Patterns in pediatric Medicaid dental claims and payment amounts: An analysis of settings and dental providers

Abstract

OBJECTIVE:

To determine the trends in the settings and types of providers that provide oral health services to pediatric patients using Medicaid in Arizona.

METHODS:

In a retrospective descriptive study, we examined the place of service and provider type of Medicaid-paid dental claims among pediatric patients from January 2016 to December 2019. We analyzed Medicaid reimbursed dental services using dental claims data.

RESULTS:

More Arizona children aged birth to 21 were treated in health clinics than in private practice/ dental support organization settings in 2019 than in 2016. Preventive and minor restorative dental claims were significantly higher in 2019 than in 2016 for pediatric patients in Arizona. Further, there was an increase in dental claims paid to non-dentists, such as dental hygienists and nurse practitioners, in 2019 compared to 2016.

CONCLUSIONS:

The place of service and provider type are shifting among pediatric Medicaid patients in Arizona. Not only is there a shift from place of service, but preventive and minor restorative dental claims are being filed by more non-dental providers. This reveals the movement towards integrated oral health in primary care for pediatric Medicaid patients in Arizona.

Private practice is the most common setting providing oral healthcare; however, group and corporate practices are becoming increasingly more common.¹ Since 2018, 91% of dentists practice in a private setting, and as of 2021, 46% of dentists are practicing in a solo practice with 10% of dentists practicing in a dental support organization (DSO).^1,2 The majority of private practices do not accept Medicaid insurance, thus tending to serve dental patients who are privately insured or who self-pay. DSOs contract with dentists in a group practice setting to centralize practice management and provide non-clinical support. In 2017, a survey of 47 DSOs found 61% of affiliated dentists accepted Medicaid and 43% of private practice dentists served only Medicaid-insured patients.^1,3 Other common settings include Federally Qualified Health Centers (FQHCs) and school-based health clinics. FQHCs provide oral health services for uninsured or Medicaid-insured children and adults. From 2001 through 2020, the number of patients served at a FQHC for oral health concerns increased from 1.4 million to 5.2 million, with majority (i.e., one-third) of the patients under the age of 18.^1,4 School-based health programs provide preventive care services at schools, improve oral health literacy, and can connect students and their families to a dental home.¹

Oral Health Integrated Care

In the United States, there is a substantial push for integrated healthcare. In 2003, the Surgeon General made the initial call for the integration of oral health into primary care, which has been repeated in subsequent reports.^1,5 Integrated oral health incorporates oral health into primary care and behavioral health settings to treat the overall health of patients. Integrated oral health can foster health promotion, oral disease prevention, and health equity.⁶ Integration of oral health into primary care can promote positive care-seeking behaviors that address barriers to care and increase the availability of services.⁶ Factors that limit access to care can also be mitigated with the implementation of integrated oral health.

Integrated oral health can be beneficial in promoting collaborative care with primary healthcare providers to address issues impacting both physical and oral health. Settings that incorporate the Oral Health Delivery Framework successfully conduct oral health screenings and fluoride varnish application into medical visits and include a referral to a dentist.¹ Since primary care tends to be the first point of contact an individual has with the health system, integrating a dental provider may increase the effectiveness and efficiency in preventing disease and can meet the needs of individuals who routinely seek medical care, but not oral healthcare.⁷

Dental Providers in Integrated Care

Access to oral healthcare can be increased by expanding provider types, such as dentists, dental hygienists, dental therapists, and functions of dental assistants into primary care. Integrating dental providers (i.e., dentists, dental hygienists, dental assistants) not only supports the oral health of pediatric patients but also their physical and mental health, which contributes to the pediatric patient’s overall health and well-being. By incorporating dental providers into the interdisciplinary team, a patient can receive an oral health screening to detect diseases and receive preventive care.⁸ Additionally, in some states, dental hygienists, dental therapists, and dental assistants can prepare, place, contour, and finish direct restorations and place and cement prefabricated crowns.⁹ Expanding provider types into primary care can address access to care barriers and address the oral health needs of pediatric patients.

