Kool Smiles Practice Model Study: Utilization and Medicaid Expenditures Across States Using Government-Provided Data

Comparison of Kool Smiles Utilization
and Medicaid Expenditures Across

States using Government-Provided Data
February 1, 2016
PREPARED FOR:
The Benevis Foundation
PREPARED BY:
Joan DaVanzo, Ph.D., M.S.W., Audrey El-Gamil, Nikolay Manolov, Ph.D,
Dorothy Chen, M.P.H., Al Dobson, Ph.D.
Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com

1
2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.
Presentation Overview
Study Context and Purpose
Study Methodology
Results Across States and Years
Geographic Analysis
Age Distribution
Summary Results by State and Year

Potential Annual Savings to the Medicaid Program and Expanded Care
to Children with Medicaid
Geographic Analysis
Across Entire State
Implications for Medicaid Program

2
Study Context and Purpose

More than 40 percent of U.S. children ages 2 to 11 experience baby
tooth decay, and about 25 percent of children ages 6 to 18 suffer from
untreated permanent tooth decay1
Oral diseases affect overall health and disproportionately affect the
poor, people of color, and children those without access to resources
to enable optimal oral health2
Only 44 percent of Medicaid children in the U.S. receive dental care,
compared to 58.1 percent for those who are covered by commercial
insurance, despite a dental benefit being required by all Medicaid and
Childrens Health Insurance Program (CHIP) programs3
1
Children and Oral Health: accessing needs, coverage, and access. Kaiser Commission on Medicaid and the Uninsured. 2012.
2 Bensley L, VanEenwyk J, and Ossiander EM. Associations of self-reported periodontal disease with metabolic syndrome and number of selfreported chronic conditions. Prev Chronic Dis. 2011; 8(3): A50.
3 Nasseh et al. Dental Care Use among Children Varies Widely across States and between Medicaid and Commercial Plans within a State. Health
Policy Institute. 2013.
3
Study Context and Purpose (contd)
Dental Support Organizations (DSOs) enable dentists to practice in some of the

most disadvantaged communities, thus, bridging the gap in access to dental
services between Medicaid and commercially insured individuals1
DSOs are largely responsible for the increase in dental visits among
Medicaid populations who previously did not receive dental services2
DSOs provide administrative support to dentists, allowing them to focus on
patient care and practice more efficiently
Benevis Practice Service (Benevis) is a DSO that provides non-clinical
support services to Kool Smiles, a national childrens dental provider
Kool Smiles dentists are led by licensed senior dentists who provide training,
professional guidance, clinical protocol, and audits
The Benevis Foundation commissioned Dobson DaVanzo & Associates, LLC
(Dobson | DaVanzo) to conduct an analysis to:
Examine the utilization and Medicaid expenditures for Kool Smiles providers
vs. non-Kool Smiles providers that operate within the same geographic area
1 Winegarden
et al. The Benefits Created by Dental Service Organizations. Pacific Research Institute. 2012
Dental Visits for Medicaid Children: Analysis and Policy Recommendations. Childrens Dental Health
Project. (2012).
Study Methodology
Benevis requested data from all states where there is a Kool Smiles
provider (15 states + DC); all data received was analyzed in the study
Benevis received recent aggregated Medicaid dental claims data for nine
states through Freedom of Information Act (FOIA) requests, which were
provided to Dobson | DaVanzo for analysis
Contained all Medicaid dental services for all ages provided within the state
Data for seven states were able to be included in the aggregate analysis
Data were aggregated by dental provider number and by dental service

code (CDT) 1 and contained the following variables:
Number of procedures performed
Unique number of patients who received the dental service
Medicaid payments
Kool Smiles providers were flagged (Yes/No)

A single Kool Smiles dental provider can represent multiple dentists practicing
Current Dental Terminology (CDT) codes are developed and updated by the
within the same dental group American
Dental Association (ADA) for reporting dental services and
1
procedures to dental benefits plans.

