April 13, 2020
As overtaxed hospitals struggle to meet the demands of a pandemic, emergency department utilization for non-traumatic dental care contributes to an overburdened system.
Hospitals across the country are facing an unprecedented public health crisis as the novel coronavirus sweeps through our communities. It has completely overwhelmed a health care system that was already overtaxed, forcing hospitals and medical providers to take drastic action to preserve resources and care for patients.
Emergency departments (EDs) were already operating near capacity before the crisis. And one significant reason people visit an ED is for non-traumatic dental care. The reasons why are complex. But the need to address it is more urgent than ever.
Inconsistent Access to Oral Health Benefits
Poor oral health remains a national concern impacting overall health. There is widespread agreement that the current oral health system is failing, with several barriers to access and care including lack of transportation and cost. The differing levels of health benefits nationwide, particularly in states that lack any public oral health coverage, is a major obstacle that drives up ED use. Specifically, people who face barriers to care often turn to EDs for relief when their pain becomes too much to bear. But dental services provided in EDs generally cost more and focus on managing pain or infections rather than addressing the oral health condition. What’s more, EDs often lack systems for oral health provider referrals, so many patients return to the ED again.
Medicaid Expansion Prompts Surge in Emergency Visits
As states have worked to increase access to oral health care, many have expanded adult Medicaid benefits to include oral health coverage. While this is a positive step forward, it has resulted in ED surges of people with significant but not emergency dental needs, most of which could have been prevented or addressed in a dental visit and with easier access to ongoing preventive care. Evidence shows this surge can happen for up to two years after Medicaid expansion before seeing a decline, as patients catch up on oral health care needs that were previously neglected due to lack of coverage.
A recent research report from the DentaQuest Partnership for Oral Health Advancement studied this phenomenon, evaluating both ED and inpatient hospital utilization for non-traumatic dental conditions in Oregon from 2013 to 2015. It found that both ED and inpatient visits more than doubled between 2013 and 2015, as a direct result of Medicaid expansion enrollment, with declines beginning in 2015. This finding mirrors trends seen when adults gain public insurance benefits and increase use of all services, not just oral health. Additional studies have shown that Medicaid expansion, when combined with adult dental coverage in Medicaid, resulted in an overall decline of ED visits.
Cost to the Health System and Communities
The current system and ED use trends also reflect major social and geographic disparities in accessing health care. According to the report, Black and American Indian or Alaskan Native patients had the highest ED utilization rate in Oregon for non-traumatic dental conditions. Residents of rural counties were also more likely to seek care at an ED, given rural areas have provider shortages and a higher rate of untreated dental needs, the authors note.
This is all a significant cost to the health system and to individuals and families. In fact, dental-related ED visits nationwide cost an estimated $2.1 billion per year, but nearly 79% of those visits could’ve been addressed in a dental office, saving up to $1.7 billion per year, according to the American Dental Association’s Health Policy Institute. “These cost savings could be used to fund Medicaid premiums, preventive dental office visits, oral health literacy efforts, or other more cost-effective interventions.”
Moving Toward A Multi-Level Approach
Though a significant challenge, the Oregon Hospital Utilization Report outlines evidence that a focus on multi-level solutions can make a difference. Oregon, for example, began implementing a unique system to offer health insurance coverage through regional coordinated care organization (CCOs), which link providers from across disciplines including behavioral and oral health. This type of proven and effective coordinated approach includes referral programs, medical-dental integration, and tools to increase access to dental care, such as teledentistry.
Multi-level solutions are especially important right now, as EDs and health care workers face the biggest public health threat in generations. The strain on these resources will be an ongoing challenge, likely for years to come.
As oral health leaders, we can prioritize these issues and drive changes to better serve our patients, providers, and communities -- through this crisis, and beyond it.