Medicaid-eligible children and their families receive dental care in a variety of settings including private practices, DSOs, health clinics¹⁰ (i.e., FQHCs, lookalikes), schools, as well as urgent care, emergency rooms or departments. FQHCs and look-alikes are uniquely positioned to incorporate oral health into primary care. FQHCs are federally funded non-profit community health centers that provide medical, dental, and behavioral health services to underserved populations and areas.^11–13 In addition to providing medical, dental, and behavioral services, FQHCs can address barriers associated with access to care by providing transportation, case management, and translation services for their patients.¹¹ Furthermore, many FQHCs have shared integrated medical and dental electronic health records, which enables patient care by promoting communication among providers, referrals among providers, consultations with professionals, improved efficiency and quality of care, and monitoring the outcomes of clinical interventions by promoting the overall health and wellbeing for the patient.¹³ Currently, not all FQHCs are providing dental services; however, within the next 10 years, it is estimated that FQHCs will provide basic dental care to approximately 16 million individuals.¹² In the U.S., there are 15,838 FQHCs, and in Arizona, there are 25 FQHCs with 238 sites and 56 sites providing dental services, and 2 look-alikes.^14,15 Medicaid is the primary payer for dental services at FQHCs, and patients under the age of 21 comprise 50% of the general Medicaid population served at 14 FQHCs across the U.S.¹²

Purpose of Study

The lack of access to a credentialed Medicaid provider in traditional private practice settings may increase the use of other settings (e.g., primary care or health clinics) for dental care. This analysis aimed to determine the specific types of settings and dental providers that provided oral healthcare services to Medicaid children under the age of 21 residing in Arizona from 2016 to 2019. We explored the number of paid dental claims filed for diagnostic, preventive, minor restorative, major restorative, and endodontic dental services across setting types. Finally, we examined the number of claims and reimbursement trends to different provider types (i.e., dentist, dental hygienist, group, and non-dental) across different settings. This information is vital to future research examining settings addressing the oral health of pediatric patients and the effectiveness of integrated oral health in primary care in the U.S.

Methods

This retrospective study utilized data from paid pediatric dental claims of Medicaid patients in Arizona over a span of 4 years (January 2016-December 2019). The study had two descriptive objectives: 1) to examine the patterns in different types of paid pediatric dental claims and the corresponding payment amounts, categorized by the place of service. By analyzing these patterns, we sought to gain insight into the utilization and payment trends of pediatric dental care within different settings. And 2) to analyze patterns in paid dental claims and reimbursement among different types of providers, considering the various place of service categories. By investigating these patterns, we aimed to understand the variations in dental care utilization and percentage of total reimbursement across different provider types and settings.

In this study, our aim was to investigate potential changes in the payment patterns of paid pediatric dental claims. Specifically, we hypothesized that during the period from 2016 to 2019, there would be a noticeable shift away from the utilization of traditional private/ corporate settings towards other settings such as health clinics. We also hypothesized that between the years 2016 and 2019, there would be a notable rise in both the number of claims and the payment amounts made to group providers and non-dental providers.

We limited claims to those paid to credentialed Medicaid providers for individuals who were aged birth to 21 years because Arizona Medicaid does not provide dental benefits for adults, except for emergencies and a limited number of adults living with developmental disabilities. This research was determined to be exempt from review by the Northern Arizona University Institutional Review Board (IRB).

Definitions

Table 1 illustrates our categorization of place of service (i.e., settings) and type of dental provider. The categorizations were validated by the Centers for Health Information and Research (CHiR) at Arizona State University (ASU). These data did not include patient information, such as name, location, or age. All dollar amounts are represented in 2016 dollars, after adjusting for inflation.

Table 1.

