Impact of Dental Care on Health Care Events and Costs · Diabetes Mellitus • Respiratory Disease ... Emergency Dental Root Planing and Scaling Endodontic Periodontal Surgery Percent

Impact of Dental Care on Health Care Events and Costs New York State Medicaid, Adults 40-64 years

Kevin Malloy MPH, New York State Department of Health Ira Lamster DDS, MMSc, Stony Brook University

Preliminary Findings

2

Background

3

Origin of Current Study

• Oral infections and the resulting inflammatory response are risk factors in the progression of some Non-Communicable Diseases (NCDs)

• Recent studies have shown reduced heath care costs and improved outcomes among those who received preventive oral care and with treatment of periodontal disease

• To-date, research has primarily looked at private payer populations

4

Study Objectives

• To investigate the relationship between utilization of dental care, health care events, and costs in a high need public payer population (NYS Medicaid)

• Describe these relationships for NCDs linked to dental health

5

• As of November 2018, New York Medicaid enrollment was more than 6.5 million individuals

• Majority (nearly 80%) enrolled in managed care

– Includes individuals with specialized health care needs including managed long term care, HIV care, mental health and substance use services, and care for developmental disabilities

• Combined federal/state/local spending in 2019 = $70.2 Billion1

– ~32% of state budget

Medicaid in New York State

1. https://www.budget.ny.gov/pubs/archive/fy19/exec/fy19book/HealthCare.pdf

6

NYS Medicaid Dental Benefit Package • Covers “Essential Services”

– Preventive, prophylactic, and other routine dental care – Services and supplies required to alleviate a serious health

condition – Inpatient diagnostic, palliative, and therapeutic dental care

7

NYS Medicaid Dental Benefit Exclusions Non covered services include: • Periodontal surgery and crown lengthening • Molar root canal for members 21 years and over* • Immediate full or partial dentures • Fixed partial dentures* • Replacement of partial or full dentures prior to schedule* • Cosmetic dentistry • Adult orthodontics • Implants (unless medically necessary)

*May be covered under certain circumstances including medical necessity

8

Prophylaxis Allowances and Policy

• Prophylaxis: Once per six-month period

• Periodontal Maintenance: Once per six-month period

Note: Not to be used in conjunction (within six-months of each other), or on the same date of service as periodontal root planning and scaling

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Treatment Allowances and Policy

• Endodontics ‒ Prior authorization required

• Surgical (Gingivectomy or gingivoplasty)

‒ Reimbursable solely for the correction of severe hyperplasia or hypertrophy associated with drug therapy, hormonal disturbances, or congenital defects

10

Treatment Allowances and Policy • Non-Surgical (Root Planning and Scaling)

‒ Must demonstrate clinical loss of periodontal attachment, and; • Periodontal pockets and sub-gingival accretions on cemental surfaces in the

quadrant(s) being treated, and/or;

• Radiographic evidence of crestal bone loss and changes in crestal lamina dura, and/or radiographic evidence of root surface calculus.

‒ Limit: every two years (per quad). No more than two quads on single date.

• Extractions ‒ Prior authorization for certain procedures

11

Study Methodology

12

Specifications

• Study period: Three years, July 1, 2012 – June 30, 2015 ‒ Dental care became part of the managed care plan benefit package in 2012

• Population: ‒ Adults ages 40 – 64 ‒ Not eligible for Medicare (dually eligible) ‒ Continuously enrolled in NYS Medicaid for 36 month study period ‒ Exclusions: residents of long term care facilities and those receiving

hospice services

13

Outcomes and Comparisons • Outcomes of Interest

– Events • Emergency Department (ED)

Visits • Hospitalizations

– Costs • ED • Hospitalization • Pharmacotherapy • Total Cost of Health Care,

Excluding Dental

• Comparison Groups – No Dental Care (referent)

– Any Preventive Care* – Preventive Care w/o Anti-Infective Tx** – Preventive Care with Anti-Infective Tx – Anti-Infective Tx w/o Preventive Care

