Framing the Issue
By the time they get to us, their mouths are bombed out." That's how Janine Costantini describes the state of many patients who visit the Dental Center at Children's Hospital Colorado in Aurora. "We have a very high volume of OR cases because at their first visit they have such extensive decay we can't treat them in the clinic," adds Costantini, the center's ambulatory practice director.
Demand for care is so great that the wait for an appointment at this safety net dental clinic runs between six and eight weeks.
In Seattle, the gap in care that developed after Washington eliminated Medicaid nonemergency dental coverage for adults in 2011 prompted Swedish Medical Center to launch a free dental program at its Community Specialty Clinic. Since it opened in January 2012, the three-day-a-week program has served 1,000 patients, and the numbers keep climbing, says Tom Gibbon, clinic manager.
The program focuses on difficult tooth extractions, usually necessitated by infection. "There's really no saving the teeth," Gibbon says. The wait for an appointment is more than three weeks. Because of demand, the dental clinic made plans to expand operations to five days a week last month.
These two hospitals are fighting at the front lines of a dental access crisis in the United States.
Several factors have combined to create the problem. The lackluster economy caused businesses to drop dental insurance or increase cost-sharing. At the same time, budget woes caused many states to eliminate or trim Medicaid dental benefits for adults, which are optional. Even when coverage is available, the rates often are so low that dentists are unwilling to take Medicaid patients.
As a result, millions of Americans, particularly those with low incomes, lack access to routine dental care. People with problems that could have been prevented or easily treated at the dentist's office wind up seeking care at the hospital emergency department. The number of ED visits for dental care nearly doubled from 1.1 million in 2000 to 2.1 million in 2010, according to the American Dental Association.
"The vast majority of the people I see in the ED related to dental issues have longstanding failure of basic dental prevention that leads to substantial decay and infection," says Bret Nicks, M.D., an emergency physician at Wake Forest Baptist Medical Center in Winston-Salem, N.C. Some patients have such bad infections that they require hospitalization.
Emergency physicians aren't qualified to extract teeth. They are able to ease patients' symptoms by treating pain and prescribing antibiotics, but can't solve the underlying problem, notes Nicks, who is a spokesman for the American College of Emergency Physicians. At Wake Forest, ED providers give the patients "the dental sheet" — a list of community dentists who accept Medicaid or provide a low-cost option.
The Affordable Care Act is expected to ease the crisis some, but not enough, the ADA reports. In states that expand Medicaid under the act, children will gain dental coverage, as will their elders in states where Medicaid includes adult dental benefits. In the insurance exchanges, adult dental coverage is not part of the essential benefits package. Plans operating in the exchanges will be required to offer pediatric dental coverage for children under 19, but families are not required to purchase the benefit.
Taking it to the community
Given the state and federal landscape, many hospitals are working to help fill the dental access gap. "The best solutions right now are the community partnerships whereby local institutions start looking at resources in the community, recognizing the need, and trying to coordinate all those things the best they can," Nicks says.
At Swedish Medical Center, the dental program grew out of a community needs assessment, Gibbon says. The hospital's Community Specialty Clinic already had strong relationships with local federally qualified health centers because it provides free specialty medical care to their patients. The health centers identified adult dental services as an unfilled gap in care. The health centers' dental directors worked with the specialty clinic to help shape the dental program.
Swedish's effort includes partnerships with Seattle Special Care Dentistry, which runs the program as part of its dental residency efforts, and Project Access Northwest, which handles case management for all the patients at the Community Specialty Clinic. Funding to build and outfit the dental procedure rooms, and to help support daily operations, is from a variety of sources, such as the medical center's foundation, Delta Dental, the local dental society and other sources. The clinic is located in a Swedish-owned building, so operational costs are spread across the system, Gibbon says.
Patients are referred to the dental clinic by primary care physicians, typically those at the federally qualified health centers. About 80 percent of the patients are uninsured, and the remaining 20 percent are on Medicaid.
Care is provided by four dental residents and 30 to 40 volunteer dentists and oral surgeons. The volunteer dentists are attracted to the dental clinic because they are committed to helping the low-income population, they can volunteer as much time as they want, and Project Access Northwest runs the program so well that the patient no-show rate is just 2 percent, Gibbon says. Also, dentists sometimes are able to shadow an oral surgeon in the clinic for CME credit.
The Swedish foundation and the local dental society pay the salaries of the residency program preceptors and dental hygienists. The state recently voted to reinstate Medicaid dental coverage for adults beginning in January 2014 but at only 20 cents on the dollar. "We'll get a little bit of money that will help pay for the preceptors and the dental assistants that we need in the clinic to keep it going," Gibbons says. For clinic patients who require dental surgery, the hospital donates OR time and physicians volunteer their services.
The dental initiative essentially is an ED diversion program. A study of emergency department visits before the dental clinic opened showed that 97 percent of the dental patients should not have been seen in the ED. "All the emergency physicians can do is treat for the infection and the pain," Gibbon says. "Then the patients cycle back. We had one patient who came through 11 times over 18 months for the same thing. Finally, when we had our clinic, the patient was referred here, we extracted several teeth that were causing the systemic infections, and the utilization stopped."
The clinic is on track to see 1,000 patients this year, almost all of whom would have been seen in an ED setting. The program saves the medical center money by providing an appropriate place for nonemergency dental care, thus preventing unpaid emergency dental claims. In the last two years, the Community Specialty Clinic as a whole saved $9 million, Gibbon says.
