Impact of income and financial subsidies on oral health care utilization among persons with disabilities in Singapore.

BACKGROUND/AIM(S): Globally, studies have shown that the dental disease burden among persons with intellectual and/or developmental disabilities (IDD) is high and can be attributed to lower utilization levels of dental services. The aim of the study was to assess the influence of income and financial subsidies on the utilization of dental care services among persons with IDD in Singapore. METHODS: Between August 2020 and August 2021, a cross-sectional study was conducted via centres offering Early Intervention Programme for Infants and Children, special education schools and adult associations in Singapore serving persons with IDD. A sample of 591 caregivers of children and adults with IDD completed the survey. Data on sociodemographic information, oral health behaviours and dental utilization were collected. Financial subsidy status was assessed by the uptake of a government-funded, opt-in Community Health Assist Scheme (CHAS) for low-income families that provided a fixed subsidy amount for dental services in the primary care setting. Statistical analysis was carried out using univariable, multiple logistic regression and modified Poisson regression. Propensity score matching was carried out in R version 4.0.2 to assess the impact of financial subsidies on oral health care utilization among persons with IDD. RESULTS: Compared to those with lower gross monthly household incomes, the adjusted prevalence ratios of having at least one dental visit in the past year, having at least one preventive dental visit in the past year, and visiting the dentist at least once a year for persons with IDD with gross monthly household incomes of above SGD$4000 were 1.28 (95% CI 1.08-1.52), 1.48 (95% CI 1.14-1.92) and 1.36 (95% CI 1.09-1.70), respectively. Among those who were eligible for CHAS Blue subsidies (247 participants), 160 (62.0%) took up the CHAS Blue scheme and 96 (35.4%) visited the dentist at least yearly. There was no statistically significant difference in the utilization of dental services among individuals enrolled in the CHAS Blue subsidy scheme among those eligible for CHAS Blue subsidies. CONCLUSION: Higher household income was associated with a higher prevalence of dental visits in the past year, preventive dental visits in the past year, and at least yearly dental visits. CHAS Blue subsidies alone had limited impact on dental utilization among persons with IDD who were eligible for subsidies.

What Are the Determinants of Dental Care Expenditures in Institutions for Adults With Disabilities? Findings From a National Survey.

OBJECTIVE: To analyze the determinants of dental care expenditures in institutions for adults with disabilities. DESIGN: Health and disability survey and insurance database. SETTING: Institutional setting. PARTICIPANTS: Adults (N=2222) living in institutions for people with cognitive, sensory, and mobility disabilities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used a Heckman selection model to correct for potential sample selection bias due to the high percentage of non-dental care users. The Heckman selection model is a 2-step statistical approach based on the simultaneous estimation of 2 multiple regression models-a selection equation (step 1) and an outcome equation (step 2)-offering a means of correcting for nonrandomly selected samples. The selection equation modeled whether the individual had consulted a dentist at least once, whereas the outcome equation explained the dental care expenditures. Disability severity was assessed by scoring mobility and cognitive functional limitations. Regressions also included sociodemographic characteristics and other health-related variables. RESULTS: Individuals with the highest cognitive limitation scores, without family visits, without supplementary health insurance, and with poor oral health status were less likely to consult a dentist. After controlling for potential selection bias, the only variable that remained statistically significant in the outcome equation was the oral health status: when individuals with poor health status had consulted at least once, they had a higher level of dental care expenditure. CONCLUSIONS: Functional limitations were barriers to accessing dental care even in institutions for adult with disabilities. These barriers should be overcome because they may worsen their oral health status and well-being. Given the lack of literature on this specific topic, our results are important from a policy perspective. Health authorities should be alerted by these findings.

Dental insurance and dental care among working-age adults: differences by type and complexity of disability.

