full population and the population with diabetes.

Table 7. Effect of DWP enrollment on ED visits for non-traumatic dental conditions

Number of ED Visits

Mean(SD)

DWP -0 .000

(0 .000)Eligible months 6,142,456

Persons 351,416

*** Significant at 1% level

9B Percent of members who were seen in the ED for non-traumatic dental related reasons within the reporting year and visited a dentist for treatment services within 60 days following the ED visit while controlling for the earned benefittier

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Measure 9B hypothesizes that DWP members are more likely to follow-up with a dentist after being seen in an ED for non-traumatic dental conditions. Table 8 provides the proportion of FMAP and DWP members who had a follow-up dentist visit within 60 days after an ED visit.

Table 8 shows that although the use of the ED for non-traumatic dental problems is higher for the FMAP population, the rate of seeing a dentist to follow-up after an ED visit among DWP members in Tier 1 are similar to rates in the FMAP population, pre- and post-implementation. The proportion of DWP members with a follow-up dental visit increases from Tier 1 to Tier 2, with 57.8% of DWP members in Tier 2 following up after being seen in an ED. Rates are not reported for Tier 3 since the number of members in Tier 3 during this time period was too low.

Table 8. Rates of follow-up dentist visits within 60 days after non-traumatic dental ED visit

Pre-implementation Post-implementationNovember 1, 2012 –

April 30, 2014May 1, 2014 –

September 30, 2015Eligibility FMAP FMAP DWP

Tier 1 Tier 2Eligible months 84,994 85,160 175,351 10,864

Number with ED visits* 2,681 2,541 3,395 83

Number with ED vis-its/1000 months

31 .57 29 .84 19 .36 7 .64

Number (%) with fol-low-up dental visits

972 (36 .20%) 956 (37 .60%)

1,232 (36 .30%)

48 (57 .80%)

*Total number of ED visits for DWP may not add up to total of Measure 9A due to missing tier information

Note: Measure 10A (Dental EPSDT utilization) -. This measure has been removed due to low mem-ber numbers. Measure 11 (DWP members who are smokers who receive a dental exam) - Data from clinical risk assessments that identify smokers are not available for evaluation.

Hypothesis 1.5 High risk populations in the DWP will be more likely to receive preventive dental care.

Measure 12 People with diabetes: routine oral evaluation

12APercentofDWPmembersidentifiedaspeoplewithdiabeteswhohavearoutine oral evaluation within the reporting year

Measure 12 hypothesizes that a greater proportion of DWP members with diabetes will have a routine oral evaluation than comparable populations in the Medicaid FMAP or SSI populations.

During the first year of implementation, 12% (n=8,540) of DWP members eligible for at least 11 months were identified as having diabetes (see technical specifications in Appendix A). Among these individuals, one-third had a routine oral evaluation (D0120, D0150, or D0180) (Figure 8). During the same year, approximately one-quarter of FMAP and SSI members with diabetes had a routine oral evaluation; these rates are relatively stable over the 3-year period.

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Figure 8. Routine oral evaluations amongmemberswithdiabetes–≥11monthsofeligibility by year


SSI 24.3% 25.0% 23.5%

DWP 33.5% 30.9%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

FMAP

SSI

DWP

Routine Oral Evaluation for Diabetics-Controlling for Population Characteristics Multivariable linear regression modeling was used to evaluate the likelihood of receiving a dental check-up, a preventive visit, or any dental visit for diabetics and non-diabetics, controlling for other characteristics. Table 9 shows results of the regression model comparing DWP members to MSP members, which adjusted for the following characteristics: age, sex, county (fixed effects), month (fixed effects), year (fixed effects), and several chronic health conditions.

For the entire population, as well as just diabetics, DWP members were significantly more likely to have had a dental check-up, a preventive dental visit, or any dental visit. Among diabetics, DWP members had 0.006 more routine oral evaluations per month than MSP members (See Appendix E for full model results).

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Table 9. Effect of DWP enrollment on utilization of routine oral evaluations among people with diabetes

Full sample Diabetics

Oral evaluations 0 .003** (0 .000)

0 .006*** (0 .001)

Preventive visits 0 .022** (0 .000)

0 .029*** (0 .002)

Any dental visit 0 .025*** (0 .000)

0 .036*** (0 .003)

Eligibility months 6,142,456 364,724

Unique individuals 351,416 19,861

***Significant at 1% level

Cost Analysis

A question of particular interest is ‘what effect does a tiered benefit program have on costs of oral health care’. To adequately assess this question, we need to control cost differences due to the fee schedule to isolate effects due to changes in utilization. For that purpose, the following analyses compute per member per month (PMPM) cost for DWP by applying the Medicaid fee schedule value for each CDT code as the reimbursement rather than the actual DWP reimbursement amount. The dependent variable is the mean dollar value of Medicaid reimbursement applied to each dental procedure for DWP members and the actual Medicaid reimbursement for MSP members. Costs are adjusted for inflation using the Consumer Price Index from the Bureau of Labor Statistics. The index year is set to 2016. The regression model compares DWP members to MSP members, adjusting for the following characteristics: age, gender, county (fixed effects), month (fixed effects), year (fixed effects), and several health conditions (see Methods section for complete details).

Figure 9 illustrates the difference between PMPM costs for the DWP members who had previously been in IowaCare (these are the members for whom DWP pre-implementation data was available) using: 1) the actual DWP reimbursement, and 2) the DWP members’ estimated costs at the Medicaid reimbursement rates. The reimbursement we used for the cost regressions (estimated Medicaid reimbursement) averages nearly $5 less than the actual DWP reimbursement per month.

Figure 9. PMPM month costs for IowaCare members, DWP members with DWP reimbursement and DWP members estimated Medicaid reimbursement

0

5

10

15

20

25

DWPreimbursment DWPestimatedMedicaidreimbursement IowaCare

Table 10 shows results from the cost analyses for the full sample and for the sample of members with a diagnosis of diabetes. We found that monthly costs for routine oral evaluations would be $5.06 lower for DWP members compared to MSP members, if reimbursement was standardized using the MSP fee schedule and controlling for differences in the characteristics between the two groups. When we considered only diabetics in DWP and MSP (n=19,861), monthly Medicaid costs would also

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be approximately $5 lower among the DWP group compared to the MSP group.

Table 10. Effect of DWP enrollment on cost of routine oral evaluations among people with diabetes

Full sample Diabetics

Effect of DWP enrollment -$5 .06*** -$4 .98***

SD (0 .118) (0 .619)

Eligibility months 6,142,456 364,724

Unique individuals 351,416 19,861

***Significant at 1% level

Incremental Cost Effectiveness Ratios (ICERs)

Table 11 presents the ICERs for each measure, calculated by applying the MSP fee schedule to both populations. For the full sample, the ICER is 1686.9 for dental exams, 230 for preventive visits and 204.1 for any visits. In other words, Medicaid saves $1,687 per additional monthly dental exam, $230 per additional monthly preventive visit and $204 per additional visit for any reason. Among diabetics, the savings for dental exams, preventive visits and any visits are $829.23, $171.57 and $140.15, respectively. Given these findings, DWP can be considered cost-effective (i.e., DWP costs less than MSP per unit increases in services) in the situation where the reimbursement schedule for both programs were the same. These cost saving might be better considered costs “avoided” since many needed services (e.g., non emergent cavities) were never provided for the members who didn’t progress to Tier 2 and will remain a cost at some point in the future. What also must be taken into account is that by design, DWP has a higher reimbursement rate and members are not allowed to receive many of the higher cost services (e.g., crowns) until Tiers 2 and 3, and relatively few members reach Tiers 2 and 3 as shown in Figure 2.

