Although the expansion of Medicaid under the Affordable Care Act has made millions of low-income and rural Americans eligible for health insurance, many states don't provide dental coverage for adults under their Medicaid programs. Paying for dental insurance on the individual market or paying for dental services out of pocket is cost-prohibitive for Medicaid beneficiaries, many of whom are at or beneath the federal poverty level. So many have turned to EDs for such care.
The researchers said Medicaid dental coverage could help reduce the need for many low-income Americans to visit emergency departments for dental conditions that may have otherwise been prevented with adequate access to basic dental care.
"It is likely that EDs will continue to provide care to individuals without adequate access to community-based dental care unless new dental service delivery models are developed to expand access in underserved areas, and unless more dental providers begin to accept Medicaid under the ACA," the researchers wrote in their study, which was published today in Health Affairs.
Stanford is the prime contractor for the AHRQ for this multi-institutional research. Kathryn McDonald, executive director of Stanford's Center for Health Policy/Center for Primary Care and Outcomes Research, is a co-author of the paper and principal investigator of the study.
Difficulty finding dental care
From 2001 to 2008, emergency room visits for routine dental conditions -- such as cavities, tooth pain and gingivitis -- increased by 41 percent in the United States, while emergency room visits for all conditions rose by only 13 percent, the study said.
This is partly due to the lack of dental coverage under Medicaid in some areas, the shortfall of dental providers in rural communities and the dearth of dentists in urban areas willing to take on new Medicaid patients.
"Past research has shown that many dentists do not accept Medicaid," said study co-author Kathryn Fingar, a researcher at Truven Health Analytics in Sacramento. "Therefore people with Medicaid may find it difficult to get dental care in an office-based setting, even if they have dental insurance and even if there is an adequate supply of dentists in their community. In these instances, patients may need to use emergency rooms for dental problems, which generally can do little for patients seeking dental care except prescribe pain medications and antibiotics."
According to the American Dental Association, an estimated 8.3 million adults on Medicaid are eligible to gain expanded dental coverage under the Affordable Care Act.
"If these newly insured individuals cannot find a provider that accepts their insurance, emergency department use for dental conditions may not be reduced, even though access to dental insurance through Medicaid has increased," Fingar said.
The study examined county-level rates of emergency room visits for nontraumatic dental conditions in 29 states in 2010. They found that an adequate supply of dental providers was associated with lower rates of emergency room visits for dental care by patients with Medicaid in rural counties, but not in urban counties, where some 90 percent of dental emergency room visits occurred.
In urban areas, expanded Medicaid dental coverage did not appear to reduce dental emergency room visits despite an adequate supply of dentists. These findings suggest that even in states whose Medicaid programs offer expanded dental coverage, patients may have difficulty locating dentists who accept Medicaid. The rate of dentists who accept Medicaid has been reported to be as low as 11 percent in Missouri, 15 percent in Florida and 20 percent in New York.
"Faced with pressure to cut costs, some states have lowered Medicaid reimbursement rates for dental services, which reduces the incentive for dentists to participate in the program," the study said.
The recession that began in 2007 led to budget cuts and increased Medicaid enrollment. In response, many states cut Medicaid benefits in order to reduce expenditures, including expanded dental coverage for adults.
Some states, including California and Washington, have since reinstated nonemergency dental services, but access continues to be limited in other states. In 2012, fewer than half of the states provided expanded dental coverage to Medicaid patients who were not pregnant or disabled.
"Emergency department data can be used as a window into the health-care resources of a community," said McDonald. "And the dental part of the emergency department data could be useful to do comparative work and help identify potential strengths and weaknesses of that community's health resources."
As of January 2013, some 45 million Americans were living in regions with shortages of dental care providers, particularly in rural areas. In coming years, the national supply of dentists is expected to decrease further as many current dentists retire.
Value of preventive care
"The large number of visits to emergency rooms for dental conditions that could be treated in outpatient settings is indicative of the fact that our health-care system treats dental care differently than other preventive care when, in fact, dental care should be considered part of a person's overall health and well-being," said Maria Raven, MD, MPH, associate professor of emergency medicine at UCSF and the study's senior author.
"It should not be considered a luxury; it should be considered a necessity," she added. "Inadequate dental care has downstream consequences, including infection, need for costly extractions and important cosmetic consequences for patients."
The authors suggest several possibilities to reduce the number of emergency room visits for dental problems:
Establish on-site dental clinics in emergency rooms.
Expand dental coverage using less-expensive telehealth and mid-level dental providers who are not dentists, but trained to perform preventive and restorative care, such as fillings and minor extractions.
Incentivize payers or providers to offer or refer patients to preventive dental care, similar to colon and cervical cancer screenings routinely offered today.
"To implement these types of solutions, which may require alterations in the way dental services are bought and paid for in the United States, dental care must be viewed not as an optional add-on but as an integral part of an individual's overall health care," the authors wrote.
INFORMATION:
Information about Stanford's Department of Medicine, which also supported the work, is available at http://www.med.stanford.edu.
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