Research Full Report: Payment Methods and Demographics Influence Patterns of Dental Service Utilization (2024)

Research Full Report

Abstract

Keywords: demographics, dental insurance, dental procedures, Medicaid, method of payment, public health, racial disparities, service utilization, socioeconomic status

While access to dental care is a privilege enjoyed by many Americans, not all people have dental care made available to them. Self-reported data from the 2019 National Health Interview Study identified only 64.9% of Americans as having visited a dentist in the last calendar year. Many groups of Americans are likely to experience an inequality in access to dental care, causing them to fall among the 35.1% of Americans who reported no access to dental care in 2019.1 The negative effects on oral health generated from a lack of access to preventive and restorative dental procedures will only be further compounded with time; as the groups that exhibit the most need for dental services will be those who lacked prior access to them.2 Therefore, identification of groups in need of support remains a prominent issue for dental public health.

Previous publications identified specific subsets of persons who are more at risk of lacking basic dental care. Wall et al3 concluded that the increasing number of uninsured American adults is correlated with the decreasing percentage of adults with a dental visit in the last year. Financial status was identified as a key determinant of oral health and has been studied extensively. A 2012 study identified income and wealth as key indicators in the use of dental care by American adults, as service utilization increased from 47.3% to 91.4% with increasing wealth.4 Poverty status has been related to adverse oral health outcomes such as caries, loss of teeth, periodontal disease, and more.5 Utilization of dental services was not just related to wealth and insurance status, as marginalized racial and ethnic groups often reported lower levels of dental service utilization than others. In a survey of minority groups across the United States, it was determined that individuals with disabilities, African American, Alaskan Native, multiracial, and Hispanic individuals all showed lower utilization of dental care.6,7 A 2018 meta-analysis of 117 studies by Reda et al8 confirmed the significance of many of the results from the individual studies described previously. This meta-analysis significantly associated the following populations with a decrease in dental care utilization: racial and ethnic minoritized groups, elderly persons, males, individuals with disabilities, low earners, poorly educated, rural populations, and uninsured individuals.8,9

To address oral health disparities, North Carolina (NC) Medicaid currently provides dental coverage to eligible adults and their children until 18 years of age. NC Medicaid's purpose includes treating disease, maintaining oral health, and treating injuries or impairments. As such, NC Medicaid covers only specific procedures for qualified individuals, most commonly routine diagnostic, restorative, oral surgery, and removable prosthodontics. Because North Carolina has not passed expanded Medicaid legislature, eligibility for NC Medicaid is strict; it is based upon stringent financial criteria with adjustments for higher-risk groups such as pregnant women and individuals with children.

The importance of studying oral health disparities has been reinforced in recent years. In 2017, an editorial was published in the American Journal of Public Health, emphasizing the need for more research aimed at identifying and understanding population-level disparities that impact the health of older adults.10 In the 2021 National Institutes of Health (NIH) Oral Health in America review, a gap was identified in current knowledge: a lack of understanding of the relationships and interactions between factors that contribute to disparities.9 While dental service utilization patterns have been described in relationship to patients' demographics, no research yet exists on the utilization of specific types of dental services, nor how various sociodemographic factors interact to affect utilization.

In response to the status of the current literature, the authors identified a unique opportunity to use data from a large patient base to study utilization of specific dental procedures. The East Carolina University School of Dental Medicine (ECU SoDM) owns and operates 9 clinical sites across the state of North Carolina. Each of these dental centers emphasizes providing care to underserved populations in North Carolina, with 8 of these centers located in rural and economically disadvantaged counties. These clinical sites utilize a centralized axiUm electronic health record (EHR) database with thousands of patients, offering the possibility of a large-scale investigation into the dental service utilization among these populations in North Carolina. Herein, this article describes the relationships between patients' demographics, methods of payment, and utilization of specific types of dental services.

Methods

The ECU SoDM owns and operates 9 Community Service Learning Centers (CSLCs) across the state of North Carolina, with each clinic compiling patient health records into a centralized axiUm database. This database, containing records from 26 710 eligible patients across the state, has successfully been utilized in previous studies for qualitative population studies such as the assessment of oral health characteristics by racial demographics.11 Approval from the ECU and Medical Center Institutional Review Board (UMCIRB) was granted, and all data were deidentified prior to analysis.

Individuals selected for inclusion in this convenience sample were adults, from 23 years old to retirement age adults older than 65 years. These patients were divided into 6 age-groups for statistical analysis of age-related trends in dental need and utilization. Visits to the CSLCs from this population were collected from the time of the school's opening, in 2011, to 2020, with 534 983 individual visits being extracted for data analysis. Patient health records were analyzed from the extracted data set using IBM SPSS Statistics for Macintosh version 25.0.

