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Table of Contents
(Click here for the interactive model––an Excel file–– or here to return to the report.)
(Click here to send a message requesting help or further information about using the model.)
Users Guide to the Dental Pricing Model
Data Sources
Model Description
Assumptions Worksheet
User Defined Fee Schedule and Fee Schedule Worksheet
Summary Worksheet
Benefit Exhibit
Continuance Exhibit
Users Exhibit
Paid Exhibit
Detail Data Exhibit and Modified Data Exhibit
Questions and Answers
Users Guide to the Dental Pricing Model
At the request of the Milbank Memorial Fund and on behalf of the Reforming States Group, PricewaterhouseCoopers has developed a model to estimate the cost of providing dental services to children covered by Title XXI. The purpose of the model is to provide a means of estimating the budget requirements for full scope dental services, and to understand the range of costs that may result under the program. A specific benefit design has been developed to serve as a starting point for the evaluation. In addition, flexibility has been built into the model to facilitate state-specific data.
This model cannot be guaranteed to provide a correct cost estimate for a given state; detailed, thoughtful analysis would be required to achieve such a result. In addition, data specific to the state may be required, such as the participation level in the Medicaid program and/or prevailing fee levels. The purpose of the model is to provide a means for obtaining a relatively quick understanding of the budget requirements of providing dental services under Title XXI.
The benefit design included in this model resulted from a series of meetings sponsored by the Milbank Memorial Fund. This benefit design consists of a fixed fee for annual preventive visits for each child. Treatment costs are to be covered through a fee schedule that is assumed to be 80% of average billed amounts. Treatment plans with an expected cost above $400 would be subject to utilization review and prior approval. Children with treatment needs above $1000 in a year would be expected to obtain services through contracted specialists, particularly if the child requires hospitalization.
This users guide is intended to provide instructions on the components of the model and the means for developing assumptions for each component.
The model allows the user to input assumptions related to levels of utilization for children of different ages and for different types of services. For example, if a state is interested in encouraging higher levels of treatment through a focus on restorative services, the model provides the ability to vary the utilization and cost assumptions for that service category. Similarly, if a state is interested in a focused outreach program to encourage a higher percentage of children to obtain any dental services, the model provides a means of evaluating the likely cost effect of that program.
In the following sections of this document, we describe the data sources that underlie the model, the specific technical details for obtaining information from the model, and the process for entering assumptions to gain an understanding of the likely costs of varying program initiatives. Throughout the model, fields that can be modified by the user are shown in blue, while those that are fixed or represent a formula are shown in black. These fields are protected from modification.
Data sources
The model is based largely on data provided by the California Medicaid (MediCal) program. We obtained two full years of detail data (fiscal years 1996 and 1997) that reported all services provided to children covered by the MediCal program. For our analysis we selected only those children having full-scope dental coverage on a fee-for-service basis. Note that some children covered by MediCal are enrolled in managed care for dental services. Others are eligible for only emergency services on a fee-for-service basis.
We organized the data in two ways:
- By age and type of service (e.g.,diagnostic, preventative, restorative, etc),
and
- By amount of claims per person per year.
The data in these formats can be printed out from within the model, although those parts of the model are protected from modification. Directions for printing out the data will be given in the Model Description Section.
The model uses the billed data provided by the MediCal program rather than the MediCal paid amount. The billed amount is used as a proxy for a fee schedule that would be adopted by each state.
Model Description
The model consists of a total of three worksheets and six exhibits. The three worksheets are interactive and allow the user to input assumptions and data. Some of the exhibits are provided for information purposes to allow users an understanding of the starting assumptions for the calculations. The remaining exhibits provide results of calculations. Specifically, the model consists of the following worksheets and exhibits. The remainder of this document describes in detail how each worksheet and exhibit is used.
- Worksheet 1 - Assumptions: allows the user to input various assumptions related to utilization of services, cost of services, and other factors that influence the per capita cost of the program. This worksheet is the primary area for user input.
- Worksheet 2 - Fee Schedule: shows the implicit fee schedule for key services and allows the user to input a different fee schedule to match local conditions. This worksheet allows users input.
- Worksheet 3 - Summary: provides the results of the calculations and allows the user to input information to calculate total budget estimates. This worksheet allows user input.
