Richard J. Manski

Dental Insurance Visits and Expenditures Among Older Adults

OBJECTIVES We examined the effect of age, income, and coverage on dental service utilization during 1996. METHODS We used data from the 1996 Medical Expenditure Panel Survey. RESULTS Edentulous and poorer older adults are less likely to have coverage and less likely to report a dental visit than dentate or wealthier older adults. CONCLUSIONS These analyses help to describe the needs of older adults as they cope with diminishing resources as a consequence of retirement, including persons previously accustomed to accessing oral health services with dental insurance.

Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries

OBJECTIVES Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults. METHODS Participantsincluded White, Black, and Hispanic adults who had experi enced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%). RESULTS To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Over whelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondents income or race/ethnicity. CONCLUSIONS Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

Dental care coverage and retirement

OBJECTIVES To examine the convergence of an aging population and a decreased availability of dental care coverage using data from the Health and Retirement Study (HRS). METHODS We calculate national estimates of the number and characteristics of those persons age 51 years and above covered by dental insurance by labor force, retirement status, and source of coverage. We also estimate a multivariate model controlling for potentially confounding variables. RESULTS We show that being in the labor force is a strong predictor of having dental coverage. For older retired adults not in the labor force, the only source for dental coverage is either a postretirement health benefit or spousal coverage. CONCLUSIONS Dental care, generally not covered in Medicare, is an important factor in the decision to seek dental care. It is important to understand the relationship between retirement and dental coverage in order to identify the best ways of improving oral health and access to care among older Americans.

Investing in Preventive Dental Care for the Medicare Population: A Preliminary Analysis

OBJECTIVES We estimated the use of preventive dental care services by the US Medicare population, and we assessed whether money spent on preventive dental care resulted in less money being spent on expensive nonpreventive procedures. METHODS We used data from the 2002 Medicare Current Beneficiary Survey to estimate a multinomial logistic model to analyze the influence of predisposing, enabling, and need variables in identifying those beneficiaries who used preventive dental care, only nonpreventive dental care, or no dental care in a multiple-variable context. We used regression models with similar controls to estimate the influence of preventive care on the utilization and cost of nonpreventive dental care and all dental care. RESULTS Our analyses showed that beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems. CONCLUSIONS Adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.

Toothache pain: Behavioral impact and self-care strategies

A computer-assisted telephone interview in Maryland of adults who had low income and were Hispanic, Black, and White and who had experienced a toothache during the previous 12 months was conducted. Respondents reported a high prevalence of toothaches, with 44.3% having experienced more than five toothaches during the preceding 10 years. Pain intensity associated with the most recent toothache was high with 45.1% of the respondents reporting the highest pain possible. Pain interfered with many aspects of normal functioning. Self-care strategies generally took precedence over professional health services. Pain sufferers used a combination of self-care and formal care strategies. Initial strategies most often focused on nonprescription medicines(home remedies and prayer. The majority of respondents ultimately sought pain relief from a dentist. We identified a number of significant differences in the strategies used across racial/ethnic groups.

THE DEMAND FOR PREVENTIVE AND RESTORATIVE DENTAL SERVICES

Chronic tooth decay is the most common chronic condition in the United States among children ages 5-17 and also affects a large percentage of adults. Oral health conditions are preventable, but less than half of the US population uses dental services annually. We seek to examine the extent to which limited dental coverage and high out-of-pocket costs reduce dental service use by the nonelderly privately insured and uninsured. Using data from the 2001-2006 Medical Expenditure Panel Survey and an American Dental Association survey of dental procedure prices, we jointly estimate the probability of using preventive and both basic and major restorative services through a correlated random effects specification that controls for endogeneity. We found that dental coverage increased the probability of preventive care use by 19% and the use of restorative services 11% to 16%. Both conditional and unconditional on dental coverage, the use of dental services was not sensitive to out-of-pocket costs. We conclude that dental coverage is an important determinant of preventive dental service use, but other nonprice factors related to consumer preferences, especially education, are equal if not stronger determinants.

Wealth Effect and Dental Care Utilization in the United States

OBJECTIVE The purpose of this article is to examine the relationship of wealth and income and the relative impact of each on dental utilization in a population of older Americans, using data from the Health and Retirement Study (HRS). METHODS Data from the HRS were analyzed for US individuals aged 51 years and older during the 2008 wave of the HRS. The primary focus of the analysis is the relationship between wealth, income, and dental utilization. We estimate a multivariable model of dental use controlling for wealth, income, and other potentially confounding covariates. RESULTS We find that both wealth and income each have a strong and independent positive effect on dental care use of older Americans (P < 0.05). A test of the interaction between income and wealth in our model failed to show that the impact on dental care utilization as wealth increases depends on a persons income level or, alternatively, that the impact on dental use as income increases depends on a persons household wealth status (P > 0.05). CONCLUSIONS Relative to those living in the wealthiest US households, the likelihood of utilizing dental care appears to decrease with a decline in wealth. The likelihood of utilizing dental care also appears to decrease with a decline in income as well.

Dental care expenditures and retirement.

OBJECTIVES To examine the relationship of dental care coverage, retirement, and out-of-pocket (OOP) dental expenditures in an aging population, using data from the Health and Retirement Study (HRS). METHODS We estimate OOP dental expenditures among individuals who have dental utilization as a function of dental care coverage status, retirement, and individual and household characteristics. We also estimate a multivariate model controlling for potentially confounding variables. RESULTS Overall, mean OOP dental expenditures among those with any spending were substantially larger for those without coverage than for those with coverage. However, controlling for coverage shows that there is little difference in spending by retirement status. CONCLUSIONS Although having dental coverage is a key determinant of the level of OOP expenditures on dental care; spending is higher among those without coverage than those who have dental insurance. We also found that while retirement has no independent effect on OOP dental expenditures once controlling for coverage, dental coverage rates are much lower among retirees.

Dental care utilization and retirement

OBJECTIVE The authors examine the relationship of dental care coverage, retirement, and utilization in an aging population using data from the Health and Retirement Study (HRS). METHODS The authors estimate dental care use as a function of dental care coverage status, retirement, and individual and household characteristics. They also estimate a multivariate model controlling for potentially confounding variables. RESULTS The authors show that that the loss of income and dental coverage associated with retirement may lead to lower use rates but this effect may be offset by other unobserved aspects of retirement including more available free time leading to an overall higher use rate. CONCLUSIONS The authors conclude from this study that full retirement accompanied by reduced income and dental insurance coverage produces lower utilization of dental services. However, they also show that retirement acts as an independent variable, whereas income, coverage, and free time (unobserved) act as intervening variables.

The effect of dental insurance on dental care use and selection bias.

Objectives:We examine the effect of dental insurance coverage on the probability of having a dental care visit in light of selection bias. Methods:We use data from the 2003 Medical Expenditure Panel Survey and use 3 different approaches to control for selection bias. First, we use a probit specification and include a rich set of independent variables that we posit control for unobserved attitudes toward risk and health care. Second, we use an instrumental variable model with family employment status as our instrument. Finally, we use a nonparametric approach to identify the upper and lower bounds of a dental insurance effect. We also ran a base probit model that did not include controls for attitudes toward risk and health care. Results:The base probit, the probit including measure of attitudes, and the instrumental variable models provided similar estimates of the effect of dental insurance on the probability to seek dental care. This may indicate that selection bias may not be a concern. All estimates were within the bounds obtained through the nonparametric approach. Conclusions:Despite concerns of the potential endogeneity of dental insurance in models that estimate dental care use, we find evidence that these concerns may be unfounded.