Table 11. Incremental cost effectiveness ratios

Dental Exams Preventive Visits Any Visits

Full Sample 1,686 .93 230 .04 204 .07

Diabetics 829 .23 171 .57 140 .15

12BWhetheramemberidentifiedashavingdiabeteshadaroutineoralevalu-ation – difference-in-difference (DID) regression model

The approach to this measure is similar to the one presented in the results section for Measure 1B. Whether members diagnosed with diabetes received a routine oral evaluation was addressed in measure 1B by including a covariate reflecting presence of a diabetes diagnosis. There were no consistent results with regard to diabetes as a predictor of whether a member had a routine oral evaluation, a preventive or diagnostic service, or an annual dental visit.

Results from the logistic and linear regression models provided evidence that having diabetes does not make one more likely to have any type of dental service regardless of the program.

Although the regression analyses presented in 12A show a significant but very small effect of being in DWP on whether a member with diabetes receives a routine oral evaluation, this significance may be the result of the large sample size used for the analysis and not evidence of any practically significant effect.

Note: Measures 13 through 20 evaluates member experiences with quality of care received in DWP and MSP; findings from the Year 1 are available at http://ppc.uiowa.edu/publications/dental-wellness-plan-evaluation

http://ppc.uiowa.edu/publications/dental-wellness-plan-evaluation


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Cost

Research Question 3 – What are the effects of the DWP on costs of dental care as compared to traditional Medicaid dental coverage?

Hypothesis 3.1 The cost for providing dental care to DWP members will be comparable to the predicted costs for providing dental care to DWP members had they been enrolled in Medicaid State Plan.

Measure 21 Compare DWP member per member per month (PMPM) dental costs to those of MSP members

21A PMPM dental costs calculated for direct provision of care per member per month

Measure 21 hypothesizes that PMPM dental costs for DWP members are comparable to the costs for this population if they had been enrolled in the MSP. Table 12 presents descriptive statistics for DWP members and MSP members. Applying the Medicaid fee schedule to both populations, average costs were lower for DWP members compared to MSP members ($10.82 versus $15.29). In addition to these lower per member costs, DWP members had more visits for any reason, more dental exams and preventive visits relative to MSP members. There was no difference in ED visits between the two groups.

Table 12. Per member per month descriptive statistics

DWP MSPMean(SD)

Mean(SD)

Medicaid Costs 10 .82 (82 .288)

15 .29 (100 .488)

Number of any visits 0 .10 (0 .600)

0 .08 (0 .506)

Number of dental exams 0 .03 (0 .163)

0 .03 (0 .156)

Number of preventive visits 0 .07 (0 .452)

0 .06 (0 .361)

Number of ED visits 0 .003 (0 .059)

0 .003 (0 .063)

Age 38 .2 (12 .728)

30 .4 (8 .903)

Note: Measure 22 evaluated member experiences with out-of-pocket dental costs for care received in DWP and MSP; findings from the Year 1 are available at http://ppc.uiowa.edu/publications/dental-wellness-plan-evaluation

EarnedBenefitStructure

ResearchQuestion4–Whataretheeffectsoftheearnedbenefitstructureon DWP members?

Hypothesis 4.1 TheearnedbenefitstructureforDWPmemberswillincreaseregularuseof routine oral evaluations.



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Measure 23 Routine oral evaluation

23A Percent of members who received a routine oral evaluation within the reporting year

Measure 23A hypothesizes that a greater proportion of DWP members have a routine oral evaluation (D0120, D0150, or D0180) compared to the Medicaid populations. Note that this measure is identical to Measure 6A, except it includes all DWP members, regardless of how long they were enrolled in the program.

As Figure 10 shows, 19.5% DWP members had a routine oral evaluation in Year 1 compared to 16.3% of FMAP members and 22.4% of SSI members. Rates in FMAP and SSI groups were comparable in the pre-implementation period and stable for all 3 groups through Year 2.

Figure 10. Members who received a routine oral evaluation


SSI 21.1% 22.4% 21.5%

DWP 19.5% 18.9%

0%

20%

40%

60%

80%

100%

FMAP

SSI

DWP

Routine Oral Evaluation-Controlling for Population Characteristics

DID regression techniques are used to estimate the likelihood of a person receiving a dental check-up, controlling for other characteristics of the population. This is for all FMAP, SSI and DWP members, regardless of how long they were in the program.

Estimates for having a routine oral evaluation are 2.34 and 2.37 for Years 1 and 2, respectively (Appendix E). This corresponds to a 10.38 and 10.70 multiplicative increase in the odds of having a routine oral evaluation, holding all other predictors fixed. Note that the DID estimate is larger for Year 2 than Year 1. This translates to DWP members being over 10 times more likely to have a routine oral evaluation in Year 1 than MSP members and nearly 11 times more likely to have a routine oral evaluation in Year 2, after controlling for the characteristics of the members in the two programs.

23B Percent of members who accessed dental care (received at least one ser-vice) who received a routine oral evaluation within the reporting year

Measure 23B examines utilization of the same routine dental evaluations (dental check-ups) from Measure 23A, except this measure limits the outcome to the population who had a dental visit of any kind (i.e. among members with a dental visit, how many received a routine oral evaluation).

In Year 1, among the 23% of DWP members who utilized any dental services, 84% received a routine oral evaluation (an indication of getting in for comprehensive care) as compared to 68% of SSI and 61% of FMAP members (Figure 11). The proportion of DWP utilizers receiving a check-up decreased from Year 1 to Year 2.

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Figure 11. Percent of dental utilizers who received a routine oral evaluation


SSI 66.7% 67.7% 65.4%

DWP 83.7% 78.2%

0%

20%

40%

60%

80%

100%

FMAP

SSI

DWP

Note: Protocols for Measure 24 (Timing of 1st recall visit), Measure 25 (Timing of 2nd recall visit) and Measure 26 (Recall exams after 1 year of enrollment) are being developed for the final report for May 2017.

Measure 27 evaluates member experiences with covered benefits in DWP and MSP; findings from the Year 1 are available at http://ppc.uiowa.edu/publications/dental-wellness-plan-evaluation

Measures 28 through 36 evaluate provider network adequacy in DWP and MSP; findings from the Year 1 are available at http://ppc.uiowa.edu/publications/dental-wellness-plan-evaluation

Member Outreach

Research Question 7 – What are the effects of DWP member outreach and referral services?

Hypothesis 7.2 Referral services will improve access to specialty dental care.

Measure 37 Specialty dental utilization

Percent of members receiving any specialty dental services

Measure 37 hypothesizes that a greater proportion of DWP members receive specialty dental services than MSP members. The specialty services are: 1) endodontics (e.g., root canal therapy), 2) periodontics (e.g., gum treatment), 3) prosthodontics (e.g., crowns, bridges and dentures) and 4) oral and maxillofacial services not including tooth extractions (e.g., surgical excision of lesion, surgical incision and drainage).

As Table 13 shows, a relatively small proportion of all members receive endodontic services (i.e., root canals) during Year 1: 1.9% of DWP members, compared to 2.2% of FMAP members and 1.8% of SSI members. Trends for endodontic services utilization among the DWP population and the comparison groups (FMAP and SSI) are relatively stable for all 3 years.

In Year 1, similar proportions of DWP, FMAP and SSI members utilize periodontal services, which include deep cleanings (i.e., scaling and root planing) to remove plaque and calculus from patients with periodontal disease. Utilization of periodontal services remain relatively stable for all 3 years.

For all 3 years, SSI members are more likely to receive prosthodontic services, which include complete and partial dentures, crowns or caps, and bridges. In Year 1, 5.2% of SSI members received some type of prosthodontic service, compared to 1.5% of FMAP members and 2.4% of DWP



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members. A similar distribution is also seen in Year 2, and the trend from Year 0 for the FMAP and SSI populations is relatively stable.

