Research Briefs

• During each year from 2013-2016, approximately 15.2% of the U.S. population needed dental care but did not obtain it.       
• Financial reasons such as “could not afford the cost,” “insurance did not cover procedures,” and “did not want to spend the money” were the top three barriers cited for not obtaining needed dental care. Respondents less frequently cited non-financial barriers such as “afraid or do not like dentists,” “dental office is too far away,” or “too busy.”
• Financial barriers to obtaining needed dental care were reported most frequently among low-income working-age adults and seniors as well as high-income working-age adults.

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• U.S. adults face access barriers to primary care due to high rates of chronic disease and an insufficient number of physicians. Dentists could fill the primary care void by offering chronic disease diagnosis and monitoring in their dental offices.       
• Expert stakeholders in the dental, medical, and public health fields in Massachusetts opined that dentists trained in systemic care could serve patients who do not have access to physicians and relieve the overburdened primary care industry while lowering health care costs.
• Reforms needed to expand the primary care scope of dentistry include changes to dental school curriculum, increased interprofessional collaboration between physicians and dentists, and implementation of governmental supervision.  

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• This report presents the number of programs, total enrollment, and graduates from advanced dental education programs in 11 disciplines, from 1975 to the present.      
• Total enrollment has increased in every discipline, with the exception of oral and maxillofacial pathology.
• The number of graduates has increased in every discipline, with the exception of periodontics.
• The number of programs has increased in six disciplines and decreased in five.

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• We update our earlier estimates of the future supply of dentists in the U.S. by revising some of our assumptions. We continuously monitored key dentist labor market decisions in recent years and concluded these changes were enough to warrant a revised analysis.    
• Under what we consider to be the most probable scenario, the per capita supply of dentists in the United States is projected to increase through 2037 even after adjusting for expected changes in hours worked and patient visits due to dentist age and gender composition.
• Understanding the future evolution of the total supply of dentists contributes only partially to the central policy question of whether the dental workforce will be able to meet population needs. The issue of provider adequacy is far more complex and further research is needed.    

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• Total dental expenditures were $124B in 2016. This was a 3.3% increase from 2015, after adjusting for inflation.
• Per capita total dental expenditures also increased in 2016, for the second year in a row.
• Dental expenditures increased in 2016 for all sources of financing (e.g. out-of-pocket, insurance, CMS programs). The breakdown of expenditure by source of financing was largely unchanged in 2016. However, CMS programs saw a slight increase.
• Total U.S. dental expenditures have increased for two straight years after being flat for several years.

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• Wisconsin, Washington and California had the lowest Medicaid reimbursement rates for both adult and child dental care services among states that provide dental services via fee-for-service.
• There is considerable variation across states in Medicaid fee-for-service reimbursement rates.

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• After adjusting for inflation, average fees for dental procedures have increased over time, especially for the three most often performed endodontic procedures.
• Reimbursement rates from third-party payers have increased slowly from 2005 to 2014, or have decreased in some cases. The difference between fees charged by dentists and reimbursement rates through third-party payers appears to be increasing over time.
• Despite a small rebound from 2014-2015, specialist dentist incomes have been stagnant. This is possibly due to declining dental care use for complex specialty procedures or changes in reimbursement rates.

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• Out of five types of dental specialists (oral surgeons, endodontists, orthodontists, periodontists, and pediatric dentists), oral surgeons are consistently the highest earning dental specialists while periodontists are the lowest earning dental specialists.
• Among the five specialist types studied in this brief, orthodontists have the lowest self-reported busyness levels while oral surgeons have the highest self-reported busyness levels.
• Among the five specialist types studied in this brief, a greater percentage of pediatric dentists work in dental service organization (DSO) affiliated practices while a lower percentage of periodontists work in DSO affiliated practices.

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• General practitioner and specialist dentists' average earnings did not change significantly in 2015.
• Dentists were slightly busier in 2015 but there is still significant unused capacity in the dental care system.
• Looking forward, 2016 data are likely to provide a better sense of whether the dental care economy is turning around or whether a "new normal" is entrenched.

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• National dental care expenditures were $117.5 billion in 2015.
• Taking into account both inflation and population growth, national dental expenditures rose between 2014 and 2015, reversing a multi-year trend.
• Research suggests that Medicaid expansion under the Affordable Care Act may have increased demand for dental care and public dental expenditures. This is an important area of future research.

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• From 2013 to 2014, the percentage of working-age adults lacking dental benefits dropped and the percentage with private dental benefits coverage increased.
• The percentage of children lacking dental benefits continued to fall in 2014 and is now at its lowest level since 1999, the first year that data became available.
• It is still too early to tell whether increases in dental benefits coverage will boost dental care utilization, particularly among working-age adults.

