Chapter
2:
Utilization of Dental Services by
children age 5 and under enrolled in Title XIX
To get a baseline measure of the utilization of dental services by children age five and under enrolled in the Iowa Title XIX program prior to the implementation of the case management program, Title XIX eligibility and claims files for fiscal year 1994 (July 1, 1993-June 30, 1994) were used. Included in these analyses were children age five and under who became eligible for Title XIX through the Aid to Families with Dependent Children program (AFDC) or AFDC-related programs (not including children eligible through the Supplemental Security Income--SSI or medically needy program). Title XIX eligibility files were used to determine the age of the child and the number of months each recipient was enrolled in Title XIX during the year. A child's age was categorized as the age the child turned during FY 1994. For example, a child who had his or her second birthday during FY 1994 was considered to be two years old.From the claims files, the dental services provided to this group of enrolled children, by dental procedure code (DPT code), were selected as well as the dentist's allowed charge (the amount Title XIX would pay for the service). The dental procedures received by each child were then linked together to determine the number of unduplicated recipients receiving each type of dental service. This unduplicated number of recipients was used as the numerator when determining rates of dental services.
Partial-year enrollment can create problems in determining the number of children enrolled in Title XIX. Several factors might lead to partial enrollment in Title XIX during a given fiscal year. For example, newborn infants are not enrolled during the months preceding birth. Children may also be enrolled for a partial year if they move out of the state, or if they lose eligibility for Title XIX. In addition, some families who do qualify may fail to sign up during all months of the year. Differences in the number of months enrolled during the year affect the likelihood of a child receiving any dental services while on Title XIX.
To account for different lengths of enrollment during the year, two measures of the number of enrollees (the denominator) were used in these analyses for determining the rates of dental services. The first measure is a simple tally of the total number of children in each age category who were enrolled at some point during FY 1994. The second method calculates the number of enrolled children in terms of full-time equivalents (FTEs). To calculate FTEs, the number of months each child is enrolled in Title XIX during FY 1994 was determined. For each individual, this was from one to 12 months. This number of months was summed across all individuals and divided by 12 to determine the number of enrolled years , or FTEs enrolled in Title XIX.
Aggregate analyses included the total number of children who had received any dental services, the total cost of dental services to this group, and the cost per enrolled child. Other analyses were broken down by age category (<1, 1, 2, etc.), including the percent receiving any dental services and the percent receiving an examination, radiograph, sealant, or treatment. The costs of dental services by age and service category are also presented. For analyses conducted by service category, the 38 most common pediatric dental procedures were used, as identified by dental procedure code. Table 2-1 shows the procedures included in each service area.
The total number of children age five and under enrolled in Title XIX through the AFDC and AFDC-related programs during FY 1994 was 64,358 (Table 2-2). Total Iowa Title XIX enrollment in June 1995 was 226,117. Therefore, children age 5 and under enrolled through the AFDC program represent approximately 28 percent of all Title XIX enrollees in Iowa. When enrollment is calculated in terms of full-time equivalents, the utilization rates increase because Title XIX enrollment decreases by about 20 percent except for enrollees under one year of age (Table 2-2). Because children are born at different times throughout the year there is an even lower ratio of FTE individuals under the age of one.
The intermittent enrollment of children on Title XIX and differences between enrolled individuals and FTEs can be understood better by considering the proportion of the year children were enrolled in Title XIX during FY 1994 (Table 2-3). Almost half of all children (48 percent) were not eligible for Title XIX for the entire year.
During FY 1994, 14,889 children age 5 and under in Iowa received at least one dental service while enrolled in the Title XIX program. This represents 23 percent of all children in this age range enrolled at some point during FY 1994 (64,358) and 31 percent of all full-time equivalents (48,158). A total of $1,387,968 was spent by the Title XIX program for these dental services provided in a dentists' office (this excludes dental care provided in a hospital operating room). The average cost per child who received dental care in a dentists' office was $93.
