Dental Services: Information on Coverage, Payments, and Fee Variation
Published: 2013-09-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: High rates of dental disease remain prevalent across the nation, especially in vulnerable and underserved populations. According to national surveys, 42 percent of adults with tooth or mouth problems did not see a dentist in 2008 because they did not have dental insurance or could not afford the out-of-pocket payments, and in 2011, 4 million children did not obtain needed dental care because their families could not afford it.
In 2011, the Institute of Medicine reported that there is strong evidence that dental coverage is positively tied to access to and use of oral health care. For families without dental coverage, federally funded health centers may offer an affordable dental care option. Health centers are required to offer sliding fee schedules with discounts of up to 100 percent for many low-income patients.
GAO was asked to examine dental services in the United States. This report describes (1) trends in coverage for, and use of, dental services; (2) trends in payments by individuals and other payers for dental services; and (3) the extent to which dental fees vary between and within selected communities across the nation. To do this work, GAO examined HHS national health survey data and national dental expenditure estimates, dental insurance claims data, and health center dental fees in 18 selected communities (based on census region, population, and dental claims volume). GAO also interviewed HHS officials and academic experts.
HHS provided technical comments on a draft of this report, which were incorporated as appropriate.
section_title: What GAO Found
paragraphs: Overall, trends in dental coverage show little change from 1996 to 2010--around 62 percent of individuals had coverage. The percentage of the population with private dental coverage decreased from 53 to 50 percent. Dental coverage through Medicaid or the State Children's Health Insurance Program (CHIP), which was established in 1997, rose from 9 to 13 percent. The increase was due primarily to an increase in the number of children covered by these federal-state health programs with mandated pediatric dental coverage. Individuals with no dental coverage decreased from 28 to 25 percent, and coverage for 10 to 12 percent of the population was unknown. Use of dental services--the percentage of individuals who had at least one dental visit--also remained relatively unchanged at around 40 percent from 1996 to 2010. Medicaid and CHIP beneficiaries, children in particular, showed increases in the use of dental services (from 28 to 37 percent), but still visited the dentist less often than privately insured children (58 percent in 2010).
GAO's analysis showed that average annual dental payments--the total amount paid out of pocket by individuals and by other payers--increased 26 percent, inflation-adjusted, from $520 in 1996 to $653 in 2010. Average annual out-of-pocket payments increased 21 percent, from $242 to $294, for individuals with private insurance and 32 percent, from $392 to $518, for individuals with no dental coverage.
Dental fees charged by local dentists and health centers varied widely. For 8 of 24 common procedures GAO examined, reported upper-end fees (the 95th percentile of the range in local dentist fees) were at least double the midpoint fees (the 50th percentile of the range in local dentist fees) in several communities. For example, in Miami, Florida, the upper-end fee of $150 for a periodic oral examination was more than twice the midpoint dental fee of $62. Dental fees also varied between local dentists billing private insurers and health centers serving residents of the same community. In general, most health centers in GAO's review offered a 100 percent discount--resulting in no fee--to the lowest-income patients for many, but not all, dental services.

section_title: Letter
paragraphs: More than a decade ago, the Surgeon General’s report on oral health  described the poor oral health of our nation as a “silent epidemic.”  Today, high rates of dental diseases remain prevalent across the nation,  especially in vulnerable and underserved populations. The cost of dental  care and lack of dental coverage are often cited as reasons individuals  may not seek needed dental care. In 2008, 42 percent of adults with  tooth or mouth problems reported they did not see a dentist because they  did not have dental coverage or could not afford the out-of-pocket  payments. Similarly, in 2011, 4 million children did not obtain needed  dental care because their families could not afford it. The Institute of  Medicine has reported that there is strong evidence that dental coverage  is positively associated with access to and use of oral health care.
Recognizing that oral health is central to a person’s overall health and  well-being, the Department of Health and Human Services (HHS) has  adopted an oral health objective as a leading health indicator in its  Healthy People 2020 initiative, which consists of 10-year national  objectives for improving the health of all Americans. Specifically, HHS’s  leading indicator for oral health is to increase the proportion of children,  adolescents, and adults who used the oral health care system in the past  12 months. The 2020 target for this leading health indicator is to increase  access to dental services—increasing the proportion of individuals aged   2 years and older who have had a dental visit in a year to 49.0 percent  from 44.5 percent in 2007.
