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Higher Cost, Inferior Care: Dental Health in Emergency Departments

Each year, nearly one million U.S. residents visit hospital emergency departments seeking treatment that EDs are not equipped to provide: dental care.

Most people seeking dental help at EDs have low incomes and receive health benefits through Medicaid. They often resort to emergency care because few dentists are willing to treat the program’s beneficiaries. The outcome, observers say, is inadequate dental services for those patients and hundreds of millions of dollars added to U.S. health care spending.

Much like an infected tooth, experts say the key to finding a solution is to understand the root of the problem.

A Growing Trend

From 2006 to 2009, the U.S. saw a 16% increase in individuals seeking dental care at emergency departments, according to a report by U.S. Agency for Healthcare Research and Quality released last fall. The report linked about 936,000 ED visits and nearly 13,000 hospital inpatient stays to dental conditions in 2009.

In California, the number of ED visits for preventable dental conditions is growing at a rate faster than the state’s population, according to a 2009 report by the California HealthCare Foundation, which publishes California Healthline. It found that total ED visits for preventable dental issues that did not result in hospitalization increased from 70,578 in 2005 to 81,508 in 2007.

The numbers are problematic, experts say, because oral health can have a significant effect on overall health. According to the CHCF report, findings by the U.S. Surgeon General have linked dental problems and infections to ear and sinus infections, weakened immune systems, heart and lung disease, and other serious health conditions.

Dentists Spurn Medicaid

Many dentists across the U.S. refuse to accept Medicaid beneficiaries. For example, only 10% of Florida dentists treat Medicaid beneficiaries, according to Frank Catalanotto of the University of Florida College of Dentistry.

The chief reason dentists will not participate in the program? Low reimbursements.

Talking with PBS’ “Frontline,” Cesar Sabates — president of the Florida Dental Association — said, “I looked into becoming a Medicaid provider … and I noticed that the reimbursement schedule was dismal. It was maybe 20% of what we normally would charge.” He noted, “Dentistry is, in fact, a business. And in order to a dentist to survive, they have to make money.”

David Perrott — senior vice present and chief medical officer of the California Hospital Association — told California Healthline, “Low-income patients show up at emergency departments for dental care because they can’t find access anywhere else,” adding, “Dentists aren’t going to see Medi-Cal patients because the reimbursements are so terrible.”

Compounding the problem in California is a series of cuts to dental benefits through Medi-Cal, California’s Medicaid program. In 2009, California eliminated coverage for non-emergency dental procedures like teeth cleanings and fillings for nearly three million adult beneficiaries of Denti-Cal, a Medi-Cal dental program.

The San Francisco Chronicle reports that the cuts have exacerbated the trend of low-income individuals seeking dental care at EDs. Data from San Francisco General Hospital show that the number of ED visits by patients with dental complaints grew from 365 in 2008-2009 to 651 in 2011-2012.

No Help From Affordable Care Act

Although the Affordable Care Act seeks to expand access to care for low-income residents, it likely will not provide significant relief for low-income individuals with dental problems.

Beth Mertz — an assistant professor at the UC-San Francisco School of Dentistry — told California Healthline that an ACA-led expansion of Medi-Cal coverage to individuals with incomes up to 138% of the federal poverty level will do little to improve access to dental care, as it doesn’t address the reimbursement issues that make participation in Medicaid so unattractive for many dentists.

California Dental Association President Lindsey Robinson agreed. She told California Healthline, “The expansion of Medi-Cal probably will not have an impact on emergency department visits for dental care, as that is already the location of last resort.”

However, the ACA could help in one respect: dental coverage that could be offered through state health insurance exchanges being developed under the law, Robert Faiella — president of the American Dental Association — noted. However, Faiella said, “People still would have to buy that coverage, and a lot of low-income individuals will not be willing to do that. So, the impact might be minimal.”

Looking for Solutions

Absent a comprehensive fix from the ACA, some observers in California are looking to the state to provide relief by undoing the 2009 cuts to dental benefits.

Robinson said, “The way to reduce emergency room visits is for the state to bring back dental services for low-income adults.” She added that Senate President Pro Tempore Darrell Steinberg (D-Sacramento) “understands this situation and has clearly stated the need to restore Medi-Cal dental services for adults.”

Whether state officials will listen to Steinberg is another matter. In his January budget statement, State Controller John Chiang (D) said California’s tax revenue exceeded estimates in Gov. Jerry Brown’s (D) fiscal year 2013-2014 budget proposal by $4.3 billion, in part because of higher-than-expected personal income taxes. Although Steinberg and other Democrats have said any extra funding should be used to increase spending on health and welfare programs, Chiang said the news “must be tempered with increased fiscal discipline in how we interpret and budget January’s collections.”

