Denti-Cal Facts and Figures - California HealthCare Foundation

Transcription

Denti-Cal facts and figures
A Look at California’s Medicaid Dental Program
May 2007
Introduction
Denti-Cal is the name given to Medi-Cal’s fee-for-service (FFS) dental program. It is
the primary public financer of dental care for some 8.5 million low-income, elderly,
and disabled people in California.
Denti-Cal
Introduction
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contents
Coverage and Cost. . . . . . . . . . . . . . . . 5
Expenditures and Services. . . . . . . . . . 9
However, while nearly all of the Medi-Cal population has access to the benefit,
Providers and Access. . . . . . . . . . . . . 18
they typically encounter serious difficulties in actually seeing a dentist. California’s
Children & Pregnant Women. . . . . . . 24
reimbursement rates for publicly funded dental care are among the lowest in the
Children’s Service Use . . . . . . . . . 25
nation, well below the fees charged by most dentists. As a result, less than half
of dental practices accept Denti-Cal patients, and access to specialty care, such as
pediatric dentistry and orthodontics, is very limited. Many Medi-Cal beneficiaries
receive no preventive dental care and often postpone treatment until their oral health
problems become severe.
Pregnant Women’s Usage . . . . . . 30
Challenges and Questions . . . . . . . . . 32
Acknowledgments. . . . . . . . . . . . . . . .34
Supplemental Information
Glossary . . . . . . . . . . . . . . . . . . . . 35
Methodology. . . . . . . . . . . . . . . . . 38
Managed Care and Providers. . . . 42
This presentation explains how Denti-Cal is funded and organized, the demographics
of the population it serves, and the challenges it faces in making dental care available
to all eligible Californians.
©2007 California HealthCare Foundation Summary of Key Findings
• Most California dentists decline to treat Medi-Cal patients. Due primarily to
the program‘s low reimbursement rates, only 40 percent of private dental
practices will accept Denti-Cal payments.
• While every major medical, dental, and public health organization recommends
that children be seen by a dentist by age one,1 only one in ten children under
age 2 who are enrolled in Medi-Cal have had a preventive dental visit.
• Although seniors and people with disabilities consume a disproportionate
share of medical services, this is not the case for dental expenditures. The
two groups represent 21 percent of Medi-Cal beneficiaries and account for
63 percent of medical care expenditures, but only 30 percent of Denti-Cal
expenditures.
Denti-Cal
Introduction
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While nearly all
Medi-Cal beneficiaries
have dental coverage,
significant barriers
impede their ability
to make use of
dental services.
• Latinos have the lowest use of dental services but the highest fee-for-service
dental expenditures.
• While the number of Medi-Cal beneficiaries receiving dental services has
increased, expenditures per beneficiary has decreased.
• Only one in five pregnant Medi-Cal beneficiaries have had a dental visit. It is
widely recognized, however, that sound oral health is essential to the overall
health of both mothers and unborn children.
1. American Academy of Pediatric Dentistry. "Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment of children.
Pediatric Dentistry 2004;26(7):81 – 3.
©2007 California HealthCare Foundation Importance of Dental Care and Oral Health
• The Surgeon General has reported that oral health problems can cause infection
and signal trouble in other parts of the body.1
• Periodontal (gum) disease in pregnant women has been associated with pre-
term and low birth weight babies, diabetes, cardiovascular disease, stroke, and
bacterial pneumonia.2
• Children frequently have poor oral health and, in California, their oral health is
Denti-Cal
Introduction
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Oral health is essential
to overall health and
quality of life at any
age.
substantially below national targets. By third grade tooth decay affects almost
two-thirds of California children.3
• Tooth decay is the most common chronic childhood disease — five times more
common than asthma and seven times more common than hay fever in 5- to
17-year-olds.4
• Nationally, nearly one in three people over age 65 has untreated dental cavities,
and one in four between the ages of 65 and 74 has severe periodontal disease.5
• Left untreated, dental diseases can result in severe pain and infection leading to
various health problems, difficulty with the activities of daily living, and in very
rare cases, death.
1. Office of the Surgeon General, U.S. Department of Health and Human Services. May 2000 fact sheet, Links Between Oral and General Health.
www.cdc.gov/OralHealth/factsheets/sgr2000-fs4.htm.
2. Maternal Chronic Infection as a Risk Factor in Preterm Low Birth Weight Infants: The Link With Periodontal Infection. Journal of the International Academy of Periodontology
2004 6/3: 89 – 95
3. Dental Health Foundation. “Mommy, It Hurts to Chew.” The California Smile Survey: An Oral Health Assessment of California’s Kindergarten and 3rd Grade Children. February 2006.
4. Office of the Surgeon General, U.S. Department of Health and Human Services. May 2000 fact sheet, Links Between Oral and General Health.
www.cdc.gov/OralHealth/factsheets/sgr2000-fs4.htm.
5. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General — Executive Summary. Rockville MD: National Institutes of Health, 2000.
www.surgeongeneral.gov/library/oralhealth/
©2007 California HealthCare Foundation Overview of the Denti-Cal Program
• The federal government requires state Medicaid programs to
provide dental services for children under the age of 21.1 The dental
Denti-Cal
Coverage and Cost
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Although there is not
component of this program in California, commonly known as
a federal requirement
Denti-Cal, is the main source of dental care financing for more than
for adults, California
8.5 million Medi-Cal beneficiaries.2
has chosen to provide
• Total fee-for-service (FFS) Denti-Cal payments in 2004 exceeded
$626 million.
• 2.2 million beneficiaries received dental services in FFS and
dental services to both
children and adults
enrolled in Medi-Cal.
managed care plans.
• Medi-Cal is funded by three sources: the federal government
(55 percent), the state general fund (38 percent), and other state
and local agencies (7 percent).3
1. “Medicaid Dental Coverage Overview” Centers for Medicare & Medicaid Services. Available at: www.cms.hhs.gov/MedicaidDentalCoverage/. Accessed October 2006.
2. Enrollment (8.5 million) is based on a minimum of one month of eligibility. The average enrollment per month is approximately 6.6 million beneficiaries and approximately
5.4 million have been enrolled for at least 11 months. Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.)
3. California HealthCare Foundation, Medi-Cal Facts and Figures, 2006.
©2007 California HealthCare Foundation Denti-Cal
Denti-Cal Program Benefits
Coverage and Cost
<< previous
All beneficiaries eligible for full-scope Medi-Cal coverage are eligible for a
comprehensive range of dental services through Denti-Cal.
1
The Denti-Cal program covers a variety of services. These include:
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The Denti-Cal program
covers most dental
2
• Diagnostic and preventive dental services
services.
(e.g., examinations, x-rays, and cleanings)
• Emergency treatment for control of pain and infection
• Fillings and tooth extractions
• Root canal treatments
• Prosthetic appliances (e.g., dentures)
• Orthodontics for children who qualify Service caps and co-payments 3 include:
• $1,800 annual cap on adult dental services
(though a number of exemptions are allowed) • $1 co-payment for services provided in a dental office and a
$5 co-payment for nonemergency care provided in an emergency room
1. The small proportion of Medi-Cal beneficiaries who are not eligible for dental services have limited-scope coverage.
2. Many services require a Treatment Authorization Request (TAR), a detailed report that explains why requested services are medically necessary and should be paid for by Medi-Cal.
3. Dentists have the option to not collect some co-payment amounts.
Sources: Medi-Cal Dental Program Web site (www.denti-cal.ca.gov/WSI/Bene.jsp?fname=BeneSrvcs) and Denti-Cal Provider Manual
(www.denti-cal.ca.gov/provsrvcs/manuals/sec2/Section_2.pdf ), p. 2 – 84.