Study Methodology:
Data Cleaning
In order to calculate an annual utilization rate per patient by provider,
a proxy was used based on the number of unique patients who
received a prophylaxis (cleaning)
We assume each patient who received any dental service would have
received at least one cleaning per year
D1110 Adult cleaning
D1120 Child cleaning
D0145 Texas First Dental Home Program
For select states, the number of dental services provided by dental

code needed to be imputed based on the published Medicaid fee
schedule for the applicable year and total Medicaid payment provided
in the data
A third party provided the Medicaid fee schedules by state that included
actual Medicaid payments per service
6
Study Methodology:
Dental Services Included

For each state, Dobson | DaVanzo examined all dental services, and
focused the analyses on four specific dental service categories
provided to children, including:
Diagnostic services: x-rays
Extraction services: simple extractions and coronal remnants
Restorative services: stainless steel crowns, fillings, pulpotomies, and a
pulpotomy-to-crown ratio
All other dental services: Includes all other CDT codes provided to
Medicaid patients across all providers
Results were presented as the annual number of services provided per

unique patient and the average monthly Medicaid expenditure per
patient within and across all dental service categories
Specific comparisons within restorative and extraction services were also
included to reflect different practice patterns between Kool Smiles and
non-Kool Smiles providers
Study Methodology:
Geographic, Age Distribution, and Stateyear Specific Analyses

Three analyses were conducted in aggregate across all states and years,
and by state
Geographic Area analysis: Compared Kool Smiles and non-Kool Smiles
providers who operated within the same geographic area, defined as the
market area where 75 percent of the Kool Smiles patients reside on
average a 7 mile radius
Age Distribution analysis: Compared Kool Smiles and non-Kool Smiles
providers within the same geographic area
Age distribution for each provider was made available by a third-party based
on actual utilization for Kool Smiles providers, and the age distribution for the
geographic area in which non-Kool Smiles providers operate
State-Year Specific analysis: Compared annual utilization and monthly

Medicaid expenditures per patient across time within and across states to
determine the extent to which changes in utilization or Medicaid
expenditures were evident
8
Study Methodology:
Analyses Cover Seven States, about 8,200

Providers, and 2.5 Million Patients
Data for seven states were included in the aggregate analysis, representing all
Medicaid dental services between 2011 and 2015 (years vary by state)
Across all states (based on the last full year of data available), analyses represent
utilization and Medicaid expenditures per patient across 164 Kool Smiles providers
and 8,077 non-Kool Smiles providers
This represents 491,390 unique patients treated by Kool Smiles and 2,022,336 patients
treated by non-Kool Smiles providers
States
Georgia
Indiana
Louisiana
Mississippi
South Carolina
Texas
Virginia
Years Data Available

2011-2012
2011-2014
2011-2012
2011-2012
2011
2011-2014
2013 - 09/2015
Geographic Area
Analysis
x*
x
x
x
x
x
x
Age Distribution
Analysis
x
x
x
x
x
* Includes the entire state, as a geographic market area was not able to be identified
9
Study Methodology:
Data Limitations
Data were provided in aggregate by provider number and dental code,
therefore limiting our ability to determine the total number of unique
patients served by each provider
Number of unique patients who received a cleaning was used as a proxy
Variability was observed in Medicaid expenditures per unit within a

dental service code across providers within a state
This was possibly attributed to denied payments by Medicaid
As a result of material variation in Arizona and Kentucky, these states

were excluded from the aggregate analyses
These states had results directionally consistent with those from all
other states
10
Geographic Area Analysis:
For All Dental Services, Kool Smiles Providers Had

