Utilization also can be measured in terms of the amount, or intensity, of services received by those who visit a dentist. The intensity of service often is measured in terms of the number of visits per person within a specified interval (such as visits per year) or expenditures per person. As with the percentage of the population that had had at least one dental visit, a previous study also has shown that the number of visits and the mean expenditure per patient also vary by such factors as income, race, sex and educational level.²

Although important and informative, these measures of dental use and intensity can be refined further. For instance, utilization can be explained further with information about the type of service received. In a similar fashion, expenditures also can be clarified further. For instance, expenditures can be analyzed in terms of the sum of charges, sum of payments or sources of payments. While sum of payments may help provide an accurate measure of reimbursement received by providers (that is, gross receipts), the sum of charges may provide a more accurate measure of the total resources used to provide all services rendered. In some instances, such as insurance discounts, charges represent the nondiscounted fee. In other cases, such as free care or bad debt, charges also capture the total value of services provided when the provider is not fully reimbursed.

This article focuses on charges as a measure of dental expenditures. It examines changes in expenditures from 1987 to 1996 among adults 18 years of age and older. (Our previous article focused on children aged 2 to 17 years.³) To adjust for inflation, dental expenditures (charges) are measured in terms of real, or constant, dollars. We also examine changes in the amount of these services from 1987 to 1996 within major demographic and socioeconomic categories, as well as changes in sources of funding, including the category "not reimbursed."

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The 1987 National Medical Expenditure Survey, or NMES, was designed to provide detailed national estimates of health expenditures, utilization, sources of payment and insurance coverage for the civilian noninstitutionalized population of the United States during the period from Jan. 1 through Dec. 31, 1987. It was sponsored by the Agency for Healthcare Research and Quality, or AHRQ (formerly the Agency for Health Care Policy and Research and, before that, the National Center for Health Services Research). NMES was a survey of approximately 34,459 people in 14,000 households; it oversampled certain population groups, including elderly people, people with limitations in activities of daily living, African-Americans, Hispanics and the poor. Data were gathered in five rounds of interviews over an 18-month period during 1987 and 1988. The combined response rate was 79.7 percent. The 1987 NMES data were released for public use in October 1992.^4,5

The 1996 Medical Expenditure Panel Survey, or MEPS, also was sponsored by AHRQ and was conducted to provide nationally representative estimates of health care use, expenditures, sources of payment and insurance coverage for the U.S. civilian noninstitutionalized population. However, it differs from the 1987 NMES in that data on household respondents in each panel are collected for two consecutive years and the survey is fielded continuously (that is, a new panel is selected every year). The sample for the 1996 MEPS consisted of 21,571 people in 10,500 households participating in the NCHS’s National Health Interview Survey. To collect health expenditure and utilization data for 1996, field researchers interviewed each MEPS household in person three times over an 18-month period. The combined response rate was 70 percent.⁶

All expenditure estimates presented in this article are per capita and are based on people who had had at least one dental visit during the year of the survey. Dental expenditure and source-of-payment information were collected as part of the household survey. In settings that do not normally specify a total charge, AHRQ staff imputed a dollar value to construct a total expense variable. They also designed a series of edits and imputation procedures for missing or inconsistent expense values and addressed three major issues:

– potential copayment amounts;

– potential flat fees;

– missing charges in cases wherein care was delivered free by the provider or under a prepaid arrangement such as a health maintenance organization, was covered by a flat fee or by Medi-caid, or was not otherwise reported by the respondent.

AHRQ staff imputed Medicaid expenses using a database consisting of average 1987 or 1996 Medicaid reimbursements for dental care by state, patient age and type of service.

All expenditure estimates contained in the tables and figures in this article are real (base = 1998), to allow for comparisons over time using constant dollars. We used the dental component of the consumer price index to adjust for the effects of inflation. Only one nominal estimate (in other words, current dollars) is presented, at the beginning of the results section, to demonstrate the importance of removing the effects of inflation when making comparisons over time.

In this article, we focus on three main sources of funding—out-of-pocket, private insurance and public sources—and a fourth category called "not reimbursed." Public sources included Medicare, Medicaid, and other federal, state and local government sources.

In the 1987 NMES, expenditure estimates were based on charges.^4,5 A category defined as "free from provider, including professional courtesy and bad debt" was included in expenditures; here, we have labeled this category as "not reimbursed." In the 1996 MEPS, unlike the earlier survey, expenditures were defined as the sum of direct payments for care provided during the year, but there also is a variable that captures total charges.⁶ The difference between charges and expenditures in the 1996 MEPS is defined by AHRQ as uncollected liability, bad debt, charitable care and discounting. This difference between charges and expenditures in the 1996 MEPS is considered as "not reimbursed" in this article and is used for purposes of comparison with the 1987 NMES. In both surveys, this category represents dental services rendered for which the dentist had received no payment. The "not reimbursed" category makes up a significant percentage of total dollar value of dental services in both surveys; therefore, we included it to provide a complete picture of the total output of the dental delivery system.