©2007 California HealthCare Foundation Comparison of Medi-Cal and Denti-Cal
Enrollment, Utilization, and Expenditures
Denti-Cal
Coverage and Cost
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Only about one of
medi-Cal
category
number
denti-Cal
percent
number
percent
every four beneficiaries
enrolled in Medi-Cal
Beneficiaries Enrolled
Total*
8,545,969
100%
8,545,969
100%
FFS
4,926,330
58%
8,168,309
96%
Managed Care
3,619,639
42%
377,660
4%
Total
6,287,942
74%
2,191,022
26%
made use of medical
FFS
3,297,545
52%
2,100,331
96%
services.
Managed Care
2,983,896
47%
90,691
4%
†
Beneficiaries using Services received any Denti-Cal
services in 2004. Three
of every four, however,
‡
Expenditures
Annual FFS Expenditures#
$19,859,258,216
$626,717,481
*Enrollment (8.5 million) is based on a minimum of one month of eligibility. The average enrollment per month is approximately 6.6 million beneficiaries and approximately
5.4 million have been enrolled for at least 11 months.
†6,501 Medi-Cal beneficiaries were enrolled in Primary Care Case Management and Prepaid Health Plan at the time of service, which are generally not considered managed care.
Managed care includes County Organized Health Systems (COHS), Commercial 2 Plan Model, Geographic Managed Care and Local Initiative (2 Plan Model).
‡Based on enrollment data.
#Total Medi-Cal FFS expenditures excluded dental expenditures. The total Medi-Cal budget is approximately $28.3 billion.
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.)
©2007 California HealthCare Foundation Recent Legislation and Policy Changes
Assembly/
Senate Bill
Denti-Cal
Coverage and Cost
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Policy changes
approved date
description
May 2003
SBx1 26
Effective July 1, 2003.
Pre-treatment x-rays to justify medical necessity for
restorations
May 2003
Rate reduction for subgingival curettage and root planing
SBx1 26
recent years have
Restrictions on posterior laboratory-processed crown
SBx1 26
driven down both
dental program in
May 2003
July 2005
Effective January 1, 2006.
October 2005
Effective October 7, 2005.
October 2005
expenditures and
$1,800 annual cap on adult dental services per
calendar year
AB 131
Provide immediate coverage of selected non-emergency
dental procedures for pregnant Medi-Cal beneficiaries in
16 new aid codes, in addition to 4 aid codes that were
added in 2002
SB 377
Reduce provider payments by 5 percent
Rescind the 5 percent provider payment reduction
AB 1735
SB 912
Effective for dates of service on or after March 4, 2006.
September 2006
Effective January 1, 2007.
Requires an oral health screening within first year of
entering public schools
use. An oral health
screening requirement
for California schools
Effective for dates of service on or after January 1, 2006.
February 2006
to the Medi-Cal
AB 1433
passed in 2006 will put
additional demands
on all dentists to see
children enrolled in
Medi-Cal.
Notes: A special legislative session is called by the Governor by proclamation to address only those issues specified in the proclamation; also referred to as a special session. Measures
introduced in special sessions are numbered chronologically with a lower case “x” after the number (for example, AB 28x). www.legislature.ca.gov/quicklinks/glossary.html.
Use of Denti-Cal Services:
Expenditures and Services
Beneficiaries and Expenditures, 2000 – 2004
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The number of
Beneficiaries Using Services
FFS Expenditures
millions
millions
$800
2.5
beneficiaries using
dental services
increased by about
one-third from 2000
to 2004. Dental
$700
expenditures increased
at an even faster
2.0
pace from 2000 to
$600
2002, but have since
fallen sharply due to
treatment restrictions
1.5
2000
2001
2002
2003
2004
1,691,142
1,775,301
2,004,146
2,061,664
2,198,187
$544,814,563
$614,289,362
$755,886,435
$714,384,350
$626,717,481
$500
and rate reductions
put in place by the
legislature.
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Denti-Cal data includes all FFS claims paid to a dental professional.)
Distribution of Procedures*
Use of Services and Expenditures, 2004
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While diagnostic
Beneficiaries Using Services
FFS Expenditures
Total: 5.63 million
Total: $627 million
Periodontics
3%
Surgery
9%
services were the
most frequently used
Periodontics
4%
Other
10%
services, restorative
Other
19%
Diagnostic
16%
Diagnostic
34%
Preventive
14%
Surgery
11%
Restorative/
Endodontic
17%
and preventive
Preventive
27%
and endodontics
accounted for the
largest proportion of
expenditures.
Restorative/
Endodontic
38%
*A description of ‘Procedure Category Groups’ can be found in the glossary. Other includes: prosthodontics removable and fixed; maxillofacial prosthetics; implant services; and
orthodontics and adjunctive general service. Surgery refers to oral and maxillofacial procedures.
Notes: Beneficiaries receiving services is a unique count within each procedure category group. Any individual may appear in one or more procedure category group. Total 2004
expenditures of $626,715,897 is $1,584 less than the total expenditures shown on pages 6 and 9. Claims that did not have procedure codes (0.01 percent of all FFS claims) were not
used in the analyses.
©2007 California HealthCare Foundation 10
Denti-Cal
Fee-for-Service Expenditures,
by Procedure Category,* 2000 – 2004
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Between 2002 and
millions
2004, the greatest
$300
expenditures were
for restorative and
$250
Restorative/Endodontic
endodontic procedures.
Due primarily to policy
$200
changes, there was
also a pronounced
$150
Other
Diagnostic
Preventive
$100
Surgery
$50
within the “other”
category (orthodontics,
prosthetics, and
Periodontics
$0
decline in spending
2000
2001
2002
2003
implant services).
2004
*A description of ‘Procedure Category Groups’ can be found in the glossary. Other includes: prosthodontics removable and fixed; maxillofacial prosthetics; implant services; and
orthodontics and adjunctive general service. Surgery refers to oral and maxillofacial procedures.
Notes: Total 2004 expenditures of $626,715,897 is $1,584 less than the total expenditures shown on pages 6 and 9.
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.) ©2007 California HealthCare Foundation 11
Medi-Cal and Denti-Cal Expenditures
per Beneficiary Using Services,
by Aid Code Group, 2004
Average Expenditure: $6,022
$3,247
$338
$14,543
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expenditures among
beneficiary groups,
$344
$321
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variation of medical
Average Expenditure: $299
— Disabled/Blind Seniors
$11,642
Unlike the wide
— Other Seniors
$9,792
Denti-Cal
dental expenditures
are largely consistent
— Other Adults
across groups.
— Disabled/Blind Adults
$346
$1,218
$273
— Other Children
$12,843
$265
Medi-Cal
— Disabled/Blind Children
Denti-Cal
Notes: 5,446 (0.26 percent) of beneficiaries with missing demographic or expenditure data were excluded from the Denti-Cal services analysis. Dental expenditures are not included in
Medi-Cal expenditures. Medical expenditures per beneficiary receiving services differs from page 11 by 6 percent because expenditures were based on service dates on page 11 and paid
dates on this page.
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004.
Denti-Cal
Top Ten Procedures,
by Highest Aggregate Payments, 2004
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The ten procedures
Total FFS
Expenditures
Beneficiaries
using Services
$33,921,191
374,699
Prophylaxis, application of fluoride,
ages 6 to 17 (preventive)
$27,034,090
586,119
Composite or Plastics Restoration
$25,701,157
254,652
$24,436,451
626,380
Subgingival Curettage and Root Planing,
per treatment (periodontics)
$23,783,892
185,434
Initial Oral Exam
$23,766,605
907,868
$22,375,017
1,405,865
$21,459,592
318,041
$21,379,091
63,473
$21,043,670
129,068
Procedure
(category)
Amalgam, two surfaces permanent
(restorative/endodontic)
(preventive)
(diagnostic)
Intraoral Periapical, additional film
Amalgam, one surface permanent
(diagnostic)
the highest payments
totaled $245 million, an
amount representing
Prophylaxis, adult
that accounted for
39 percent of dental
expenditures in 2004.
