Every 18 minutes someone walks into an emergency room in Massachusetts seeking help for a dental problem, whether crumbling teeth or gum disease, that could have been handled as easily by a dentist.
The good news is that number, an average from 2019, was down significantly from two years prior. The bad news is that these patients continue to seek the most expensive treatment choice available when they visit the ER, and they layer costs upon an already burdened health care system in doing so. The irony is that many of these patients end up seeking costly treatment in the ER precisely because they have few other alternatives or resources.
Massachusetts must find a solution to this persistent problem — a point underscored again this past week in a report delivered to the state’s Health Policy Commission, whose job is to look for ways to reduce health care costs.
Good ideas are on the table. One of the most significant, endorsed by the Massachusetts Dental Society, would create a midlevel category of caregiver called a dental therapist. Working under the aegis of actual dentists, these therapists would be licensed to handle basic dental needs and procedures, mostly for underserved groups.
In addition, the commission endorses referral programs pointing patients from the ER to a dentist’s office, or telemedicine that would connect them to a dentist’s office remotely.
That people wander into the state’s emergency rooms in search of help with their teeth is no new phenomenon. A brief by the Health Policy Commission five years ago looked deeply into this issue and its root causes: “Obtaining oral health care is challenging for vulnerable populations in general, but low-income, non-elderly adults experience the greatest barriers to receiving oral health care,” it found.
Various factors contribute. Medicaid coverage for dental health is inconsistent among adults. For those lucky enough to have it, just 1 in 5 dentists across the country accept those policies. The ones that don’t cite bureaucratic hassles and low reimbursements rates as reason.
The net result is to funnel people without dental coverage into the ER when a problem arises. A paper published late last year in the Journal of Oral and Maxillofacial Surgery cited data logging 2.2 million such trips to ERs across the country in 2016 -- at an estimated cost of $2.4 billion.
Compounding the problem, the paper added, 9 in 10 of those patients did not get adequate care from the ER, “resulting in inadequate treatment at a higher cost relative to restorative dental care, additional burden on (emergency department) staff, and an increased likelihood of return to the (ER) for recurrent pain.” Put simply, had those patients just seen a dentist, their care would’ve been more cost effective, better suited to their condition and less likely to lead to a return visit.
Perhaps the tide is turning, in Massachusetts if not everywhere else. The recent report by the Health Policy Commission cited a 12.5% percent decline from 2017 to 2019 in ER visits for non-traumatic dental conditions.
But it also found the economic underpinnings of the 29,118 visits in 2019 haven’t changed: Two-thirds of trips to the ER for non-traumatic dental conditions that year involved patients with incomes below the median.
Alternatives for those patients have not come quickly. The dental therapist approach, for instance, has been sitting around for a while. Two years ago, lawmakers refiled a bill to create that category of clinician. The Massachusetts Dental Society backed the idea, provided it was buttressed by licensure and training requirements. It also noted it could only succeed as part of a “multifaceted approach” to improving access to dental health; education for community health workers, and enlisting schools to spread the word about the need for oral health screenings, were among the other steps.
“The ultimate solution needs to include more efforts related to prevention,” the society stated in written testimony to a legislative committee.
Alas, the legislation didn’t survive to become law before the end of the Legislature’s session. It has since been refiled, again, as H.1308 and S.743.
That idea, along with others from the Health Policy Commission, warrants prompt attention on Beacon Hill this time around. Easing the financial weight on hospitals and their ERs is critically important, though not as critical as connecting a large segment of the state’s population to reliable, affordable dental care.