Lower Annual Utilization and Monthly Medicaid
Expenditures per Patient
Across all states and years analyzed, Kool Smiles providers perform 15
percent fewer procedures per patient than non-Kool Smiles providers
who operate within the same geographic area
Kool Smiles patients have an average monthly Medicaid expenditure
that is 33 percent lower than non-Kool Smiles patients
Overall Annual Utilization and Monthly Medicaid Expenditure per Patient Across All States and All Years for
Providers Contained in the Geographic Area Analysis: Kool Smiles vs. Non-Kool Smiles Providers
Number of Dental Services per Patient
10
9
8
$35.00
15% Lower
Total: 8.77
Total: 7.47
5.30
6
5
4.32
2
1
1.62
1.18
1.96
1.85
0
Kool Smiles Providers
Non-Kool Smiles Providers
Select Diagnostic Services
33% Lower
Total: $21.79
$19.40
$20.00
$15.00
4
3
$30.00
$25.00
Monthly Medicaid Expenditure per

Patient for All Dental Services
Total: $32.75
$11.69
$10.00
$10.63
$5.00
$7.77
$0.00
$2.33
$2.72
Select Restorative and Extraction Services
All Other Dental Services
Source: Dobson |
DaVanzo analysis of
Medicaid dental claims
data received under
FOIA.
Note: All Other Dental
Services category
included all other CDT
codes provided to
Medicaid patients
across all providers.
11
For Diagnostic Services, Despite Higher Utilization,

Kool Smiles Providers have Lower Monthly Medicaid
Expenditures per Patient
While Kool Smiles providers perform more x-rays per patient than non-Kool
Smiles providers, Kool Smiles has lower monthly Medicaid expenditures per
patient
This is due to Kool Smiles providers performing a different x-ray service
Overall Annual Utilization and Monthly Medicaid Expenditure per Patient of X-Rays
Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
2.3
2.0
Number of X-Rays per Patient

6% Higher
1.96
1.85
1.8
1.5
Monthly Medicaid Expenditure per Patient

for X-Rays
$3.00
14% Lower
$2.50
$2.72
$2.33
$2.00
1.3
$1.50
1.0
0.8
$1.00
0.5
$0.50
0.3
$0.00
0.0
Source: Dobson | DaVanzo analysis of Medicaid dental claims data received under FOIA.
12
Across All Restorative and Extraction Services, Kool

Smiles Providers Have Lower Annual Utilization and
Monthly Medicaid Expenditures per Patient
Kool Smiles providers have 27 percent lower annual utilization and
monthly Medicaid expenditures per patient across all restorative and
extraction services
Annual Utilization and Monthly Medicaid Expenditure per Patient for Restorative and
Extraction Services Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
1.80
1.60
1.40
1.20
Number of Restorative and

Extraction Services per Patient
Total: 1.62
27% Lower
$10.00
Total: 1.18
1.06
1.00
0.80
0.20
0.00
0.05
0.06
0.21
0.10
Simple Extractions
Total: $7.77
$8.00
$6.69
$6.00
0.77
0.60
0.40
Monthly Medicaid Expenditure per Patient for

Restorative and Extraction Services
$12.00
Total: $10.63
27% Lower
0.02
0.09
0.21
0.23
Stainless Steel Crowns
$4.74
$4.00
$0.05
$0.57
$0.10
$0.28
$2.20
$0.45
$2.00
$0.00

Pulpotomies
$2.20
$1.12
Coronal Remnants
Fillings
13
Kool Smiles Provides Fewer Extractions per Patient

than Non-Kool Smiles Providers
Kool Smiles provides 42 percent fewer extractions, including both simple

extractions and removal of coronal remnants, than non-Kool Smiles providers
Across both services, the monthly Medicaid expenditure per patient for Kool
Smiles patients for extractions is 53 percent lower than that of non-Kool
Smiles patients
Annual Utilization and Monthly Medicaid Expenditure per Patient for Simple Extractions and
Coronal Remnants Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
for Simple Extractions and Coronal
Remnants
Number of Simple Extractions

and Coronal Remnants per Patient
0.30
0.25
0.20
42% Lower
Total: 0.25
0.02
Total: 0.15
$0.80
0.05
$0.60
0.23
0.10
$0.40
0.10
Total: $1.17
$1.20
$1.00
0.15
0.05
$1.40
$0.20
53% Lower
$0.05
Total: $0.55
$1.12
$0.10
$0.45
$0.00
0.00