To ensure sufficient numbers to produce reliable national estimates, we combined socioeconomic variable categories when necessary. We used the SUDAAN statistical package (Version 7.11, Research Triangle Institute, Research Triangle Park, N.C.) to calculate standard errors and perform statistical tests because it can adjust for the correlation introduced by the complex sample design used for the 1987 NMES and 1996 MEPS surveys.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Per capita dental expenditures among those who had had a visit. The average nominal per capita expenditures (charges) for dental services provided to adults aged 18 years and older who had had a dental visit increased from $288.97 in 1987 to $428.32 in 1996. However, when the effect of inflation is removed from these numbers, the NMES and MEPS data show a decrease in the real per-patient expenditures from $529.93 in 1987 to $467.29 in 1996 (Table 1).

View this table: [in this window] [in a new window]   TABLE 1 1987 NMES* AND 1996 MEPSREAL (BASE = 1998) EXPENDITURE DATA FOR ADULTS AGED 18 YEARS AND OLDER WITH A DENTAL VISIT.

A decrease in the real dental expenditures between the two surveys among whites from $538.03 in 1987 to $467.49 in 1996 resulted in a narrowing of the gap between whites and blacks from $87.80 in 1987 to $29.62 in 1996. Hispanics reported a drop of $147.51, or 25.3 percent, in the average amount of dental services as measured by real expenditures. In 1987 Hispanics reported higher expenditures, on average, than non-Hispanics, but in 1996 Hispanics reported lower expenditures.

Adults in the highest income category reported the largest decrease in real expenditures, from $571.48 in 1987 to $488.00 in 1996. Although expenditures tended to increase with the level of income in both survey years, the gap between the highest income group and the lowest decreased from $108.65 in 1987 to $56.09 in 1996.

Expenditures on dental services by women were greater than those by men in both surveys, but expenditures by patients of both sexes were less, on average, in 1996 than in 1987.

Expenditures on dental services by women were greater than those for men by both surveys. This difference narrowed somewhat between the two surveys from $30.95 in 1987 to $19.36 in 1996. Expenditures by patients of both sexes were less, on average, in 1996 than in 1987.

Sources of funding. This section examines three sources of funding for dental services rendered—out-of-pocket, private insurance and public funding—and a fourth category labeled "not reimbursed." A fifth residual category labeled "other" is included in Tables 2 and 3 for completeness, but is not discussed.

View this table: [in this window] [in a new window]   TABLE 2 1987 NMES* AND 1996 MEPSREAL (BASE = 1998) EXPENDITURE DATA FOR ADULTS AGED 18 YEARS AND OLDER WITH A DENTAL VISIT, BY AGE AND SOURCES OF FUNDING.

View this table: [in this window] [in a new window]   TABLE 3 1987 NMES* AND 1996 MEPSREAL (BASE = 1998) PER CAPITA EXPENDITURE DATA FOR ADULTS AGED 18 YEARS AND OLDER WITH A DENTAL VISIT, BY POVERTY LEVEL AND SOURCES OF FUNDING.

As measured in real per-patient dollars, private insurance payments decreased in every age group except among adults 65 years of age and older. However, as a percentage of the total, private insurance payments increased in every age group. Public funding declined in terms of real per-patient dollars in all age groups, and as a percentage of the total in all age groups except those aged 55 to 64 years. The value of nonreimbursed care increased in all age groups in terms of real per-patient dollars and as a percentage of the total.

Figure 1 (page 632) shows that the relative contribution of these four categories varied by age of the patient in 1996. For patients in the groups aged 18 to 34 years and 35 to 54 years, out-of-pocket and private insurance contributions were about equal and together accounted for 78.8 percent to 85.8 percent of the total. However, for older patients, the predominance of out-of-pocket over private insurance contributions increased with age. Among those aged 65 years and older, out-of-pocket payments accounted for about two-thirds (67.6 percent) of the total, whereas private insurance accounted for less than one-fifth (18.1 percent). Nonreimbursed care ran from a high of 16.7 percent of the total among those aged 18 to 34 years to a low of 9.8 percent among those aged 65 years and older. The level of public funding was relatively low for all age groups (2.0 percent to 4.0 percent).

View larger version (57K): [in this window] [in a new window]   Figure 1. Sources of funding for dental services among adults aged 18 years and older who had had a dental visit, by age in years, according to the 1996 Medical Expenditure Panel Survey.

Private insurance increased in real dollars and as a percentage of the total for all income levels except the highest, in which it decreased somewhat in real dollars but increased as a percentage of the total dollar. The greatest increase was in the income category of 100 to 200 percent of the FPL, where private insurance increased from $87.82 in 1987 to $119.95 in 1996, and from 19.6 percent to 29.2 percent of the total.

Public funding increased both in real dollars and as a percentage of the total for patients below the FPL. However, for patients with an income 100 to 200 percent of the FPL, public funding dropped from an average of $45.79 in 1987 to $18.24 in 1996. As a percentage of the total, public funding dropped from 10.2 percent to 4.4 percent. As shown in Table 3, public funding played a minor role in expenditures for other income levels.