Table 2-1. Thirty-eight most common dental procedures used in analyses of dental utilization, by service category
Procedure Code Procedure Code Examinations Treatment services--continued Initial exam (check-up) 00110 Silver filling, 1 surface--adult tooth 02140 Periodic (recall) exam 00120 Silver filling, 2 surfaces--adult tooth 02150 Emergency exam 00130 Silver filling, 3 surfaces--adult tooth 02160 Radiographs (X-rays) Silver filling, 4 surfaces--adult tooth 02161 Full mouth series (all teeth) 00210 White filling, 1 surface--front tooth 02330 PAs (single tooth) 00220 White filling, 2 surfaces--front tooth 02331 Additional PAs 00230 White filling, 3 surfaces--front tooth 02332 Occlusal 00240 White filling, 4 surfaces--front tooth 02335 Single Bitewing (side teeth) 00270 White filling, 1 surface--child back tooth 02380 2 Bitewing x-rays 00272 White filling, 1 surface--adult back tooth 02385 4 Bitewing x-rays 00274 Stainless Steel Crown--baby tooth 02930 Panorex (whole mouth) 00330 Stainless Steel Crown--adult tooth 02931 Preventive Pulpotomy (remove nerve) 03220 Child cleaning 01120 Tooth extraction--single tooth 07110 Child cleaning and fluoride 01201 Tooth extraction --additional tooth 07120 Sealant per tooth 01351 >Space Maintainer--fixed, one side of mouth 01510 Treatment services Space Maintainer--fixed, both sides of mouth 01515 Silver filling, 1 surface--baby tooth 02110 Space Maintainer--removable, one side of mouth 01520 Silver filling, 2 surfaces--baby tooth 02120 Space Maintainer-- removable, both sides of mouth 01525 Silver filling, 3 surfaces--baby tooth 02130 Hospital visit 09420 Silver filling, 4 surfaces--baby tooth 02131 Table 2-2. Iowa Title XIX enrollment, by age, FY 1994
Age Individuals FTEs FTEs as a percent of individuals Under 1 9,885 4,429 45% 1 13,009 10,245 79% 2 11,314 9,085 80% 3 10,772 8,681 81% 4 10,200 8,242 81% 5 9,178 7,504 82% Total 64,358 48,186 75% Table 2-3. Length of eligibility, FY 1994
Months of eligibility Percent 12 months 52% 9-11 months 10% 6-8 months 14% 1-5 months 23% The proportion of enrollees by age who received any dental services is shown in Table 2-4. Very few children under age three received any dental services. The proportion of children receiving an initial exam and/or a periodic exam is shown in Table 2-5, and the proportion receiving a prophylaxis is shown in Table 2-6. Again, very few children under age three received an exam or prophylaxis, whereas about half of the five-year-olds received such services (about two thirds of the FTEs). Three quarters of the children who received any dental services also received a prophylaxis.
Table 2-4. Children receiving any dental service, by age, FY 1994
Age Number receiving any dental service Rate per FTE Rate per enrollee Under 1 80 2% 1% 1 452 4% 3% 2 1,195 13% 11% 3 3,046 35% 28% 4 4,883 59% 48% 5 5,233 70% 57% Total 14,889 31% 23% A relatively small percentage of children received radiographs, with the distribution skewed toward older children, as would be expected. Five percent or less of children age three and under received radiographs, compared to 14 percent of children age four and 26 percent of those age five. Sealant usage was very low. One-half of one percent or fewer of children received sealants in any age category. This finding is not unexpected, however, because sealant placement is only reimbursable for permanent molars which do not usually erupt until age six.