- Exhibit 1 - Benefit: calculates the relative value of the benefit design input by the user in the Assumptions worksheet. This exhibit performs calculations but does not have any user input.
- Exhibit 2 - Continuance Table: shows a distribution of costs per user by dollar level of expenditure and age. This exhibit is for information purposes.
- Exhibit 3 - Users: displays information on the percentage of users of various types of services by age. This exhibit is for information purposes.
- Exhibit 4 - Paid: displays information on the per capita cost of services in the historical MediCal database. This exhibit is for information purposes.
- Exhibit 5 - Detail Data: displays information on the underlying data subset by service category and age. This exhibit performs calculations but does not have any user input.
- Exhibit 6 - Modified Data: displays information on the underlying data modified by the fee schedule input by the user. This exhibit performs calculations but does not have any user input.
Assumptions Worksheet
This worksheet represents the main user interface with the model. Information on the effect of changing assumptions is displayed next to each input section to provide immediate information to the user. This section will explain each of the six assumption sections in detail with examples.
Two features of the worksheet are included to make the information easier to find and use.
Features
First, in five of the assumption sections, we have included a box off to the right that contains a summary of the resulting PMPM costs. This feature will allow the user to see the impact of changes in assumptions as they are made, rather than toggling to the Summary Sheet.
Second, the assumptions that the user may modify are shown in blue text. In four of the six sections, a button is located on the right side that resets the assumptions in that section. This function will always reset the assumptions back to values of 1.00 if the section is for fee schedule or utilization adjustment. If the assumption section is for member or user distributions, then the values will be reset to the distributions from the underlying MediCal data.
Assumptions Sections
The Assumptions Worksheet is divided into six sections. These sections are:
- Contract Assumptions
- User Defined Fee Schedule
- Fee Schedule Assumptions
- Utilization Assumptions
- Cost Distribution Assumptions
- Membership Distribution Assumptions
Contract Assumptions
In this section, the user defines the benefit levels and coverage described in the discussion of the Benefit Exhibit. The effect of modifications to the benefit design input here will be calculated in the Benefit exhibit and will flow to the Summary worksheet. The model allows for three tiers of coverage. Each of these tiers is presented in the Assumption Worksheet.
In the first tier, or the "Percentage of Claims Under First Threshold", the user defines the estimated diagnostic and preventive costs for an individual for a particular year ($150 for example). Then the user defines to what extent these diagnostic and preventive charges are covered (100% for example). This input will be interpreted by the model to mean that of all the claims billed in a given year for an individual, the first $150.00 are assumed to be preventive and diagnostic and the dentist will be paid a fee schedule equivalent to 100% of billed charges for these services.
The example described above is input as follows:
Note that the user is allowed to set the estimated diagnostic and preventive costs for each age category.
In the second tier, or the "Percentage of the claims between the first & second threshold", the user defines the amount of billed charges above the diagnostic and preventive charges (previously specified in the first tier) are to covered and at what percentage. For example, if the tier one assumptions have been set as in the paragraph above ($150, 100%) and the second tier is set on the Assumptions Worksheet as follows:
then the services in excess of $150 for an individual will be paid at 80% for the next $1,000. Said another way, the billed charges up to $150 are paid at 100%, and the services between $150 and $1,150 are paid at 80%.
The third tier, or the "Percentage of the claims over the second threshold", represents the case where claims for an individual for a year exceed the second threshold ($1,150 in the example above). For this tier, the user enters the percentage of billed charges the dentist will be paid. An important note is that when an individual's claims exceed the second threshold, the individual's second and third tier claims for the year are assumed to be paid at the third tier percentage. Thus if the third tier is defined as follows:
and claims for an individual exceed the second threshold amount of $1,150 (total annual billed claims of $2,000 for example), the dentist is reimbursed $1,260 ($1,850 x 0.60 + $150 x 1.0). This method for pricing services is used to allow for the possibility that states will negotiate different contracts with specialty providers. We would expect that all services required by children with high levels of need will be provided under these special contracts, similar to a case rate payment approach. States not wishing to use this approach may set the second threshold at a very high level, such as $10,000, or may set the payment level for the second and third tiers at the same level.