DWP members are less likely to receive oral and maxillofacial services, which exclude tooth extractions in Years 1 and 2, than FMAP and SSI members, although this difference is not substantial. Here again, the trend in utilization of this type of dental service remains relatively stable among FMAP and SSI members for the 3 year period.

Table 13. Percent of members with specialty dental visits by study group and program year

Pre-implemen-tation

Post-implementation

Year 0 Year 1 Year 2May 2013 – April 2014

May 2014 – April 2015 May 2015 – April 2016

FMAP SSI FMAP SSI DWP FMAP SSI DWPEndodontics

(D3000-3999)

N%

1,722

2 .3%

754

1 .9%

1,321

2 .2%

641

1 .8%

3,663

1 .9%

1,356

2 .4%

718

2 .0%

3,881

1 .8%

Periodontics

(D4000-4999)

N%

1,799

2 .4%

1,018

2 .6%

1,529

2 .6%

978

2 .8%

4,655

2 .4%

1,502

2 .7%

1,025

2 .9%

5,670

2 .7%

Prosthodontics

(D5000-D6999)

N%

1,221

1 .6%

1,879

4 .8%

911

1 .5%

1,859

5 .2%

4,615

2 .4%

934

1 .6%

1,803

5 .1%

4,895

2 .3%

Oral & Maxillo-facial Surgery

(D7260-7999)

N%

624

0 .8%

605

1 .6%

440

0 .7%

452

1 .3%

1,259

0 .6%

413

0 .7%

418

1 .2%

1,083

0 .5%

EffectoftheearnedbenefitstructureonutilizationofselectedspecialtyservicesThe earned benefit structure limits coverage for many specialty services until a DWP member has reached Tier 2 or Tier 3. The plan requires that a minimum of 6 months must elapse from the date of the first comprehensive exam before a member can access the first routine oral evaluation and enter Tier 2 (Figure 9). At least 12 months, and up to 24 months, must elapse before a member can become eligible for Tier 3. Given these time requirements, we examined the most common specialty services received by DWP members by tier and year.

Table 14 provides a breakdown of the percent of specialty services provided to members in each tier by year. For example, of the 23,981 resin based composites provided to DWP members in Year 1, 60% were provided to members while they were in Tier 1 and 40% were provided to members while they were in Tier 2. A few general trends can be seen in Table 14, which are depicted graphically in Figure 12.

The following services decreased from Year 1 to Year 2

• The number of complete dentures provided decreased by 49%, from 7,787 units to 3,999 units.• The number of extractions decreased by 9%, from 61,252 to 55,655.• The number of general anesthesia cases decreased by 27%, from 2,239 to 1,637.

The following services increased from Year 1 to Year 2

• Resin based composite restorations increased 56% and amalgam restorations increased by 47%. • The number of removable partial dentures provided increased from 2 to 591.• Periodontal services increased, with scaling/root planing increasing by 57% and periodontal

maintenance increasing by over 300%.• Denture repairs, adjustments, and relines increased by 54%.• Fixed prosthodontics (i.e. bridgework) increased by over 500% and single crowns increased

by nearly 1000%.

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Table 14. Percent of selected specialty services provided to DWP members by program year and tier

Year 1 Year 2Tier 1 Tier 2 Tier 3 Total

selected specialty services

Tier 1 Tier 2 Tier 3 Total selected specialty services

Member(%)

183,710 (95%)

9,215 (5%)

121,554 191,069 (86%)

21,969 (10%)

8,934 (4%)

139,200

Restorative

Resin based composites

60% 40% 23,981 40% 47% 13% 37,391

Amalgams 61% 39% 10,353 42% 45% 13% 15,219

Endodontics

Anterior root canal therapy

87% 13% 1,288 74% 18% 8% 1,415

Premolar root canal therapy

91% 9% 1,339 72% 19% 9% 1,518

Molar root ca-nal therapy

91% 9% 1,474 73% 20% 8% 1,771

Periodontal

Scaling/root planing

88% 12% 4,962 8% 83% 9% 7,790

Perio mainte-nance

55% 46% 772 13% 34% 53% 3,281

Full mouth debridements

99% 1% 2,797 96% 3 .5% <1% 2,254

Prosthodontics

Complete dentures

95% 5% 7,787 83% 13% 4% 3,999

Removable partial den-tures

50% 50% 2 2% 0 98% 591

Interim den-tures

91% 9% 2,011 77% 20% 3% 1,961

Repairs, adjustments, relines

77% 23% 981 48% 37% 15% 1,507

Fixed prost-hodontics (bridgework)

90% 10% 39 21% 4% 76% 237

Single crowns 28% 72% 277 3% 17% 80% 2,974

OMFS

Extractions 95% 5% 61,252 86% 10% 3% 55,655

General an-esthesia

95% 6% 2,239 80% 17% 3% 1,637

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Figure 12. Number of selected specialty services provided to DWP members in Years 1 and 2

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ConclusionsThe DWP earned benefit structure offers three levels of coverage to members. Core benefits (Tier 1) include emergency and stabilization services; members earn additional benefits in Tiers 2 and 3 if they return for regular dental care – specifically, routine oral evaluations. In the first year of implementation, approximately 20% of DWP members received a routine oral evaluation. This rate falls between the rate found in the adult FMAP population (16%) and the rate found in the adult SSI population (22%).

This low utilization of routine oral evaluations was reflected in the low numbers of DWP members who became eligible for Tier 2 and Tier 3 benefits. Among the DWP members who were enrolled in May 2014 (n=112,983), only 3% were in Tier 2 at the end of the first 2 years, along with another 4% in Tier 3. These low rates may be related to lack of knowledge about their dental benefit structure. A Public Policy Center survey of DWP members in 2015 found that more than two-thirds of respondents did not know about the three benefit levels prior to taking the survey.6 Low utilization rates also may be a partial function of high levels of churn in the DWP program. From the original May 2014 cohort, 45% were no longer enrolled in the DWP as of April 2016.

Cost analysis examined average per person monthly costs in DWP compared to MSP by applying a common fee schedule to services covered and adjusted for the characteristics of the members in both programs. These analyses showed that costs would be approximately $5 lower per DWP member than for MSP members, given the services received by each population. However, this difference may be related to the large proportion of DWP members that remained in Tier 1, and were thus ineligible for more complex dental care beyond emergency and stabilization services.

In additional models that adjusted for differences in the characteristics of the members, including demographics and chronic health conditions, there were no significant differences between DWP and MSP groups in the utilization of three key outcomes considered in this report: annual (any) dental visit, preventive or diagnostic dental services, and routine oral evaluations. However, modeling does indicate that utilization rates of these outcomes in DWP members (excluding ED visits) increased from Year 1 (2014-2015) to Year 2 (2015-2016). Since these models also take into account length of member eligibility, this change can be interpreted as a change in the overall DWP program performance – potentially related to improved program administration, participation by dentists, increased knowledge among members, or other factors.

Similarly, there were no significant differences in the utilization of EDs for non-traumatic dental conditions; DWP members were as likely to use the ED for dental-related diagnoses as MSP members. However, DWP members in Tier 2 were more likely to follow-up with a dentist within 60 days of an ED visit.

In general, the proportion of DWP members who received specialty dental services (e.g., root canal therapy, dentures, or extractions) was similar to utilization in the FMAP population; the SSI comparison group had slightly higher rates of prosthodontic services and oral and maxillofacial surgery. During Year 1, dentists delivered 7,787 complete dentures to DWP patients; this number decreased by nearly 50% in Year 2, indicating significant pent-up demand for this service in the DWP population. Tooth extractions also decreased slightly, with 55,655 extractions performed in Year 2.