Simple Extractions
Coronal Remnants
14
Kool Smiles Provides Fewer Pulpotomies than Non-Kool

Smiles Providers
While both groups of providers delivered a similar number of stainless steel crowns
per patient across all states and all years, Kool Smiles providers performed 39
percent fewer pulpotomies than non-Kool Smiles providers, which led to a
significantly lower pulpotomy-to-crown ratio
The monthly Medicaid expenditure per patient for stainless steel crowns and
pulpotomies in total is 10 percent lower for Kool Smiles than non-Kool Smiles
patients
Annual Utilization and Monthly Medicaid Expenditure per Patient for Stainless Steel Crowns
and Pulpotomies Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
for Stainless Steel Crowns and Pulpotomies
Number of Stainless Steel Crowns

and Pulpotomies per Patient
0.6
0.55
0.5
$2.50
0.4
0.3
0.35
2% Lower
0.21
0.2
0.1
$3.00
36% Lower
0.21
10% Lower
Total: $2.48
Total: $2.77
$0.57
$0.28
$2.00
$1.50
39% Lower
0.06
0.09
0.0
$1.00
$2.20
$2.20
$0.50
$0.00
Stainless Steel
Pulpotomies
Pulp-to-Crown
Crowns
Ratio
Stainless Steel Crowns
Pulpotomies
15
Kool Smiles Patients Also Receive Fewer Fillings than

Patients Treated by Non-Kool Smiles Providers
Stainless steel crowns are sometimes a suitable substitute for multi-surface fillings
for children with advanced decay in primary teeth1
Kool Smiles provides a comparable number of stainless steel crowns and fewer
fillings per patient than non-Kool Smiles providers
The monthly Medicaid expenditure per patient for stainless steel crowns and fillings
combined is 22 percent lower for Kool Smiles than non-Kool Smiles patients
Annual Utilization and Monthly Medicaid Expenditure per Patient for Stainless Steel Crowns
and Fillings Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
1 Guideline
on Pulp
Therapy for Primary and
Immature Permanent
Teeth. AAPD. 37(6):244252.
16
Age Distribution Analysis:
Controlling for Patient Age Shows that Kool

Smiles is a Conservative Dental Provider
After limiting the analysis to providers within the same geographic area with a
comparable proportion of patients aged 4 to 9 years old, Kool Smiles patients have
annual utilization that is 23 percent lower than non-Kool Smiles patients
For all dental services, Kool Smiles patients have a 38 percent lower monthly
Medicaid expenditure than non-Kool Smiles patients
Utilization became comparable for diagnostic services, and remained lower for all restorative
services, resulting in a lower monthly Medicaid expenditure per patient for all service categories
and across all dental services in total
Overall Age Adjusted Annual Utilization Rates and Monthly Medicaid Expenditure per Patient Across All States and
All Years for Providers Contained in the Geographic Area Analysis: Kool Smiles vs. Non-Kool Smiles Providers
Number of Dental Services per Patient
10
9
8
7
Total: 8.96
23% Lower
$35.00
$25.00
5.34
$15.00
3
1.05
1.62
$20.32
Total: $23.63
$20.00
4.25
38% Lower
$30.00
Total: 6.93
6
5
$40.00
Monthly Medicaid Expenditure per

Patient for All Dental Services
Total: $37.85
1.75
$5.00
$0.00
0
Select Diagnostic Services
$14.13
$10.00
1.86
$12.21
$8.42
$2.99
$3.40
Select Restorative and Extraction Services
All Other Services
17
Age Distribution Analysis:
After Controlling for Age, Kool Smiles Providers have