* Any preventive care group is not mutually exclusive from the other preventive care groups ** Anti-Infective Therapy (Tx) was defined as tooth extraction and/or endodontic therapy

14

Non-Communicable Disease (NCD) Cohorts • Cardiovascular Disease (CVD)

– Major cardiac septal anomalies – Major congenital heart diagnosis – CHF – Valvular disorders – Anginas and Ischemic heart disease – Myocardial infarction – Arterial fibrillation – Dysrhythmias and conduction disorders – Hx coronary artery bypass – Hx coronary angioplasty – Cardiac device status – Coronary atherosclerosis – Hypertension – Ventricular and atrial septal defects – Minor chronic diagnosis – Other major cardiovascular diagnoses

• Diabetes Mellitus

• Respiratory Disease – Major anomalies – COPD and bronchiectasis – Chronic pulmonary diagnoses – Asthma – Chronic bronchitis

• Cognitive Impairment – Neurodegenerative diagnosis except multiple

sclerosis and Parkinson’s – Alzheimer’s Disease and other dementias

Identified using 3M® Clinical Risk Grouping Software

15

Analysis

• Demographics

• Cross-sectional (yearly)

• Longitudinal: Utilization in years 1 and 2 with outcomes in year 3

• Effect of increasing frequency of preventive care utilization

• Effects within NCD cohorts

16

Preliminary Findings

17

Cohort Demographics

19.2%

24.3% 24.0% 21.5%

11.0%

40-44 45-49 50-54 55-59 60-64

Years

Age

58.2

41.8

Sex

Female Male

Final Cohort Size: n= 535,038 25.3%

18.2% 16.9%

21.8%

4.8%

13.1% Race

White Black Asian

Hispanic Others Unknown

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94.1

5.9

Medicaid Program

Managed care Fee for service

Cohort Demographics

3.7% 9.2%

5.5% 5.7% 6.8%

68.8%

0%

10%

20%

30%

40%

50%

60%

70%

Northeast Western Central Hudson Valley

Long Island New York City

Region of Residence in NYS

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Cohort Demographics Clinical Risk Group Assignment* % of Cohort

Healthy 17.1 %

Significant Acute Disease 3.0 %

Single Minor Chronic Disease 6.5 %

Minor Chronic Disease in Multiple Organ Systems 3.3 %

Single Dominant Disease or Moderate Chronic 20.5 %

Chronic Disease in Multiple Organ Systems 40.4 %

Dominant Chronic Disease in 3 + Organ Systems 4.0 %

Dominant Metastatic Malignancies 0.7 %

Catastrophic Conditions 4.7 %

*Assignment generated using 3M® Clinical Risk Grouping Software

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Cohort Demographics

• More than a quarter (27%) received Supplemental Security Income (SSI) from the Federal Government based on being aged, blind, or disabled

• More than a third (36%) received cash assistance from the State

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27.72%

15.69%

8.87%

2.80%

2.21%

1.43%

0.02%

0% 5% 10% 15% 20% 25% 30%

Preventive Care Restoration

Extraction Emergency Dental

Root Planing and Scaling Endodontic

Periodontal Surgery

Percent of Cohort Receiving at Least One Service

Percent of Study Cohort Utilizing Dental Services*, 2012-2013

* Not mutually exclusive

Utilization of Dental Services

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Comparison Groups

60%

28% 21%

7% 5%

0%

10%

20%

30%

40%

50%

60%

70%

No Dental Any PC* PC without AI PC with AI AI without PC

Percent of Cohort by Utilization Category, 2012-2013

* Not mutually exclusive from other groups with PC Note: Mutually exclusive groups do not sum to 100 because of utilization of other dental services

Key: PC = Preventive Care AI = Anti-Infective Therapy

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Cross-sectional: Event Rates by Dental Care Utilization, July 2012 – June 2013