6 Reynolds JC, Damiano PC, McKernan SC, et al. Evaluation of the Dental Wellness Plan: Member Experiences in the First Year. September 2015. http://ppc.uiowa.edu/sites/default/files/dwp_consumer_survey_report.pdf. Accessed 12/29/2016.

http://ppc.uiowa.edu/sites/default/files/dwp_consumer_survey_report.pdf

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AppendixA:TechnicalSpecifications

Measure 1: Annual (any) dental visit (Measures 1A & 1B)

1A Percent of members who had an annual (any) dental visitDefinition NCQA HEDIS ADV7; NQF 13888 adapted for adults

Proposed Analytic Method

1. Means tests between DWP members and 3 comparison groups before and after implementation

2. Incremental Cost-Effectiveness Ratio (ICER) utilizing DWP and MSP members and DWP and DDIA members before and after implementation

Variations from the Proposed Analytic Method

3. IowaCare and DDIA not included as a comparison groups

4. ICER comparing DWP and MSP members only; DWP and DDIA comparison will be included in final report.

Specifications

Numerator: One or more dental visits with a dental practitioner during the measurement year. A member had a dental visit if they had a submitted claim/encounter for any dental service.

Denominator: Unduplicated number of all enrolled adults

CDT codes: Any

1B Whether member received an annual (any)dental visit

Definition NCQA HEDIS ADV; NQF 1388 adapted for adults and individuals


1. Regression Discontinuity Design (RDD) comparing DWP members and MSP members at the threshold

2. Difference in Differences (DID) for DWP members and three comparison groups before and after implementation


1. Protocol for RDD is being developed for the final report

2. DID will compare DWP and MSP members only.

Measure 6: First preventive oral evaluation* (Measures 6A & 6B)

6A Percent of members who have a routine oral evaluation within their first 6-12 months in the programDefinition Original measureProposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation


IowaCare and DDIA not included as a comparison groups.

Specifications

Dental exam defined using Dental Quality Alliance (DQA) technical specifications and DWP exam requirements.

Numerator: Unduplicated number of all enrolled adults with ≥ 6 months enrollment who received a comprehensive or periodic oral evaluation.

Denominator: Unduplicated number of all enrolled adults with ≥ 6 months enrollment.

CDT Codes: D0120 (periodic oral evaluation), 0150 (comprehensive oral evaluation), 0180 (comprehensive periodontal evaluation)

Note: DQA Proposed Adult Measures only specify CDT codes for periodontal maintenance and fluoride application.

7 National Committee for Quality Assurance (NCQA). Healthcare Effectiveness Data and Information Set (HEDIS®) Measures. Available at http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

8 National Quality Forum (NQF), National Voluntary Consensus Standards for Child Health Quality Measures: A Consensus Report, Washington, DC: NQF; 2011. Available at https://www.qualityforum.org/Projects/c-d/Child_Health_Quality_Measures_2010/Final_Report.aspx.

http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

https://www.qualityforum.org/Projects/c-d/Child_Health_Quality_Measures_2010/Final_Report.aspx

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6B Whether member received a routine oral evaluation within their first 6-12 months in the program Definition Original measureProposed Analytic Method DID for DWP members and three comparison groups before and after implementation


DDIA not included as a comparison groups.

*This measure previously used the term “dental exam”, which was replaced with “oral evaluation” for clarification.

Measure 7: Second preventive oral evaluation (recall)* (Measures 7A & 7B)

7A Percent of members who have a recall within 6-12 months of their first oral evaluation Definition Original measureProposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation


Protocol is being developed for final report.

7B Whether member received a recall within 6-12 months of their first oral evaluation Definition Original measure


1. RDD comparing DWP members and MSP members at the threshold

2. DID for DWP members and three comparison groups before and after implementationVariations from the Proposed Analytic Method


*This measure was previously used the term “dental exam”, which was replaced with “oral evaluation” for clarification.

Measure 8: Any diagnostic or preventive dental care

Percent of members who receive any diagnostic or preventive dental careDefinition Original measureProposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation



Specifications

Preventive and diagnostic services defined based on CMS 416 (Lines 12B and 12E)

Numerator: Unduplicated number of all enrolled adults who received a diagnostic or preventive dental service

Denominator: Unduplicated number of all enrolled adults.

CDT Codes: Preventive (D1000-1999)

Diagnostic (D0100-0999)

For cost and DID analyses, preventive dental services were restricted to D1000-1360; radiographic services were excluded since they are not strictly preventive. Diagnostic dental services were restricted to routine oral evaluations (D0120, D0150, D0180) and caries risk assessments (D0601-0603).

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Measure 9: Use of ED for non-traumatic dental related treatment (Measures 9A & 9B)

9A Percent of members who were seen for non-traumatic dental reasons in an ED for 1, 2, 3 or more visits per year while controlling for the earned benefit tier Definition Dental Quality Alliance (DQA) Proposed Adult Measures9


1. Means tests between DWP members and three comparison groups before and after implementation

2. ICER utilizing DWP and MSP members and DWP and DDIA members before and after implementationVariations from the Proposed Analytic Method

1. ED will be calculated as visits per 1,000 months

2. ICER compares DWP and MSP members only

Specifications

Non-traumatic dental diagnoses: Primary diagnosis code (ICD-9) 521.00-529.9.

Numerator: Unduplicated number of adults who were seen in an ER for 1, 2, 3 or more visits for non-traumatic dental reasons.

Denominator: Unduplicated number of all enrolled adults seen in an ER at least once for any reason.

For cost analyses, dental ED visits were identified by revenue codes 450-459 and 981 based on the HEDIS definition. Equivalence mapping for ICD-9 diagnostic codes to ICD-10 are available upon request.

9B Percent of members who were seen in the ED for non-traumatic dental related reasons within the reporting year and visited a dentist for treatment services within 60 days following the ED visit while controlling for the earned benefit tierDefinition DQA Proposed Adult MeasuresProposed Analytic Method Means tests between DWP members and the three comparison groups



Specifications

Numerator: Unduplicated number of adults who were seen in the ED for non-traumatic dental related reasons in the reporting year and visited a dentist for treatment services within 60 days following the ED visit.

Denominator: Unduplicated number of all enrolled adults seen in an ED for non-traumatic dental related reasons.

9 Dental Quality Alliance (DQA). Proposed Adult Measures. Available at http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/DQA_2016_Measures_Under_Consideration.pdf?la=en.

http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/DQA_2016_Measures_Under_Consideration.pdf?la=en

http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/DQA_2016_Measures_Under_Consideration.pdf?la=en

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Measure 12: People with diabetes: oral evaluation* (Measures 12A & 12B)

12A Percent of DWP members identified as people with diabetes who have a dental exam within the reporting yearDefinition DQA Proposed Adult Measures


1. Descriptives and comparisons for DWP members over time

2. Means tests between DWP members and MSP members over time

3. ICER utilizing DWP and MSP members and DWP and DDIA members before and after implementationVariations from the Proposed Analytic Method

ICER compares DWP and MSP members only.

Specifications

Diabetes: At least one emergency visit defined by one of the procedure codes: 99281-99288 or one of the revenue codes: 450-459, 981 and with a principal diagnosis of diabetes (ICD-9-CM 250.00-250.99, 357.2, 362.0, 366.41, 648.0) or one hospital discharge defined by one of the procedure codes: 99221-99223, 99231-99233, 99238, 99239, 99251-99255, 99261-99263, or 99291 or one of the revenue codes (100-149, 119, 120-124, 129, 150-154, 159, 160-169, 200-229, 720-729, or 987) with a principal diagnosis of diabetes (ICD-9-CM 250.00-250.99, 357.2, 362.0, 366.41, 648.0 or DRG 205 or 294).