Assessment of the disease burden within the patient population was performed by utilizing the decayed component of the decayed, missing, and filled teeth (DMFT) index, as the decay (D) score was representative of unmet dental need in the population. The DMFT index serves as a measure of present and past dental needs, as it measures the number of teeth that present with active caries (D), previously extracted (M), and previously restored (F). Failed appointments were defined as a patient no-show or cancellation within 24 hours of the appointment. Racial identity, ethnicity, and employment status were self-reported upon the patient's initial screening. Proxies of dental service utilization were analyzed across the population via the percentage of persons receiving specified treatments, grouped into categories as per the American Dental Association CDT codes (2021). Following assessment of the entire data set, patients were divided into applicable categories including age-groups, racial subgroups, ethnic groups, employment status, and number of cumulative failed appointments. These groups from the individual-level data set were cross-tabulated with the primary type of payment method utilized. Within the individual-level data set, the type of payment method utilized for cross-tabulation was the most used payment method by that patient. Measures of disease burden and type of dental service utilized derived from the procedure-level data set were cross-tabulated with the payment method utilized at the procedure. The significance of cross-tabulation results was determined using chi-square analysis (P ≤ .05).

Results

Data were collected from 26 710 eligible patient records and 534 983 individual visits in the ECU SoDM axiUm database. Two data sets were extracted for analysis: one was at the individual patient level and the other was at the procedure level. Demographics of the studied population were extracted from all the records that were deemed eligible for the study. Table ​Table11 displays demographic information and primary payment method recorded from patient EHRs.

The procedure-level data set was analyzed for payment method, D score, and dental procedure type. These factors were necessary to be recorded at the procedure level in order to cross-tabulate the values with the procedure type being performed. Table ​Table22 visualizes the breakdown of procedure types, dental need, and payment methods for the procedure-level data.

Upon cross-tabulation, payment method was significantly associated (P < .001) with patient-level characteristics that include age-group, ethnicity, race, employment status, and number of failed appointments. Individuals older than 65 years showed a significantly higher proportion of appointments paid via self-pay (81.0%) than younger age-groups, with a lower proportion of appointments paid through private insurance or Medicaid. Hispanic and non-Hispanic individuals in the population showed similar rates of self-payment, 66.3% and 69.1%, respectively. However, non-Hispanic individuals showed a larger proportion of coverage by private insurance (18.9%) and Medicaid (10.6%), while Hispanic individuals showed a high utilization of SoDM grants (21.7%). African American and multiracial individuals showed a lower proportion of self-payment than other racial groups, with a greater usage of private insurance and Medicaid options in both groups. Breakdown by employment status showed slight difference in rates of self-payment between employed and unemployed individuals. However, significant differences were shown with unemployed individuals paying more often using Medicaid and employed individuals using private insurance. Among individuals with 4 or more failed appointments, a higher proportion paid via Medicaid than those with no failed appointments (Table ​(Table33).

Table ​Table44 shows the distribution of payment source by the presence of untreated decay at the patient's initial screening examination and procedure types. A significant difference was noted between individuals with no decay present (D score = 0) as compared with those with decay present (D score >0), with D score = 0 patients paying slightly more often through Medicaid, and D score >0 individuals through private insurance. Utilization of dental service types was also significantly associated with the type of payment method that the patient utilized at that appointment (P < .001). Compared with the procedure-level average of 62.5%, a greater proportion of self-pay was found for procedures classified as diagnostic, preventive, maxillofacial prostheses, implants, fixed prosthodontics, and orthodontics. Categories with a greater proportion of payment through private insurance (compared with the average 21.6%) were preventive, restorative, endodontic, periodontic, and fixed prosthodontic treatment types. The proportion of procedures with payment by Medicaid (compared with the average 12.3%) was relatively higher in categories classified as restorative, periodontics, removable prosthodontics, and oral surgery (Table ​(Table44).

Discussion

Utilization can be viewed as the interplay of supply and demand for dental services where out-of-pocket cost and need play a key role in the demand for care.12 The results identified significant variation in demand based on patients' sociodemographics and payment method. Patients' age, ethnicity, race, employment status, and number of failed appointments were all associated with the type of payment method that the patients used.

Chi-square analysis indicated that there were differences in payment method by age-group. The 65+ years age-group showed the highest utilization self-payment (82.7%) among all age-groups. This was an expected result, as many Americans receive private dental insurance from their employers.13 As such, a retiring population can be expected to show a smaller proportion of private insurance coverage. With 81% of individuals older than 65 years paying out of pocket for treatment, the findings indicated that this group lacked payment options to finance their care (Table ​(Table3).3). However, this age-group also utilized a wide array of dental services, suggesting that financial barriers may not exist for many adults 65 years or older who are seeking dental care. Further research is needed to gain a better understanding of the enabling factors and barriers that influence care utilization for this age-group.