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• Dental care utilization among working-age adults did not change in 2014.
• Dental care utilization continued to increase among elderly adults in 2014 and is at its highest level since the Medical Expenditure Panel Survey began tracking dental care utilization in 1996.
• Although not statistically significant, dental care utilization increased 2 percentage points in 2014 among working-age adults with public insurance. This might signal the early impact of Medicaid expansion under the Affordable Care Act, but further research is needed.

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• Endodontists are consistently the second-highest earning dental specialists.
• Endodontists' incomes were hit the hardest by the impact of the Great Recession and, along with pediatric dentists, are the only dentists to see definitive signs of post-recession income recovery.
• Endodontists' self-reported busyness levels are among the lowest of all dentists. General practitioner dentists tend to perform at least two-thirds of the most common endodontic procedures.
• Endodontists are among the least likely dentists to work in corporate dental practice.

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• More than one in three adults ages 19 through 64 with private dental benefits do not have a single dental claim within the year.
• Fees paid to dentists through private dental benefits plans are significantly lower than market fees. This leads to substantial differences in total dental spending estimates based on "market" versus "actual" fees.
• For the majority of adults, total copayments, coinsurance and premiums exceed the “market” value of dental care.

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• Large group dental practices, measured in terms of employee size, grew from 1992 to 2012. In 2012, large group dental practices accounted for 3.9 percent of dental practice employees, while very small dental practices accounted for 80.7 percent of dental practice employees.
• Large group medical practices, measured in terms of employee size, also grew from 1992 to 2012. In 2012, large group medical practices accounted for 29.6 percent of medical practice employees, while very small medical practices accounted for 33.6 percent of medical practice employees.
• The drivers of consolidation of dental and medical practices are very different; medical practice is not a good model for dental practice.

• In a tertiary health care setting, physicians reported they were dissatisfied with the referral system to dentists, the coverage of dental care services for patients, and their ability to distinguish a worrisome oral lesion from a variant of normal.
• More than half of worrisome lesions were referred to physician specialists instead of dentists specifically due to the lack of a referral system.
• Efforts to improve the referral system to dentists, facilitate the creation of an electronic referral system, and promote dental education for physicians could increase both physician and dentist satisfaction and the quality and efficiency of care for patients.

• Average annual per-patient dental expenditures in the U.S. were $685 in 2013. 
• Average expenditures for patients in the 90th percentile were $1,624. Expenditures at this level and above could represent a financial burden to dental patients.
• Contributing to this burden are out-of-pocket expenditures which, as a percentage of the total expenditure, are higher for dental services compared to other sectors of the health care system.
• Patients with high dental expenditures represent a relatively small percentage of the U.S. population, and the services they receive are not usually required annually.

• More than one in four children ages 1 through 18 with private dental benefits do not have a single dental claim within the year.
• Fees paid to dentists through private dental benefits plans are significantly lower than market fees. This leads to substantial differences in total dental spending estimates based on "market" versus "actual" fees.
• For the majority of children, total copayments, coinsurance, and premiums exceed the “market” value of dental care.

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• As of September 2015, 22 states did not provide any dental benefits to adults in their Medicaid programs beyond emergency procedures.
• We estimate that it would cost between $1.4 and $1.6 billion per year to provide dental benefits to Medicaid adults in these 22 states. The state shares represent between 0.4 and 2.1 percent of total Medicaid spending depending on the state.
• Providing dental benefits to Medicaid adults may lead to enhanced savings for states in other areas, such as hospital emergency department spending. Further research is needed in this area.

• Most accountable care organizations (ACOs) are not responsible for dental care as part of their ACO contract. Nine percent of the largest commercial contracts and 25 percent of Medicaid contracts hold providers responsible for the cost and quality of dental services.
• The top reason ACOs report for excluding dental care is a lack of integrated health information technology. The perceived potential for cost savings associated with dental care is the top motivation among ACOs that include or plan to include dental care.
• Despite research suggesting that integration of dental care may benefit patients, financing and delivery of dental care remains disconnected from other health services, even among ACOs working to improve overall population health. Integration of dental care may present an opportunity for improved accountability for total health, yet to date, there is little incentive for ACOs to facilitate access to these services.

• The number of emergency department (ED) visits for dental conditions in the United States fell from 2012 to 2013, the first decline since the early 2000s.
• There were per-capita declines among all age groups except adults ages 50 to 64. The largest per-capita decline was among young adults ages 19 to 25.
• Looking forward, there are substantial opportunities to reduce ED visits for dental conditions through targeted referral programs and enhanced coverage for preventive dental services among vulnerable populations.