Table 2-5. Children receiving an initial or periodic exam, by age, FY 1994
Age Number of exams Rate per FTE Rate per enrollee Under 1 22 0.5% 0.2% 1 373 4% 3% 2 1,111 12% 10% 3 2,921 34% 27% 4 4,660 57% 46% 5 4,947 66% 54% Total 14,034 28% 22% Table 2-6. Children receiving a prophylaxis, by age, FY 1994
Age Number receiving a prophylaxis Rate per FTE Rate per enrollee Under 1 3 0.07% 0.03% 1 138 1% 1% 2 593 7% 5% 3 2,103 24% 20% 4 3,993 49% 39% 5 4,484 60% 49% Total 11,314 24% 18% Few children age three or less received any treatment beyond routine diagnostic and preventive care (Table 2-7). Less than ten percent of the children under age four received any treatment services, increasing to 20 percent of the five-year-olds (24 percent based on FTEs). Thirty percent of those children who received any dental services also received treatment services.
Regarding costs of the 38 most common services provided, 22 percent of the expenditures were for diagnostic services, including exams and radiographs, and 27 percent were for preventive services, including prophylaxis, fluoride treatments, and dental sealants. The remaining 50 percent was for treatment. In all age categories, more dollars were spent on treatment than on either diagnostic or preventive services (Table 2-8). In four of the six age categories, at least half of all expenditures were for treatment services. If all treatment procedures received by these children are included (not just the 38 most common procedures), the percent of total expenditures going to treatment increases to 64 percent.
Table 2-7. Children receiving treatment services, by age, FY 1994
Age Number with treatment Rate per FTE Rate per enrollee Under 1 10 0.2% 0.1% 1 40 0.4% 0.3% 2 266 3% 2% 3 723 8% 7% 4 1,560 19% 15% 5 1,797 24% 20% Total 4,396 9% 7% Table 2-8. Cost by type of service for the 38 most common services, by age, FY 1994
Exam/Radiograph Preventive Treatment Age Dollars Percent Dollars Percent Dollars Percent Under 1 $357 42% $65 8% $435 51% 1 $5,576 35% $3,202 20% $7,309 45% 2 $18,246 21% $14,824 17% $55,754 63% 3 $47,738 21% $53,899 24% $123,438 55% 4 $83,887 22% $108,285 28% $191,327 50% 5 $99,155 24% $128,658 31% $193,911 46% Total $254,959 22% $308,932 27% $572,175 50% Operating Room-based Dental Care
Although fewer than 25 percent of children age five and under received any dental services, there were some children with oral health problems so severe they required dental treatment in a hospital operating room under general anesthesia. Dental care provided in hospital operating rooms to these particularly high-risk children age 5 and under during FY 1994 was evaluated using Title XIX claims and utilization files. First, all hospital claims with a diagnosis of dental caries (ICD-9 code 521.0) were selected for children eligible through AFDC and AFDC-related programs. The dental care provided at each hospital visit was then matched to the hospital claim using the recipient ID number and the date of service. Information was collected regarding the services provided, what the hospital and dentist charged for this care and what Title XIX would pay for this care (the allowed charge). These costs are a conservative estimate of the cost of providing dental care in the operating room because they do not include any pre-operative or post-operative care or costs associated with anesthesia.
There were 317 children age five and under enrolled in Title XIX during FY 1994 for whom dental care was provided in a hospital operating room in Iowa. This represents 0.5 percent of the 64,358 children age five and under enrolled in Title XIX at some point during FY 1994 or 2.1% of the children who received any dental services. The number of children receiving dental care in an operating room varied significantly by age (Table 2-9) with the highest number of cases occurring in two-year-olds and gradually declining with age. Although the actual number of children is small, one out of every ten two-year-olds and one in 20 one-year-olds who received any dental care, received at least some of their dental care in the operating room. No children under age one received care for dental caries in an operating room during FY 1994.
