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MyView: Changing the culture of coverage

July 11, 2016
Photo of Dr. Terry
Bruce R. Terry, D.M.D.
The Journal of the American Dental Association published a report in April 2014 regarding the overuse of emergency room services for dental-related problems, which quickly became a favorite for commentary. The report stated that during the three-year period from 2008 to 2010, 1 percent of emergency room visits were dental related. Of those dental ER visits, 57 percent were related to dental caries and only 2.7 percent were related to swelling. The average cost of treatment for these patients was $760.

It was the $760 that caught my eye. How is that a good use of resources? I understand that this report tells us the average cost and not the collected amount, but I used this information during a meeting with a hospital chief financial officer last year when I was seeking assistance for a Mission of Mercy in Pennsylvania event. I spoke with the CFO about how Pennsylvania adult Medicaid dental coverage was shut down in October 2011, fueling more dental emergencies to Pennsylvania hospitals. Over lunch I commented on the study and said this was a real problem that our mission would address and asked if the hospital would like to contribute to the event as it would decrease the number of ER visits for the near future.

To my surprise, the CFO smiled and told me that I was looking at the equation all wrong. He agreed that ER visits for dental care are expensive and unnecessary in most cases but that the hospital does not lose money. Rather, it makes money. Excuse me? That’s right, hospitals make money on ER patient visits. More patients through the doors, more money. I was told that some money comes from patients and insurance, but hospitals are given money from state and federal funds for patients that can’t pay. Hospitals are not allowed to refuse treatment and therefore get compensation when no other funds are available. While he agrees that it’s a poor use of Medicaid and insurance dollars, the hospital doesn’t really care.

That lunch was quite an eye-opener. How are we going to fix this dysfunctional system if the main player actually benefits? I am surprised that they don’t advertise for dental emergencies to visit their ERs. You would think that the insurance carriers and Medicaid payers would want to put a stop to this practice with better and more cost-efficient dental care options for those who must turn to the ER, but sadly that does not happen.

I called two other dentists who run a hospital-based dental clinic. I asked them if their clinic makes money, hoping that it was the model I was looking for. Unfortunately, I was told that their clinic does not make money but that their hospital operates it at a loss as a service to the community. I really don’t want to give up on this idea. While I understand it’s not that simple, I continue to look for solutions. There must be a more fiscally sensible model that can help patients who show up at the ER with a dental emergency.

We hear all the time about fraud and waste in the health care system, but the efforts to curb these issues are almost always focused on offsite providers who are accused of taking advantage of the system. Upcoding and billing for services never provided seem to be the poster children for Medicaid fraud. While this policing is necessary, it falls short of the total issue. I would think that health insurance providers and state Medicaid gatekeepers would want to save money so as to help more patients.

The $760 spent on each ER dental visit could be used to fund several visits for patients who desperately need dental care but can’t afford it.
Cost shifting can provide the dollars for treatment for these individuals rather than spending it on lab tests, antibiotics and pain medication — the standard treatment in emergency rooms. Why spend more to ameliorate symptoms when we could spend less to treat the real problem?
Maybe hospitals could open an emergency dental department to solve emergency problems with direct dental care rather than palliative care. This model could work at a break-even level unlike the current hospital general practice residency programs and more effectively than the current ER model. Having a dentist on staff with a dental chair and the necessary equipment to provide care like restorations, extractions and root canal treatment could help patients without dental insurance while not taking patients who have dental insurance away from private dental offices.

Unfortunately, my experience tells me it’s just not that simple. State employees who monitor and control Medicaid payments are using other people’s money and are not invested in where the money goes. If they were, I wouldn’t be writing this editorial.

The same could be said for the medical insurance companies with a dental component who seem to be more concerned with denying coverage for a legitimate dental procedure while gladly paying a hospital bill. Even if the ER hospital care is paid at 40 percent of billed charges by a medical insurance carrier it still represents too much money for inadequate care.

This message has to start at the top. Those in charge need to change the culture of coverage and apply the available funds in better ways. I know this sounds self-serving coming from me, a dentist, but it really is a logical argument.

How can we continue to waste valuable funds for expensive palliative care? Directing dollars to actual dental care would cost less and provide a higher level of care. ER visits only delay the problem. We all know that antibiotics and pain medication don’t resolve dental disease. Removal of caries, extractions and root canal treatment are what remove dental disease.

Why don’t hospitals carve out room for dental clinics to deal with this problem? Why is dental care an afterthought in the emergency health care system?
If community hospitals have the means to operate for-profit or not-for-profit with general health needs, then they can do the same for dental needs. Hospitals are there for the community regardless of the ability to pay.

There needs to be an equivalent system for emergency dental care for those unable to pay. Proper care could be delivered and real dental issues would be resolved. My ideas may sound idealistic, but my goal is to treat dental disease rather than sweep it under the rug.
Maybe someone should listen?

This editorial, reprinted with permission, originally appeared in the March/April 2016 edition of the Pennsylvania Dental Journal. Dr. Terry is past editor of the journal and president-elect of the Pennsylvania Dental Association.