• Cost barriers to dental care fell significantly in 2014, continuing a trend that began in 2010. This decline is now in its fourth year, reversing the increase that occurred from 2000 to 2010. Young adults and low-income adults had the largest decline in cost barriers to dental care from 2013 to 2014.
• Cost barriers for dental care remain significantly higher than for other types of health care services.
• More research is needed to assess whether the Affordable Care Act, namely Medicaid expansion, is affecting dental benefits coverage and cost barriers to dental care.

• We examined career satisfaction among dentists working in two types of large group practice: those affiliated with a dental management organization, and those completely owned and operated by dentists.
• Dentists working in large group practices affiliated with dental management organizations were less satisfied with certain aspects of their practice, such as income and feeling emotionally drained, but were most satisfied with others, such as weekends off and reported fewer hours spent on nonclinical tasks, compared to dentists working in practices that were dentists owned and operated.
• As dental practice structures evolve, it is important to continue studying the implications for both dentists and patients.

• From 2002 to 2012, market share increased for dental firms with 20 employees or more, while dental firms with fewer than five employees experienced a decline in market share.
• During the same period, very large dental firms - those with 500 employees or more - also saw increases in the number of establishments, number of employees and annual receipts.
• Market penetration of very large firms varies by state, from a low of none in seven states to a high of seven percent of the Florida market.

• In 2015, all medical plans offered through Covered California include embedded pediatric dental benefits. This represents a significant change from 2014, when no medical plans were embedded.
• We estimate that this policy change led to about a $7 increase in child medical plan monthly premiums. It also resulted in a slight and statistically insignificant decline in child stand-alone dental plan (SADP) premiums. Potential declines in SADP premiums will have to be monitored in the coming years.
• While the California experience suggests that child dental benefits obtained via embedded medical plans are less costly than SADPs with respect to monthly premiums, further research is needed to examine differences in deductible arrangements, total out-of-pocket costs, and provider networks.

• There is an upward trend in the share of medical plans with embedded dental benefits in the health insurance marketplaces.
• While pediatric dental benefits are an essential health benefit under the Affordable Care Act, many plans do not offer first dollar coverage for preventive dental services.
• Medical plans with embedded pediatric dental benefits are more likely than stand-alone dental plans to provide first dollar coverage for preventive services.
• Information on dental benefits is much more transparent in the 2015 Federally-Facilitated Marketplace compared to 2014.

• Centers for Medicare & Medicaid Services’ projections for health care spending growth tended to overestimate actual growth in spending during the period 1999 to 2012. The accuracy of spending growth projections also decreased with the projection horizon.
• Centers for Medicare & Medicaid Services’ spending projections for dental care appear to be more accurate than projections for prescription drug expenditures, but not as accurate as projections for other components of health care.

• Due to the Affordable Care Act, the Medicaid market for dental care will grow significantly in many states. Even in many states electing not to expand Medicaid eligibility, there will still be a large influx of adults and children into Medicaid.
• In an overall stagnant dental care sector, driven by declining dental care use among middle- and high-income adults, Medicaid represents one of the few market segments with expanding demand for dental care.
• Translating expanded Medicaid dental benefits coverage to expanded access to dental care and ultimately, improved oral health, will require significant reforms to Medicaid programs. States can draw on a significant body of evidence to guide reforms.

• From 2003 to 2013, Medicaid reimbursement rates for pediatric dental care services have not kept up with inflation in most states. In contrast, most states have seen increases in inflation-adjusted private dental insurance charges.  
• States that have implemented reimbursement increases along with other Medicaid program reforms have seen significant gains in provider participation and access to dental care. The impact of fee changes in the private market has been studied less.
• As Medicaid continues to expand, policy makers ought to examine the extent to which key enabling conditions are in place to translate expanded coverage to expanded access to care.  Adequate provider reimbursement is one of these enabling conditions.

• Cost and low perceived need are the top reasons why adults indicate they do not intend to visit a dentist in the next 12 months. This is true among adults of all ages and income levels.
• Other important reasons for not visiting a dentist include lack of time, difficulty traveling to a dentist, anxiety, and difficulty finding a dentist that accepts Medicaid.
• The prominence of "no need" as a reason for forgoing dental care may be driven by improvements in oral health, changes in oral health literacy, or a significant shift in the value proposition of dental care.  Further research is needed in this area.

