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. Author manuscript; available in PMC: 2026 Jun 18.
Published in final edited form as: J Am Dent Assoc. 2026 Jan 12;157(5):512–520.e4. doi: 10.1016/j.adaj.2025.11.003

Pediatric dental surgeries in children with intellectual disabilities and autism paid by means of Medicaid

Katherine M Rancaño 1, Ashley Kranz 2
PMCID: PMC13273628  NIHMSID: NIHMS2123908  PMID: 41528281

Abstract

Background:

Use of ambulatory surgery centers (ASCs) relative to hospital outpatient departments (HOPDs) for outpatient surgeries for dental caries for children with intellectual disabilities and related conditions (IDRC) and autism has not been characterized.

Methods:

This cross-sectional analysis of Medicaid data (2016-2020) from 40 states examined 601,286 outpatient dental surgeries performed in ASCs and HOPDs in children (1-18 years) with IDRC, autism, and without either condition (IDRC/A) overall and by race and ethnicity. Multivariable regression models estimated regression-adjusted probabilities of receiving care in ASCs. Models included year and state fixed effects and child-level clustered standard errors.

Results:

Among surgeries in ASCs and HOPDs, the regression-adjusted predicted probability of ASC use was 14.0 percentage points (pp) lower for children with IDRC (15.9%, p<0.001) and 3.8pp lower for autistic children (26.1%, p<0.001) than children without IDRC/A (29.9%). Racial and ethnic differences within disability groups were small. Among surgeries in ASCs and HOPDs, the probability of ASC use was 1.8pp lower for Hispanic autistic children (p=0.009) than White autistic children. Among children without IDRC/A who were treated in an ASC or HOPD, ASC use was 0.6pp higher for Hispanic (p<0.001) and 1.1pp higher for Black children (p=0.001) than White children.

Conclusions:

Children with IDRC and autism were less likely to receive care in ASCs than HOPDs than children without these disabilities.

Practical Implications:

Because ASCs are less costly than HOPDs, providing more care at ASCs for children with IDRC and autism may help to reduce costs for this population.

Introduction

Children with developmental disabilities have a high risk for dental caries.1 Dental caries prevalence estimates for this population range from 17%-67% depending on the definition, conditions included, measures, and sample employed.2–6 Risk for dental caries in this population is multifactorial. Contributing factors include poor dental hygiene due to oral sensory sensitivities or limited cognitive abilities and manual dexterity, sugar content/side effects of medications, and delayed and unmet dental care due to difficulty finding a dentist, lack of caregiver knowledge on the consequences of poor oral health, and logistical and financial barriers to accessing dental care.1,7 Delayed and unmet dental care contribute to disparities for children with Medicaid as well as by race and ethnicity in children with disabilities.8,9

The American Academy of Pediatric Dentistry recommends general anesthesia (GA) when dental needs are acute and significant and in cases of extreme uncooperative behavior, anxiety, or severely limited communication abilities.10 Children with autism and IDRC often require GA for dental procedures, as many struggle to remain still and quiet for extended periods during treatment, have limited communication abilities, dental anxiety, oral sensory sensitivities, and exhibit resistant behaviors.

Dental procedures with GA are frequently furnished in hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs).11,12 Free-standing ASCs function independently of traditional hospitals. Many ASCs specialize in specific types of surgeries or populations, including pediatrics and dentistry. Understanding where care is delivered has important implications for cost, access, and patient safety. ASCs may help reduce costs, as pediatric dental surgeries paid by Medicaid were about $560 less in ASCs than HOPDs in 2011-2012.12 Additionally, ASCs may increase access to care, with rates of pediatric dental surgeries in ASCs increasing since 2019.13

Understanding ASC use relative to HOPD use has important implications for children with IDRC and autism, due to the growing prevalence of these conditions,14,15 and for equity, given the persistent challenges that families and children with IDRC and autism face in obtaining dental care.7,16 The objective of this study is to describe rates of outpatient pediatric surgeries for dental caries performed in ASCs and HOPDs among children with IDRC and autism compared with children without either condition and to examine effect modification by race and ethnicity. We use both person-first and identity-first language when referring to autism, given the diversity in preference within the autistic community.17 We also use “autism” to refer to children diagnosed with Autism Spectrum Disorder as some perceive the label “disorder” as ableist.18