Many families that cannot afford dental care obtain it from health centers,  for which federal funds provide a substantial part of revenue. Dental  services that are provided by health centers must be available to all  patients, regardless of their ability to pay. All health centers must have fee  schedules for all services, including any dental services provided, that  reflect prevailing fees in the area and a schedule of discounts (or sliding  fee schedule) for individuals who earn annual incomes equal to or less  than 200 percent of the federal poverty level (FPL).
You asked us to examine dental coverage, and use of and payments for  dental services in the United States. This report describes (1) trends in  coverage for and use of dental services, (2) trends in payments for dental  services made by individuals and other payers, and (3) the extent to  which dental fees vary between and within selected communities across  the nation. You also asked us to examine national expenditures for dental  services. We report national dental expenditures from 1996 through 2011  in appendix I.
To provide information on trends in dental coverage and the use of dental  services by type of coverage, we obtained and analyzed data files from  the Medical Expenditure Panel Survey (MEPS) for 1996, 2004, and 2010  on dental visits, dental services, and coverage status. We selected these  years for our analysis because 1996 was the first year MEPS was  administered and 2010 was the most recent year for which data were  available; we included 2004 to provide three points in time for our  analysis. MEPS is administered by HHS’s Agency for Healthcare  Research and Quality (AHRQ) and is a nationally representative survey of  the noninstitutionalized population, including families, medical providers,  and employers across the United States. We based our analysis on a  similar analysis conducted by AHRQ for its Chartbook 17 publication. We  analyzed data on dental coverage and dental visits (including the  category of service obtained during the visit, such as preventive or  restorative) per year, as well as differences in coverage status and dental  visits based on demographics such as age group and income level. We  also examined use of dental services by individuals in urban and rural  areas; to ensure adequate sample sizes, we combined several years of  MEPS data. Information for the urban and rural analysis is presented in  appendix II. MEPS collects information on private dental coverage but  does not collect information specifically about whether dental coverage is  included in health plans offered by public programs such as health  coverage provided by the Department of Veterans Affairs (VA),  Department of Defense (DOD), or Medicare Advantage.could not determine for this population whether those individuals had  dental coverage, and we categorized that group as unknown.
To identify trends in dental payments by individuals and other payers, that  is, how much individuals paid out of pocket for dental care and how much  dental insurers or other payers, such as Medicaid, paid for dental claims,  we obtained and analyzed MEPS 1996, 2004, and 2010 data files on  dental visits, payments, and coverage status.variances by demographic group, including age group and income level.
In addition, we analyzed  To determine the extent to which dental fees varied between and within  certain communities, we analyzed dental claims data compiled by FAIR  Health, Inc. as of January 2013,  and obtained dental fee schedules from  selected federally funded health centers. The FAIR Health dental data set  contains over 140 million claims, including geozip data (the first 3 digits of  a postal zip code) and American Dental Association (ADA) Current  Dental Terminology (CDT) billing codes. We selected 24 dental  procedures for comparison by identifying the CDT billing codes with the  most dental claims in each of six categories of dental services—five  codes each for diagnostic, preventive, and restorative services; and three  each for endodontic, periodontic, and oral surgery services. Academic  experts and ADA officials agreed that our list of 24 CDT codes was  representative of the most common dental procedures. To select large  communities, we identified the geozip with the most dental claims in the  core city in the largest metropolitan statistical area in each of the nine  U.S. Census Bureau divisions.communities, we selected nine small communities in the same states  based on their population. Because geozip boundaries do not align with   For comparison to our large  metropolitan statistical area designations, we selected one geozip (the  one with the most dental claims) to represent each large and each small  metropolitan area. We examined the 50th percentile dental fee and the  95th percentile dental fee for each of our 24 CDT codes from a geozip in  each large and small community. To identify dental fees charged by  federally funded health centers, we obtained documentation and met with  officials from HHS’s Health Resources and Services Administration  (HRSA), which administers the Health Center Program. HRSA provided a  list of health centers that served residents of our 18 selected communities  and that provided dental services. We obtained full fee and sliding fee  schedules from one health center that served each community, although  some health centers did not provide or bill separately for all 24  procedures.