• Since Fiscal Year 2012, per-capita outpatient dental emergency department visits have decreased in Maryland. The decline can be attributed to reduced visits among children and adults ages 21-40.
• The decrease in outpatient dental emergency department visits among children could be attributed to reforms Maryland has instituted in its pediatric Medicaid program since 2007.
• As the majority of expenditure for outpatient dental emergency department visits is financed by Medicaid, an effective statewide emergency department diversion program could save Maryland Medicaid up to $4 million per year.

• In 2013, the average Medicaid fee-for-service reimbursement rate was 48.8 percent of commercial dental insurance charges for pediatric dental care services.
• In 2014, the average Medicaid fee-for-service reimbursement rate was 40.7 percent of commercial dental insurance charges for adult dental care services in states that provide at least limited adult dental benefits in their Medicaid program.
• From 2003 to 2013, for pediatric dental care services, Medicaid fee-for-service reimbursement relative to commercial dental insurance charges fell in 39 states and rose in seven states and the District of Columbia.
• The available evidence strongly suggests that increasing Medicaid reimbursement rates for dental care services, in conjunction with other reforms, increases provider participation and access to dental care for Medicaid enrollees.

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• There is often confusion among Medicaid enrollees when it comes to the availability of dental benefits in Medicaid, particularly for adults.
• The majority of adults rate oral health as important. Adults with private health insurance are slightly more likely to rate oral health as important compared to adults with Medicaid. There is no difference in reported oral health importance between Medicaid-enrolled children and children with other forms of health insurance.
• Medicaid-enrolled adults report higher rates of average, poor and bad self-perceived oral health status compared to adults with other forms of health insurance. However, there is no difference in reported oral health status between Medicaid-enrolled children and children with other forms of health insurance.
• Among Medicaid-enrolled adults and children, the main reasons for not visiting a dentist include many dental services not being covered by Medicaid and difficulty finding a dentist that accepts Medicaid.

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• Based on triage status, dental emergency department (ED) visits were less likely than nondental ED visits to be categorized as immediate or urgent and more like to be categorized as semi-urgent or non-urgent.
• About two-thirds of dental ED visits occurred outside of normal business hours. Also, a dental ED visit was more likely to occur outside of normal business hours than a non-dental ED visit.
• The triage status of dental ED visits and arrival time at the ED did not vary by primary payer.
• The majority of dental ED visits can be diverted to a dental office. The savings from diverting these ED visits, estimated to be up to $1.7 billion per year, could be used to fund Medicaid premiums, preventive dental visits or other more cost-effective interventions.

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• The final 2014 take-up rate of stand-alone dental plans in the health insurance marketplaces has not improved much since February 2014.
• Overall, the 2014 take-up rate of dental benefits for children appears low when compared to the objectives of the Affordable Care Act. Although further analysis is needed based on full enrollment data, our ongoing analysis of marketplace enrollment continues to suggest that the lack of a true mandate for pediatric dental benefits within the health insurance marketplaces is having important consequences.
• The final 2014 take-up rate of dental benefits for children in states where dental benefits are only available through stand-alone dental plans is only 26.1 percent, emphasizing that the lack of a true mandate for pediatric dental benefits is impacting consumer behavior.
• Because data are not available on the number of children obtaining dental benefits through medical plans, it is impossible to determine the total number of children and adults who obtained dental benefits through the health insurance marketplaces.

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• The take-up rate of stand-alone dental plans in the newly established health insurance marketplaces through February 2014 varies considerably from state to state. Idaho has the highest take-up rate for children and Alabama the highest for adults.  
• Overall, the take-up rate of stand-alone dental plans for children is low when compared to the objectives of the Affordable Care Act. Although further analysis is needed based on full enrollment data, early results suggest the lack of a true mandate for pediatric dental benefits within the health insurance marketplaces is having important consequences.
• Due to data limitations, it is unclear whether consumers are purchasing dental benefits primarily through stand-alone dental plans or medical plans with embedded dental benefits. 

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• The number of group practices in the United States is increasing; they are expanding and changing in character and structure. Understanding the evolution of group practices has been difficult because past discussions and research have suffered from a lack of specificity, and the information gathered was less insightful.
• A classification system for group dental practices is needed that would allow studies to be done and comparisons made in a more useful manner and allow a better understanding of contemporary dental group practice.
• Six basic types of group practice are identified and described.

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• Traditional estimates of dental practice expenses have not included owner dentist salaries as a practice expense.
• When owner dentist salaries are included as a cost, practice expenses average about 90% of gross billings.
• Taking into account the actual collection rate on gross billings, practice expenses (including owner salaries) are, on average, about 97% of gross billings collected.

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