User Defined Fee Schedule and Fee Schedule Worksheet
The user has the option of either using the MediCal billed charges as a base for modeling or entering their own fee schedule. To enter a fee schedule, click on the "Enter Fee Schedule" button and you will see the following input page:
From here, the user may enter a specific fee schedule for the given services. These services make up 85% of all dental costs in the MediCal data. The total cost is imputed from the fee schedule input by the user divided by 0.85. This truncated fee schedule allows the user to input a minimum amount of information while achieving a result that more accurately reflects local payment levels, if desired.
The user can reset the fees to the MediCal values by clicking the "Reset Fee Schedule" button on the right side.
When the user is finished entering fees, click the "Return to Assumptions" button.
The user has the option to switch between the MediCal billed charges and the user defined fee schedule. This is done the clicking the desired option in the box shown below:
Fee Schedule Assumptions
This section allows the user to apply factors to the fee schedule selected above in two different ways. The first is by applying a single factor to all of the fees. This is accomplished by using the input cell at the bottom of the Fee Schedule section. For example, if the user felt that fees would be 20% higher than the MediCal billed amount, then the user would enter the following:
If the user wanted to be more selective about which services and age categories to adjust, then the user would enter factors into the table. For example, if the user wanted to decrease fees by 10% for diagnostic services and increase fees by 10% for restorative services, the user would enter the following (changes shown in bold):
The button on the right side can be used to reset all of the fee level adjustments back to 1.0.
Utilization Assumptions
This section is set up exactly like the Fee Schedule Assumptions section. It applies the factors to the utilization in the MediCal data. Users input adjustment factors to reflect expected levels of utilization. For example, if a policy initiative is developed that is intended to double the use of restorative services, the user would input a factor of 2.0 in the appropriate cells. The user may also input aggregate utilization increases that are applied to all service categories.
Cost Distribution Assumptions
This section allows the user to change the percentage of members assumed to use any services by age category. For example, if the user believes that 50% of all members will be users of dental services in a given year, then the user would change the inputs in this section to:
The numbers directly above the blue user inputs (2.67%, 28.66%, 38.84% and 28.58%) are the percentages of members by each age category from the MediCal data that use services. If the user chooses to reset the inputs, they will be reset to the MediCal values.
The user also has the ability to set the relative cost of any additional users. Note that changes in costs for the base data would be made either in the Fee Schedule adjustment section of the Utilization section. Additional users are defined as users in excess of those derived from the MediCal data. Thus using the example above, 21.42% (50% user defined less 28.58% MediCal) of the users in the Ages 15-18 category would be considered additional users. If the user wanted to assume that these additional users had costs 30% lower costs than the MediCal defined users, then the user would enter the following:
Note that if the percentage of users defined is less than the MediCal defined percentage, then any costs removed will not be dependent on the "Costs of additional users in excess of average" input. For example, if the user wanted to assume 1.00% of the Under 2 members would use services instead of 2.67%. Also assume that the "Costs of additional users in excess of average" input has been set to 70% as above. Then the 70% assumption will have no impact on the Under 2 age category cost calculation.
Different assumptions regarding utilization rates for new population groups may be appropriate if the user believes the new group has a different risk profile than the MediCal population included here. For example, some policy makers may believe that newly enrolled children will have a higher level of need for dental services than those who are already enrolled. Alternatively, policy makers may believe that children in the income category covered by Title XXI will have a lower level of need than the MediCal average.
Membership Distribution Assumptions
This section allows the user to change the distribution of members among age categories. The model uses the MediCal data to set the initial assumptions.
If the user wished to change the distribution of members so that there were no members in the 15-18 age category, the user has two ways to accomplish this. The distribution can be set so that the percentages sum to 100% or the user could simply enter "0.00%" in the Age 15-18 input box as follows:
The percentages need not sum to one. The model will adjust the input percentages internally to sum to one.
The distribution can be reset to the MediCal percentages by clicking the "Reset User Defined Percentages" button.
This section does not allow the user to change the number of members. That is done on the Summary Sheet.
Summary Worksheet
The summary sheet provides the cost estimate of the model based on the assumptions input by the user and the underlying data. In addition, information on the total estimated state program cost is shown based on the average number of children expected to participate and the state/federal cost share.
The table at the top of the sheet displays the estimated dental costs per member per month (PMPM). Per member per month costs are presented by age and service category. The weighted-average of the age-based total PMPM costs is displayed as "Resulting PMPM".