Nonreimbursed care rose in every income category, both in terms of real per capita dollars and as a percentage of the total. In both survey years, the average amount of nonreimbursed care was highest for those with an income below the FPL, and it amounted to $101.48 per patient and 23.5 percent of the total in 1996.

Figure 2 (page 634) shows that the relative contribution of the three sources of funding and the "not reimbursed" category varied by income level in 1996. Out-of-pocket payments made up one-half of the total for those in the category of 100 to 200 percent of the FPL, about 47 percent in the upper-income groups and 36.3 percent in the below-FPL group. Private insurance accounted for 18.4 percent of the total for those with incomes below the FPL and rose to 40.5 percent among those in the highest income category. Public funding accounted for 20.9 percent of the total among those with incomes below the FPL and dropped to 4.4 percent of the total or less among those in higher income categories. Nonreimbursed care accounted for 23.5 percent of the total among those below the FPL, 15.5 percent among those with incomes 100 to 200 percent of the FPL, and somewhat smaller percentages (11.7 percent and 10.6 percent) among those in the middle- and upper-income categories.

View larger version (54K): [in this window] [in a new window]   Figure 2. Sources of funding for dental services provided to adults aged 18 years and older who had had a dental visit, by income level, according to the 1996 Medical Expenditure Panel Survey. FPL: Federal poverty level.

View larger version (60K): [in this window] [in a new window]   Figure 3. Sources of funding for dental services among adults aged 18 years and older who had had a dental visit, by income level, according to the 1987 National Medical Expenditure Survey, or NMES, vs. 1996 Medical Expenditure Panel Survey, or MEPS. FPL: Federal poverty level.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

Among adults, out-of-pocket payments were reduced among patients at all age and income levels. Some of the largest reductions in out-of-pocket payments were reported among people with incomes below the FPL. However, out-of-pocket payments were highest among those aged 65 years and older ($360.94, or 67.6 percent of the total in 1996). As baby boomers move into retirement age, retaining most or all of their teeth, there may be increased pressure for affordable dental insurance plans for elderly people, coverage of dental services under Medicare or both.

Overall, private insurance declined somewhat in terms of real dollars from 1987 to 1996, but increased as a percentage of the total value of dental services. One reason for the increase in private insurance as a source of funding among elderly people (in terms of real dollars and as a percentage of the total) may be that they are working longer and, therefore, maintaining their dental insurance.

Public funding was most prevalent in the two lowest income groups. For those with incomes below the FPL, public funding increased in terms of real dollars and as a percentage of the total from 1987 to 1996. However, for those with incomes 100 to 200 percent of the FPL, public funding decreased dramatically both in real dollars and as a percentage of the total.

Charges not reimbursed just about doubled as a percentage of total charges at every income level, reaching its highest level in lower income categories. Within the "not reimbursed" category, it is not possible to determine the individual contributions of charity care, bad debt, professional courtesy, uncollected liability and discounting. These may vary by the income level of the person receiving the care. Charity care may be more common among lower-income adults and discounting more common among higher-income adults who have dental insurance. In addition, it is not possible to determine if some of the changes over time in this category may be due to measurement errors or differences in design between the two surveys.⁷

As pointed out in the first article in this series,³ the total dollar value of nonreimbursed care is skewed toward patients in higher income levels. One reason for this is that there are more patients who fall into these income categories. However, it also is clear that when calculated on a per-patient basis, the amount of nonreimbursed care was greatest in terms of dollars and as a percentage of the total among adults below the FPL. The next highest level of nonreimbursed care, calculated on a per-patient basis, was reported by adult patients with incomes at 100 to 200 percent of the FPL.

The decrease in real per-patient dental expenditures may be related to a shift in the mix of dental services provided, from relatively expensive restorative procedures to relatively less expensive preventive and diagnostic services.^8,9 Although this conclusion goes beyond the findings presented in this article, it is supported by research that found a decrease in real expenditures on Class II and Class III dental procedures from 1980 to 1995 among insured adults 19 to 64 years of age.¹⁰ That study did not report a decrease for adults aged 65 years and older.

	CONCLUSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Additional research is needed to further explore the relationship between shifts in the mix of dental procedures and the decrease in per-patient dental expenditures reported in this article. One possible implication of the findings reported here is that future increases in dentists’ gross revenues may depend on an increase in the number of patients seen, rather than an increase in the average revenue per patient.

View larger version (85K): [in this window] [in a new window]   Dr. Brown is the associate executive director, Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "brownja{at}ada.org". Address reprint requests to Dr. Brown.

View larger version (85K): [in this window] [in a new window]   Mr. Wall is the manager, Statistical Research, Health Policy Resources Center, American Dental Association, Chicago.

View larger version (87K): [in this window] [in a new window]   Dr. Manski is a senior scholar, Agency for Healthcare Research and Quality, Rockville, Md. He also is a professor, Department of Oral Health Care Delivery, Dental School, University of Maryland, Baltimore.