Ethnic and racial minoritized populations have been previously identified in meta-analyses as groups with low utilization of dental services.8 When compared with non-Hispanic individuals, Hispanic persons showed a lower utilization of private insurance and Medicaid payment (Table ​(Table3).3). With similar rates of self-payment, the major difference was the large proportion of Hispanic individuals who paid via SoDM grants. Grants for financing care that are specific to migrant farmworkers in North Carolina via the NC Farmworker Health Program may have skewed these results since a large proportion of these farmworkers identify as Hispanic. Thus, the sample Hispanic group included in this study may not be representative of other Hispanic populations in North Carolina. Among racial minoritized groups, individuals classified as African American in the population showed lower rates of self-payment compared with other groups. Instead, African American individuals revealed a higher proportion of payment through private insurance and Medicaid (Table ​(Table33).

Private dental insurance coverage in the United States is most often linked to a person's employer, with businesses offering dental insurance as an employment benefit.13 Therefore, it was expected that unemployed individuals would show a lower rate of private insurance utilization. This notion was confirmed, as the data saw 23.5% of employed individuals paying via private insurance, with only 12.3% of unemployed persons using this method. Interestingly, unemployed and employed individuals showed similar rates of self-payment, only differing significantly in their utilization of Medicaid versus private insurance (Table ​(Table3).3). This may indicate that the group defined as “self-pay” could include both those who are low income but do not qualify for Medicaid and those who have sufficient financial resources but choose not to purchase private dental insurance.

Although many NC citizens qualify for Medicaid, they may find difficulty in locating dentists who accept Medicaid payment. A common reason for why dentists do not accept Medicaid patients is their higher likelihood for failing to show up to their appointments.14 While at least half of all failed appointments were among patients who were classified as “self-pay,” we identified that the proportion of patients with Medicaid increased with the number of failed appointments. The proportion of patients who received Medicaid benefits was highest among patients who failed 4 or more appointments. Conversely, only a small proportion of individuals who never had failed appointments were Medicaid-insured patients (Table ​(Table3).3). Notably, Medicaid policy does not allow providers to bill patients for missed appointments. Policy makers ought to explore methods to support case management to improve appointment rates for dental care among Medicaid recipients.

Self-payment was associated with more expensive procedures such as maxillofacial prostheses, implants, fixed prosthodontics, and orthodontics. Private insurance covered a greater proportion than average when it came to procedure categories including restorative, fixed prosthodontics, endodontics, and periodontics. Interestingly, preventive procedures showed a lower rate of payment via Medicaid than other procedure types (Table ​(Table4).4). This seems to be indicative of a missed opportunity for Medicaid to pay for more cost-effective preventive procedures, as that would help in reducing dental disease burden across the studied population in the future. However, in North Carolina, Medicaid offers coverage for most preventive procedures that a patient would be likely to utilize. Thus, an alternative explanation for this low Medicaid usage rate for preventive procedures could be that Medicaid-insured individuals are not utilizing their preventive benefits. Incentive programs to reward the use of preventive Medicaid benefits may offer a solution to reduce disease burden and lessen the amount of future, costlier treatment.

This project had several strengths, with the primary strength reporting on an extensive database including large numbers of patients and procedures collected over a long time frame, from 2011 to 2020, over a large geographic area. With such a large data set spanning over many years, this study provides a long-term perspective on the utilization of dental services that shorter studies fail to offer. A unique advantage of this study was that the data were collected before the COVID-19 pandemic. Thus, the data were not affected by pandemic-induced changes in patient seeking dental care behavior that have been noted by other studies.15 A limitation of this study was the reliance on primary payment method for determining relationships, as payment for an appointment will often be split between insurance coverage and out-of-pocket payment. Similarly, an individual's primary payment method may not have stayed consistent over such a long study, introducing some misclassification error into the individual-level statistics. As a result of sampling only patients at ECU dental clinics, the population in this study may not be generalizable to the rest of North Carolina. Future studies will build upon these results to examine geographical variance in relationships between payment method and patient demographics across the differing NC locales served by the ECU SoDM. Additional analysis beyond the scope of this article may utilize different statistical analyses to determine explanatory factors.

Several studies have identified broad patterns of dental utilization based on patients' sociodemographics, but many of these studies focused only on the utilization of dental treatment in general. The results revealed a significant association within the ECU SoDM patient population between sociodemographics and payment method, as well as payment method and utilization of specific types of dental care. This study found age, employment status, race, ethnicity, and number of failed appointments to be significantly associated with the type of payment method the patient primarily utilized. Likewise, payment method was related to the type of dental services that the patient utilized. A lack of dental insurance coverage for adults older than 65years was seen, with high rates of self-payment compared with other age-groups.

Footnotes

References