The costs resulting from this calculation show the dental claims component only. In addition, the user needs to enter the costs associated with administering the program. Administrative costs for the state are entered as a percentage of total costs. This value would typically be similar to the average administrative costs of the Medicaid program, and would range from 3% to 7%, although other values may also be valid.
In addition, if the program will contract with private dental plans, a plan administrative cost may be entered. States will need to decide whether to price premium rates at a value similar to the fee-for-service equivalent cost, in which case no additional plan administrative cost would be added. Alternatively, if plans will be paid an amount in addition to the estimated fee-for-service amount, a value would be entered, typically ranging from 8% to 15%. Many states that contract with private health plans to provide services assume the plans will cover the administrative costs through more efficient delivery of services.
The administrative assumption section of the model is shown below.
Below the administration section is a funding calculation that allows the user to change two assumptions, which are displayed in blue:
- the percentage of the costs to be covered by the state government and federal governement, and
- the estimated average number of children covered by the dental program for the year being covered.
Once these assumptions have been set by the user, the model will calculate the annual cost of the dental program for both the state and federal government.
The model then shows a resulting annual state cost of $812,974, an annual federal cost of $1,219,460, and a total cost of $2,032,434.
The summary sheet also has buttons that can be used to print out the summary page and three other worksheets and exhibits. To print out the summary, assumptions, and fee schedule worksheets and the benefit calculation exhibit, simply place the mouse pointer over the button like the one below and left-click.
There are three remaining buttons on the summary worksheet. These allow the user to print the two raw data displays and a display of dental code descriptions. As described in the Data Section, we have presented the data by age and type of service, which can be printed by left-clicking the "Print Data " button. The data are also displayed by amount of claims per person per year, which can be printed by left-clicking the "Print Continuance Tables" button. These two exhibits will be further described in the Continuance Table Sheet and the Detail Data Sheet sections.
Benefit Exhibit
Basics
This exhibit calculates the adjustments that are applied to the billed charges in the model to price the Contract Assumptions input into the Assumptions Worksheet. Based on discussions with the working group, an initial plan design was developed with the following structure:
- An initial diagnosis and preventive services visit will be covered annually for each child based on a fee schedule that pays 100% of billed charges.
- Treatment plans that require more than $400 in services in a year will require prior authorization.
- The model allows for separate payment levels for treatment plans expected to cost above and below a specified threshold. The threshold currently used in the model is $1000.
- Services for treatment plans between the first and second threshold (i.e., under $1000) will be paid at a fee schedule equal to 80% of billed charges.
- Services for treatment plans above the second threshold (i.e., above $1000) will be paid at a different fee schedule; in this case the fee level is also set at 80%, similar to treatment plans under the second threshold.
Each of these benefit tiers is presented in the Benefit Exhibit. For each age group and tier, the percentage of claims that fall into each tier is shown as well as the "Adjustment Factor". The end result of the calculation is an "Adjustment Factor", which is described below.
Tiers
In the first tier, or the "Percentage of Claims Under First Threshold", the user defines (on the Assumptions Sheet) the estimated diagnostic and preventive costs for an individual for a particular year ($150 for example). The user then defines the payment level for these diagnostic and preventive services (100% for example). This input will be interpreted by the model to mean that of all the claims billed in a given year for an individual, the first $150 are assumed to be preventive and diagnostic and the dentist will be paid 100% of this amount.
In the second tier, or the "Percentage of the claims between the first & second threshold", the user defines the amount of billed charges above the diagnostic and preventive charges (previously specified in the first tier) that are to covered and at what percentage. For example, if the tier one assumptions have been set as in the paragraph above ($150, 100%) and the second tier is set on the Assumptions Sheets as follows:
then the services in excess of $150 for an individual will be paid at 80% for the next $1,000. Said another way, the billed charges up to $150 are paid at 100%, and the services between $150 and $1,150 are paid at 80%.