Efforts are under way to replicate the program or create something similar elsewhere in the state, says Gibbon, who is chairman of the Washington Free Clinic Association. Four or five volunteer dental programs have opened up in the last year across the state, he says.
A focus on kids
At the Children's Hospital Colorado, about 85 percent of the dental clinic patients are on Medicaid, and the rest are a combination of uninsured and underinsured patients.
The hospital is able to sustain the clinic by relying on pediatric dental residents, many of whom are licensed dentists coming back to specialize, Costantini says, adding that paying residents' salaries, as opposed to private dentists, makes the program financially viable.
The clinic, which averages about 33,000 visits each year, partners with community organizations such as Head Start and the Aurora Public Schools to reach underserved, at-risk children, many of whom are unable to obtain preventative dental care on a routine basis. Very often, by the time these children, even those as young as 1 or 2, are seen in a clinic, they have severe dental disease. Limited diets and harmful habits, such as putting a child to bed with a bottle or providing drinks with higher sugar content, increases the risk of tooth decay.
Often pediatricians don't realize the importance of early dental care. "A lot of primary care providers are saying children don't have to see the dentist until they're 3 or 4 or 5," Costantini says. "By that time, it's too late." American Academy of Pediatric Dentistry guidelines recommend that children have their first dental visit no later than age 1, and the American Academy of Pediatricians recommends that the first dental visit occur at age 1.
Cavities on baby teeth are not benign spots on teeth that will fall out anyway. "When there is an infection in the mouth, it is going to affect the secondary teeth if left untreated," Costantini explains. "You're also swallowing that bacteria every day, and that's going to affect your overall health."
Many kids who visit the 4,000-square-foot clinic need extra care. The department performs nearly 1,200 operative procedures under general anesthesia each year. The hospital reduces fees 35 percent for uninsured families who have to pay out of pocket and works with families to create monthly payment arrangements. "We don't want them to have to make a choice between putting dinner on the table and paying us," Costantini says. Some care is written off as charity. "We never deny treatment because the family can't pay."
Although the clinic helps to ease the dental access problem, it hasn't decreased the volume of ED visits for nonemergency dental problems. One reason is that some private dentists send their pediatric patients to the Children's ED when they're not available, Costantini says. "It's unfair to our residents because they are called at all hours of the night," she adds.
She has devised magnets and flyers for distribution at Head Start locations and many corporate dental clinics that explain when a dental problem warrants a trip to the primary care physician, when to go to the dentist, when to go to urgent care and when to go to the ED. She's also working with the local dental society to solve the problem.
Going where the need is
Not all dental access programs involve care at a clinic. Baystate Health fostered the creation of BEST Oral Health, run by the nonprofit Partners for a Healthier Community. The initiative, launched in 2005, offers on-site dental health education; screening; preventive services, including fluoride varnish; and treatment at early childhood education centers and elementary schools in the Springfield, Mass., area.
At each site, for the first six months, the program focuses on education and screening, provided by Tufts Community Dental Services, says Frank Robinson, Partners for a Healthier Community executive director and director of community health planning for Baystate. The second six months offers care from dentists from Commonwealth Mobile Oral Health Services.
The program is offered at 45 sites in Hampden County and serves between 5,000 and 7,000 children. They now get care in school, and the program's focus on early prevention and treatment often stops dental problems from occurring or from becoming severe enough to prompt an ED visit. "Hospitals can't solve the problem in the ED," Robinson says. "The solution has to be upstream."
— Geri Aston is a contributing writer to H&HN.
Assess needs, resources
A community needs and resources assessment is critical in finding and focusing on dental access gaps. Hospitals creating dental access programs can partner with existing community resources to reach the target population, coordinate services, create referral networks and obtain financial support.
One approach to developing a dental access program for an underserved population involves partnering with a dental residency program. This model gives residents the experience they need and hospitals the providers they need at a resident's salary, as opposed to a private dentist's salary.
Beyond the clinic
It is important to have a plan in place to handle extra needs of low-income patients. Some hospitals offer discounted services with payment plans. Others donate OR time for surgeons who volunteer their services. Others have relationships with community providers of free or low-cost services.
Although creating and maintaining a dental access program costs money, it saves money in the emergency department by creating a space to provide nonemergency dental service. It also helps patients because EDs can treat pain and infection, but they aren't able to fix the underlying dental problem causing those symptoms.
Building on success
Dental access programs can foster advocates for broader change. Champions of the BEST Oral Health program participated in a successful effort to establish Medicaid reimbursement for fluoride varnish application during well-child visits. Representatives from Swedish Medical Center's Community Specialty Clinic provided statistics and stories as part of the successful push to restore some adult dental coverage in Medicaid.
Lower-income Americans hit hardest
48% of lower-income* American adults have not seen a dentist in a year or more, compared with 30% of middle- or higher-income Americans.
47% of lower-income Americans have a family dentist, compared with 75% of middle- and higher-income Americans.
36% of lower-income Americans have lived with an untreated cavity, compared with 18% of their middle- and higher-income counterparts.
18% of lower-income Americans report that they or a household member has sought emergency department treatment for dental pain at some point in their lives, compared with 7% of middle- and higher-income Americans.
7% of lower-income adults have had all their teeth removed, compared with 3% of middle- and higher-income adults.
*Lower income is defined as those earning less than $30,000 annually.
Source: "The Dental Divide in America," an American Dental Association-sponsored survey of 1,200 adults in April 2013