Methods

Sample

This study used 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF), which provide information about Medicaid-enrolled individuals and encounters the care they receive. We used the TAF Other Services (OT) file to identify outpatient surgical procedures for dental caries, identified using diagnosis code K02 from the International Classification of Diseases (ICD) tenth revision. We identified procedures in ASCs and HOPDs using the place of service variable or using other data elements when place of service was missing (Table S1). Although dental GA procedures are furnished in offices, patients receiving office-based procedures may be less comparable to patients receiving care in ASCs and HOPDs in terms of treatment needs and health status. Therefore, our sample includes only procedures in ASCs and HOPDs.

We used TAF Demographic and Eligibility Files to examine children up to 18 years with full Medicaid benefits. We required 8-months of continuous enrollment (six months prior to procedure and two months following procedure) and examined surgeries occurring July 1, 2016 to January 31, 2020 to exclude the emergence of the COVID-19 pandemic. We excluded from our analysis state-years that were deemed “unusable” or of “high concern” by the Data Quality Atlas (DQA) based on claim or encounter volume and validity of diagnosis codes in the OT file.19 The DQA assesses the completeness and validity of TAF data by state-year across numerous dimensions. We excluded state-years if place of service was unknown for 20 percent or more of dental caries procedures in a state-year. After exclusions for missing information on sex and race and ethnicity, our sample included 601,286 surgical procedures for dental caries in ASCs and HOPDs in 40 states that contributed one to five years of data (Tables S2 and S3). To examine differences by race and ethnicity, our sample included 539,711 surgical procedures. We limited our analysis to children who were Black, Hispanic, and White because for most of the remaining racial and ethnic categories, there were fewer than 50 surgeries were furnished in an ASC.

Variables

Our dependent variable measures surgical procedures for dental caries performed in an ASC (vs. HOPD). The place of service was identified using the approach described above.

Our exposure variable identified disability status, defined as having intellectual disabilities and related conditions (IDRC), autism, or neither (without IDRC/A). Children with IDRC and autism were identified based on having one or more diagnosis codes with these conditions as defined by the Centers for Medicare and Medicaid Services (CMS) Chronic Condition Warehouse20 during the eight-month observation period. IDRC includes codes for mild to profound intellectual disability, Down Syndrome, and chromosomal anomalies. Autism includes codes for autism and pervasive developmental disorders.

Seven categories for race and ethnicity were included in primary analyses (see Table 1). Because children at higher risk of poor outcomes may be more likely to receive care in an HOPD, we adjusted for risk of mortality using a pediatric-specific surgical risk score developed by Rhee and colleagues.21 This risk score is based on age (children <24 months of age are considered at higher risk) and diagnosis codes—inclusive of 69 health condition categories from the Agency for Healthcare Research and Quality’s Clinical Classifications Software Refined.22 The score typically ranges from 0 to 6 or more. Because these are low-risk procedures and >97% of the sample had a score of 0, we created a dichotomous indicator of low risk (score=0) or some risk (score>0). Age in years at the time of the procedure was calculated using date of birth and date of procedure.

Table 1.

Characteristics of children with outpatient surgeries in an ambulatory surgery center and hospital outpatient department for pediatric dental surgeries for dental caries (n = 601,286)