Table 2-9. Children age five and under enrolled in Title XIX
receiving dental care in an operating room, by age, FY 1994
Age Number Percent of all children on Title XIX Percent of all children on Title XIX who had a dental visit Under 1 0 0.0% 0.0% 1 25 0.3% 5.5% 2 121 1.1% 10.1% 3 85 0.8% 2.8% 4 58 0.6% 1.2% 5 28 0.3% 0.5% Total 317 0.5% 2.1% The total charges (the amount billed by both the hospital and the dentist) for this care was $817,266 with an average charge per child of $2,578. The total allowed charges for these children was $539,348 at an average of $1,701 per child. The charges and allowed charges broken out by hospital and dentist are shown in Table 2-10. Seventy-four percent of the allowed charges were related to the hospital component of care.
Table 2-10. Difference between hospital and dentist charges and the allowed charges for
operating room dental care for children age 5 and under enrolled in Title XIX, FY 1994
Hospital charges Hospital allowed charges Dentist charges Dentist allowed charges Total $574,482 $395,658 $242,784 $143,690 Average $1,812 $1,248 $766 $453 Range $770-5,713 $498-4,685 $110-4,090 $23-1,482 The total allowed charges for these children is shown by age in Table 2-11. Although the largest total allowed charges were for two-year-olds (the age category with the most cases), the average total allowed charge increased by age, perhaps related to increasing need from having more teeth at risk for decay for a longer period of time.
Table 2-11. Operating room dental care broken out by hospital and dentist allowed charges for children age 5 and under enrolled in Title XIX, by age, FY 1994
Age Total allowed charges Hospital allowed charges Dentist allowed charges Average total allowed charges 1 $31,930 $23,639 $8,290 $1,277 2 $196,948 $147,131 $49,818 $1,627 3 $150,425 $109,498 $40,926 $1,770 4 $105,252 $74,052 $31,200 $1,815 5 $54,793 $41,338 $13,456 $1,957 Total $539,348 $395,658 $242,784 $1,701 The procedures completed on these children are consistent with children in poor oral health (Table 2-12). The five most commonly provided procedures (other than examinations) in the operating room were: stainless steel crowns, and amalgam and composite fillings (for the restoration of decayed teeth), and pulpotomies and extractions (for treatment of extensive decay affecting the nerves of teeth).
Table 2-12. Most common dental procedures
provided in the operating room (OR) , FY 1994
Procedure Number Percentage of all OR procedures Stainless Steel Crowns 1,918 30% Amalgam fillings 1,242 20% Composite fillings 757 12% Pulpotomies 756 12% Exams/X-rays 463 7% Extractions 424 7% Summary
The allowed charges for both the dental office-based care and dental care provided in a hospital operating room during FY 1994 totaled $1,927,316 for the 14,889 children age five and under who received a dental service, (31 percent of all enrolled children based on FTEs). This was an average of $129 per child who received any dental care. The allowed charges for the dentists' portion of this amount is $1,531,658 while the hospital portion was $395,658. The total allowed charges for the 317 children who received dental care in the hospital operating room was $559,348 ($143,690 of which was for the dentists' allowed charges) at an average of $1,701 per case. The dental office-based care for all 14,889 children who received any dental services totaled $1,387,968 in allowed charges for an average of $93 per child treated.
This indicates that operating room-based care provided to two percent of the children age five and under who received a dental service accounted for 29 percent of all the allowed charges for dental services during FY 1994. If anesthesia, pre-operative and post-operative care were included, this percentage would be even higher. Excluding the hospital allowed charges, the care for children treated in the operating room accounted for almost 10 percent of all dollars spent on dentists' services. Average costs for operating room dental care increased with age, probably as a result of older children having worse oral health problems at the time of their visit. Two-year-olds were the most likely to have received dental care in the operating room. This is due, at least in part, to inappropriate use of the baby bottle (e.g. sleeping with the bottle).
This low-income population tends to have a higher rate of dental disease, so early intervention is critically important yet difficult to target. Identifying the relatively few children who are using a large percentage of resources early enough to make a difference poses a particularly difficult challenge. Improving our understanding and knowledge of ways to identify children most at risk early and/or effectively preventing the disease from occurring in the first place is critically important to prevent the costly treatment of children with early childhood caries in hospital operating rooms.
