Smiles Across America Webinar Series
Implications of CHIPRA: Utilization of Dental Services among Young Children
Date: 12/10/2015
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CE Credit Available
OUR MISSION Oral Health America’s mission is to change lives by connecting communities with resources to drive access to care, increase health literacy, and advocate for policies that improve overall health through better oral health for all Americans, especially those most vulnerable.
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HEALTH LITERACY
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Campaigns for Oral Health Equity Educate the public, including policy makers, about the importance of oral health for overall health Emphasize the need to prioritize oral disease alongside other serious health conditions Advocate for policies that positively impact programs and stakeholders Current campaigns include:
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IMPLICATIONS OF CHIPRA: Utilization of dental services among young children
Nicole Thurlow Zautra, MPH Indiana University, Bloomington
PRESENTATION OUTLINE 1. Introduction
2. Method 3. Results
4. Discussion 5. Conclusion
INTRODUCTION
DENTAL CARIES Prevalence, severity, and treatment cost increase with age and duration of delay
ORAL HEALTH IN CHILDHOOD
Good oral health in childhood means better oral health for life.
REDUCING DENTAL DISEASE Prevention of tooth decay requires a comprehensive, integrated approach that addresses many factors including: •
Environment (e.g., access to community water fluoridation and number of dental providers);
•
Economic (e.g., payment for dental services and dental insurance);
•
Personal or social norms/behaviors (e.g., health literacy, diet, oral hygiene care and transmission of disease);
•
Political (e.g., funding, support for community water fluoridation and scope of dental practice).
DENTAL CARE Greatest unmet
healthcare need among low-income children under five
CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) Goal: to motivate states to develop mechanisms for increasing enrollment of eligible children in Medicaid/CHIP
Dental health components: 1. 2.
Federally established dental benefit parameters Prenatal and early childhood dental education for parents
METHOD
FISHER-OWENS MODEL OF CHILDREN’S ORAL HEALTH
(Fisher-Owens et al., 2007)
ADAPTED STUDY MODEL
Dental care system characteristics
CommunityLevel Influences
Health care system characteristics
Family-Level Influences Socioeconomic status
Child-Level Influences Use of dental care
Oral Health
Dental insurance
STUDY DESIGN Retrospective time-series DV’s: 1) dental visit, and 2) total dental expenditure IV’s: Based on Fisher-Owens et al. model Child: age, sex, race/ethnicity, insurance status Family: income level Year: 2009-2012
STUDY HYPOTHESES 1. The implementation of CHIPRA was associated with an increase in child dental service utilization.
2. The implementation of CHIPRA was associated with a decrease in the total Medicaid expenditures for child dental services.
DATA SOURCE
Medical Expenditure Panel Survey, household component
Years 2009-2012
STUDY CRITERIA INCLUSION
EXCLUSION
• 0-5 years of age
• >5 years of age
• Continuous Medicaid/CHIP enrollment (experimental group) or uninsured (control group) during survey period
• Privately insured or noncontinuous Medicaid/CHIP enrollment during survey period
ANALYSIS METHOD Heckman’s 2-Step procedure 1. Logistic regression of dental visit by predictors 1. Linear regression of dental expenditure by predictors
Mill’s ratio generated in step 1 Inverse Mill’s ratio included in step 2
RESULTS
CHILD CHARACTERISTICS Sex
Age 25000000
20000000 15000000
Male 50%
10000000 5000000 0 Age Category 0-1 years
2-3 years
4-5 years
Female 50%
CHILD CHARACTERISTICS Insurance Status
Uninsured 36% Medicaid/ SCHIP 64%
Race/Ethnicity 20000000 18000000 16000000 14000000 12000000 10000000 8000000 6000000 4000000 2000000 0 Race/Ethnicity Category Non-Hispanic White
Non-Hispanic Black
Hispanic
Other
FAMILY CHARACTERISTICS Family Income Level 20000000 18000000 16000000 14000000 12000000 10000000 8000000 6000000 4000000 2000000 0
Year
2012 24%
2011 24%
2009 25%
2010 27%
Weighted Odds Ratios of Dental Visit by Logistic Regression 1. Child characteristics
Odds Ratio
95% Confidence Interval
Age: 0-1 years
0.03**
(0.02, 0.04)
2-3 years
0.13**
(0.10, 0.17)
4-5 years
---
---
Sex: Female
--0.92
(0.79, 1.07)
---
---
Non-Hispanic black
1.27*
(1.04, 1.56)
Hispanic
1.41**
(1.18, 1.69)
1.33
(0.99, 1.79)
1.60**
(1.34, 1.91)
---
---
1.11 1.09 1.03 --1.03
(0.89, 1.39) (0.79, 1.50) (0.80, 1.33)
0.99 --1.21 1.2
(0.81, 1.22)
Male Race/ethnicity: Non-Hispanic white
Other Insurance status: Medicaid/SCHIP Uninsured 2. Family characteristics Family income level: Poor/negative Near poor Low income Middle income High income
(0.73, 1.44)
3. Year 2009 2010 2011 2012 Note: N=41,370,241; *p<0.05; **p<0.01 Data source: 2009-2012 Medical Expenditure Panel Survey
(0.98, 1.50) (0.97, 1.49)
Weighted Linear Regression of Dental Expenditure ( â&#x2030;Ľ 1 dental visit) β
SE
p-value
Age: 0-1 years
-231.13
50.14
<.001**
2-3 years
-97.59
20.34
<.001**
4-5 years
--8.12
0.81
1. Child characteristics
Sex: Female Male Race/ethnicity: Non-Hispanic white
---1.98 ---
Non-Hispanic black
-9.77
11.32
0.39
Hispanic
15.25
12.36
0.22
Other
32.54
17.48
0.06
110.69
12.92
<.001**
-14.87
17.92
0.41
Near poor
-31.76
17.68
0.07
Low income
-15.25
17.43
0.38
Insurance status: Medicaid/SCHIP Uninsured
---
2. Family characteristics Family income level: Poor/negative
Middle income
---
High income
-9.25
15.36
0.55
2009
-3.28
11.83
0.78
2010
---
2011
29.91
8.3
0.01**
2012
-2.49
8.3
0.76
3. Year
Note: N=24,665,641; *p<0.05; **p<0.01 Data source: 2009-2012 Medical Expenditure Panel Survey
DISCUSSION
STUDY SIGNIFICANCE Child age remains a barrier to dental care No observed impact on dental utilization
CHIPRA may have contributed to increased frequency of dental service utilization among those already accessing services
STUDY HYPOTHESES 1. The implementation of CHIPRA was associated with an increase in child dental service utilization.
2. The implementation of CHIPRA was associated with a decrease in the total Medicaid expenditures for child dental services.
POLICY IMPLICATIONS CHIPRA requires improvement Suggestions: 1. Increase dental service reimbursements 2. Reduce administrative burden on providers
CONCLUSION
CONCLUSIONS
Future study of CHIPRA is necessary Itâ&#x20AC;&#x2122;s too soon!
New policies specific to dental care are needed
Dr. Hsien-Chang Lin
Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
CE Credit Available
Contact Information • Nicole Thurlow Zautra– ntz@Indiana.edu • Tyler Brown tyler.brown@oralhealthamerica.org