Without IDRC/A (n=572,699)
n (%)		 IDRC (n=7,950)
n (%)		 Autism (n=20,697)
n (%)
Place of service
  ASC 171,511 (30.0) 1,244 (15.7)** 5,216 (25.2)**
  HOPD 401,188 (70.1) 6,706 (84.4) 15,481 (74.8)
Race and ethnicity
  American Indian / Alaska Native, non-Hispanic 34,584 (6.0) 186 (2.3) 463 (2.2)
  Asian, non-Hispanic 16,355 (2.9) 234 (2.9) 653 (3.2)
  Black, non-Hispanic 112,254 (19.6) 925 (11.6) 3,037 (14.7)
 Hawaiian / Pacific Islander, non-Hispanic 4,075 (0.7) 36 (0.5) 77 (0.4)
  Hispanic 171,925 (30.0) 2,667 (33.6) 5,749 (27.8)
  Multiracial, non-Hispanic 4,764 (0.8) 34 (0.4) 148 (0.7)
  White, non-Hispanic 228,742 (39.9) 3,868 (48.7)** 10,570 (51.1)**
Age in years, mean (SD) 5.4 (3.4) 9.3 (4.6)** 8.1 (3.9)**
Sex
  Female 270,360 (47.2) 3,479 (43.8)** 4,074 (19.7)**
   Male 302,339 (52.8) 4,471 (56.3) 16,623 (80.3)
Pediatric surgical risk
  Low risk 558,058 (97.4) 7,889 (99.2)** 20,621 (99.6)**
  Some risk 14,641 (2.6) 61 (0.8) 76 (0.4)
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Note: Two-sample t-tests and chi-square tests of independence were used to assess differences between children with autism vs. without IDRC/A and differences between children with IDRC vs. without IDRC/A. Sixty children in the IDRC and autism rows had co-occurring diagnoses for IDRC and autism.

**

p<0.001.

ASC = ambulatory surgery center; HOPD = hospital outpatient department; IDRC = intellectual disability and related conditions; Without IDRC/A = children without IDRC or autism

Analysis

Characteristics of dental surgeries in ASCs and HOPDs were compared between children without IDRC/A to children with IDRC and to autistic children using two-sample t-tests for continuous variables and chi-square tests of independence for categorical variables. We estimated three logistic regression models to examine the probability of receiving dental surgical care in ASCs (versus HOPD) for: (1) a child with IDRC relative to a child without IDRC/A; (2) an autistic child relative to a child without IDRC/A; and (3) a child with IDRC relative to an autistic child. Models included child demographics (age, sex, race and ethnicity), an indicator of surgical risk, and year and state fixed effects, with standard errors clustered at the child level. To examine effect modification by race and ethnicity, we added an interaction to models 1 and 2 between disability status (autism, IDRC, and no IDRC/A) and race and ethnicity (Black, Hispanic, and White).

We used results from these models to calculate adjusted predictions of ASC use by disability status and for the disability status and race and ethnicity interaction among surgeries in ASCs and HOPDs. To do this, we used the entire estimation sample from each model and assigned each observation to each health status (IDRC, autism, neither) leaving other covariates unchanged to generate a predicted probability of ASC use for each child. We repeated this process for each disability status, and each racial/ethnic group when relevant, and reported the mean predicted probabilities. We calculated differences in these average adjusted probabilities of ASC use to compare differences by disability status and to compared differences by within each disability status by race and ethnicity, with White children serving as the reference group. All statistical analyses were conducted using STATA/MP 18.0 and p-values <0.05 indicate statistical significance. This study was deemed exempt by RAND’s human subjects’ protection committee.

Results

Characteristics of pediatric surgeries for dental caries in ASCs and HOPDs

Overall, 1.3% (7,950) and 3.4% (20,697) of surgeries in ASCs and HOPDs were furnished to children with IDRC and autism, respectively (Table 1). A larger share of surgeries among children with IDRC was in White patients (48.7% vs. 39.9%, p<0.001) and a smaller share was performed in ASCs (15.7% vs. 30.0%) when compared to surgeries for children without IDRC/A. Similar patterns were observed for surgeries among children with autism. Compared with surgeries for children without IDRC/A, a larger share of surgeries for autistic patients was in White patients (51.1% vs. 39.9%) and a smaller share was performed in ASCs (15.2% vs. 30.0%).

Table 2 describes surgeries in ASCs and HOPDs by race and ethnicity for children with IDRC, autism, and without IDRC/A. More than half of dental surgeries in ASCs and HOPDs received by children with IDRC (51.8%) and autism (54.6%) were performed in patients who were White compared to 44.6% of surgeries in children without IDRC/A. Within each disability group, a higher share of surgeries was furnished to Hispanic children (IDRC=19.7%, autism=31.9%, without IDRC/A=39.7%) than Black (IDRC=13.4%, autism=20.6%, without IDRC/A=24.2%) or White (IDRC=13.4%, autism=23.0%, without IDRC/A=26.1%) children. No other notable differences in characteristics were observed across race and ethnicity within each disability group.

Table 2.