Root Canal Therapy (3 canals)
Pulpotomy (therapeutic)
Notes: Only procedures with at least 100 claims were used in the analysis. A description of ‘Procedure Category Groups’ can be found in the glossary. Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.) ©2007 California HealthCare Foundation 13
Denti-Cal
Top Ten Procedures,
by Frequency of Use, 2004
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Diagnostic and
Total FFS
Expenditures
Beneficiaries
using Services
$22,375,017
1,405,865
$23,766,605
907,868
$10,856,298
794,625
delivered in 2004. The
$8,725,450
772,881
ten most frequently
$24,436,451
626,380
used services totaled
ages 6 to 17 (preventive)
$27,034,090
586,119
Intraoral Periapical, single, first film
$6,066,056
494,968
$8,572,567
449,697
$33,921,191
374,699
$16,814,589
318,224
Procedure
(category)
Intraoral Periapical, each additional film
(diagnostic)
Initial Oral Exam
(diagnostic)
Periodic Oral Evaluation
Bitewings, two films
Prophylaxis, adult
(diagnostic)
(diagnostic)
(preventive)
(diagnostic)
Bitewings, four films
(diagnostic)
Amalgam, two surfaces permanent
preventive dental
services accounted for
the majority of care
about $182 million,
or 29 percent of total
expenditures.
Single Tooth Extraction
(oral and maxillofacial surgery)
Notes: Use is determined by the count of unique beneficiaries with one or more claims for each procedure. Only procedures with at least 100 claims were used in the analysis.
A description of ‘Procedure Category Groups’ can be found in the glossary.
Denti-Cal
Beneficiaries and Expenditures,
by Age Group (in years), 2004
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Contrary to the
Medi-Cal
denti-cal
Beneficiaries
service users
FFS Expenditures
standard of care, less
than 4 percent of
number
share
of total
Number
share
of Medi-Cal
number
share
of total
Younger than 1
629,139
7.4%
6,042
1.0%
$576,828
0.1%
1
280,797
3.3%
25,544
9.1%
$5,051,674
0.8%
under age 2 received
2
262,111
3.1%
54,914
21.0%
$14,010,576
2.2%
a dental service
3
259,281
3.0%
81,344
31.4%
$23,303,405
3.7%
in 2004. Medi-Cal
4
250,962
2.9%
83,381
33.2%
$25,036,092
4.0%
5
236,209
2.8%
84,703
35.9%
$25,123,575
4.0%
6 to younger than 13
1,491,220
17.5%
525,657
35.3% $130,170,878
20.8%
1,330,061
15.6%
330,307
24.8% $102,023,395
16.3%
2,916,081
34.1%
658,922
22.6% $218,150,910
34.9%
890,108
10.4%
241,681
27.2%
$82,133,418
13.1%
24.5% $625,580,751
10.0%
Age Group
(in years)
65 and older
TOTAL (all ages)
8,545,969
100.0% 2,092,495
children under age 6
and Medi-Cal seniors
65 and older use dental
services far less than
other age groups.
Notes: Beneficiary counts are based on those with at least one month of enrollment in 2004. Medi-Cal beneficiaries include all those enrolled while the Denti-Cal beneficiaries include
only those with claims. 5,446 (0.26 percent) of beneficiaries with missing demographic or expenditure data were excluded from analysis.
Sources: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.)
Denti-Cal
by Aid Code Group, 2004
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Seniors and people
Medi-Cal
denti-cal
Beneficiaries
service users
FFS Expenditures
with disabilities
account for 30 percent
Aid Code Group
number
share
of total
Number
share of
Medi-Cal
Number
share
of total
Disabled/Blind Adults
797,746
9.3%
269,250
33.8%
$93,221,901
14.9%
Disabled/Blind Children
151,224
1.8%
50,469
33.4%
$13,359,323
2.1%
expenditures but
Disabled/Blind Seniors
158,288
1.9%
50,780
32.1%
$17,484,163
2.8%
63 percent of medical
Other Adults
2,123,222
24.8%
391,188
18.4%
$125,538,369
20.1%
Other Children
4,588,556
53.7%
1,141,423
24.9%
$311,937,100
49.9%
726,933
8.5%
189,385
26.1%
$64,039,895
10.2%
8,545,969
100.0%
2,092,495
24.5%
$625,580,751
100.0%
Other Seniors
Total
of Denti-Cal
care expenditures.1
Notes: Beneficiary counts are based on those with at least one month of enrollment in 2004. Medi-Cal beneficiaries include all those enrolled while the Denti-Cal beneficiaries include
only those with claims. 5,446 (0.26 percent) of beneficiaries with missing demographic or expenditure data were excluded from analyses.
Sources: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.)
©2007 California HealthCare Foundation 1. California HealthCare Foundation Medi-Cal Facts
and Figures, 2006.
16
Denti-Cal
by Race and Ethnicity, 2004
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Distribution of dental
Medi-Cal
denti-cal
Beneficiaries
service users
FFS Expenditures
expenditures by
ethnicity is similar to
number
share
of total
Number
share
of Medi-Cal
Number
share
of total
White
1,800,311
22.6%
501,883
27.9%
$158,800,040
26.8%
the ethnic distribution
Latino
4,399,706
55.2%
978,360
22.2%
$286,457,470
48.4%
of the overall Medi-Cal
Black
836,507
10.5%
225,930
27.0%
$64,126,234
10.8%
population. Latinos use
Asian
801,222
10.1%
253,850
31.7%
$73,273,528
12.4%
dental services least
Other
136,333
1.7%
31,261
22.9%
$9,710,465
1.6%
7,974,079
100.0%
1,991,284
25.0%
$592,367,737
100.0%
Ethnicity
Total
frequently.
Notes: Ethnicity is self-reported. Asian includes Chinese, Japanese, Amerasian, Asian Indian, Filipino, Cambodian, Korean, Samoan, Laotian, and Vietnamese. Other includes
American Indian, Hawaiian, and Guamian. 5,446 (0.26 percent) of beneficiaries with missing demographic or expenditure data were excluded from analyses. Beneficiary counts are
based on those with at least one month of enrollment in 2004. Medi-Cal beneficiaries include all those enrolled while the Denti-Cal beneficiaries include only those with claims.
Barriers to Receiving Dental Services
There are a number of access barriers that may affect use of the Denti-Cal program.
They include:
• Lack of knowledge about Denti-Cal benefits and services. Medi-Cal
beneficiaries often do not receive specific information about covered dental
services and where to seek care. For example, a majority of parents of
Medi-Cal children reported that their children didn’t have dental benefits
(when they actually did).1
Denti-Cal
Providers and Access
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These barriers
contribute to the
low rates of use
of Medi-Cal dental
services.
• Difficulty finding dentists who accept Denti-Cal beneficiaries. Only
40 percent of California’s dentists accept publicly insured patients.2
Less than half of pediatric dentists in the state participate in Denti-Cal,
two-thirds of whom place restrictions on their participation.3
• Language and cultural barriers. Nearly half of all Medi-Cal beneficiaries using
dental services are Latino, while only 9 percent of dentists accepting these
patients are Latinos. This shortage of Latino dentists is growing.4
• Challenging treatment authorizations for some services. Dentists may not
fully understand which services require a Treatment Authorization Request (TAR).