Brown echoed Chiang’s warning in his State of the State address last month, saying state officials should practice fiscal discipline by using any extra funds to pay down debt and boost reserves instead of restoring funds to social programs.

Another option to address increasing need for dental care in EDs is for hospitals to start staffing dentists. Regular ED physicians only can prescribe painkillers and antibiotics for damaged teeth and refer patients to dentists.

Mertz said that using dentists in EDs only “deals with the disease at the very end of the process.” She said, “That’s like dealing with diabetes once a foot needs to be amputated.”

Staffing dentists at EDs could be part of a larger solution, Robinson said. She explained that California also should “establish an office of oral health, with a state dental director — something California has been lacking for nearly 20 years.” Robinson added, “With strong leadership, this person could guide the state in developing the best strategies and implementing the most effective programs, not to mention pulling down available federal dollars.”

Other states are trying to find their own ways to reverse the trend.

According to “Frontline,” Terry Dickinson — executive director of Virginia Dental Association — has started a program in the state called Remote Area Dental that provides no-cost care to patients with the help of volunteer dentists. Meanwhile, Minnesota has started training dental therapists, which are roughly equivalent to nurse practitioners in general medicine. Advocates say that dental therapists can perform simple preventive dental procedures for less money than dentists.

Faiella said the ADA is placing its faith in partnerships in various states between dental societies and local clinics. “These programs are built to divert dental patients from emergency rooms, and they are working,” he said. In addition, he recommended that states continue water fluoridation programs and “teaching people about how oral health affects general health.”

In California, Perrott said he is discussing possible solutions to the problem with members of the ADA. He said, “We haven’t figured out anything yet, but we’re working on it.”

Here’s a look at what else is happening in health reform.

In the States

  • Wisconsin Gov. Scott Walker (R) last week announced that his state will not participate in the Medicaid expansion under the Affordable Care Act, but he proposed an alternative plan to help reduce the number of uninsured state residents (Baker, “Healthwatch,” The Hill, 2/13). Walker would expand coverage to low-income state residents through federally subsidized private health care exchanges (Cheney, Politico, 2/14).
  • Expanding Medicaid in Colorado would save the state about $134 million by 2025 at no cost to taxpayers, according to an analysis by the Colorado Futures Center at Colorado State University (Kennedy, USA Today, 2/13). The analysis explained that not expanding the federal program would be more costly, in part because Medicaid enrollment is expected to grow under the ACA’s other provisions and because of an expected reduction in employer-sponsored insurance (Whitney, “Capsules,” Kaiser Health News, 2/13).
  • Illinois last week became the third state to receive conditional approval from HHS to move forward with a partnership insurance exchange in the state, joining Arkansas and Delaware. Illinois Gov. Pat Quinn (D) said “hundreds of thousands” of state residents will gain coverage through the exchange. He added, “They will also gain the peace of mind that comes from knowing that the care will be there if they need it” (Daly, Modern Healthcare, 2/13).

Rolling out Reform

  • Many states are implementing marketing efforts to boost awareness and spur enrollment in the health care exchanges, which are scheduled to open for enrollment in October. Some states are modeling their advertising campaigns after the programs that Massachusetts used to roll out its 2006 health care reform law. That campaign included ad placements on public transportation, motor vehicles and at tax agencies, and a high-profile partnership with the Boston Red Sox. In addition, health care centers and groups — including CVS Caremark and Planned Parenthood — are hoping to use their relationship with uninsured patients to increase awareness (Radnofsky/Corbett Dooren, Wall Street Journal, 2/12).
  • A potential loophole in the Affordable Care Act might mean fewer children will receive dental coverage than hoped (Winfield Cunningham, Politico, 2/15). Under the ACA, insurance plans offered through the health insurance exchanges must cover 10 essential health benefits, including children’s dental coverage. However, plans that do not include children’s dental coverage can be approved so long as exchanges offer dental coverage as a stand-alone option (Corbett Dooren, Wall Street Journal, 2/18).

On the Hill

  • Sens. Sherrod Brown (D-Ohio) and Jay Rockefeller (D-W.Va.) are urging Congress to extend an expiring health care tax credit for U.S. residents who are laid off when their jobs are outsourced. The Health Coverage Tax Credit pays 72.5% of health care premiums for some workers who lost their jobs because of international trade competition. However, the credit is set to expire in 2013, when subsidies and tax credits become available to U.S. residents to purchase coverage in the health insurance marketplaces under the Affordable Care Act (Ethridge, CQ Roll Call, 2/12).

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