The third tier, or the "Percentage of the claims over the second threshold", represents the case where claims for an individual for a year exceed the second threshold ($1,150 in the example above). For this tier, the user enters the percentage of billed charges the dentist will be paid. An important note is that for individuals whose claims exceed the second threshold, the individual's second and third tier claims for the year are assumed to be paid at the third tier percentage. For example, assume the third tier is defined as follows:
If claims for an individual exceed the second threshold amount of $1,150 (total annual billed claims of $2,000 for example), then the dentist is reimbursed $1,260 ($1,850 x 0.60 + $150 x 1.0). This method for pricing services is used to allow for the possibility that states will negotiate different contracts with specialty providers. We would expect that all services required by children with high levels of need will be provided under these special contracts, similar to a case rate payment approach. States not wishing to use this approach may set the second threshold at a very high level, such as $10,000, or may set the payment level for the second and third tiers at the same level.
Adjustment Factors
The model assumes that the billed charges have already been multiplied by the second tier percentage entered on the Assumptions page. For example, if on the Assumptions page under Contract Assumptions, the user has entered the second tier assumptions as follows:
all of the billed charges will have been multiplied by 80%. Consequently, in the section of the exhibit labeled "Percentage of the claims between the first & second threshold", the adjustment factor is always 1.00.
For the first tier adjustment factor, we divide the first tier payment percentage by the second tier payment percentage. For example, if 100% of services are covered for the first $150, and the next $1,000 of services are covered at 80%, the first tier adjustment factor is 1.25 (100% / 80%).
For the third tier adjustment factor, we divide the third tier payment percentage by the second tier payment percentage. For example, if 100% of services are covered for the first $150, and the next $1,000 of services are covered at 80%, with the remaining services covered at 60%, then the third tier adjustment factor is 0.75 (60% / 80%).
Resulting Factor
The Adjustment Factors for each tier and age category are multiplied by the percentage of claims in each tier to calculate a Resulting Factor for each age group. This factor is applied to the billed data to estimate the per capita cost based on the specific benefit design input by the user in the Assumptions Worksheet.
The exhibit is displayed below.
Continuance Exhibit
This exhibit shows billed claims from the MediCal data by age category and range of annual claim dollars per user. For example, in the Age 6-14 category, there were 2,775 users who had total annual claims between $2,250 and $2,499. Total claims paid for this group over fiscal years 1996 and 1997 were $6,557,690. This represents 1.61% of total claims in the Age 6-14 category for the two fiscal years. The Age 6-14 continuance table is shown below.
This exhibit is based on the original MediCal billed data and will not change as assumptions are changed. The information is used to develop the benefit adjustment factors described above and provides an understanding of the distribution of dental claims per child.
Users Exhibit
An important component of estimating the cost of dental services for newly covered populations is the percentage of the population expected to use services and the percentage using each type of service.
This exhibit has two tables that show similar information in different formats.
Table I shows the percentage of members in a particular age category using services in each type of service. For example, of the enrollees age six to fourteen, 35.9% of them used diagnostic services during a one-year period.
At the bottom of this table is the percentage of enrollees in an age category using any service during a one-year period. Any one enrollee may use a number of different types of services during a year (such as diagnostic and restorative), and therefore may be represented in several of the service categories for a particular age group. However, this user will only be counted once in the "Any Service" percentage. In the case of six to fourteen year-olds, 38.8% of enrollees used services in at least one of the service categories.
Table II presents the percentage of enrollees known to be users by service category. For example, of the enrollees aged two through five using services, 94.3% of them used diagnostic services and 77.9% of them used preventive services. These data underlie the base cost calculations and may help policy makers determine whether the MediCal distribution of the use of services best meets their state's policy goals and utilization patterns. The data may also be used to identify programs that target specific age groups and service categories.
The data in these exhibits are fixed and cannot be modified. Changes in assumptions regarding utilization are made in the "Assumptions" worksheet described below.
Paid Exhibit
For information purposes, we calculated the average paid cost per person per month for dental services provided by the MediCal program. The data on this page is fixed and does not enter into the model in any way. The weighted-average of the age-based total PMPM costs is displayed as "Resulting PMPM".
Because the costs are based on the amount actually paid by MediCal for services, rather than a fee schedule, they are generally lower than those based on a fee schedule. This exhibit can be printed by clicking on the "print exhibit" button.
The exhibit is shown below.
Detailed Data Exhibit and Modified Data Exhibit
The Detail Data exhibit shows the raw MediCal data by dental procedure codes. The codes starting with a "D" are standard ADA codes, while the "X" codes are MediCal specific. General service categories are identified for modeling purposes. The Modified Data exhibit begins with the same information as is used in the Detail Data sheet, but is modified by a user-defined fee schedule. The user does not make modifications directly to these exhibits, but instead inputs changes into the Assumptions and Fee Schedule worksheets.