Categorization of Place of Service and Dental Provider Type

Categories	Definition
Place of Service
Private/DSO	Office, dentist
Health clinics	Community mental health center, FQHC, independent clinic, military treatment facility, mobile unit, public health clinic, rural health clinic, telehealth
Emergency/urgent	Emergency room-hospital, urgent care facility
IHS	Indian Health Services, Tribal 638
Other	Ambulatory surgical center, assisted living facility, end-stage renal disease treatment facility, group home, home, hospice, independent laboratory, inpatient hospital, mass immunization center, nursing facility, off campus-outpatient hospital, on campus-outpatient hospital, other place of service, pharmacy, prison/correctional facility, school, skilled nursing facility, temporary lodging
Dental Provider Type
Dentist	Dentist
Dental hygienist	Dental hygienist
Group	638 FQHC, clinics, community/rural health center, FQHC, integrated clinics
Non-dental	Certified registered nurse anesthetist, DO-physician osteopath, group-payment ID, hospital, MD-physician, pharmacy, psychologist, registered dietician, registered nurse practitioner

Note. DSO = dental support organization; FQHC = federally qualified health clinic; IHS = Indian Health Services. The definition represents the various settings that comprise the place of service and dental provider type.

Type of Dental Claim

We used the American Dental Association’s Code on Dental Procedures and Nomenclature (CDT) 2019 to identify and categorize the type of dental claim into five categories. We selected procedure codes that examined preventive (i.e., D0120-D1999), minor restorative (i.e., D2140-D2664), major restorative (i.e., D2710-D2999), endodontic (i.e., D3110-D3999),¹⁶ and other. Procedure codes classified as other did not fit into preventive, minor restorative, major restorative, or endodontic categories.

Data Evaluation

The dataset was obtained from CHiR at ASU which is responsible for storing and managing the data for the Arizona Medicaid system. Contents of this database are all paid dental claims made to the Medicaid system for children aged birth to 21 years. The ASU IRB reviewed the dataset for Health Insurance Portability and Accountability Act compliance and authorized it for the intended research.

Aggregate information from dental claims paid by Medicaid during the selected calendar years is included in the dataset. The dataset contains provider data, such as provider name, the place of service based on zip code, type of provider (e.g., general dentist, dental hygienist, other health care provider), type of facility (private/DSO office, health clinic, urgent/emergency department, tribal, and other) and the general location, as well as the dental code billed, count of claims, and month of service. The dataset also includes the amounts paid to the provider in a series of dollar ranges based on the overall data distribution. We present inflation-adjusted amounts for dental claims reimbursed (in 2016 dollars). Medicaid does not categorize or define providers by volume or amount paid; therefore, this analysis was conducted by our team independently.

We added the code categories to be able to group preventive and restorative services although the original dataset included the dental code paid. The dental services were grouped using the CDT 2019 dental codes for preventive, minor restorative, major restorative, endodontic, and other.

We present the trends in the number of dental claims paid in Arizona in each place of service between 2016 and 2019. We also illustrate the trends in the inflation-adjusted dollar amount paid for dental service in Arizona in each place of service between 2016 and 2019. We descriptively analyzed the number of claims paid to each type of provider. We then stratified the data by preventive, minor restorative, major restorative, endodontic, and other to examine the number of claims paid for each. To answer our second question, we then stratified the data by provider type (i.e., dentist, dental hygienist, group, and non-dental).

Results

The 4-year trends in the total number of Medicaid pediatric dental claims paid in Arizona revealed a 32.7% increase from 2016 (n = 3,106,526) to 2019 (n = 5,042,579). Our analysis of the trends in types of settings (private/DSO, health clinic, emergency/urgent care, Indian Health Service [IHS], and other) where dental claims were paid demonstrated a significant increase in claims paid to health clinics in 2019, compared to 2016. In 2016, 0.3% (n = 7,835) of the total claims were paid to health clinics compared to 6.6% (π = 333,083) of the total claims in 2019. The number of claims paid to IHS, emergency/urgent care, and other all remained consistent between 2016 to 2019 (Figure 1).

Figure 1. The Percentage of Dental Claims Paid per Place of Service.

Note. The percentage of dental claims paid is shown for the types of settings for the years 2016 and 2020. DSO = dental support organization; IHS = Indian Health Services.