At least one outpatient/physician/non-acute inpatient visits defined by one of the procedure codes: 92002-92014, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99271-99275, 99289, 99290, 99301-99303, 99311-99313, 99321-99323, 99331-99333, 99341-99355, 99384-99387, 99394-99397, 99410-99404, 99411, 99412, 99420, 99429, 99499 or one of the revenue codes: 118, 128, 138, 148, 158, 190-199, 510-529, 550-559, 570-599, 660-669, 770-779, 820-859, 880-889, 982 or 983 and with a diagnosis of diabetes (ICD-9-CM 250.00-250.99, 357.2, 362.0, 366.41, 648.0).

Numerator: Unduplicated number of all enrolled adults (enrolled at least 11 months in the study year) identified as people with diabetes who received a comprehensive or periodic oral evaluation OR comprehensive periodontal examination at least once.

Denominator: Unduplicated number of all enrolled adults (enrolled at least 11 months in the study year) identified as people with diabetes.

CDT Codes: D0120 (recall), 0150 (comprehensive), or 0180 (comprehensive periodontal exam)

*This measure was previously used the term “dental exam”, which was replaced with “oral evaluation” for clarification.

12B Whether a member identified as having diabetes had a dental exam within the reporting year Definition DQA Proposed Adult MeasuresProposed Analytic Method DID for DWP members and MSP members before and after implementation


DDIA not included as a comparison group. Additional utilization regression analysis was also performed.

Measure 21: Compare DWP member per member per month (PMPM) dental costs to those of MSP members (Measures 21A & 21B)

21A PMPM dental costs calculated for direct provision of care per member per month

Definition DQA Proposed Adult Measures


1. RDD comparing DWP members and MSP members at the threshold

2. DID for DWP members and MSP members before and after implementationVariations from the Proposed Analytic Method

DDIA is not included as a comparison group.

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21B PMPM dental costs calculated for direct provision of care per member per month for all enrolled adults who received at least one dental service during the reporting yearDefinition DQA Proposed Adult MeasuresProposed Analytic Method DID for DWP members and MSP members before and after implementation


Protocol is being developed for the final report.

Measure 23: Routine oral evaluations* (Measures 23A & 23B)

23A Percent of members who received a comprehensive or periodic oral evaluation within the reporting year Definition DQA Proposed Adult MeasuresProposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation

Variations from the Proposed Analytic Method in Interim Report

1. IowaCare and DDIA not included as a comparison groups.

2. D0180 also included as a qualifying oral evaluation for this measure.

Specifications

Dental exam defined using DQA technical specifications and DWP exam requirements.

Numerator: Unduplicated number of all enrolled adults who received a comprehensive or periodic oral evaluation.

Denominator: Unduplicated number of all enrolled adults.

CDT Codes: D0120 (periodic oral evaluation), 0150 (comprehensive evaluation), or 0180 (comprehensive periodontal evaluation)

23B Percent of members who accessed dental care (received at least one service) who received a comprehensive or periodic oral evaluation within the reporting yearDefinition DQA Proposed Adult Measures

Proposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation



Specifications

Numerator: Unduplicated number of all enrolled adults who received a comprehensive or periodic oral evaluation.

Denominator: Unduplicated number of all enrolled adults who received at least one dental service.

CDT Codes: D0120, 0150, 180

*This measure was previously used the term “routine dental exam”, which was replaced with “oral evaluation” for clarification.

Measure 24: Timing of 1st recall visit

Percent of members who receive their 1st recall exam within 6-12 months of initial oral evaluationDefinition Original measureProposed Analytic Method Descriptives and comparisons for DWP over time



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Measure 25: Timing of 2nd recall visit

Percent of members who receive their 2nd recall visit within 6-12 months of 1st recallDefinition Original measureProposed Analytic Method Descriptives and comparisons for DWP over time



Measure 26: Recall exams after year one of enrollment

Percent of members who receive their 2nd recall visit within 6-12 months of 1st recall in each year of enrollmentDefinition Original measureProposed Analytic Method Means tests between DWP members and three comparison groups before and after implementation



Measure 37: Specialty dental utilization

Percent of members receiving any specialty dental servicesDefinition Original measureProposed Analytic Method Means tests between DWP members and three comparison groups


IowaCare and DDIA not included as comparison groups.

Specifications

Measure 39: Time to recall exams at 6-12 month intervals

Time to recall exams at 6-12 month intervals when recall visits are defined as any visit that includes a comprehensive or periodic oral evaluationDefinition Original measureProposed Analytic Method Survival analyses for new members in DWP and MSP



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Appendix B: Linear and Logistic DID Results Predicting Annual (Any) Dental Visit

Logistic regression

Variable Estimate Standard Error

95% Confidence Intervals Z Pr > |Z|

Intercept -3.1255 0.0529 -3.2293 -3.0218 -59.04 <.0001

Year 1 -0.1279 0.0135 -0.1543 -0.1014 -9.47 <.0001

Year 2 -0.1416 0.0149 -0.1708 -0.1125 -9.52 <.0001

Program

FMAP 0.1757 0.0216 0.1334 0.2180 8.15 <.0001

IowaCare or DWP -0.9383 0.0972 -1.1288 -0.7477 -9.65 <.0001

SSI Referent group

In DWP Year 1 1.1371 0.1140 0.9137 1.3605 9.98 <.0001

In DWP Year 2 1.2307 0.1139 1.0074 1.4540 10.80 <.0001

Institutional level of care -0.0067 0.0255 -0.0567 0.0433 -0.26 0.7934

Has reduced spending months -0.1093 0.0118 -0.1324 -0.0862 -9.27 <.0001

Newly eligible for dental services in the year 0.1001 0.0208 0.0593 0.1410 4.80 <.0001

Months since newly eligible for DWP 0.0384 0.0650 -0.0890 0.1658 0.59 0.5550

Months since newly eligible for SSI -0.0830 0.0478 -0.1766 0.0106 -1.74 0.0822

Months since newly eligible for FMAP 0.0347 0.0293 -0.0226 0.0921 1.19 0.2351

Months since newly eligible for IowaCare 0.1402 0.0644 0.0141 0.2664 2.18 0.0294

Has Mental Health diagnosis 0.3418 0.0129 0.3165 0.3671 26.46 <.0001

Has Obesity diagnosis 0.1738 0.0157 0.1430 0.2046 11.05 <.0001

Has Substance Abuse -0.0106 0.0187 -0.0473 0.0261 -0.57 0.5715

Has Heart Disease diagnosis 0.0518 0.0152 0.0221 0.0815 3.42 0.0006

Has Diabetes -0.0002 0.0198 -0.0390 0.0387 -0.01 0.9937

Race

American Indian -0.0016 0.0559 -0.1113 0.1080 -0.03 0.9769

Asian -0.1314 0.0579 -0.2448 -0.0180 -2.27 0.0231

Black -0.0968 0.0208 -0.1376 -0.0560 -4.65 <.0001

Hispanic 0.1808 0.0390 0.1044 0.2572 4.64 <.0001

Multiple-Hispanic 0.0883 0.0591 -0.0275 0.2041 1.49 0.1351

Multiple-other -0.0752 0.0805 -0.2329 0.0825 -0.93 0.3500

Pacific Islander -0.0915 0.0955 -0.2786 0.0956 -0.96 0.3378

Unknown -0.0612 0.0159 -0.0923 -0.0301 -3.86 0.0001

White Referent group

Male -0.2687 0.0132 -0.2945 -0.2428 -20.35 <.0001

Age groups

21-44 years 0.1232 0.0440 0.0369 0.2095 2.80 0.0051

45-65 years 0.0585 0.0454 -0.0304 0.1474 1.29 0.1968

19-20 years Referent group

% of Federal Poverty Level (FPL)