OBJECTIVES: People with disabilities experience barriers to dental care, which may vary depending on type of disability and disability complexity (e.g., impact on activities of daily living). The purpose of this study was to examine differences in dental insurance, receipt of dental checkups, and delayed and unmet needs for dental care by type and complexity of disability. METHODS: We conducted cross-sectional analysis of 2002-2011 data from the Medical Expenditure Panel Survey. Multivariable logistic regression analyses compared adults ages 18-64 in five disability type groups (physical, cognitive, vision, hearing, or multiple disabilities) to those with no disabilities, and compared people with complex activity limitations to those without complex limitations. RESULTS: All disability types except hearing had significantly higher adjusted odds of being without dental insurance, as did people with complex activity limitations. All disability groups except those with cognitive disabilities had increased odds of receiving dental checkups less than once a year. Similarly, all disability groups were at increased risk of both delayed and unmet needs for dental care. Odds ratios were generally highest for people with multiple types of disabilities. CONCLUSIONS: There are significant disparities in having dental insurance and receiving dental care for adults with disabilities, especially those with multiple types of disabilities, after controlling for socioeconomic and demographic differences. Further, disparities in care were apparent even when controlling for presence of dental insurance.

Ethics, Economics and Dentistry for Individuals with Disabilities in New York State.

The ADA Principles of Ethics and Code of Professional Conduct is an expression of the obligation occurring between the profession and society to meet the oral health needs of the public. At a time of economic concerns for the profession, suggestions are made to bring together the ethics of the profession and the need to expand services to underserved populations, including individuals with disabilities and the poor. The profession's effort to secure economic support for such an effort is possible with increased legislative awareness of the magnitude of the problem. To this end, the number of individuals with disabilities was developed for each Congressional district in New York State in an effort to challenge members of Congress to recognize the need in terms of their constituents, rather than in terms of the tens of millions with disabilities in the United States-which become "just numbers," not actual people.

Should we provide oral health training for staff caring for people with intellectual disabilities in community based residential care? A cost-effectiveness analysis.

Oral health training is often introduced into community-based residential settings to improve the oral health of people with intellectual disabilities (ID). There is a lack of appropriate evaluation of such programs, leading to difficulty in deciding how best to allocate scarce resources to achieve maximum effect. This article reports an economic analysis of one such oral health program, undertaken as part of a cluster randomized controlled trial. Firstly, we report a cost-effectiveness analysis of training care-staff compared to no training, using incremental cost-effectiveness ratios (ICERs). Effectiveness was measured as change in knowledge, reported behaviors, attitude and self-efficacy, using validated scales (K&BAS). Secondly, we costed training as it was scaled up to include all staff within the service provider in question. Data were collected in Dublin, Ireland in 2009. It cost between €7000 and €10,000 more to achieve modest improvement in K&BAS scores among a subsample of 162 care-staff, in comparison to doing nothing. Considering scaled up first round training, it cost between €58,000 and €64,000 to train the whole population of staff, from a combined dental and disability service perspective. Less than €15,000-€20,000 of this was additional to the cost of doing nothing (incremental cost). From a dental perspective, a further, second training cycle including all staff would cost between €561 and €3484 (capital costs) and €5815 (operating costs) on a two yearly basis. This study indicates that the program was a cost-effective means of improving self-reported measures and possibly oral health, relative to doing nothing. This was mainly due to low cost, rather than the large effect. In this instance, the use of cost effectiveness analysis has produced evidence, which may be more useful to decision makers than that arising from traditional methods of evaluation. There is a need for CEAs of effective interventions to allow comparison between programs. Suggestions to reduce cost are presented.

Dental Economics and the Increasing Numbers of Individuals with Disabilities in New Jersey.

The dual needs of 1) providing increasing oral healthcare for individuals with special needs, and 2) improving the economics of dental practice, are explored in a review of the State of New Jersey and its counties.

Oral health delivery systems for older adults and people with disabilities.

This article describes new oral health care system models designed to meet the needs of a rapidly growing population of older adults and people with disabilities. These populations are not currently able to access traditional dental offices and clinics to the same degree that younger and much healthier population groups do. So new models proactively target specific community organizations where these high-risk underserved population groups live, work, go to school, or obtain other health or social services. Collaborative on-site and clinic-based teams establish "Virtual Dental Homes" that provide ongoing, year-round access to oral health services designed to prevent mouth infections, deliver evidence-based preventive care, and restore infected individuals to stable and sustainable oral health. These new delivery models are beginning to demonstrate better health care delivery, better health outcomes, and the potential to drive down total health care costs for older adults and people with disabilities.

