Improving Accessibility and Utilization of Dental Services for Vulnerable Populations

Child Health Policy Research Symposium

University of Southern California

March 2, 2009Dana Hughes, DrPHInstitute for Health Policy Studies & Dept. of Family and Community Medicine

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• Models of Improved Access and Utilization

– Outreach and enrollment

– Insurance

– Providers

• Policy Implications

– Opportunities and Challenges

SECTION HEADING

High Level of Need Among Children in California

• Two-thirds of Kindergarteners and third graders have filled cavities and 28% have untreated cavities

• One-fourth of children ages 0-11 have never visited a dentist

• Half of all children ages 0-5 have never visited a dentist

• Children ages 0-11 with:

• No insurance: 40% never visited a dentist

• Denti-Cal: 27% never visited a dentist

• HF and other public: 16% never visited a dentist

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Pregnant Women, California, 2002-2007

Dental problem No dental care No dental care-women w/dental

problem

52% 66% 62%

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Dental problems and lack of receipt of dental care during pregnancy among women delivering in CA,

MIHA 2002-2007 (n=21,732)

Marchi, K , Weintraub, et .al . UCSF Center on Social Disparities in Health, Dept. of Family and Community Medicine. Unpublished data.

Children’s Health Initiatives

Two major components:

• New insurance product called “Healthy Kids”

• Aggressive and coordinated outreach and enrollment assistance

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Enrollment Analysis

• Quasi-Experiment That Compares Enrollment Before and After CHI Between:

– Santa Clara County (“treatment sample”)

– External comparison area (“comparison sample”)

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Outcome Measure

• New Entries to Medi-Cal and Healthy Families from 2001-2002:

“All children enrolling in Medi-Cal or Healthy Families who have not had coverage through one of these programs in the prior 11 months”

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CHI Has Had a Significant Impact

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Medi-Cal and Healthy Families

Without CHIWith CHI

Source: Enrollment Files for the Medi-Cal and Healthy Families Programs. *Difference is significantly different at the .01 level.

Ne

w

En

trie

s

48,629

62,084*

Total Impact: Medi-Cal, Healthy Families and Healthy Kids

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Without CHIWith CHI

77,000

48,629

Ne

w

En

trie

s

15,000

Without CHI With CHI

Impact on Access and Utilization

Survey to Compare the Experiences of Recent and Established Enrollees

•Recent Enrollees

– Children who recently became eligible for Healthy Kids

– Measure experiences during six months before enrolling

•Established Enrollees

– Children who recently renewed eligibility at one year

– Measure experiences during the prior six months on Healthy Kids

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Percentage

Impact of Healthy Kids on Having a Usual Source for Dental Care

**Difference is statistically significant at p-value < 0.01.

Los Angeles study includes children ages 4 and 5; San Mateo includes ages 3 to 18; Santa Clara includes ages 4 to 18.

**

Percentage

Impact of Healthy Kids on Having a Preventive Dental Visit

In the Past Six Months

****

**Difference is statistically significant at p-value < 0.01.

San Mateo study includes children ages 3 to 18; Santa Clara includes ages 4 to 18.

Percentage

Impact of Healthy Kids on Having a Dental Treatment In the Past Six Months

** **

NOTE: Dental treatment includes a cavity filling or tooth extraction

**Difference is statistically significant at p-value < 0.01.

San Mateo study includes children ages 3 to 18; Santa Clara includes ages 4 to 18.

Percentage

Impact of Healthy Kids on Unmet Need for Dental Care In the Past Six Months

**

****

**Difference is statistically significant at p-value < 0.01.

Los Angeles study includes children ages 4 and 5; San Mateo includes ages 3 to 18; Santa Clara includes ages 4 to 18.

Average Annual Costs per Enrollee for Dental and Other Services, San Mateo

Healthy Kids Enrollees, 2006

Average Annual Costs per Enrollee for Dental and Other Services, San Mateo

Healthy Kids Enrollees, 2006

Type of Service Costs

Dental Care Costs $234.93

Other Care Costs $483.60

Total Costs $718.53

N 1,380Source: Health Plan of San Mateo

Healthy Kids Dental Users by Type of Provider, San Mateo, 2005

Percent of

Provider All Users

San Mateo Med. Center 39.1

and County Clinics

Private Dentists 43.3

Private Dental Groups 20.9

Sonrisas Dental Clinic 5.8

Tooth Mobile 0.5

N 1778

Source: Health Plan of San Mateo

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Challenges and Opportunities

• Insurance Coverage

Declining employment-based/dependent coverage

Healthy Kids programs funding

Eligible but unenrolled

• Provider Availability

Reimbursement rates

Ramifications of loss of Adult Dental Benefit under Medi-Cal

Mounting pressures on safety net

• “Cultural”/Clinical Attitudes

Lack of importance place on oral health

Lack of attention on care during early years and pregnancy

SECTION HEADING

• SCHIP reauthorization

Dental wrap-around option

Mandatory performance reporting

New parent education

Mandatory information for beneficiaries

Studies and commissions

Expanded outreach/enrollment activities

• Slow, but increasing attention to oral health, in general and needs of young children and pregnant women, specifically.

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Challenges and Opportunities