A few of the "X" codes have been mapped to "D" codes. The codes we mapped were for services where the user has the option of defining the specific fee on the Fee Schedule Worksheet. We mapped the codes so the user would only have to work with one set of dental codes. As a result of this mapping, several "D" codes will appear more than once on the Data Detail Exhibit and the Modified Data Exhibit. The output of the model is not affected by this mapping.
Adjustments that have been made to the data are described below.
The per capita costs are calculated by dividing the appropriate claim dollar amount by the number of monthly eligibles. For purposes of these calculations, the count of eligibles is defined as the number of member months of MediCal fee-for-service eligibility in our database. The total member months of MediCal eligibility for fiscal years 1996 and 1997 for each age group can be seen at the top of each section.
The fields displayed in this exhibit are as follows:
Field Description
Billed The MediCal billed claims for fiscal years 1996 and 1997. MediCal Paid The MediCal paid claims for fiscal years 1996 and 1997. Adjusted Billed The Billed column adjusted for
- user assumed fee schedule adjustments,
- the second tier payment percentage, and
- adjustments to allow for average cost variations for additional users.
Units The MediCal units of service for fiscal years 1996 and 1997. Units/100 Units per 1,000 users. This value is calculated by dividing the data in the Units column by the number of member months of eligibility and multiplying by 12,000. Adjusted Units/1000 The Units/1000 column adjusted for
- user assumed utilization adjustments, and
- adjustments to allow for utilization variations for additional users.
Adjusted Cost/Units Adjusted Billed column divided by the Units column. Cost Sharing Member cost sharing, which is currently defined as $0. Resulting Cost/Unit Adjusted Cost/Unit less the Cost Sharing. Resulting PMPM Resulting cost per member per month, calculated as the Resulting Cost/Unit multiplied by adjusted Units/1000 and divided by 12,000.
The resulting PMPM costs are aggregated from this point in the modeling. They are summed according to their general service category. The only adjustment made to the data is for a portion of the information described in the benefit design section. Specifically, the payment level of the middle tier of services is applied in this exhibit. The remaining adjustments for benefit design are applied in the Summary Worksheet.
Questions and Answers
Q: How do I change the relative level of the state and federal shares of program cost?
A: This is done on the Summary Sheet. See box on "Federal/State Funding" in the section Summary Worksheet above.
Q: How do I change the administrative expense associated with either the carriers or the state program?
A: This is done on the Summary Sheet. See "Program Administration" in the section Summary Worksheet above.
Q: How do I enter the total number of children I expect to be covered under this program?
A: This is done on the Summary Sheet. See box on "Federal/State Funding" in the section Summary Worksheet above.
Q: How do I change the age distribution of children covered?
A: This is done on the Assumptions Sheet under Percentage of Members by Age Group. See "Membership Distribution Assumptions" in the section User Defined Fee Schedule and Fee Schedule Worksheet above.
Q: How do I change the percentage of members who will actually use dental services in a given year?
A: This is done on the Assumptions Sheet under Cost Distribution Assumptions/Percentage of Members Using Services. See "Cost Distribution Assumptions" in the section User Defined Fee Schedule and Fee Schedule Worksheet above.
Q: How do I input my own dental fee schedule?
A: This is done on the Assumptions Sheet under User Defined Fee Schedule and Fee Schedule Worksheet above. See table at the beginning of section User Defined Fee Schedule and Fee Schedule Worksheet above.
Q: How do I adjust the payments to providers based on the claim amount?
A: This is done on the Assumptions Sheet under Contract Assumptions. See "Contract Assumptions" in the section Assumptions Worksheet above.
Q: How do I change the utilization (globally or by age and service category)?
A: This is done on the Assumptions Sheet under Utilization Assumptions. See "Utilization Assumptions" in the section User Defined Fee Schedule and Fee Schedule Worksheet above.
Q: How do I apply adjustment factors to fee schedule (globally or by age and service category)?
A: This is done on the Assumptions Sheet under Fee Schedule Assumptions. See "Fee Schedule Assumptions" in the section User Defined Fee Schedule and Fee Schedule Worksheet above.
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