FAIR Health Sheds Light on Provider Care Patterns of Risk-Based Dental Care

Privately insured patients in states where Medicaid requires dental risk assessments and risk-based care approaches receive more risk assessments and preventive dental services than private patients in states where there is no such requirement, a FAIR Health study has shown. Drawing on our database of billions of private healthcare claims, FAIR Health performed an analysis of risk assessments and preventive dental service utilization by geographic location on privately insured patients in the period 2014 to 2017. The type of preventive services measured were cleanings, fluorides and sealants.

New Codes for Risk

In 2014, the American Dental Association introduced three new CDT®1 billing codes to identify patients as having a low, medium or high risk of dental decay, or caries. Many state Medicaid programs have since introduced pediatric caries risk-assessment requirements and risk-based plans, which generally require that reimbursement for additional dental examinations be denied unless a caries risk assessment has been conducted. In most cases this is also tied to other preventive and diagnostic services. Privately insured use of the three codes has risen greatly, increasing 2,437 percent from 2014 to 2017, according to FAIR Health data.

Dental disease in children can affect physical development and growth and has implications for social development, school attendance and future success. In this country, about 22 percent of children ages 2-5 have had dental caries in primary teeth. Over 20 percent of children ages 6-11 have caries in permanent teeth, and over half (58 percent) have caries in permanent teeth at ages 12-19.

FAIR Health’s goal in conducting the analysis was to determine if the use of risk-assessment codes and rates of preventive and diagnostic services in the privately insured population were higher in states with Medicaid risk-assessment requirements, such as Arizona, Connecticut, Delaware, Georgia, Illinois, Iowa, Nevada, Tennessee and Texas. We also studied risk assessment by gender and the prevalence of risk assessment and preventive and diagnostic services in rural versus urban locations.

State-by-State Analysis

Our state-by-state analysis revealed that Texas had the highest percentage of risk assessments compared to dental cleanings. Vermont, Montana, New Hampshire and Delaware had the second, third, fourth and fifth highest prevalence of risk assessments. All of these states had Medicaid programs that provided for caries risk assessments.

FAIR Health found, based upon our data from privately insured populations, that although pediatric males and females were targeted equally for risk assessment, more males were shown as being at higher risk. Our regional analysis also showed that urban populations consistently had a higher percentage of risk assessments performed for children than rural populations.

Fillings and preventive treatments were more common in the risk-assessment population than in the non-risk-assessment population in all states. This may suggest that, in states with the Medicaid risk-assessment requirement, providers have adopted the concept of risk-based care and disease avoidance for their privately insured patients.

FAIR Health’s custom analytics, such as those exemplified by this study, are designed to client specifications. Our one-of-a-kind analyses can be based on numerous variables, including geographic area, services performed, patient demographics and more. Such analyses can be useful in informing strategic decisions and policy formulation. For more information on FAIR Health custom analytics, email us at info@fairhealth.org or call us at 855-301-3247, Monday through Friday, 9 am to 6 pm ET.


1 The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), American Dental Association (ADA). All rights reserved.