Effect of an annual benefit limit on adult dental expenditure and utilization: a cross-sectional analysis.

OBJECTIVES: Despite widespread use of dental benefit limits in terms of the types of services provided, an annual maximum on claims, or both, there is a dearth of literature examining their impact on either cost to the insurer or health outcomes. This study uses a natural experiment to examine dental care utilization and expenditure changes following Indiana Medicaid's introduction of a $600 individual annual limit on adult dental expenditure in 2003. METHODS: In a before and after comparison, we use two separate cross-sections of paid claims for 96+ percent of the Medicaid adult population. Paid claims were available as a per-member-per-year (PMPY) figure. RESULTS: Between 2002 and 2007, the eligible population decreased 3 percent (from 323,209 to 313,623), yet the number of people receiving any dental services increased 60 percent and total Medicaid dental claims increased 18 percent (from $34.1 million to $40.1 million). In both years, those Dually (Medicare/Medicaid) Eligible had the largest percentage of members receiving services, about 75 percent, and the Disabled Adult group had the lowest percentage (5-8 percent), yet both populations are likely to have high dental need due to effects of chronic conditions and medications. CONCLUSIONS: The increase in the number and percentage of people receiving Diagnostic and Restorative care suggests that the expenditure limit's introduction did not impose a barrier to accessing basic dental services. However, among those receiving any service, PMPY claims fell by 37 percent and 31 percent among the Dually Eligible and Disabled Adults categories, respectively, suggesting that the benefit limit affected these generally high need populations most.

Survey of ambulatory surgery dentistry.

A telephone survey of New York State's most significant providers of Medicaid hospital ambulatory surgery dental treatment for special needs patients was conducted in June and July of 2011 to assess whether there had been changes in the availability of dental services following implementation of the Ambulatory Patient Groups (APG) Medicaid payment methodology and the April 2011 35% reduction in fee-for-service reimbursement to dentists who provide this dental care. With release of "Oral Health in America: A Report of the Surgeon General" in 2000, attention was focused on the link between oral health and general health, with the report highlighting the difficulties individuals with special needs experienced with respect to their oral health and accessing dental care. The New York State Department of Health in 2005 released its "Oral Health Plan for New York State." It had three stated objectives pertaining to those with special needs. None of these objectives has been met, and the response to this survey revealed waiting times for access to ambulatory surgery dental programs of up to two years and an overall probable 10% to 15% decrease in availability as a direct result of the APG payment methodology and reduction in fee-for-service reimbursements. New York is failing not only to meet the objectives of its own oral health plan, but also to adequately meet the dental health care needs of its most vulnerable citizens.

Should dentists be concerned about the weight of their patients?

This opinion paper considers obesity and its relationship to dental practice. Twenty-three per cent of people in England are estimated to be obese, a figure that is predicted to continue rising. It follows that obese patients are frequently encountered in general dental practice. The authors review the links between obesity and dental health, the possible barriers and challenges to providing dental care for obese people, and how these may be overcome. They also report the findings of a London survey investigating the current provision of specialist dental services for obese patients who cannot be treated in a standard dental chair. Services across London were highly variable and in some areas no provision was identified. The implications of the rising prevalence of obesity for service planners and practitioners are also discussed.

Would you believe that about 1-in-5 U.S. children has a disability?

A review of a series of federation reports documents the numbers of youngsters with a variety of special health care needs who are residents in our communities and are dependent upon local dentists for needed services. The increased costs for health care and complexities of access to this care are emphasized. While dental schools have introduced changes in their curricula to improve the preparation of new graduates to provide services for patients with special health care needs, the challenge is to provide current practitioners with programs to ensure the treatment of youngsters (and the not so young) with disabilities.