To determine the reliability of the MEPS, FAIR Health, and health center  data, we reviewed related documentation, talked to agency officials and  academic experts, and reviewed other studies that used the data to  address similar research questions. We determined that the MEPS, FAIR  Health, and health center data were sufficiently reliable for the purposes  of our report.
We conducted this performance audit from October 2012 to September  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives. (For more information on  our scope and methodology, see app. III.)
subsections: section_title: Background
subsections: section_title: Dental Services
paragraphs: Dental services cover an array of procedures, from preventive services,  such as cleanings, to more complex services, such as root canals (see  table 1).
Most individuals with dental coverage have private dental insurance.  Private dental insurance plans may be a stand-alone plan or be included  as a part of medical insurance. Stand-alone dental plans require  individuals to enroll separately; they are not a part of the individual’s  medical insurance plan. The types of dental services covered by dental  plans vary widely among private plans. For example, one plan may  include “comprehensive” care such as routine diagnostic and preventive  services, restorative services, and oral surgery, while another may cover  more limited services such as emergency care only. Cost sharing for  dental services usually involves an annual deductible—and according to a  Bureau of Labor Statistics survey of employers, in 2008, the median  deductible was $50 per person. After the individual meets the  deductible, dental plans may pay a percentage of covered services up to  a maximum annual benefit. In 2008, the reported median annual  maximum was $1,500.
Individuals may also obtain dental coverage in other ways, such as  through federal programs. Federal programs may cover dental services  as a required benefit, support purchase of stand-alone dental coverage  for eligible beneficiaries, or support coverage of dental services as part of  broader coverage under individuals’ medical coverage plans, for example.  Benefits included in these types of coverage may vary widely depending  on factors such as type of plan purchased, family income, or veteran’s  status (see table 2).
HHS’s HRSA reported that in 2011, over 4 million patients used dental  services at federally funded health centers. Under the Health Center  Program, health centers—which must be located in federally designated  medically underserved areas or serve a federally designated medically  underserved population—are required to provide pediatric dental  screenings and preventive dental services, as well as emergency medical  referrals, which may also result in the provision of dental services. Health  centers may provide required services, including required dental services,  directly or via formal contract or referral agreements. However, health  centers are not required to provide a full range of dental services.
A health center must establish a fee schedule for its services that is  consistent with locally prevailing rates and reflects the health center’s  reasonable costs of providing services. A health center must also  establish a sliding fee schedule for individuals who earn annual incomes  equal to or less than 200 percent of the FPL. 2011, over 92 percent of the more than 20 million patients served by  health centers nationwide had income less than or equal to 200 percent  of the FPL (and were eligible for a sliding scale fee based on income and  family size).
The 2013 federal poverty guidelines state that a family of four at 200 percent of the  poverty level has an income of $47,100 per year.
section_title: Dental Care under the Patient Protection and Affordable Care Act
paragraphs: The Patient Protection and Affordable Care Act (PPACA) has designated  pediatric dental care as an essential health benefit that new health plans  must cover in the new health care exchanges and the small-group and  individual markets. Exchanges may allow plans to offer stand-alone  dental coverage providing, at a minimum, pediatric dental care. Adult  dental coverage is not included as an essential health benefit. Plans that  have grandfathered status under the law are not required to offer pediatric  dental coverage. PPACA has the potential to change the benefits and  out-of-pocket payments associated with dental coverage; however, the  extent of these changes is uncertain.
section_title: National Survey Data Show That Rates of Dental Coverage and Use of Dental Services Remained Generally Unchanged from 1996 to 2010
paragraphs: The rate of individuals with dental coverage remained largely unchanged  from 1996 to 2010; around 62 to 63 percent of the population had private  or Medicaid or CHIP dental coverage. In addition, from 1996 to 2010, the  percentage of individuals who had a dental visit remained about the  same, around 41 to 43 percent.
subsections: section_title: Coverage of Dental Services Remained Relatively Unchanged from 1996 to 2010
paragraphs: Our analysis of MEPS data showed that overall, the rate of dental  coverage—the percentage of individuals reporting that they had dental  coverage through private insurance or Medicaid or CHIP—remained  relatively unchanged from 1996 to 2010.62 percent of individuals reported having dental coverage, and in 2010,  63 percent reported having dental coverage. For about 10 to 12 percent   Specifically, in 1996,   of the population, including many individuals covered by Medicare and  other federal health programs, dental coverage status is unknown.