The review and processing of TARs can be slow.5
1. Personal communication with Robert Isman, DDS, MPH. Dental Program Consultant, Medi-Cal Dental Services Branch, California Department of Health Services. Results from
2003 California Health Interview Survey.
2. 2003 California Dentist Survey, UCLA Center for Health Policy Research.
3. Morris PJ, Freed JR. Nguyen et al. “Pediatric dentists' participation in the California Medicaid program.” Pediatric Dentistry 2004 Jan – Feb;26(1):79 – 86.
4. Hayes-Bautista DE, Kahramanian MI, Richardson EG, et al. “The rise and fall of the Latino dentist supply in California: Implications for dental education.” J Dent Educ 2007;
71(2):227 – 234.
5. Health Consumer Alliance and Health Rights Hotline. Denti-Cal Denied: Consumers’ Experiences Accessing Dental Services in California’s Medi-Cal Program. December 2002.
Denti-Cal
Characteristics of Denti-Cal Dentists
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Primarily because of
the program’s low
Distribution by Specialty
Acceptance of Publicly Insured Patients*
Among Dentists Seeing Publicly Insured Patients
Among Dentists in Private Practice
Other†
(3%)
Pediatrics
reimbursement rates,
60 percent of private
practice dentists in
(7%)
Orthodontics
California do not see
(7%)
Denti-Cal patients.
Accept
More than 80 percent
(40%)
of dentists who do
Do Not Accept
General Practitioners
(60%)
(83%)
accept Denti-Cal are
general practitioners.
*In addition to Medi-Cal, public insurance could include, for example, Healthy Families (HF), TriCare, Veteran’s Administration. However, the overall percentage of the population in
California covered by these other programs is very small with the exception of HF.
†Other includes: endodontics, periodontics, prosthodontics, surgery, and public health.
Source: 2003 California Dentist Survey, UCLA Center for Health Policy Research. (These data are not from the MIS/DSS.)
Denti-Cal
Distribution of Race and Ethnicity,
Beneficiaries vs. Dentists
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Of the 40 percent
of dentists who
Beneficiaries Using Services*
Denti-Cal Dentists†
Seeing Publicly Insured Patients
Other
(2%)
Other
(1%)
(1%)
Latino
(9%)
(11%)
patients, most are
White or Asian,
Black
Black
see publicly insured
while 49 percent of
beneficiaries receiving
services are Latino, a
Asian
ratio that may result
(13%)
Latino
(49%)
Asian
(47%)
White
(42%)
White
in cultural or language
difficulties.
(25%)
Note: “Other” includes American Indian, Hawaiian, and Guamian.
Sources:*Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dentist.)
†2003 California Dentist Survey, UCLA Center for Health Policy Research. ©2007 California HealthCare Foundation 20
Denti-Cal
Distribution of Dentists Accepting
Medi-Cal and Service Use, by Region, 2004
*
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The San Joaquin
Beneficiaries
using services
Region
medi-cal
denti-cal
3%
4%
3%
19%
13%
12%
3 Sacramento Area
5%
5%
5%
4 San Joaquin Valley
7%
14%
15%
5 Central Coast
5%
5%
4%
6 Los Angeles
35%
37%
37%
dentists accepting
7 Other Southern California
27%
22%
24%
Medi-Cal.
2 Greater San Francisco Bay Area
3
2
1
disproportionately
Dentists
1 Northern and Sierra
1
Valley has a
higher number of
using services than
4
5
6
7
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dentist.)
*2003 California Dentist Survey, UCLA Center for Health Policy Research.
Denti-Cal
Denti-Cal Reimbursement vs.
Average General Practice Fees, 2005
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Denti-Cal
reimbursement
General practice fees
Denti-cal
payment
pacific region
50th Percentile
pacific region
75th Percentile
Periodic Oral Exam
$15
$41
$50
Comprehensive Oral Exam
$25
$60
$71
Complete x-rays, with bitewings
$45
$100
$120
category / selected Procedure
Diagnostic
tends to be
significantly lower than
the median American
Dental Association
general practice
Preventive
Prophylaxis (cleaning), adult
$40
$80
$90
fees for the pacific
ages 6 to 17
$40
$75
$85
region, which includes
California.
Restorative
Amalgam, 2 surfaces, permanent tooth
Crown, porcelain fused to base metal
$48
$124
$148
$340
$750
848
$215
$511
$595
$45
$120
$145
Endodontics
Anterior Endodontic Therapy
Oral Surgery
Extraction, single tooth
Source: American Dental Association, Survey of General Practice Fees, 2005.
Access as Measured by Time Since Last
Dental Visit, All Ages,* 2003
Denti-Cal
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Despite dental benefits
9.1%
coverage, 13 percent
13.4%
10.7%
Never been to dentist
of Medi-Cal
4.9%
4.7%
beneficiaries have
23.5%
42.0%
1 to 6 months
55.6%
56.5%
51.8%
19.3%
21.9%
24.5%
20.5%
21.7%
7 to 12 months
17.7%
11.1%
1 to 2 years
6.8%
9.1%
10.4%
18.5%
3 to 5 years
7.4%
2.1%
6.2%
7.5%
never been to a
dentist, compared
to only 5 percent for
Health Insurance Type
Uninsured
Medi-Cal
Healthy Families
Employment-based
Privately Purchased
those with private or
employment-based
insurance. 11.8%
More than 5 years
4.3%
0.3%
2.8%
3.8%
*Time since last dental visit includes information for those 2 years of age and older and younger children in cases where a tooth was present.
Sources: Geographic Selection: Entire State of California. 2003 California Health Interview Survey.
Importance of Dental Services and Oral
Health for Children and Pregnant Women
Children. Tooth decay is the most common preventable chronic infectious
disease among U.S. children.1 Twenty-eight percent of children ages 2 to 5 exhibit
Denti-Cal
Children & Pregnant Women
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Mothers with healthy
mouths are much
decay in their primary teeth. By age 11, half of children have tooth decay and by
more likely to have
age 19, the figure rises to two-thirds. Low-income children have twice as much
healthy babies who
untreated decay as children in higher income families. This may result in health and
are free from early
appearance problems that can greatly reduce a child’s ability to succeed at school.
dental decay. Good
Pregnant Women. A growing body of research suggests that serious gum
oral health is essential
(periodontal) disease is associated with premature birth and low birth weight.
for the intellectual and
Pregnant women with periodontal disease are four times more likely to have a
physical development
pre-term delivery than healthy women. In addition, mothers are the most common
2
transmission source of decay-causing bacteria to their infants. Partly in response to
of children.
this research, Denti-Cal expanded dental coverage for diagnostic, preventive, and
periodontal services for pregnant women in “limited scope” Medi-Cal aid codes in
2002; in 2005, new legislation added this coverage for virtually all pregnant women
in 16 additional codes.3
1. U.S. Centers for Disease Control and Prevention. December 2006 (www.cdc.gov/OralHealth/Topics/child.htm).
2. Pregnancy and Dental Care. California Dental Association. 1995 to 2006 (www.cda.org/library/articles/pregnancy.htm).
3. Denti-Cal Bulletin Vol. 21 No. 41, December 2005.
Denti-Cal
Preventive Dental Service Use,
Children’s Service Use
by Age Group, 2004
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All measures indicate
that by age 2, only
Enrollment
one in ten children had
at Any Time
Continuously for
at least 11 months
average monthly
Younger than 1
1%
2%
1%
1
7%
10%
9%
2
19%
25%
23%
3
29%
38%
37%
enrolled in Medi-Cal,
4
30%
41%
38%
the more likely he or
5
33%
43%
41%
she will receive dental
33%
41%
40%
services.