Lower X-Ray Utilization and Expenditures
After age adjustment, Kool Smiles providers perform 13 percent fewer x-rays per
patient than non-Kool Smiles providers
This difference in utilization results in a monthly Medicaid expenditure per
patient that is 12 percent lower than non-Kool Smiles providers
Age Adjusted Overall Utilization and Monthly Medicaid Expenditure per Patient for
X-Rays Across All States and All Years: Kool Smiles vs. Non-Kool Smiles Providers
18
Summary Results by State and Year:
Monthly Medicaid Expenditures per Patient are

Consistently Lower than Non-Kool Smiles Providers
The difference in the monthly Medicaid expenditures per patient
among Kool Smiles and non-Kool Smiles providers within the same
geographic area and year across all dental services range from 23
percent (Georgia, 2011 & Texas, 2014) to 62 percent (Mississippi, 2011)
Percent Differences in Monthly Medicaid Expenditure per Patient for All Dental
Services: Kool Smiles vs. Non-Kool Smiles Providers By State and Year
Aggregate 2011
2012
2013
2014
2015
Georgia
-24%
-23%
-25%
South Carolina
-24%
-24%
Indiana
-38%
-27%
-36%
-41%
-41%
Texas
-40%
-49%
-42%
-30%
-23%
Louisiana
-40%
-35%
-42%
Virginia
-41%
-48%
-40%
-33%
Mississippi
-61%
-62%
-59%
Shading = Years of data available for analysis
19
Potential Annual Savings to the Medicaid Program:
Medicaid Could Save $193 Million Dollars Annually by

Kool Smiles Treating All Patients in their Existing
Service Areas (in select states)
Analyses were conducted to determine the annual potential savings to the

Medicaid program if the Kool Smiles care protocol was to be applied to all
non-Kool Smiles patients within the same geographic area
Savings were estimated by calculating the annual Medicaid cost per patient
within Kool Smiles and applying that amount to each non-Kool Smiles
patient; the difference between actual and extrapolated Medicaid
payments for non-Kool Smiles patients represents savings
Estimated Medicaid Savings for Applying Kool Smiles Care Protocol
to Non-Kool Smiles Patients within the Same Geographic Area
State
Georgia*
Indiana
Louisiana
Mississippi
South Carolina
Texas
Virginia
Total
Annual Medicaid Savings in

Selected Geographic Areas
$51,167,304
$26,029,926
$12,998,068
$11,012,841
$31,597,694
$36,145,897
$24,112,957
$193,064,687
Source: Dobson | DaVanzo analysis of Medicaid

dental claims data received under FOIA.
Note: Annual estimates based on last full year
of available data for each state.
* Includes the entire state, as a geographic
market area was not able to be identified
20
Medicaid Could Save Over $550 Million Dollars

Annually by Kool Smiles Treating All Patients in Select
States
Analyses were also conducted to determine the potential savings to the

Medicaid program if the Kool Smiles care protocol was to be applied to all
non-Kool Smiles patients across the entire state
Simulation assumes that the demographic and clinical characteristics of
non-Kool Smiles patients across the state are consistent with the Kool
Smiles population
Estimated Medicaid Savings for Applying Kool Smiles Care
Protocol to Non-Kool Smiles Patients Across the Entire State
State
Georgia
Indiana
Louisiana
Mississippi
South Carolina
Texas
Virginia
Total
Annual Medicaid Savings

in in Entire State
$51,167,304
$84,390,564
$23,512,804
$58,584,802
$44,444,920
$235,499,301
$58,622,869
$556,222,564
Source: Dobson | DaVanzo analysis of Medicaid

dental claims data received under FOIA
Note: Annual estimates based on last full year of
available data for each state.
21
Annual Medicaid Savings Could Provide Care for Up to