While the overall percentage of individuals with dental coverage generally  stayed the same between 1996 and 2010, the percentages with private  dental and without insurance coverage decreased and the percentage  with Medicaid dental coverage increased. Specifically, the percentage of  individuals with private coverage was 53 percent in 1996 and 50 percent  in 2010 (see fig. 1). The percentage of individuals with dental coverage  under Medicaid increased steadily in each of the years we examined,  from 9 percent in 1996 to 13 percent in 2010. The percentage of  individuals reporting that they did not have dental coverage decreased  from 28 percent in 1996 to 25 percent in 2010, leaving at least one in four  individuals with no dental coverage—approximately 76 million people—in  2010. For 10 to 12 percent of individuals in each year we examined, it is  unknown whether they had dental coverage. These individuals reported  having some type of health coverage, such as Medicare coverage, but  the MEPS survey structure did not allow us to determine whether that  health coverage included dental coverage.
Rates of private dental coverage among individuals in the high-income  category (over 400 percent of FPL) were higher than any other income  category in 1996, 2004 and 2010 (see fig. 2). Individuals in the poor-,   low-, and middle-income groups saw a decline in the rates of private  coverage over the same period.
The percentage of individuals with Medicaid dental coverage   increased from 9 percent in 1996 to 13 percent in 2010. This trend was  largely driven by an increase in children covered by Medicaid, which  requires pediatric dental coverage. The overall percentage of children   (ages 0-20 years) reported to have dental coverage—through private  coverage or Medicaid—increased from 72 percent (59 million) in 1996 to  81 percent (71 million) in 2010, and fewer children were uninsured,  because more children were covered by Medicaid in 2010 than in prior  years. The percentage of children with dental coverage through Medicaid  increased from 18 percent (15 million) in 1996 to 33 percent (29 million) in  2010 (see fig. 3). This was the largest increase in coverage for any age  group in Medicaid. The percentage of children with private dental  coverage decreased from 54 percent (44 million) in 1996 to 48 percent  (42 million) in 2010. In addition, rates of children without dental coverage  declined from 27 percent (22 million) to 17 percent (15 million) over the  same period.
The percentage of individuals who used dental services—those who  reported having at least one dental visit during the year—remained  relatively unchanged at around 40 percent from 1996 to 2010.  Specifically, about 43 percent of individuals in 1996 and 41 percent in  2010 had a dental visit. Table 3 shows our analysis of MEPS data on the  use of dental services.
Trends in dental visits by individuals with private dental coverage largely  explained why the percentage of individuals with a dental visit remained  relatively unchanged from 1996 to 2010. Specifically, over this period the  percentage of individuals with private dental coverage who had a dental  visit remained the same, at around 56 percent (see table 4), and  individuals with private coverage made up a large majority—around 80 to  85 percent—of the population with dental coverage during that time  period. The number of individuals without dental coverage who had a  dental visit declined—from 26 percent, or 19 million individuals, in 1996 to  18 percent, or 14 million individuals, in 2010.
The percentage of individuals with Medicaid who had a dental visit  increased from 1996 to 2010. This increase reflects an increase in the  number of children with Medicaid coverage who had a dental visit,  although these children still had dental visits at lower rates than privately  insured children (58 percent). The percentage of children with Medicaid  dental coverage with a dental visit increased from 28 percent, or 4 million  children, in 1996 to 37 percent, or 11 million children, in 2010. (See   fig. 4.)
Among individuals who reported having a dental visit, there was an  increase in the percentage reporting that they received diagnostic and  preventive services (for example, exams and cleanings) and a decrease  in those reporting that they received other services, such as restorative  services (for example, fillings), from 1996 to 2010. Specifically, the  percentage of visits for diagnostic and preventive services as a proportion  of total dental services increased (see fig. 5). Seventy-six percent of  dental visits in 2010 consisted of diagnostic or preventive services (43  and 33 percent, respectively). This is an increase from 69 percent in  1996, when diagnostic and preventive services made up 40 and 29  percent of services received, respectively. The percentage of visits for  other types of services decreased from 1996 to 2010. Specifically,  restorative services—such as fillings—decreased slightly from 8 percent  to 6 percent as a proportion of total dental services received in those  years. Other services that decreased included prosthetic and orthodontic  services.
