The financial impact to providers of patients presenting at the Emergency Department (ED) for minor medical complaints or problems that could readily – and more cost effectively – be managed by a GP, community clinic or urgent care center is well known. Some studies place the cost of ED misuse to the healthcare system at over $4 billion a year.
Patients who use the ED as their “family doctor” may be underinsured or have no insurance at all. And the risk to a hospital´s bottom line of such visits should not be overlooked as insignificant. It should be recognized.
While these visits currently represent only about 1.5 percent of all ED visits, they account for more than $2.1 billion in ED costs. For its part, Medicaid in one recent year spent over $500 million on dental-related ED visits. The American Dental Association estimated that this amount of Medicaid dollars would have paid for upwards of 1 million dental visits a year.
Most of the complaints that patients present with at the ED are related primarily to pain management and infection, which the ED treats mostly with analgesics and antibiotics. Since most EDs are not equipped to provide routine dental care, most of these patients are released with instructions to see a dentist at the earliest opportunity. This limitation, in addition to generating avoidable costs, can also put the lives of patients at risk.
According to the American Dental Association, the average cost of each visit to the ED for what amounts to routine dental care averages approximately $750 (this cost can dramatically increase if the patient is hospitalized). A visit to a dentist, on the other hand, would cost between $90 and $200. Assuming that up to 79 percent of ED visits for dental care can readily be shifted to a dental office, doing so could represent cost savings of upward of $1.7 billion to providers and the health care system in general. These savings could be put to better use funding more cost-effective dental interventions, such as preventative dental office visits, to a wider patient population.
Cost-of-Care is Greatest Driver of ED Visit for Dental Problems
There is some evidence that the increase in patients using the ED as their first option for dental care may be due to a lack of dental insurance (only half of American workers receive dental benefits from their employer), or inadequate insurance (Medicaid insurance limits and elimination of state adult Medicaid dental benefits). The cost of dental care and the benefit limitations of dental insurance play important roles. It’s also worth noting that young adults (between the ages of 14 and 18), African Americans, women ages 21-34 and seniors (many who mistakenly believe that Medicare covers dental care) also have higher use of the ED-as-dental-office than other groups. And, equally relevant, is that more than 25 percent of patients with ED dental visits had made a previous visit the same year while 21 percent had made two or four visits in that year.
People who forego preventative dental care because of cost are the ones who often end up at the ER for dental care once the pain, infection or other problems become unbearable. The U.S. government estimates that about four in ten – or almost half – of all adults had no dental visit in the past year (many dentists recommend semi-annual check-ups and cleaning). And, more than 25 percent of working-age adults and almost 20 percent of seniors have untreated cavities. And the lack of dental care can be fatal. In 2007, a 12 -year old boy with medicaid benefits died after “an infection from an untreated dental abscess spread to his brain. His mother was not able to find a dentist to treat the her son’s decaying teeth.
With these statistics, it’s no wonder an increasing number of patients are showing up at the ED with mostly preventable dental problems.
To make matters worse, these same patients often end up taking more prescriptions, including pain medicines, than they otherwise would have. The reason for this is simple and direct. Since most, if not the vast majority, of EDs do not have dentists on staff, they have little resort but to give patients prescriptions for antibiotics and painkillers while telling them to see a dentist “as soon as possible.” Of course, if these patients had access to a dentist, they would not have landed in the ED to begin with. The result is often a vicious circle with a patient making repeated visits to the ED when prescriptions, especially for pain, run out.
What Providers Can Do
Just as the challenges and causes of patients using the ED for first-line dental care arguably have their roots in the fact that there has always been a disconnect between dentistry and the rest of the medical profession. (Remember that in the 19th Century, dentistry was the bailiwick of barbers), addressing this 200-year-old disconnect may offer some solutions.
Recent provider efforts to better integrate dental care with primary care, including patient education, has shown significant success in reducing the use of the ED for routine or non-emergency dental care. This type of integration also creates additional health and cost benefits since improved dental health leads to better health in general, including reduced risk for heart disease, stroke and oral cancers.
Some of these include:
- Having hospital dental residents teach primary-care providers to conduct oral exams, teach parents about diet and dental health and apply fluoride to children.
- Working with local communities to recruit dentists to provide low or no-cost preventative care to non-insured or lower income patients who, as payment, agree to do community service. One such program in Michigan resulted in a reduction of around 72 percent over five years in ED visits for dental care, with one local hospital reporting savings of more than $6 million in under five years.
- Increasing referral coordination to local dentists helped some hospitals in Main reduce ED visits for dental pain and infection by about 70 percent with savings reportedly in the millions of dollars. Under this program, patients receive one prescription for painkillers and/antibiotics. To get more, they need to use the referral of a local dentist.
- Having an urgent care dental clinic located in the hospital helped one provider in Virginia reduce dental-related treatments in the ED by about 50 percent. It also saw a 66 percent reduction in patients with repeat visits to the ED for dental complaints.
- Integrating dental care into an ACO (or creating an ACO which includes dental services) is another strategy providers could consider to reduce the number of ED dental visits. One provider in Minnesota created an ACO combined with a regional medical center, social service organizations, an FQHC and contracted dentists. The provider reported that this ACO did succeed in reducing unnecessary trips to the ED for dental care.
Another challenge coming from the historical separation of dentistry from primary care is that many, if not most, use different EHR systems, which can make coordinating and integrating care a challenge. But this is something that can be overcome.
Providers, many of whom already have a wide variety of health education programs for their communities, should consider including information about community health centers, university dental schools and other locations where patients can receive dental care. It’s also worth noting that many of these may offer lower-cost or sliding scale fees for a wide range of services. Dental schools, for example, may offer a wide range of services at up to 50 percent lower cost than area private practices. Some also offer walk-in emergency clinics. This type of educational partnership benefits everyone.