0% FPL Referent group

38-75% FPL 0.1246 0.0152 0.0949 0.1543 8.22 <.0001

76-100% FPL 0.1568 0.0212 0.1152 0.1984 7.39 <.0001

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1-37% FPL 0.1015 0.0148 0.0726 0.1304 6.87 <.0001

101-133% FPL 0.1859 0.0233 0.1401 0.2316 7.96 <.0001

134% and over FPL 0.0901 0.0461 -0.0003 0.1806 1.95 0.0507

Urbanicity

Urban Influence code 3-12 -0.1038 0.0126 -0.1285 -0.0791 -8.23 <.0001

Urban Influence code 1-2 Referent group

Number of months in Medicaid 0.1908 0.0023 0.1864 0.1952 84.40 <.0001

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Linear regression



Intercept -0.0524 0.0085 -0.0691 -0.0357 -6.15 <.0001

Year 1 -0.0244 0.0027 -0.0297 -0.0191 -9.00 <.0001

Year 2 -0.0268 0.0030 -0.0327 -0.0208 -8.81 <.0001

Program

FMAP 0.0397 0.0044 0.0310 0.0484 8.96 <.0001

IowaCare or DWP 0.0219 0.0095 0.0033 0.0405 2.31 0.0210

SSI Referent group

In DWP Year 1 0.0341 0.0159 0.0030 0.0652 2.15 0.0315

In DWP Year 2 0.0523 0.0158 0.0213 0.0834 3.30 0.0010

Institutional level of care -0.0014 0.0057 -0.0126 0.0098 -0.25 0.8035



Months since newly eligible for DWP -0.0088 0.0134 -0.0351 0.0175 -0.65 0.5139

Months since newly eligible for SSI -0.0155 0.0082 -0.0315 0.0006 -1.89 0.0590


Months since newly eligible for IowaCare 0.0271 0.0054 0.0166 0.0375 5.06 <.0001



Has Substance Abuse -0.0008 0.0037 -0.0081 0.0064 -0.23 0.8194


Has Diabetes 0.0012 0.0038 -0.0063 0.0086 0.30 0.7625

Race

American Indian 0.0002 0.0096 -0.0186 0.0190 0.02 0.9825

Asian -0.0204 0.0088 -0.0376 -0.0032 -2.33 0.0201

Black -0.0162 0.0035 -0.0231 -0.0092 -4.56 <.0001

Hispanic 0.0286 0.0066 0.0156 0.0416 4.31 <.0001


Multiple-other -0.0149 0.0131 -0.0405 0.0107 -1.14 0.2536


Unknown -0.0106 0.0026 -0.0156 -0.0056 -4.12 <.0001


Male -0.0441 0.0022 -0.0483 -0.0399 -20.39 <.0001

Age groups

21-44 years 0.0205 0.0073 0.0062 0.0347 2.80 0.0050

45-65 years 0.0100 0.0075 -0.0047 0.0247 1.34 0.1814




38-75% FPL 0.0211 0.0027 0.0157 0.0264 7.72 <.0001

76-100% FPL 0.0254 0.0038 0.0180 0.0327 6.74 <.0001

1-37% FPL 0.0182 0.0027 0.0129 0.0235 6.69 <.0001

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101-133% FPL 0.0269 0.0040 0.0191 0.0348 6.75 <.0001

134% and over FPL 0.0094 0.0056 -0.0016 0.0203 1.68 0.0936

Urbanicity




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Appendix C: Linear and Logistic Regression Results Predicting Any Preventive or Diagnostic Service –

Logistic regression



Intercept -3.7947 0.0632 -3.9186 -3.6707 -60.00 <.0001

Year 1 -0.1372 0.0155 -0.1676 -0.1068 -8.85 <.0001

Year 2 -0.1497 0.0166 -0.1823 -0.1171 -8.99 <.0001

Program

FMAP 0.1458 0.0250 0.0968 0.1949 5.83 <.0001

IowaCare or DWP -1.9678 0.1402 -2.2427 -1.6930 -14.03 <.0001

SSI Referent group

In DWP Year 1 2.3798 0.1604 2.0653 2.6943 14.83 <.0001

In DWP Year 2 2.4240 0.1601 2.1102 2.7377 15.14 <.0001

Institutional level of care 0.0056 0.0280 -0.0492 0.0605 0.20 0.8404



Months since newly eligible for DWP 0.1631 0.0779 0.0104 0.3158 2.09 0.0363

Months since newly eligible for SSI -0.1672 0.0558 -0.2767 -0.0578 -3.00 0.0027


Months since newly eligible for IowaCare 0.0990 0.1366 -0.1687 0.3667 0.73 0.4684



Has Substance Abuse -0.1506 0.0214 -0.1924 -0.1087 -7.05 <.0001


Has Diabetes -0.0441 0.0224 -0.0881 -0.0002 -1.97 0.0492

Race

American Indian -0.2068 0.0687 -0.3415 -0.0722 -3.01 0.0026

Asian -0.0984 0.0656 -0.2269 0.0302 -1.50 0.1336

Black -0.2490 0.0250 -0.2980 -0.2001 -9.97 <.0001

Hispanic 0.1787 0.0447 0.0910 0.2663 4.00 <.0001


Multiple-other -0.0488 0.0942 -0.2335 0.1358 -0.52 0.6043


Unknown -0.0120 0.0182 -0.0476 0.0236 -0.66 0.5080


Male -0.2663 0.0153 -0.2963 -0.2363 -17.40 <.0001

Age groups

21-44 years 0.0924 0.0526 -0.0106 0.1955 1.76 0.0788

45-65 years 0.0893 0.0541 -0.0167 0.1953 1.65 0.0988


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38-75% FPL 0.1770 0.0173 0.1430 0.2109 10.22 <.0001

76-100% FPL 0.1819 0.0238 0.1353 0.2286 7.64 <.0001

1-37% FPL 0.1020 0.0169 0.0689 0.1352 6.04 <.0001

101-133% FPL 0.2390 0.0257 0.1886 0.2894 9.29 <.0001

134% and over FPL 0.2084 0.0561 0.0984 0.3185 3.71 0.0002

Urbanicity




Linear regression



Intercept -0.0892 0.0073 -0.1035 -0.0748 -12.22 <.0001

Year 1 -0.0221 0.0023 -0.0267 -0.0175 -9.40 <.0001

Year 2 -0.0237 0.0026 -0.0288 -0.0187 -9.20 <.0001

Program

FMAP 0.0277 0.0039 0.0200 0.0354 7.06 <.0001

IowaCare or DWP 0.0517 0.0082 0.0356 0.0677 6.31 <.0001

SSI Referent group

In DWP Year 1 0.0422 0.0150 0.0128 0.0715 2.82 0.0048

In DWP Year 2 0.0517 0.0149 0.0224 0.0809 3.47 0.0005

Institutional level of care 0.0004 0.0050 -0.0094 0.0101 0.08 0.9391



Months since newly eligible for DWP -0.0005 0.0130 -0.0260 0.0251 -0.04 0.9709

Months since newly eligible for SSI -0.0196 0.0067 -0.0328 -0.0065 -2.92 0.0035

Months since newly eligible for FMAP 0.0107 0.0042 0.0025 0.0189 2.56 0.0106

Months since newly eligible for IowaCare 0.0264 0.0039 0.0188 0.0340 6.85 <.0001



Has Substance Abuse -0.0224 0.0032 -0.0288 -0.0161 -6.97 <.0001

Has Heart Disease diagnosis 0.0047 0.0025 -0.0002 0.0096 1.89 0.0585

Has Diabetes -0.0040 0.0034 -0.0106 0.0027 -1.17 0.2419

Race

American Indian -0.0287 0.0079 -0.0443 -0.0132 -3.63 0.0003

Asian -0.0111 0.0077 -0.0262 0.0041 -1.43 0.1528

Black -0.0317 0.0030 -0.0375 -0.0259 -10.64 <.0001

Hispanic 0.0231 0.0059 0.0115 0.0346 3.91 <.0001


Multiple-other -0.0075 0.0117 -0.0304 0.0154 -0.64 0.5203


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Unknown -0.0023 0.0023 -0.0068 0.0021 -1.02 0.3055