section_title: Average Payments for Dental Services Increased from 1996 to 2010
paragraphs: Average annual payments made on behalf of or by individuals for dental  services—including payments from other payers such as insurers and  out-of-pocket payments—increased from 1996 to 2010. Average annual  inflation-adjusted dental payments increased 26 percent from $520 per  year in 1996 to $653 per year in 2010 (see table 5). The average annual  payments made—including out-of-pocket payments and payments by  other payers—increased 24 percent for the privately insured, 39 percent  for individuals with Medicaid, and 38 percent for those without dental  coverage. In addition, in 2010, average annual dental payments (out of  pocket and payments made by other payers) for those with private  coverage were nearly twice as much as the payments made by and on  behalf of individuals with Medicaid coverage.
Average annual payments for dental services varied across income  levels. Payments made by and on behalf of individuals in the low-, and  middle-income groups increased steadily from 1996 to 2010. However,  average annual payments made by and on behalf of individuals who were  poor increased from $373 in 1996 to $493 in 2004, and then decreased to  $437 in 2010. For low-income individuals, that is, individuals with  incomes at or below 200 percent but above 100 percent of the FPL,  dental payments had the largest increase. Specifically, average annual  dental payments for the low-income group increased from $393 in 1996 to  $558 in 2010 (see fig. 6), about 42 percent. Average annual dental  payments also increased for middle- and high-income individuals—23  and 25 percent, respectively.
Individuals’ out-of-pocket payments for dental services, separate from  payments by other payers, when adjusted for inflation, generally  increased from 1996 to 2010 (see fig. 7). Specifically, average annual  out-of-pocket payments made by individuals with private coverage  increased 21 percent from 1996 to 2010—from $242 to $294. Individuals  with no dental coverage experienced the greatest increase in average  annual out-of-pocket payments, from $392 to $518, a 32 percent  increase. For individuals with Medicaid coverage, their average annual  out-of-pocket payments remained relatively unchanged, $64 in 1996 and  $59 in 2010.
section_title: Fees Charged for Dental Services Varied between and within Communities
paragraphs: Dental fees charged by dentists and health centers varied across  geographic areas and within communities. For 24 common dental  procedures, dental fees charged by local dentists varied significantly  between the 18 communities we examined. In addition, dental fees varied  widely within communities. Dental fees also varied between local dentists  and health centers that serve residents of the same community, but all  health centers are required to offer sliding fee schedules for low-income  individuals.
subsections: section_title: Dental Fees Varied Widely between Communities
paragraphs: For 24 common dental procedures, midpoint dental fees—the amount  where half of fees charged were higher and half were lower—varied  widely between the 18 communities we examined. For example,  midpoint dental fees for an adult prophylaxis (commonly called teeth  cleaning) in large communities ranged from $76 in Nashville, Tennessee,  to $155 in New York, New York. In smaller communities, midpoint fees  ranged from $59 in Jackson, Tennessee, to $88 in Fresno, California (see  fig. 8). Similarly, midpoint fees charged for a child prophylaxis ranged  from $55 to $105 in large communities and $48 to $71 in small  communities. Dental fees, as with other health care costs, vary by  location. (See tables 10 to 27 in app. IV for more information on the range  of dental fees for other common dental procedures in selected  communities.)
Several factors can contribute to geographic variation in dental fees,  including local wages and the cost of space and equipment needed to  operate a practice. Although we identified no current peer-reviewed  research that established a correlation between individual factors and the  level of dental fees, geographic variation in spending for medical services  is well documented. For example, the Congressional Budget Office  reported that a number of factors, including facilities, supplies, and  wages, influence geographic variation in health care spending. The  Centers for Medicare & Medicaid Services (CMS), in setting Medicare  payment rates for health care services, establishes a geographic practice  cost index for each Medicare payment locality to account for variation in  practice expenses. CMS reported that it did not have any comparable  practice cost index for Medicaid dental fees.
section_title: Dental Fees Varied Widely within Communities
paragraphs: Dental claims data also showed significant differences within communities  for all 24 common dental procedures we examined. Fees within the  private practice dental setting are affected by local market conditions and  decisions within the individually owned practices. FAIR Health dental  claims data showed that within communities the difference between  midpoint and upper-end fees was as high as 143 percent for localized  delivery of antimicrobial agents. Upper-end fees were at least double the  midpoint fees in at least one community for 8 of the 24 common  procedures we examined (see table 6). (See app. IV for information on all  24 procedures in all 18 selected communities.)