Characteristics children with outpatient surgeries in an ambulatory surgery center and hospital outpatient department for pediatric dental surgeries for dental caries analyzed to examine intersectional differences by disability status and race and ethnicity (n = 535,051)

Without IDRC / A (n = 512,921) IDRC (n = 7,403) Autism (n = 19,299)
Black Hispanic White Black Hispanic White Black Hispanic White
n (%) 112,254 (21.9) 171,925 (33.5) 228,742 (44.6) 925 (12.4) 2,667 (8.0) 3,868 (51.8) 3,037 (15.7) 5,749 (29.7) 10,570 (54.6)
Place of service, N (%)
  ASC 27,116 (24.2) 68,304 (39.7) 59,791 (26.1) 124 (13.4) 524 (19.7) 520 (13.4) 625 (20.6) 1,833 (31.9) 2,435 (23.0)
  HOPD 85,138 (75.8) 103,621 (60.3) 168,951 (73.9) 801 (86.6) 2,143 (80.4) 3,348 (86.6) 2,412 (79.4) 3,916 (68.1) 8,135 (77.0)
Age in years, mean (SD) 5.5 (3.5) 5.0 (3.0) 5.6 (3.4) 9.4 (4.7) 8.8 (4.4) 9.6 (4.6) 8.1 (4.0) 7.6 (3.7) 8.4 (4.0)
Sex, N (%)
  Female 54,502 (48.6) 80,565 (46.9) 106,395 (46.5) 390 (42.2) 1,216 (45.6) 1,684 (42.7) 645 (21.2) 1,084 (18.9) 2,093 (19.8)
  Male 57,752 (51.5) 91,360 (53.1) 122,347 (53.5) 535 (57.8) 1,451 (54.5) 2,170 (56.3) 2,392 (78.8) 4,665 (81.1) 8,477 (80.2)
Pediatric Surgical Risk, N (%)
  Low risk 109,600 (97.6) 166,641 (96.9) 223,704 (97.8) 919 (99.4) 2,646 (99.2) 3,838 (99.2) 3,026 (99.6) 5,727 (99.6) 10,538 (99.7)
  Some risk 2,654 (2.4) 5,284 (3.1) 5,038 (2.2) NR 21 (0.8) 30 (0.8) NR 22 (0.4) 32 (0.3)
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Note: IDRC = intellectual disability and related conditions; Without IDRC/A = children without IDRC or autism.

NR, not reported due to small cell size and data use agreement restrictions.

Regression-adjusted predicted probability of ASC use by disability status among surgeries in ASCs and HOPDs

Among surgeries in ASCs and HOPDs, the regression-adjusted probability of ASC use was 15.9% (95% confidence interval (CI)=15.1% to 16.8%) for children with IDRC and 26.1% (95%CI=25.5% to 26.7%) for autistic children compared to 29.9% (95%CI=29.8% to 30.1%) for children without IDRC/A (Figure 1). Children without IDRC/A receiving care in ASCs and HOPDs were 14.0 and 3.8 percentage points (pp) more likely to use an ASC than children with IDRC or autism, respectively (p<0.001 for both) (Figure 1 and Table S5). Children with IDRC receiving care in ASCs and HOPDs were 9.5pp less likely than autistic children to receive care in an ASC (95%CI=−10.5 ton −8.4, p<0.001) (Table S4).

Figure 1.

Figure 1.

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Regression-adjusted predicted probabilities of having a pediatric dental surgery at an ambulatory surgery center (compared to a hospital outpatient department) by disability status.

note. Brackets illustrate differences in adjusted probabilities for each group compared to children without IDRC/A among surgeries in ambulatory surgery centers and hospital outpatient departments. *p<0.05, **p<0.001. We show the probability for the without IDRC/A group derived from the regression model that included children with IDRC and without IDRC/A. This probability is similar to the model that included children with autism and without IDRC/A (29.9%).