21%
29%
25%
23%
32%
30%
Age Groups
(in years)
TOTAL (all ages)
any kind of preventive
dental visit in 2004.
The longer a child is
Notes: Preventive services were defined here as: sealants; prophylaxis without topical fluoride application for children under 13; prophylaxis without topical fluoride application for
children 13 and older; prophylaxis with topical fluoride application for children under age 6; Prophylaxis with topical fluoride application for children ages 6 to 17; space maintainers.
Includes managed care and fee for service enrollees. Service dates in 2004 used. Further information on these three measures can be found in the methodology section.
Source: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004.
Denti-Cal
Access for Children Age 2 to 12,
by Time Since Last Dental Visit, 2005
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Despite dental benefit
26.4%
26.8%
Never been to dentist
coverage, about
16.1%
23.1%
24.9%
one in four Medi-Cal
33.6%
beneficiaries between
48.3%
Less than 6 months
54.1%
57.6%
49.7%
22.6%
16.5%
21.9%
7.5%
1 year up to 2 years
4.4%
6.6%
2.2%
2.6%*
2 years up to 5 years
5.8%
1.3%*
0.5%*
0.6%
1.0%*
More than 5 years
0.7%*
0.2%*
0.0%
0.0%*
0.0%
the ages of 2 and 12
have never been to a
26.0%
19.0%
6 months up to 1 year
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dentist.
Uninsured
Medi-Cal
Healthy Families
Employment-based
Privately Purchased
*Unstable estimate.
Note: This CHIS method rounds percentages and population estimates. As a result of this rounding, percentages may not exactly match the quotient resulting from using the
frequencies, dividend, and divisor.
Source: 2005 California Health Interview Survey (www.chis.ucla.edu).
Use of Selected Children’s Dental Services,
Medi-Cal vs. Healthy Families, 2004
Denti-Cal
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In 2004, children
Proportion of Beneficiaries Enrolled Continuously for 11 Months
were less likely to
Dental Sealant
(ages 6 to 19)
Initial Dental Visit
(ages 4 to 18)
Periodic Dental Visit
(ages 4 to 19)
Prophylaxis
(ages 4 to 19)
Annual Dental Visit
10%
Medi-Cal
Healthy Families
11%
16%
receive dental services
than those enrolled in
Healthy Families.
19%
25%
35%
37%
45%
52%
(ages 4 to 18)
54%
Notes: All claims used in this analysis were based on service dates in CY 2004. Further information on the Healthy Families measures that were used can be found in the
methodology section.
Sources: Healthy Families Dental Plan Quality Measurement Report for Services Provided in 2004, July 2006 (www.healthyfamilies.ca.gov/hfhome.asp and
www.mrmib.ca.gov/MRMIB/HFP/2004DentalRpt.pdf ). Medstat analysis of Medi-Cal MIS/DSS data, CY 2004.
Denti-Cal Pediatric Reimbursments
Compared to General Practice Fees, 2003
Denti-Cal
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Denti-Cal
reimbursement for
General practice fees
category / selected Procedure
Denti-cal
payment
PACific Region
50th
Percentile
CA State
50th
Percentile
CA State
75th
Percentile
pediatric purposes
is much lower than
Diagnostic
Periodic Oral Exam
$15
$39
$35
$43
$25
$50
$48
$56
$45
$91
$92
$102
the fees charged
by general practice
dentists. California’s
Preventive
Prophylaxis (cleaning)
$30
$55
$59
$65
Dental Sealant
$22
$40
$42
$50
$48
$109
$107
$122
lowest of all state
$340
$728
$730
$775
Medicaid programs.
$215
$500
$500
$650
$45
$100
$100
$115
Restorative
reimbursement rates
are among the very
Endodontics
Oral Surgery
Notes: These data reflect pediatric Denti-Cal reimbursement compared to commercial insurers and other payers in the state and in the region (AK, CA, HI, OR, WA) and are
based on 2004 Medicaid payment rates and 2003 ADA payment data.
Source: 2003 ADA Fee Survey.
Reimbursement Rates for Common
Children’s Dental Services,
California vs. Selected States, 2006
Denti-Cal
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While low,
reimbursement rates
category / Procedure
CA
OH
PA
NY
Periodic Oral Exam
$15.00
$17.08
$20.00
$29.00
comparable to those
$25.00
$26.35
$20.00
$29.00
of Medicaid dental
$45.00
$60.00
$45.00
$58.00
Prophylaxis (cleaning), adult
$40.00
$34.13
$34.00
$58.00
states with large
Dental Sealant
$22.00
$22.00
$25.00
$43.00
Medicaid populations.
$48.00
$54.00
$50.00
$84.00
$340.00
NA
$300.00
$580.00
$215.00
$247.63
$180.00
$250.00
$45.00
$52.45
$45.00
$45.00
Diagnostic
Preventive
in California are
programs in other
Restorative
Endodontics
Oral Surgery
Sources: www.denti-cal.ca.gov/provsrvcs/manuals/sec4/Section_4.pdf
http://emanuals.odjfs.state.oh.us/emanuals/GetDocument.do?nodeId=%23node-id%2867%29&docId=Document%28storage%3DREPOSITORY%2CdocID%3D%23
node-id%281209308%29%29&locSource=input&docLoc=%24REP_ROOT%24%23node-id%281209308%29&version=8.0.0
www.dpw.state.pa.us/omap/provinf/feesched/0204feesched.xls
www.health.state.ny.us/health_care/medicaid/fees/docs/dentalfees03.pdf
www.health.state.ny.us/health_care/medicaid/fees/docs/dentalfees03.pdf
Denti-Cal
Dental Care During Pregnancy,
Pregnant Women’s Usage
by Age Group (in years), 2004*
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Across all age groups,
13 to 17
18%
fewer than one in
five pregnant women
18 to 22
19%
23 to 27
28 to 32
19%
17%
38 to 42
17%
All Ages
(13 to 65)
receive any dental
services.
18%
33 to 37
43 and older
19%
19%
*Data are for pregnant women ages 13 to 65 enrolled in a Medi-Cal FFS plan who had a dental visit 6 months after their first visit to a medical provider.
Note: Dental data is based on service date. See the Methodology section for further information.
Sources: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. Aid Code Category Tree for CIDCUM CEL106 Scheme — Primary to Secondary Categories (MCSS Aid Codes.xls).
Denti-Cal
Dental Care During Pregnancy,
Pregnant Women’s Usage
by Aid Code/Category, 2004*
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Research has shown
Aid Code
Description
Dental Visit
Medically Needy, Families
dental care use for
all pregnant women
3N
AFDC-1931(B) Non CalWORKs
29%
3V
AFDC-1931(B) Non CalWORKs, Emergency Services Only
13%
ranges from 23 to 31
34
AFDC-MN
28%
percent.* For Medi-Cal
Minor Consent †
7N
Under 21, All Pregnancy-related Services, No Share of Cost
2%
MN/MI Alien without SIS
pregnant women, 2 to
29 percent had a dental
58
OBRA Alien
15%
visit, depending on
5F
OBRA Alien, Pregnant Woman
17%
their aid code.
Other 200% Income Disr/Aid76
44
200% FPL, Pregnant Citizen
20%
48
200% FPL, Pregnant OBRA
17%
Public Assistance, Families
30
CalWorks
31%
29%
All Other Aid Codes
Total (across all aid codes)
19%
*Data are for pregnant women ages 13 to 65 enrolled in a Medi-Cal FFS plan who had a dental visit 6 months after their first visit to a medical provider.