Our analysis of the inflation-adjusted dollar amount paid for claims (in 2016 dollars) reveals a steady growth in reimbursement for claims paid to health clinics. The average dollar amount of reimbursement made for claims in health clinics significantly increased in 2019, compared to 2016. In 2016, $599,600 was paid to health clinics, which accounted for 0.8% of total reimbursement in that year. In 2019, $11,087,628 were paid to health clinics, accounting for 11.7% of the total Medicaid pediatric dental dollars reimbursed. While private/DSOs accounted for 97.1% of the total dollars reimbursed for pediatric dental claims in 2016, this dropped to 83.5% in 2019.

Our analysis of the number of claims paid to health clinics for types of services revealed an increase in claims paid for preventive (16.4% in 2016 to 33.9% in 2019) and a decrease in the claims paid for other services (81.8% in 2016 to 58.7% in 2019; Figure 2).

Figure 2. The Percentage of Dental Claims Paid per Procedure Type in Health Clinics.

Note. Preventive, minor restorative, and other procedure types are shown in percentage for the years 2016 and 2019. Dental claims were identified and categorized into five categories using the American Dental Association’s Code on Dental Procedures and Nomenclature (CDT) 2019.

Our results found health clinics were paid more for preventive dental claims in 2019 compared to 2016. Reimbursement (in dollars) for preventive dental claims in 2016 made up 2.2% of the total amount paid for dental claims to health clinics, which increased to 17.8% in 2019. Reimbursement for other dental claims dropped from 97.2% of the total in 2016 to 66.5% in 2019 (Figure 3).

Figure 3. The Percentage of Total Reimbursement of Dental Claims by Procedure Type in Health Clinics.

Note. The percentage of reimbursement of dental claims is shown by procedure type for years 2016 and 2019.

Our analysis of the types of providers (i.e., dentist, dental hygienist, group, and non-dental) across the different places of service, where dental claims were paid, demonstrated an increase in the total number of claims paid to non-dental providers in health clinics. We observed the type of provider who provided services for claims paid to health clinics between 2016 and 2019. The largest change observed across the five settings was in health clinics. Figure 4 illustrates this trend. In 2016, 66.7% (π = 5,228) of the total claims from health clinics were paid for group provider services, compared to 98.4% (π = 327,832) paid to group providers during 2019. While 33.3% of claims were paid for services provided by dentists in 2016, this dropped to 0.9% of claims being paid for services provided by dentists in 2019. Within health clinics, group provider services saw the largest increase in paid claims between 2016 and 2019 and dentists saw the largest decrease.

Figure 4. Percentage of Dental Claims Paid in 2016 Compared to 2019 by Provider Type in Health Clinics.

Note. The percentage of dental claims paid from 2016 compared to 2019 is shown for provider type in health clinics over five-years.

Discussion

We examined the various types of settings where Medicaid enrolled children under the age of 21 living in Arizona between 2016 and 2019 received oral health care. We found a decrease in Medicaid-insured children receiving treatment in private practice / DSO settings coupled with an increase in oral health services provided at health clinics. Additionally, claims filed through health clinics for preventive (increased from 16.4% to 33.9%) and minor restorations (increased from 1.7% to 6.0%) were higher in 2019 compared to 2016. After adjusting for inflation, there was an increase in total dollar amount reimbursed for dental claims to health clinics in 2019 compared to 2016 ($599,600 in 2016 to $11,087,628 in 2019). Furthermore, we identified dental claims paid per provider type (e.g., dentist, dental hygienist, group, and non-dental) increased for nondental providers in health clinics from 2016 to 2019. These findings support our hypothesis highlighting the place where children receive oral healthcare and who is providing that care is changing in Arizona.