Regression-adjusted predicted probability of ASC use by disability status and race and ethnicity among surgeries in ASCs and HOPDs

Differences in ASC use by race and ethnicity among autistic children and children without IDRC/A were small (Figure 2 & Table S5 & S6). Among autistic children using ASCs and HOPDs, the probability of ASC use was 1.8pp lower for Hispanic (95%CI=−3.1% to −0.4%, p=0.009) than White children; no difference was observed between Black and White autistic children. Among children without IDRC/A receiving care in ASCs and HOPDs, the probability of ASC use was 1.1pp higher in Hispanic (95%CI=0.8% to 1.4%, p<0.001) and 0.6pp higher in Black (95%CI=0.2% to 0.9%, p<0.001) when compared to White children.

Figure 2.

Figure 2.

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Regression-adjusted predicted probabilities of having a pediatric dental surgery at an ambulatory surgery center (compared to a hospital outpatient department) by disability status and race and ethnicity.

Brackets illustrate the difference in adjusted probabilities for each group compared to children without IDRC/A who are White among surgeries in ambulatory surgery centers and hospital outpatient departments. We show probabilities for the without IDRC/A group derived from the regression model that included children with IDRC and without IDRC/A because these probabilities were similar to those from the model that included children with autism and without IDRC/A (White=29.7%, Black=30.2%; Hispanic=30.8%) *p<0.05, **p<0.001.

Discussion

This cross-sectional study used Medicaid data from 40 states to describe pediatric surgeries for dental caries performed at ASCs and HOPDs among children with IDRC, autism, and without IDRC/A. We found lower use of ASCs than HOPDs among children with IDRC and autism compared to children without IDRC/A and small differences in ASC use across race and ethnicity when examined by disability status.

Access to ASCs has important implications for equity, access, and health care costs. Medicaid is a key source of health coverage for children with special health care needs (42%),7,23 and spending is generally higher for children with special health care needs, particularly those eligible via disability pathways (e.g., receipt of Social Security Income benefits24). As procedures performed in ASCs are less costly than HOPDs,25–28 even after considering increased dental rehabilitation payments now allowed by CMS,29 lower ASC utilization relative to HOPD use may contribute to higher costs for state Medicaid programs. ASCs may help to reduce barriers to dental treatment by providing an additional setting for care, which is important due to the long and increasing wait times for these patients in hospitals.30 This is particularly important for children with IDRC and autism because they face significant barriers to dental care.7,16 Elucidating drivers of lower ASC use relative to HOPD use in patients with IDRC and autism is important for promoting affordable and equitable access to dental care.

In our sample of surgeries furnished in ASCs and HOPDs, we found differential ASC use by disability status, with the largest difference observed for children with IDRC compared to children without IDRC/A. It remains unclear if this differential access is due to clinical or other reasons. Having a pediatric chronic condition, like IDRC or autism, may contribute to greater surgical case complexity. If there is a high risk for complication, a patient may be better served in an HOPD, a setting with easier access to inpatient and emergency care.10 Additionally, there are other factors that may lead to care being provided in an HOPD, such as patient age31 and the presence of other health conditions that often co-occur with IDRC and autism (e.g., severe obesity32, Attention-Deficit/Hyperactivity Disorder33). Further, the American Society of Anesthesiologists Physical Status Classification (ASA) is used in dentistry to guide decisions on sedation, anesthesia, and perioperative risk management.34 Patients with IDRC and autism may be more likely to receive higher ASA classifications, which may prompt providers to choose to care for these patients in an HOPD as they are classified as “too risky” for an ASC. However, ASC use could also be determined by profit-seeking behavior. Most ASCs (95%) are for-profit, and Medicaid beneficiaries with greater case complexity may be less financially lucrative.35 Tian et al. observed that fewer surgeries were delivered in ASCs than HOPDs for children who had one or more chronic conditions and for expensive procedures in publicly insured patients, suggesting that ASCs may selectively choose more profitable procedures.36 Similarly, a study of adults found that ASC patients were more likely to be White, covered by private insurance, less socially vulnerable, and with fewer prior admissions (i.e., healthier), suggesting that vulnerable, more medically complex patients have less access to ASCs.37

In our study, children with IDRC were the least likely to receive care in an ASC than an HOPD. It is possible that providers were concerned about providing care to children with IDRC in ways that were not captured by our pediatric surgical risk score, which is based on diagnosis codes and age. It is also possible that a larger share of autistic patients were considered suitable for care in ASCs (vs. HOPD) than IDRC patients as only about one-quarter of autistic children in the US have “profound autism”38 and practitioners may have been better able to accommodate the needs of autistic patients in an ASC (e.g., communication strategies, sensory sensitives).39