†In September 1997, the Department of Health Services implemented four new aid codes (7M, 7N, 7P, and 7R) as a better method of identifying beneficiaries eligible for confidential
services.
Notes: Dental data is based on service date. See the methodology for further information. Omnibus Budget Reconciliation Act (OBRA).
Sources: Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. Aid Code Category Tree for CIDCUM CEL106 Scheme — Primary to Secondary Categories (MCSS Aid Codes.xls).
©2007 California HealthCare Foundation *Garfield, M.L, et al., Oral health during pregnancy,
Journal of the American Dental Association (JADA),
Vol. 132, pp. 1009 – 1016 July 2001. (Note that the
methods in the JADA are not identical to those used in
the analysis of Medi-Cal data.)
31
Important Challenges for the
Denti-Cal Program
The generally low use of dental services by all Medi-Cal beneficiaries, and
the particularly low use by children under age six, pregnant women, and
seniors suggests that having Medi-Cal dental coverage is not the same
as having access to dental care. While the reasons for low rates of use
Denti-Cal
Challenges and Questions
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While dental services
represent more
than 5 percent of
personal health care
expenditures nationally,
are numerous and complex, interventions are needed at the beneficiary,
only about 2 percent
provider, and policy levels if disparities in access are to be reduced.
of the Medi-Cal budget
is spent on dental
services.
Source: Heffler S., Smith S., Keehan S. et al. U.S. Health Spending Projections for 2004 – 2014. Health Affairs, January to June 2005; Suppl Web Exclusives:W5 – 74 – W5 – 85.
Important Questions for the
Denti-Cal Program
• What is the impact on access to dental care of the $1,800 annual cap on
adult dental services?
• To what extent can the provision of dental services reduce the prevalence or
severity of medical conditions?
• Are there savings in the cost of medical care (e.g., neonatal infant care) as a
result of providing periodontal disease prevention and treatment services to
Denti-Cal
Challenges and Questions
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There are many
unanswered questions
about dental care for
that merit further
research.
pregnant women?
• Are there dental treatment cost savings for children as a result of intervening
at an earlier age?
• Do dental treatment utilization and costs of dental services for Children with
Special Health Care Needs (CSHCN ) differ from those for other children?
• What are the effects of case management, reimbursement levels, training of
providers, parent education, etc. on access to and cost of dental care?
Denti-Cal
Acknowledgments
Acknowledgments
<< previous
Much of the information and data for this presentation was provided by Lisa Simonson Maiuro of Thomson/
MEDSTAT and her colleagues Kirsten Murtagh, Christine Rinehart, Wes Peterson, Paul Schneider, and Mikki
Melton. MEDSTAT provides market intelligence, decision support solutions, and research services for managing
health care costs and quality. We would like to particularly acknowledge the expertise and guidance provided to
this project by Robert Isman, D.D.S., M.P.H., dental program consultant with the Medi-Cal Dental Services Branch.
In addition, this project was guided by the expertise of the following advisors:
Cecilia Echeverría, M.P.H., M.P.P.
Program Officer
The California Endowment
Elizabeth Mertz, M.A.
Program Director, Center for the Health Professions
University of California, San Francisco
Jared I. Fine, D.D.S., M.P.H.
Dental Health Administrator
Alameda County Public Health Department
Gilbert Ojeda
Director, CA Program on Access to Care
UC Office of the President
Dana Hughes, Dr.P.H.
Associate Professor
Institute for Health Policy Studies
University of California, San Francisco
Nadereh Pourat, Ph.D.
Adjunct Associate Professor of Health Service
UCLA School of Public Health
Senior Research Scientist
UCLA Center for Health Policy Research
Robert Isman, D.D.S., M.P.H.
Dental Program Consultant
Medi-Cal Dental Services Branch
California Department of Health Services
Agnes Lee
Principal Consultant
Senate Office of Research
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We would like to know.
Click to complete our survey at
www.chcf.org/feedback and
enter Report Code #1151.
Thank you.
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California HealthCare
Foundation
476 Ninth Street
Jane A. Weintraub, D.D.S., M.P.H.
Lee Hysan Professor
Chair, Division of Oral Epidemiology and Dental Public Health
Center to Address Disparities in Children’s Oral Health
UCSF School of Dentistry
Kim Lewis, J.D.
Health Attorney
Western Center on Law and Poverty
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Oakland, CA 94607
510.238.1040
www.chcf.org
supplemental information
Glossary
Methodology
Managed Care and Provider Info
County and Age Tables
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Glossary of Terms and Abbreviations | Denti-Cal Facts and Figures
Amalgam
An alloy used in direct dental restorations.
Bitewings
X-rays of the crowns of top and bottom molars to
show decay between teeth and under fillings.
Bitewing Radiographs
X-rays used to reveal the crowns of several upper
and lower teeth as they bite down.
Capitation Rate
A fee or payment of a uniform amount for each
person in a managed care health plan.
Composite
Tooth-colored filling material made of a plastic
dental resin.
Crown
Anatomical Crown: That portion of tooth normally
covered by, and including, enamel;
Artificial Crown: Restoration covering or replacing
the major part, or the whole of the clinical
crown, of a tooth;
Clinical Crown: That portion of a tooth not covered
by supporting tissues.
Dental Procedure Categories
Below are dental procedure categories related to
the charts and tables in this presentation.
Procedure
Category
Description
Diagnostic
Includes exams, x-rays
Oral and
Maxillofacial
Surgery
Includes extractions
Other
Implant services, prosthetics,
prosthodontics
Periodontics
Includes treatment of gums, tissue,
and bone that support the teeth
Preventive
Includes prophylaxis and sealants
Restorative/
Endodontic
Treatment of root and nerve of root
Disabled Adults
Disabled people who are 21 years of age or older.
Includes Medically Needy, Blind/Disabled, and
Public Assisted Blind/Disabled.
Disabled Children
Disabled people who are 0 to 20 years of age.
Includes Medically Needy, Blind/Disabled, and
Public Assisted Blind/Disabled.
Endodontics
A dental specialty concerned with treatment of the
root and nerve of the tooth.
Federally Qualified Health Centers (FQHC)
A public entity or private non-profit provider that
has been approved by Medicare or Medicaid to
provide primary and preventive health care services
such as dental, mental health, substance abuse,
hospital, and specialty care services to underserved
populations.
Film
See radiograph.
Gingiva
Soft tissues overlying the crowns of unerupted
teeth and encircling the necks of those that have
erupted.
Subgingival Curettage: The removal of tartar
deposits or ulcerated tissues from periodontal
pockets.
Gingivitis: Inflammation of gingival tissue without
loss of connective tissue.
Intraoral
Inside the mouth.
Intraoral Periapical
Inside the mouth at or around the apex of a root of
a tooth.
Limited Scope
Limited scope recipients have restricted services.
Beneficiaries in certain aid code categories, for
example, may be restricted to emergency or
pregnancy-related services.
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Maxillofacial surgery
Surgery of, pertaining to, or affecting the jaws and
the face.
Prophylaxis
A scaling and polishing procedure performed to
remove dental plaque, tartar, and stains.
MIS/DSS
The Medi-Cal Management Information System/
Decision Support System that includes Medi-Cal
paid outpatient, inpatient, and pharmacy claims. It
also contains eligibility and demographic data for
beneficiaries and providers.
Prosthetic
A device, either external or implanted, that
substitutes for or supplements a missing or
defective part of the body.
Orthodontics
A dental specialty concerned with straightening or
moving misaligned teeth or jaws with braces or
surgery.