Key: PC = Preventive Care AI = Anti-Infective Therapy

19.6

15.2 14.2

18.5

26.7

No Dental Any PC** PC without AI

PC with AI AI without PC

Hospitalization Rate Per 100 People

74.6 65.1 61.2

77.2

114.7



ED Visit Rate Per 100 People

* *

*

Statistically different from No Dental (p < 0.01) *

* *

*

* *

Referent Group

** Not mutually exclusive from other groups with PC

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Cross-sectional: Costs1 by Dental Care Utilization, July 2012 – June 2013

Key: PC = Preventive Care AI = Anti-Infective Therapy ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug

1. Per Person Average Cost. Total healthcare cost excludes cost of dental care

$4,961 $4,220 $4,025

$4,825

$6,443



ED/HOSP/RX

$8,687 $9,512 $9,250

$10,321 $11,447



Total Healthcare

* *

*

*


* * *

Referent Group


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Longitudinal: Year 3 Event Rates by Dental Utilization in Years 1 and 2

76.4 68.5 62.8

79.0

116.3



ED Visit Rate Per 100 People

* *

*

*

Key: PC = Preventive Care AI = Anti-Infection Therapy

21.1

16.2 14.4

19.6

30.0



Hospitalization Rate Per 100 People


* *

*

*

Referent Group


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Longitudinal: Year 3 Costs1 by Dental Utilization in Years 1 and 2

Key: PC = Preventive Care AI = Anti-Infective Therapy ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug

1. Per Person Average Cost. Total health care cost excludes cost of dental care

$6,524 $5,705 $5,209

$6,621

$8,660



ED/HOSP/RX

$11,227 $11,271 $10,500

$12,692 $14,348



Total Healthcare


* *

* *

* *

Referent Group


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Impact of Frequency of Preventive Care

Key: ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug Note: Overall change in rates across increasing frequency of preventive care was statistically significant (p<0.001) for all categories of care

85.3 75.4

64.4 57.1 55.1

23.2 18.8 14.2 12.6 11.9

0

20

40

60

80

100

None One Two Three Four or More

Year 3 Events Rates Per 100 People, by Number of Preventive Visits over Years 1 and 2

ED Hospitalizations

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NCDs Focus: Difference in Preventive Care vs No Dental Rate reductions and cost savings among those with NCDs

Year 3 outcomes based on utilization of services in years 1 and 2

•ED (-13.1 per 100 ppl) •Hosp (-7.6 per 100 ppl) •Total Cost PP (-$772)

CVD

•ED (-16.9 per 100 ppl) •Hosp (-10.3 per 100 ppl) •Total Cost PP (-$2,065)

Diabetes


Respiratory


Cognitive Impairment

Key: ED = Emergency Department Visit Hosp =Hospitalization Total Cost PP = Total average cost per person, excluding cost of any dental care

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Concluding Remarks • This study is comprehensively examining the effect of dental treatment on

health care outcomes and costs in a Medicaid program • Preliminary findings

– Provision of preventive dental services is associated with: • Reduced ED and hospitalization rates • Reduced ED, Hospitalization, and Rx costs • Reduced Total Healthcare Costs for those with NCDs

– Beneficial effects are modified by: • The need for anti-infective therapy (endodontic treatment and or tooth extraction) • Frequency of preventive care utilized

• This analysis is continuing, to more specifically define associations and adjust

for the unique needs of subsets of this Medicaid population

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Acknowledgements

Analytic Support Provided by: Yizhao Xi, Data Analyst, New York State Department of Health

Bin Cheng PhD, Associate Professor of Biostatistics, Columbia University Medical Center

This study is supported by: The New York State Department of Health;

The John A. Hartford Foundation; The DentaQuest Foundation; and

the Santa Fe Group.

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Questions

Corresponding Author:

Ira B. Lamster D.D.S., M.M.Sc. Clinical Professor

Stony Brook University School of Dental Medicine Dean Emeritus

Columbia University College of Dental Medicine

Email: [email protected]

mailto:[email protected]

Impact of Dental Care on Health Care Events and Costs · Diabetes Mellitus • Respiratory Disease ... Emergency Dental Root Planing and Scaling Endodontic Periodontal Surgery Percent

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