Male -0.0337 0.0019 -0.0374 -0.0300 -17.89 <.0001

Age groups

21-44 years 0.0099 0.0061 -0.0021 0.0219 1.61 0.1067

45-65 years 0.0107 0.0063 -0.0018 0.0231 1.68 0.0923




38-75% FPL 0.0260 0.0024 0.0213 0.0308 10.73 <.0001

76-100% FPL 0.0253 0.0034 0.0186 0.0319 7.45 <.0001

1-37% FPL 0.0140 0.0024 0.0093 0.0187 5.87 <.0001

101-133% FPL 0.0299 0.0036 0.0229 0.0370 8.29 <.0001

134% and over FPL 0.0142 0.0046 0.0051 0.0233 3.05 0.0023

Urbanicity




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Appendix D: Effect of DWP Enrollment on Utilization of Dental Care Services

Full Population

Variable

Number of Dental Exams

Coefficient (SE)

Number of Preventive Visits

Coefficient (SE)

Number of ER Visits

Coefficient (SE)

Number of Any Visits

Coefficient (SE)

DWP 0.003*** 0.022*** -0.000 0.025***(0.000) (0.000) (0.000) (0.001)

Age 0.000*** 0.000*** -0.000*** 0.000***(0.000) (0.000) (0.000) (0.000)

Male -0.006*** -0.018*** 0.001*** -0.024***(0.000) (0.000) (0.000) (0.001)

Has Mental Health Problem 0.007*** 0.018*** 0.001*** 0.025***(0.000) (0.001) (0.000) (0.001)

Has Substance Abuse Problem -0.004*** -0.012*** 0.003*** -0.015***(0.000) (0.001) (0.000) (0.001)

Has Asthma 0.002*** 0.005*** 0.001*** 0.007***(0.000) (0.001) (0.000) (0.001)

Has Diabetes 0.000 -0.000 -0.000 0.000(0.000) (0.001) (0.000) (0.001)

Has CAD -0.000 -0.001 -0.000 -0.001(0.000) (0.001) (0.000) (0.001)

Has Obesity 0.005*** 0.012*** -0.000* 0.017***(0.000) (0.001) (0.000) (0.001)

Has Hypertension 0.002*** 0.004*** 0.000 0.006***(0.000) (0.001) (0.000) (0.001)

Has Parkinson’s/MS 0.010*** 0.024*** -0.000 0.034***(0.002) (0.006) (0.001) (0.008)

Has COPD or Emphysema -0.000 -0.003*** 0.001*** -0.003***(0.000) (0.001) (0.000) (0.001)

Has Renal Failure -0.005*** -0.012*** -0.001*** -0.016***(0.001) (0.002) (0.000) (0.003)

Has Chronic Kidney Disease -0.000 -0.002 0.000 -0.002(0.001) (0.002) (0.000) (0.003)

Has AMI -0.006*** -0.016*** -0.001*** -0.022***(0.001) (0.003) (0.000) (0.005)

Has Dementia 0.000 -0.002 0.001 -0.002(0.004) (0.010) (0.002) (0.014)

Has Developmental Delay 0.005 0.015* -0.002** 0.021*(0.004) (0.009) (0.001) (0.012)

Has Depression -0.000 -0.001 0.000 -0.001(0.000) (0.001) (0.000) (0.001)

Has Intellectual Delay 0.006 0.010 -0.002** 0.015(0.004) (0.010) (0.001) (0.014)

Has Schizophrenia -0.001 -0.003 0.001 -0.004(0.001) (0.004) (0.001) (0.005)

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Has Mood Disorder 0.001 0.000 0.001*** 0.001(0.000) (0.001) (0.000) (0.002)

Has Anxiety -0.000 -0.001 0.001*** -0.002(0.000) (0.001) (0.000) (0.001)

Has Major CA 0.002* 0.006** -0.001*** 0.008**(0.001) (0.003) (0.000) (0.004)

Constant 0.011*** 0.019*** 0.006*** 0.029***(0.002) (0.004) (0.001) (0.006)

N 6,142,456 6,142,456 6,142,456 6,142,456Persons 351,416 351,416 351,416 351,416R-squared 0.002 0.003 0.001 0.003

*** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level

Robust standard errors in parentheses are clustered at the individual level

Population with Diabetes

Variable

Number of Dental Exams

Coefficient (SE)

Number of Preventive Visits

Coefficient(SE)

Number of ER Visits

Coefficient(SE)

Number of Any Visits

Coefficient(SE)

DWP 0.006*** 0.029*** -0.000 0.036***(0.001) (0.002) (0.000) (0.003)

Age 0.000*** 0.000*** -0.000*** 0.001***(0.000) (0.000) (0.000) (0.000)

Male -0.005*** -0.016*** 0.000 -0.021***(0.001) (0.002) (0.000) (0.003)

Has Mental Health Problem 0.002 0.004 0.001 0.006(0.001) (0.004) (0.000) (0.005)

Has Substance Abuse Problem -0.004*** -0.009*** 0.001* -0.013***(0.001) (0.003) (0.000) (0.004)

Has Asthma -0.001 -0.001 0.001 -0.002(0.001) (0.003) (0.000) (0.004)

Has CAD -0.003*** -0.008*** 0.000 -0.011***(0.001) (0.002) (0.000) (0.003)

Has Obesity 0.005*** 0.013*** -0.000* 0.018***(0.001) (0.002) (0.000) (0.003)

Has Hypertension -0.001* -0.003 0.000 -0.004(0.001) (0.002) (0.000) (0.003)

Has Parkinson’s/MS 0.009 0.013 -0.002*** 0.022(0.007) (0.017) (0.000) (0.024)

Has COPD or Emphysema -0.001 -0.006** 0.001* -0.007*(0.001) (0.002) (0.000) (0.003)

Has Renal Failure -0.006*** -0.014*** -0.001* -0.020***(0.001) (0.003) (0.000) (0.005)

Has Chronic Kidney Disease 0.002 0.003 -0.000 0.005(0.002) (0.004) (0.001) (0.006)

Has AMI -0.005** -0.017*** -0.001*** -0.023***(0.002) (0.005) (0.000) (0.007)

Has Dementia -0.010 -0.030* 0.001 -0.040*(0.007) (0.016) (0.002) (0.023)

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Has Developmental Delay -0.001 0.004 -0.003*** 0.003(0.008) (0.023) (0.001) (0.031)

Has Depression 0.001 0.004 -0.000 0.004(0.001) (0.003) (0.000) (0.005)

Has Intellectual Delay 0.013 0.021 -0.000 0.034(0.010) (0.024) (0.002) (0.032)

Has Schizophrenia -0.003 -0.013 0.001 -0.016(0.004) (0.011) (0.002) (0.015)

Has Mood Disorder 0.004*** 0.007* 0.001* 0.011**(0.001) (0.004) (0.001) (0.005)

Has Anxiety -0.001 -0.003 0.000 -0.004(0.001) (0.003) (0.000) (0.004)

Has Major CA -0.002 -0.005 -0.000 -0.007(0.003) (0.007) (0.000) (0.009)