Dental fees within communities also varied widely for diagnostic  procedures. For the most common diagnostic procedure, a periodic oral  evaluation of an established patient, the percentage difference between  reported midpoint and upper-end fees in large communities ranged from  20 percent to 142 percent (see table 7). For example, in Miami, Florida,  half of the fees charged by dentists for a periodic oral examination of an  established patient were $62 or less, but 5 percent of fees charged for  that procedure were $150 or more, a 142 percent difference. In small  communities, the percentage difference was less, ranging from   17 percent to 58 percent.
Dental fees within communities also varied widely for restorative  procedures. For the most common restorative procedure, a filling, the  percentage difference between reported midpoint and upper-end fees in  large communities ranged from 19 percent to 67 percent (see table 8).  For example, in Phoenix, Arizona, half of the fees charged by dentists for  a filling were $195 or less, but 5 percent of fees charged for that  procedure were $325 or more, a 67 percent difference. In small  communities, the percentage difference was smaller, ranging from   13 percent to 38 percent.
Dental fees also varied between midpoint fees of local dentists billing  private insurers and the full fees of the federally funded health centers  that serve residents of the same community. In the 18 communities we  examined, full dental fees for a tooth extraction (the most common oral  surgery procedure) were typically lower at health centers. For patients  with incomes at or below 100 percent of the FPL, 10 health centers  offered a 100 percent fee discount and 8 health centers had fees ranging  from $16 to $148 for extracting a tooth (see table 9). Health centers’ full  fees—which fewer than 8 percent of health center patients pay—were  often, but not always, lower than the midpoint fees charged by local  dentists. In some cases, midpoint fees charged by local dentists were  higher than health center fees by a wide margin. For example, in Los  Angeles, the midpoint fee charged by local dentists for a tooth extraction  was nearly 3 times the full fee charged by a health center serving  residents of the same community. In other cases, full fees were higher  than those of local dentists. For example, in Fresno the health center’s full  fee was $177 for a tooth extraction compared to the midpoint fee charged  by local dentists of $142. (See app. IV for additional information on local  dentist fees and health center dental fees.)
To assist health centers in establishing sliding fee schedules for low- income patients, HRSA officials told us that, as of June 2013, they were  in the process of preparing guidance on discounting fees for all services  provided as part of a health center’s scope of project, including dental  services. In technical comments on a draft of this report, HHS noted that  the draft guidance was in final clearance, indicating that it was uncertain  whether the final policy would include guidance on establishing full-fee  schedules. According to HHS, there is often a significant unmet need for  dental care services among patients served by health centers and as a  result, health centers and their community boards must make decisions  about whether to provide additional dental services to meet this need and  develop a fee schedule consistent with Health Center Program  requirements. HHS commented that variation in fees and discounts reflect  each health center's unique community characteristics as well as the  board's decision on how best to balance their ability to provide these  services against the unmet need in their community.
section_title: Agency Comments
paragraphs: HHS reviewed a draft of this report and provided technical comments,  which we incorporated as appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of Health  and Human Services, interested congressional committees, and others.  In addition, the report will be available at no charge on the GAO website  at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or iritanik@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix V.
section_title: Appendix I: National Dental Expenditures
paragraphs: To determine national trends in U.S. dental expenditures, we obtained  national expenditure data from HHS’s Centers for Medicare & Medicaid  Services’ (CMS) Office of the Actuary. In 2011, national expenditures for  dental services in the United States were about $108 billion, an inflation- adjusted increase from $64 billion in 1996 (see fig. 9). Inflation-adjusted  expenditures in the United States for dental services rose an average of  3.6 percent per year between 1996 and 2011—ranging from a 0.8 percent  decrease in 2009 to a 6.9 percent increase in 2002.
section_title: Appendix II: Urban and Rural Dental Visit Rates
paragraphs: Individuals who lived in urban and rural areas reported dental visits at  different rates, with individuals in urban areas reporting higher rates of  dental visits. For example, in all age groups, fewer individuals in rural  areas reported having a dental visit than individuals in urban areas (see  fig. 10). Specifically, 34 percent of individuals ages 65 and older living in  rural areas had dental visits in a year, compared with 45 percent of their  counterparts in urban areas, for 2008 through 2010. The rates for children  were similar: 35 percent of children 0 to 20 years old living in rural areas  reported a dental visit in a year, compared with 45 percent of children in  urban areas.