Periapical
At or around the apex of a root of a tooth.
Periodontal
Pertaining to the supporting and surrounding
tissues of the teeth.
Periodontal Disease: Inflammatory process of the
gingival tissues or periodontal membrane of the
teeth, resulting in an abnormally deep gingival
fissure, possibly producing periodontal pockets
and loss of supporting bone.
Periodontics: A dental specialty concerned with
the treatment of gums, tissue, and bone that
support the teeth.
Prosthodontics
Replacement of missing teeth with artificial
materials, such as a bridge or denture.
Pulp
Connective tissue that contains blood vessels and
nerve tissue which occupies the pulp cavity of a
tooth.
Pulpotomy
Surgical removal of a portion of the pulp with the
aim of maintaining the vitality of the remaining
portion by means of an adequate dressing; pulp
amputation.
Radiograph
An image produced by projecting radiation on
photographic film. Radiographs are commonly
called x-rays.
Root
The anatomic portion of the tooth that is covered
by cementum and is located in the alveolus (socket)
of the jawbone.
Root Canal
The portion of the pulp cavity inside the root of a
tooth; the chamber within the root of the tooth that
contains the pulp.
Root Canal Therapy
The treatment of disease and injuries of the pulp
and associated periradicular conditions.
Root Planing
A procedure designed to remove microbial flora,
bacterial toxins, calculus, and diseased cementum
or dentin on the root surfaces and in the pocket.
Scaling
Removal of plaque, tartar, and stain from teeth.
Sealants
Plastic resin placed on the biting surfaces of molars
to prevent bacteria from attacking the enamel and
causing tooth decay.
Space Maintainers
The permanent teeth may not erupt in their proper
alignment, resulting in malocclusion, or crooked
teeth. The main causes of malocclusion are a lack
of space for the permanent teeth to erupt properly
and the premature loss of the baby teeth, which
usually guide the permanent teeth to their proper
location. To prevent malocclusion due to premature
loss of the primary teeth, space maintainers may
be used to guide the teeth into proper alignment.
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Treatment Authorization Request (TAR)
A detailed report that explains why the services a
beneficiary has requested are medically necessary
and should be paid for by Medi-Cal.
X-Ray
See Radiograph.
Source: American Dental Association glossary of dental terms, www.ada.org/public/resources/glossary.asp.
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Methodology | Denti-Cal Facts and Figures
Claims Data
The analysis for this chartbook was based on
the Medi-Cal Management Information System/
Decision Support System (MIS/DSS) that includes
Medi-Cal paid claims. The MIS/DSS includes only
federally funded aid codes and does not include
data for state funded aid codes.
The MIS/DSS Dental Table is compiled from
all records on the Outpatient Service Table with
a Claim Type (CLMTYPE) equal to 5, where the
value 5 specifies a dental claim. Child Health and
Disability Prevention Program (CHDP) claims are
also included in the dental table, however, since
the CHDP program is not part of Denti-Cal, CHDP
claims were omitted from the analysis.
In total there are approximately 22 million dental
claims for approximately 2.1 million Medi-Cal
recipients.
While Denti-Cal technically refers only to
dental services through Medi-Cal fee for service
(FFS), this chartbook includes dental claims for
services through Medi-Cal fee for service (FFS) and
managed care plans.
Expenditure and Service Dates
While it is recognized that more timely data is
generally preferable, it was necessary to rely on
2004 paid claims data due to the fact that over
a 10-month period in 2005, dental claims were
submitted with a value of “0” in the payment
fields. Given the relative stability of expenditures
from one year to the next, the use of 2004 data
All Seniors
rather than 2005 data is unlikely to materially
change the results or their interpretation.
In cases where dental services and expenditures
were compared, only FFS claims where the service
was provided by a dental professional were used
because they were the only claims with reliable
payment data. However, since such claims
comprised 99.6 percent of all Medi-Cal dental
claims they provide a comprehensive picture of
Medi-Cal dental services and expenditures.
•Disabled/blind seniors
•Other seniors (non-blind/disabled seniors)
Enrollee Demographic Data
Demographic data on a claim (e.g., age and
ethnicity) may vary by claim, therefore all
demographic data associated with an enrollee was
based on information obtained from the beneficiary
at the time of enrollment. The age of the recipient was based on the age of
the beneficiary as of January 2004.
Aid codes were grouped into six categories for
ease of reporting:
All Children
•Disabled/blind children
•Other children (non-blind/disabled children)
All Adults
•Disabled/blind adults
•Other adults (non-blind/disabled adults)
Access/Utilization Measures
There are many definitions of and methods by
which to measure access to care and utilization.
One of the most basic is a utilization rate, i.e.,
the proportion of a population that uses a service
in a specified time period. The numerator in this
equation is typically an unduplicated count of users,
i.e., an individual is only counted once regardless
of the number of times that person is seen or the
number of services received. The denominator,
however, can be specified in several different
ways, each of which tends to influence how the
data are interpreted.
Most of the slides used an unduplicated count
of enrolled members over the course of the year.
This reflected the aggregate number of people
who had the benefit of dental services at any time
during the period analyzed. However, it is important
to note that in Medi-Cal, where over the course of
a year some individuals may be eligible for a month
or two while others may be eligible for the entire
year, it isn’t reasonable to assume that people
who have been enrolled for a month have had the
same opportunity to receive dental care as those
who have been enrolled for a year. For this reason,
Denti-Cal often uses “average monthly enrollees”
as the denominator when reporting utilization
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rates. Average monthly enrollees is the sum of the
anytime during the year” will result in the lowest
number of people enrolled each month over the
course of a year divided by 12, and is intended to
reduce the effect of varying periods of eligibility.
The result is utilization rates that are higher than
those calculated using unduplicated enrollees.
Three methods for calculating the denominator
were used for slides 25, 26, and 29 showing the
percentage of children receiving a dental service:
utilization rates since the denominator is the largest
compared to the other two measures.
1. Enrolled at any time during the year;
2. C
ontinuously enrolled during the year,
with only one gap in enrollment of no
more than 30 days; and
3. Average monthly eligibles.
This approach allowed for a sense of how the
data, and therefore the interpretation of the data,
can change with different measures. The second
method, continuously enrolled for 11 months or
more during the year, looked at the population that
has been continuously enrolled for a defined period
of time. This methodology is used by HEDIS ®
and Healthy Families; however, it does present a
limitation: information on many enrollees — those
enrolled for less than 11 months in a year — is not
taken into account.
Clearly, there are pros and cons associated with
each method used for calculating utilization rates.
In general, of the three measures, “enrolled at
Dental Health Professional Shortage Area1
This is the percent of the total county population
living in a Medical Service Study Area (MSSA)
that has been designated as having a shortage of
dental professionals. The federal criteria states that
a geographic area will be designated as having a
dental professional shortage if the following three
criteria are met:
1. T
he area is a rational area for the delivery of
dental services
2. O
ne of the following conditions prevails in
the area:
a. It has a population to full-time equivalent
dentist ratio of at least 5,000 to 1; or
b. It has a population to full-time equivalent
dentist ratio of at least 5,000 to 1, but
greater than 4,000 to 1 and has an
unusually high needs for dental services
or insufficient capacity of existing dental
providers.
3. D
ental professionals in contiguous areas are
overused, excessively distant, or inaccessible
to the population of the area under
consideration.
Analysis Notes Related to Specific Slides
Medi-Cal and Denti-Cal Expenditures Per Beneficiary
Using paid claims in 2004, the denominator for
dental claims is the number of beneficiaries
enrolled in only FFS plans (DENTAL_PLAN_CD
= 000) at the time the claim was submitted
and where the vendor code indicated “dentist”
(VENDOR_CD = 27) The denominator for
Medi-Cal medical claims is the number of
beneficiaries enrolled in only FFS plans
(PRODUCT = 3) at the time the claim was
submitted.