The findings of this study demonstrate a movement towards integration of oral health in alternative healthcare settings for pediatric patients. Since 2001, oral health has been increasingly incorporated into primary care and behavioral health settings. We found an increase in dental claims paid by provider type (i.e., dentist, dental hygienist, group, and non-dental) in health clinics from 2016 to 2019 indicating a movement towards integrated oral healthcare. Despite the effectiveness of integrated oral health, clinical and technical barriers persist. Clinical barriers include a limited scope of practice for medical and dental providers, inadequate cross-discipline training, lack of agreement on patient acceptance, and limited demonstration of clinical effectiveness.^1,17 Technical barriers include lack of time, lack of facility space, and incompatible electronic health records systems.^1,18 While the Patient Protection and Affordable Care Act have been successful in increasing access to care and implementing quality integration measures for children,^1,18 more efforts are needed to integrate oral health into other settings and ultimately increase access to care.

The type of insurance (i.e., public, private) directly influences where pediatric patients receive services for oral health. The findings of this study support existing claims that health clinics are a common avenue for Medicaid-insured children to receive dental services. Specific to Arizona, 41% of children are enrolled in the Medicaid system; however, 15% of all Medicaid-insured children do not receive dental services.^19–21 Our results indicate an increase in dental service utilization at health clinics and a decrease in dental service utilization in private practice/DSO settings for pediatric patients from 2016 to 2019. This is curious as the majority of dentists (i.e., 91%) work in a private practice setting.¹ However, this is not surprising as 72% of dentists in Arizona in 2016 did not treat Medicaid-insured children.²² In 2020, the Medicaid reimbursement rate for dental providers was 82.0%, an increase from 73.8% in 2017, suggesting low provider participation is not solely due to low reimbursement rates.²³ Since insurance type influences dental service utilization, health clinics that accept Medicaid are important in addressing the oral health needs of pediatric patients.

Limitations and Strengths

Although the present results display an increase in health clinic utilization for the pediatric Medicaid population and support the integration of oral health into primary care, itis appropriate to recognize several potential limitations. First, the place of service variable had increasing missing data from 2016 to 2019. The results for the aims were interpreted with caution as we did not have enough information to identify an explanation for the missingness. Finally, the generalizability of this study is limited as the data analyzed comes from Arizona’s Medicaid system and only captures the pediatric population receiving Medicaid. The findings are not guaranteed to generalize to the larger population in the U.S. as the data are not drawn from a random sample. Certain limitations of this study could be addressed in future research. For example, an analysis of all emergency department dental claims paid using both dental and medical codes would provide a better understanding of where children are accessing dental care.

This study adds to existing research examining the integration of oral health into primary care settings by identifying that dental providers are beginning to be incorporated into multidisciplinary teams. This study highlights health clinics as an important safety net to meet the needs of pediatric patients, especially those insured through Medicaid, since many private practice dentists do not serve Medicaid-insured children.^22,24,25 This study demonstrates an increase in dental service utilization among the pediatric population at health clinics with a slight decrease in private practice setting utilization. Therefore, it is important to increase the number of dental providers by integrating oral health into other settings (i.e., schools, FQHCs, primary care) to meet the needs of pediatric patients.

In terms of future research, it would be useful to extend the current findings by examining the integration of oral health into other settings to identify the most common avenue pediatric patients use for dental services and provider type billing for the service. Rigorous studies are needed to explore the effectiveness of dental services provided by dental and non-dental providers (i.e., nurse practitioners) in integrated oral health settings for pediatric patients. The present research, therefore, contributes to a growing body of evidence suggesting the integration of oral health into other settings is effective in addressing oral health concerns among pediatric patients.

Conclusion

We determined that while private practice /DSOs are the most common setting serving Medicaid pediatric patients with oral health concerns in Arizona, there is an increase in the utilization of health clinics among the pediatric Medicaid population. We can assume that Medicaid-insured children are seeking health clinics for dental services as a result of integrating oral health into primary care. We can further assume the increase in dental service utilization among pediatric patients in FQHCs is due to the inclusion of a dental provider (i.e., dentist, dental hygienist). This study furthers our understanding of the settings, types of providers, and procedure types that pediatric patients utilize for dental services, and future research should examine the implications integration of oral health in other settings has for pediatric patients.