section_title: Appendix III: Scope and Methodology
paragraphs: To provide information on the trends in dental coverage rates, use of  dental services, and payments by individuals and other payers for dental  services, we analyzed nationwide data from the Medical Expenditure  Panel Survey (MEPS). We examined and analyzed data from 3 years:  1996, 2004, and 2010. We selected these years for our analysis because  1996 was the first year MEPS was administered and 2010 was the most  recent year for which data were available, we included 2004 to provide  three points in time for our analysis. MEPS is administered by the  Department of Health and Human Services’ (HHS) Agency for Healthcare  Research and Quality (AHRQ) and is a nationally representative survey of  the noninstitutionalized population, including families, medical providers,  and employers. MEPS collects self-reported information on individuals’  demographics, health and insurance status, and use of medical services  by setting and provider type, as well as expenses and payments related  to those medical and dental visits, among other things. We analyzed  responses to MEPS questions about types of dental insurance coverage,  number of dental visits, types of dental procedures received, and  payments made related to those visits. A dental visit refers to care by or  visits to any type of dental care provider, including general dentists,  dental hygienists, dental technicians, dental surgeons, orthodontists,  endodontists, and periodontists. For this report, we referred to all visits as  dental visits.
To determine whether an individual had private dental insurance  coverage, we examined MEPS data and noted whether the individual  reported having dental insurance or had private insurance pay on a dental  claim during the year. Thus, we considered an individual to have private  dental coverage if he or she (1) reported having dental insurance or   (2) had that insurer pay on a dental claim.
To identify adult Medicaid coverage by state, we used a list of states  provided by the Centers for Medicare & Medicaid Services (CMS) for  2004 and 2010. For states that were identified as having “limited” or  “emergency only” dental coverage, we did not consider those benefits to  be Medicaid dental coverage. Our analysis of adult Medicaid coverage  based on the list from CMS resulted in only small differences from a  similar analysis conducted by AHRQ for its Chartbook 17 publication that  examines dental coverage and expenses.
To categorize dental procedure codes, we consulted with AHRQ and  used the same categories used by AHRQ for its Chartbook 17. For  example, AHRQ placed various dental procedure codes related to  preventive dental care—such as teeth cleaning and sealant application— in the preventive services category.
In MEPS, expenses are defined as the sum of payments for care  received, including out-of-pocket payments and payments made by  private insurance, Medicaid, Medicare, and other sources. For this report,  we referred to MEPS expenses as payments—payments by insurers or  other payers as well as out-of-pocket payments made by individuals. To  present the dental payments in constant 2010 dollars, we used the  Consumer Price Index for All Urban Consumers (CPI-U) as the price  deflator for both the aggregate dental payments and the out-of-pocket  payments.
To identify potential differences in dental service use and payments by  demographic groups, we looked at responses by age group, income level,  and urban or rural area. We examined income level in terms of the federal  poverty level. To conduct the urban and rural analysis, we assigned  individuals to one of three groups based on the county they lived in— each county was designated urban, suburban, or rural based on the Rural  Urban Continuum Codes (RUCC).follows: those who lived in counties designated 1, 2, or 3 in the RUCC  were urban; counties designated 4, 6, or 8, suburban; and in counties  designated 5, 7, or 9, rural.
We categorized those individuals as  In conducting the urban and rural analysis, to ensure adequate sample  sizes, we combined MEPS data for 2008, 2009, and 2010. This was the  only analysis where a combination of years was necessary. Despite this  effort, small sample sizes for some analyses limited the reliability of the  results, and in those cases, we did not report those analyses.
To determine the reliability of the MEPS data, we reviewed related  documentation, interviewed agency officials, and identified other studies  that used MEPS to address similar research questions to compare the  published data with our findings. We determined that the MEPS data  were sufficiently reliable for the purposes of our report.
