Trends and Disparities in Oral Health Outcomes, Dental Care Utilization and Out-of-Pocket Dental Expenditure Among Medicare Beneficiaries

Abstract

Objectives: Despite the significance of oral health on overall health, Medicare excludes dental care from its coverage, leaving beneficiaries at risk of oral diseases and high out-of-pocket expenses. We assessed trends and socio-economic disparities in oral health outcomes (OHO), dental care utilization (DCU) and out-of-pocket dental expenditure (OOPDE) among Medicare beneficiaries (MB) using the National Health and Nutrition Examination Survey (NHANES) and the Medical Expenditure Panel Survey (MEPS).

Methods: OHO included edentulism, dental caries, and periodontal diseases. DCU was defined as past-year dental visit. OOPDE was described as spending at least $1500 OOPDE. Spending at least 5% of household income on dental care was defined as Catastrophic Financial Burden (CFB). Trends were evaluated with relative percentage change (RPC) estimates, and age and sex-adjusted linear trends in binary logistic regression models. The influence of coverage type was assessed on OHO, DCU and OOPE by conducting different types of regression models. Propensity Score matching (PSM) was used to investigate the effect of dental coverage (DenC) on DCU among MB with supplemental public insurance (MB/Pub). The associations of utilizing preventive services with OOPDE and CFB were also evaluated using binary regressions.

Results: Individuals 65 years were included in the analyses. From NHANES, we had three different samples; 3,480, 2,425, 3,253 participants were included to assess edentulism and coronal caries, root caries, and periodontal diseases, individually. Both edentulism and root caries decreased significantly during the study period; 23.26% to 16.59%, RCP:27.13%; p-trend: 0.022, and 12.55% to 4.36; RPC: -65.26%; p-trend.001, respectively. Regarding periodontal diseases, the prevalence increased significantly from 69.63% to 79.45% (RCP:14.10%; p-trend: 0.005). Severe periodontists also escalated throughout the study (64.52% to 73.40%, RPC: 13.76; p-trend: 0.019). DCU was a strong predictor of all OHO. Regarding our MEPS analysis, we analyzed 36,229 adults. Among MB, DCU increased significantly from 44.72 % to 52.46% (RPC: 17.31%; p-trend.001). The logistic regression output suggested a strong association between coverage and DCU. MB/Pub with DenC had the highest odds of DCU (OR= 12.17, CI95= 6.13-26.29). The Average Treatment Effect from our PSM indicated that the average odds of DCU will increase by 39% if all MB/Pub had a DenC compared to the average if none of the same beneficiaries had DenC. The prevalence of paying $1500+ OOPDE increased significantly from 5.76% to 9.14% (RCP: 58.68%; p-trend: .001). Finally, while holding all other variables constant, utilizing preventive services decreased the likelihood of spending $1500 OOPDE by 41% (AOR=0.59, CI95=0.48-0.72) and lifted 26% of MB out of CFB (AOR=0.74, CI95=0.59-0.94).

Conclusion: DCU is a strong predictor of OHO irrespective to coverage. Further, DenC was significantly associated with DCU, and our results illustrated causality of DenC on DCU among MB/Pub. Consequently, we can conclude that DenC and OHO are associated by transitive property. Given that MB are at risk for growing need for dental care as they age, until dental care is fitted within one’s medical care, and financially supported, poor oral health will remain the “silent epidemic” that jeopardizes the quality of life for older adults.