1.9 Million More Medicaid Children Who Currently Do
Not Receive Dental Care
The estimated annual Medicaid savings could be used to treat Medicaid

children who are currently not receiving any dental care
Based on the estimated savings for applying the Kool Smiles care protocol
to non-Kool Smiles patients, approximately 790,000 children with Medicaid
in the Kool Smiles geographic area, or 1.9 million children across the states,
could receive dental care for the same total annual Medicaid expenditures
Estimated Number of Additional Medicaid Children Who Could be
Treated by Kool Smiles due to Annual Medicaid Savings
State
Georgia
Indiana
Louisiana
Mississippi
South Carolina
Texas
Virginia
Total
Additional Patients
in Geographic Area
266,581
78,552
72,767
40,834
143,701
105,694
82,206
790,335
Additional Patients
Across Entire State
266,581
254,670
131,632
217,226
202,128
688,624
199,857
1,960,717
Source: Dobson | DaVanzo analysis

of Medicaid dental claims data
received under FOIA.
Note: Annual estimates based on
last full year of available data for
each state.
22
Implications for the Medicaid Program
Detailed analyses within and across states over time suggest that Kool
Smiles is a low-cost and conservative provider of dental service for
Medicaid patients
Kool Smiles routinely provides a comparable number of diagnostic services but
fewer restorative and extraction services than non-Kool Smiles providers
After adjusting for providers with similar age distributions, Kool Smiles
providers have a average monthly Medicaid expenditures per patient that is
38 percent lower than non-Kool Smiles providers
If the Kool Smiles care protocol was to be applied to non-Kool Smiles

providers for these select states, Medicaid could save about $193 million or
treat an additional 790,000 underserved children with Medicaid in the
geographic areas where Kool Smiles already operates
23
Dobson|DaVanzo
Dobson DaVanzo & Associates, LLC (Dobson|DaVanzo) is a
health care economics consulting firm based in the
Washington, D.C. metropolitan area
Contact information:
(703) 260-1760
joan.davanzo@dobsondavanzo.com
al.dobson@dobsondavanzo.com
www.dobsondavanzo.com

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Comparison of Kool Smiles Utilization

and Medicaid Expenditures Across

Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Summary Results by State and Year

Implications for Medicaid Program

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Study Context and Purpose

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Study Context and Purpose (contd)

Dental Support Organizations (DSOs) enable dentists to practice in some of the

Data were aggregated by dental provider number and by dental service

Kool Smiles providers were flagged (Yes/No)

procedures to dental benefits plans.

For select states, the number of dental services provided by dental

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Dental Services Included

Results were presented as the annual number of services provided per

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Geographic, Age Distribution, and Stateyear Specific Analyses

State-Year Specific analysis: Compared annual utilization and monthly

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Analyses Cover Seven States, about 8,200

Years Data Available

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Variability was observed in Medicaid expenditures per unit within a

As a result of material variation in Arizona and Kentucky, these states

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Geographic Area Analysis:

For All Dental Services, Kool Smiles Providers Had

Non-Kool Smiles Providers

Select Diagnostic Services

Monthly Medicaid Expenditure per

Kool Smiles Providers

Non-Kool Smiles Providers

Select Restorative and Extraction Services

All Other Dental Services

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Geographic Area Analysis:

For Diagnostic Services, Despite Higher Utilization,

Number of X-Rays per Patient

Monthly Medicaid Expenditure per Patient

Kool Smiles Providers

Non-Kool Smiles Providers

Kool Smiles Providers

Non-Kool Smiles Providers

2016 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

Geographic Area Analysis:

Across All Restorative and Extraction Services, Kool

Number of Restorative and

Monthly Medicaid Expenditure per Patient for

Kool Smiles Providers

Geographic Area Analysis:

Kool Smiles Provides Fewer Extractions per Patient

Kool Smiles provides 42 percent fewer extractions, including both simple

Number of Simple Extractions

Kool Smiles Providers

Non-Kool Smiles Providers

Kool Smiles Providers

Non-Kool Smiles Providers

Geographic Area Analysis:

Kool Smiles Provides Fewer Pulpotomies than Non-Kool

Number of Stainless Steel Crowns

Kool Smiles Providers