To determine the extent to which dental fees varied between and within  selected communities, we analyzed dental insurance claims data and  dental fees charged by selected health centers in nine states  corresponding to the nine U.S. Census Bureau divisions. Using 2010  Census data, we selected two communities in each state, one large  based on population and volume of dental claims and one small based on  population. Our nine selected community pairs, large and small (with  selected geozips), were Phoenix (850) and Flagstaff (860), Arizona; Los  Angeles (900) and Fresno (936), California; Miami (331) and Palm Coast  (321), Florida; Chicago (606) and Champaign (618), Illinois; Boston (021)  and Pittsfield (012), Massachusetts; Minneapolis (554) and Mankato  (560), Minnesota; New York (100) and Elmira (148), New York; Nashville  (372) and Jackson (382), Tennessee; and Dallas (752) and San Angelo  (768), Texas.
To identify representative dental fees in each community, we analyzed   (1) 2012 dental insurance claims data compiled by FAIR Health, Inc., as  of January 2013, and (2) dental fee schedules from selected health  centers serving these communities. Based on the FAIR Health claims  data, we selected 24 of the most of commonly billed dental procedures in  six categories of the American Dental Association’s (ADA) Current Dental  Terminology (CDT) codes: five diagnostic, five preventive, five restorative,  three endodontic, three periodontic, and three oral surgery.consulted with academic dental experts and ADA officials to confirm that   We  the CDT codes we selected were representative of common dental  procedures. We also compared our list of common dental procedures to  data from the ADA Survey of Dental Fees. We also obtained health  center dental fees for these 24 procedures in our 18 selected  communities. Based on a list of health centers provided by HHS’s Health  Resources and Services Administration (HRSA), we selected one health  center (the center that served the most dental patients) in each  community. We obtained full-fee and sliding fee schedules from each  health center, although some health centers did not provide or bill  separately for all 24 procedures. The 18 health centers studied may not  be representative of the more than 1,200 health centers supported by  HRSA.
For each selected dental procedure, we extracted from the FAIR Health  data set the midpoint dental fee (the 50th percentile) and the upper-end  fee (the 95th percentile). A percentile indicates the percentage of reported  fees that were below the stated amount; for example, 95 percent of  reported fees fall below the 95th percentile. Within each community, we  selected one geozip (an area that shares the first three digits of a postal  zip code) with the most dental claims to represent the community.  Because geozip boundaries do not align with metropolitan statistical area  designations, we selected one geozip (the one with the most dental  claims) to represent each large and each small metropolitan area. Large  metropolitan areas can include multiple geozips. For example, the Los  Angeles/Long Beach metropolitan area includes geozips 900 to 912  (excluding 909).
To determine the reliability of the FAIR Health and health center data, we  reviewed related documentation, interviewed agency officials and  academic experts, and conducted data testing for missing data. We  determined that both the FAIR Health and health center data were  sufficiently reliable for the purposes of our report.
section_title: Appendix IV: Dental Fees Charged for Common Dental Procedures in 18 Communities
paragraphs: This appendix presents information on local dentist fees and health center  fees for 24 common dental procedures in the 18 communities (by specific  geozips) we examined (see tables 10 to 27).
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, Kim Yamane, Assistant  Director; George Bogart; Carolyn Fitzgerald; Mollie Hertel;   Elizabeth Morrison; and Terry Saiki made key contributions to this   report.
section_title: Related GAO Products
paragraphs: Oral Health: Efforts Under Way to Improve Children’s Access to Dental  Services, but Sustained Attention Needed to Address Ongoing Concerns.  GAO-11-96. Washington, D.C.: November 30, 2010.
Medicaid: State and Federal Actions Have Been Taken to Improve  Children’s Access to Dental Services, but More Can Be Done.   GAO-10-112T. Washington, D.C.: October 7, 2009.
Medicaid: State and Federal Actions Have Been Taken to Improve  Children’s Access to Dental Services, but Gaps Remain. GAO-09-723.  Washington, D.C.: September 30, 2009.
Medicaid: Extent of Dental Disease in Children Has Not Decreased, and  Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121.  Washington, D.C.: September 23, 2008.
Health Resources and Services Administration: Many Underserved Areas  Lack a Health Center Site, and the Health Center Program Needs More  Oversight. GAO-08-723. Washington, D.C.: August 8, 2008.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.:   May 2, 2007.
Oral Health: Factors Contributing to Low Use of Dental Services by Low- Income Populations. GAO/HEHS-00-149. Washington, D.C.:   September 11, 2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income  Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000.