Constant 0.007 -0.007 0.008*** 0.000(0.007) (0.014) (0.002) (0.021)

N 364,724 364,724 364,724 364,724Persons 19,861 19,861 19,861 19,861R-squared 0.003 0.004 0.002 0.004

*** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level

Robust standard errors in parentheses are clustered at the individual level

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Appendix E: Linear and Logistic Regression Results Predicting a Routine Oral Evaluation

Logistic regression results for routine oral evaluation



Intercept -3.8967 0.0645 -4.0231 -3.7702 -60.41 <.0001Year 1 -0.1332 0.0158 -0.1642 -0.1022 -8.43 <.0001Year 2 -0.1495 0.0169 -0.1825 -0.1164 -8.86 <.0001Program

FMAP 0.1401 0.0252 0.0908 0.1894 5.57 <.0001IowaCare or DWP -1.927 0.142 -2.2054 -1.6486 -13.57 <.0001SSI Referent group

In DWP Year 1 2.3385 0.162 2.0209 2.6561 14.43 <.0001In DWP Year 2 2.3674 0.1617 2.0505 2.6842 14.64 <.0001Institutional level of care -0.0006 0.0284 -0.0562 0.055 -0.02 0.9831Has reduced spending months -0.1308 0.0168 -0.1638 -0.0979 -7.78 <.0001Newly eligible for dental services in the year 0.1067 0.0238 0.06 0.1534 4.48 <.0001Months since newly eligible for DWP 0.1476 0.0777 -0.0048 0.3 1.9 0.0576Months since newly eligible for SSI -0.1753 0.0561 -0.2853 -0.0652 -3.12 0.0018Months since newly eligible for FMAP 0.0699 0.0339 0.0036 0.1363 2.07 0.0388Months since newly eligible for IowaCare 0.1249 0.1377 -0.1451 0.3948 0.91 0.3646Has Mental Health diagnosis 0.3264 0.0148 0.2973 0.3554 22.03 <.0001Has Obesity diagnosis 0.1537 0.0177 0.119 0.1884 8.68 <.0001Has Substance Abuse -0.1509 0.0215 -0.193 -0.1088 -7.02 <.0001Has Heart Disease diagnosis 0.0314 0.0174 -0.0027 0.0654 1.8 0.0711Has Diabetes -0.0427 0.0225 -0.0868 0.0014 -1.9 0.0579Race

American Indian -0.2018 0.0696 -0.3382 -0.0653 -2.9 0.0038Asian -0.1063 0.066 -0.2357 0.023 -1.61 0.1071Black -0.2602 0.0252 -0.3097 -0.2107 -10.31 <.0001Hispanic 0.1826 0.0447 0.0949 0.2703 4.08 <.0001Multiple-Hispanic 0.0485 0.0706 -0.0898 0.1869 0.69 0.492Multiple-other -0.0725 0.096 -0.2607 0.1156 -0.76 0.4499Pacific Islander -0.0425 0.1061 -0.2505 0.1654 -0.4 0.6885Unknown -0.0103 0.0183 -0.0461 0.0255 -0.57 0.5712White Referent group

Male -0.267 0.0154 -0.2972 -0.2369 -17.34 <.0001Age groups

21-44 years 0.1251 0.0536 0.0201 0.2301 2.34 0.019545-65 years 0.1262 0.055 0.0184 0.2341 2.29 0.021819-20 years Referent group



38-75% FPL 0.1834 0.0175 0.1491 0.2177 10.49 <.000176-100% FPL 0.1798 0.0241 0.1327 0.227 7.47 <.00011-37% FPL 0.1018 0.0171 0.0683 0.1353 5.96 <.0001101-133% FPL 0.2389 0.026 0.1879 0.2899 9.18 <.0001

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134% and over FPL 0.1573 0.0573 0.045 0.2695 2.75 0.006Urbanicity

Urban Influence code 3-12 -0.0991 0.0146 -0.1277 -0.0705 -6.78 <.0001Urban Influence code 1-2 Referent group


Linear regression results for routine oral evaluation



Intercept -0.0923 0.0071 -0.1063 -0.0783 -12.94 <.0001Year 1 -0.0208 0.0023 -0.0254 -0.0162 -8.86 <.0001Year 2 -0.023 0.0026 -0.028 -0.018 -9 <.0001Program

FMAP 0.0261 0.0039 0.0185 0.0337 6.74 <.0001IowaCare or DWP 0.0544 0.008 0.0388 0.07 6.83 <.0001SSI Referent group

In DWP Year 1 0.0375 0.0146 0.0088 0.0662 2.56 0.0105In DWP Year 2 0.0439 0.0146 0.0153 0.0725 3.01 0.0026Institutional level of care -0.0007 0.0049 -0.0103 0.0089 -0.14 0.8888Has reduced spending months -0.0321 0.0009 -0.0339 -0.0303 -35.14 <.0001Newly eligible for dental services in the year 0.0212 0.0026 0.016 0.0263 8.02 <.0001Months since newly eligible for DWP -0.0033 0.0128 -0.0283 0.0217 -0.26 0.7948Months since newly eligible for SSI -0.0202 0.0066 -0.033 -0.0073 -3.07 0.0021Months since newly eligible for FMAP 0.0117 0.0041 0.0037 0.0198 2.86 0.0043Months since newly eligible for IowaCare 0.0262 0.0038 0.0188 0.0336 6.95 <.0001Has Mental Health diagnosis 0.0496 0.0022 0.0453 0.054 22.48 <.0001Has Obesity diagnosis 0.0275 0.0029 0.0219 0.0331 9.6 <.0001Has Substance Abuse -0.0222 0.0032 -0.0284 -0.016 -7 <.0001Has Heart Disease diagnosis 0.0037 0.0025 -0.0011 0.0085 1.5 0.1343Has Diabetes -0.004 0.0033 -0.0105 0.0026 -1.19 0.2351Race

American Indian -0.0273 0.0079 -0.0427 -0.0119 -3.48 0.0005Asian -0.0119 0.0075 -0.0267 0.0029 -1.57 0.1159Black -0.0321 0.0029 -0.0378 -0.0263 -10.98 <.0001Hispanic 0.023 0.0058 0.0116 0.0343 3.97 <.0001Multiple-Hispanic 0.0094 0.0097 -0.0096 0.0283 0.97 0.3341Multiple-other -0.0101 0.0115 -0.0326 0.0123 -0.88 0.3772Pacific Islander -0.0004 0.0139 -0.0277 0.0268 -0.03 0.9745Unknown -0.0021 0.0022 -0.0065 0.0022 -0.96 0.3361

White Referent groupMale -0.0331 0.0019 -0.0367 -0.0294 -17.86 <.0001Age groups

21-44 years 0.0134 0.006 0.0017 0.0251 2.24 0.025245-65 years 0.0147 0.0062 0.0026 0.0268 2.38 0.017519-20 years Referent group

% of Federal Poverty Level (FPL)0% FPL Referent group1-37% FPL 0.0137 0.0024 0.0091 0.0183 5.82 <.0001

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38-75% FPL 0.0265 0.0024 0.0218 0.0312 11.07 <.000176-100% FPL 0.0243 0.0034 0.0177 0.0308 7.24 <.0001101-133% FPL 0.0295 0.0036 0.0225 0.0365 8.28 <.0001134% and over FPL 0.01 0.0045 0.0012 0.0187 2.22 0.0261

UrbanicityUrban Influence code 3-12 -0.0136 0.0019 -0.0173 -0.01 -7.3 <.0001Urban Influence code 1-2 Referent group


Access, Utilization & Cost Outcomes: Iowa Dental Wellness ... · Page 1 Return to TOC March 2017...

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