Percent of Children Receiving Preventive Services in
2004, by Age
Preventive services were defined as: Sealants;
prophylaxis without topical fluoride application for
children under age 13; prophylaxis without topical
fluoride application for children 13+; prophylaxis
with topical fluoride application for children under
age 6; prophylaxis with topical fluoride application
for children ages 6 to 17; and space maintainers.
All claims used in this analysis were based on
service dates in 2004. 0.03 percent of individuals
with a dental claim in 2004 did not have any 2004
eligibility information and were dropped from the
analysis. 0.2 percent of claims were dropped from
the analysis due to missing data.
1. More detailed federal criteria and information can be found at http://bhpr.hrsa.gov/shortage/hpsacritdental.htm. The California county designations, spanning 2001 to 2005, came from the California Office of Statewide Health Planning and
Development, Medical Service Study Areas, California Healthcare Workforce Catalog April 2005. These data are available at http://gis.ca.gov/catalog/BrowseRecord.epl?id=23784.
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Children’s Dental Services 2004: Comparing Healthy
Families and Medi-Cal
The measures and calculation methods used for
this slide are described in the Healthy Families
Dental Quality Measurement Report, July 2006,2
and were applied to the Denti-Cal data.3
Calculations for the five Denti-Cal measures that
are analogous to Healthy Families measures are
outlined below.
Measure 1 – Annual Dental Visit
Step 1: Identified all individuals continuously
enrolled in Medi-Cal during 2004 that were
between the ages of 4 through 18, inclusive.
The count of unique individuals was defined as
the denominator.
Step 2: Using the list of unique individuals
identified in Step 1, if at least one dental claim
existed then the individual was counted in the
numerator.
existed indicating a sealant treatment (defined
claim existed indicating a periodic dental visit
as orig_dental_cd equal to 045, 046, 047 or
PROC1_CD equal to X2301, X2303, X2305) from
a dentist (where the VENDOR_CD was equal
to 27) then the individual was counted in the
numerator.
(defined as PROC1_CD equal to D0120 or
ORIG_DENTAL_CD=015) from a dentist (where
the VENDOR_CD was equal to 27) then the
individual was counted in the numerator.
Measure 3 – Initial Dental Visit
Step 1: Identified all individuals enrolled in Medi-Cal
for at least 11 months during 2004 who were
between the ages of 4 through 19, inclusive. The
count of unique individuals was defined as the
denominator.
existed indicating an initial dental visit (defined as
PROC1_CD equal to D0110 or ORIG_DENTAL_
CD=010) from a dentist (where the VENDOR_
CD was equal to 27) then the individual was
counted in the numerator.
Measure 2 – Dental Sealant
Measure 4 – Periodic Dental Visit
denominator.
denominator.
identified in Step 1, if at least one dental
Measure 5 – Prophylaxis
for at least 11 months during 2004 that were
between ages of 4 through 19, inclusive. The
denominator.
existed indicating a prophylaxis treatment
(defined as ORIG_DENTAL_CD equal to 050,
049, 061, 062 or PROC1_CD equal to D1120,
D1110, D1201, D1205) from a dentist (where
the VENDOR_CD was equal to 27) then the
individual was counted in the numerator.
Dental Care During Pregnancy
Using the Medstat Episode Grouper (MEG), this
analysis identified all women ages 13 to 65 who
were enrolled in a fee-for-service medical plan
in 2004 and had an episode summary category
of vaginal deliveries or C-sections. Given the
limitation of one calendar year of dental data, the
analysis took the case numbers for all women
2. Healthy Families, Data Insights, Dental Plan Quality Measurement Report for Services Provided in 2004, July 19, 2006 meeting (www.mrmib.ca.gov/MRMIB/HFP/2004DentalRpt.pdf ).
3. Ages for Medi-Cal enrollees were determined by subtracting the birth date listed on the eligibility file from December 31, 2004.
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who met these criteria in the first six months of
2004 and determined how many had a dental
visit within six months of the first service date
of their pregnancy episode. (A first service date
is determined by the woman’s first encounter
with a health care provider.) While this approach
is a good indicator of dental care for women who
are pregnant, it has obvious shortcomings. First,
a woman may have had a dental visit during her
pregnancy, but sometime later than six months
after her first service date. Second, a woman may
have had a first service date late in her pregnancy
and the dental visit may have actually occurred
after delivery. Time constraints and data limitations
precluded the use of a methodology to address
these limitations.
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Managed Care and Provider Information | Denti-Cal Facts and Figures
Managed Care for Medi-Cal Dental Beneficiaries1
• Denti-Cal is the name given to Medi-Cal‘s feefor-service (FFS) dental program, for which 95
percent of Medi-Cal beneficiaries are eligible.
The remaining 4 percent are enrolled in one of
several dental managed care plans.
• Dental managed care services are available in
Denti-Cal Providers3
• More than half of managed care beneficiaries
received their care through Access Dental Plan
and Western Dental plans.
• Sacramento County is the only county in
California that has more dental managed care
than FFS enrollees.
Los Angeles, Riverside, Sacramento, and San
Bernardino Counties.
• In 2004, there were 377,660 Medi-Cal
beneficiaries enrolled in a dental managed care
plan, of which 90,691 (24 percent) received at
least one dental service.
• More than half of all enrolled dental managed
care beneficiaries are located in Sacramento
County.
• Dental managed care is required for the
CalWORKs population and several other
populations in Sacramento County, the only
county which imposes such mandates.2
• In 2004 there were approximately 11,000
providers or provider organizations.4
• More than 2,000 providers or provider
organizations (21 percent) are group dental
practices.
• Of the $626 million Denti-Cal paid in 2004,
$273 million (41 percent) went to group
dental practices.
• One dental group accounted for 7 percent
of all paid claims; no other group practice or
individual dentist accounted for more than
1.5 percent of all paid claims.
• Roughly 2,000 providers or provider
organizations filed 20 or fewer claims.
• 53 percent of providers or provider
organizations saw 50 or more beneficiaries.
• 42 percent of providers or provider
organizations saw 100 or more beneficiaries.
• In 2004, there were seven dental plans that
provide dental managed care services to
Medi-Cal beneficiaries.
1. Total beneficiaries enrolled in a FFS Dental Plan were 8,168,309, based on eligibility data. Denti-Cal managed care plans and the counties they serve include: Access Dental Plan serves Los Angeles and Sacramento Counties, American Health Guard
serves Los Angeles County, Delta Dental Plan serves Sacramento County, DentiCare Dental Plan serves Riverside, Sacramento, and San Bernardino Counties, UHP Healthcare serves Los Angeles and San Bernardino Counties, Universal Care serves
Los Angeles county, and Western Dental Services serves Los Angeles, Riverside, Sacramento, and San Bernardino Counties.
2. Rouillard, Shelley. Sacramento Geographic Managed Care: Eight Years Later. Community Services Planning Council. 2003. p. 20. Accessed on November 28, 2006. Available at www.communitycouncil.org/cspc-gmc_report.pdf.
3. Medstat analysis of Medi-Cal MIS/DSS data, CY 2004. (Includes all FFS claims paid to a dental professional.)
4. Providers and provider organizations, as referenced in this slide, may include multiple dentists with multiple office locations. Rural health clinic and FQHC claims comprise less than 2 percent of all dental claims.

Denti-Cal Facts and Figures - California HealthCare Foundation

Transcription

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