Another factor that may have contributed to the lower probability of ASC use than HOPD use in children with IDRC is the misperception that children with IDRC are inherently more medically complex, unable to communicate, and more burdensome to provide care given the additional factors that must be taken into consideration when developing a treatment plan (e.g., anesthesiologic complications, contraindicators with medications, craniofacial anomalies).40,41 These misperceptions lead to disability-based discrimination in health care settings.42 In the U.S., 32% of adults with disabilities have felt discriminated against in health care settings.43 Disability-based discrimination can include inaccessible medical equipment, providers declining to care for people with disabilities because of complications related to their condition, provider’s self-perceived incompetence related to providing care, and feeling overwhelmed by the demands of disabled patients.40–42,44

We observed small differences in the probability of ASC use by race and ethnicity when examining differences within disability status among surgeries in ASCs and HOPDs. Our findings partly disagree with extant studies, as ASC use was higher for Hispanic and Black children without IDRC/A and only Hispanic children with autism had lower ASC use when compared to White children with similar conditions. Studies of adults and children that examined surgeries paid by both private and public insurers in a few states have found lower ASC use among Black versus White patients.36,45 Even when stratified by insurance-type, Tian and colleagues found that a Black child was significantly less like to receive care in an ASC than a White child.36 Our study differs from these prior studies in that we examined surgery for dental caries and examined most states in the US (compared to two or three states in the prior studies). Further study is needed to elucidate differences in ASC use by race and ethnicity given the pronounced risk for dental caries and high rate of GA among minoritized racial and ethnic groups.13,46

This study has several limitations. First, this cross-sectional study provides information about correlations and not causal relationships. Second, concerns about the quality of TAF data led us to exclude many state-years of data,19,47–49 meaning our findings may not be generalizable to all states. Third, we did not examine procedures in dental offices, which depending on the state can account for a large share of these procedures among Medicaid-enrolled children.12 Fourth, although we used state fixed effects to control for state-level time invariant factors, we acknowledge that time-varying factors at the state-level may confound the associations examined. Fifth, the pediatric surgical risk score used in this study relies on information available in claims data and may not capture all risk factors present in children with IDRC and autism. Finally, given our focus on an uncommon surgery for pediatric dental caries and in small populations (i.e., autistic children and children with IDRC), we lacked a sample large enough to explore outcomes in all racial and ethnic groups. Importantly, research by Sheen et al. finds that the incidence of these types of dental surgeries was highest among American Indian/Alaskan Native children with Medicaid at 74 cases per 10,000 enrollees in 2021.13

Conclusion

This analysis of Medicaid found lower rates of ASC use compared to HOPD use among children with IDRC and autism compared to children without IDRC/A, with no differences observed by race and ethnicity within disability status. Recognizing that ASCs can reduce health care costs and promote timely delivery of care, and individuals with disabilities encounter barriers to care, driven by both implicit and explicit biases, additional research is needed to understand why there are differential rates of ASC and HOPD use among children having dental surgery performed in ASCs and HOPDs for children with IDRC and autism compared to children without IDRC/A.

Supplementary Material

Supplementary Table - S1
Supplementary Table - S2
Supplementary Table - S3
Supplementary Table - S4
Supplementary Table - S5

Funding statement:

Ashley Kranz received support for this study from the Agency for Health Care Research and Quality (AHRQ), grant no: R01 HS027994-03.

Footnotes

Conflict of interest statement: The authors report no conflict of interest.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table - S1
NIHMS2123908-supplement-Supplementary_Table_-_S1.docx (14.4KB, docx)
Supplementary Table - S2
NIHMS2123908-supplement-Supplementary_Table_-_S2.docx (14.7KB, docx)
Supplementary Table - S3
NIHMS2123908-supplement-Supplementary_Table_-_S3.docx (17.5KB, docx)
Supplementary Table - S4
NIHMS2123908-supplement-Supplementary_Table_-_S4.docx (15.4KB, docx)
Supplementary Table - S5
NIHMS2123908-supplement-Supplementary_Table_-_S5.docx (15.8KB, docx)

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