1. Doctor, my tooth hurts: The cost of incomplete dental care in the emergency room By Elizabeth E. Davis, Ph.D. Amos S. Deinard, M.D., M.P.H. Eugenie W. H. Maiga University of Minnesota Presented at the American Public Health Association Conference, November 2007

2. Background Access to dental care remains a significant public health problem in the US: –Lack of dental insurance (44% of adults in BRFSS 1995 survey had no dental insurance) –Finding a dentist is an issue for those in public programs (16% dentist participation in Medicaid in North Carolina in 1998, as cited in Slifkin et al. 2004) As a result, many do not receive preventive dental care or restorative dental care and may postpone treatment until they have nowhere else to go other than a hospital emergency room (ER). ER care is costly and may be incomplete.

3. Objectives of the study Determine the frequency and estimate the charges of dental-related ER visits. Determine the frequency and estimate the charges of repeat visits to the ER for dental- related visits. Based on the results, demonstrate that ER care is costly and incomplete and discuss policy alternatives.

4. Related research Social cost of lack of access to regular dental care: –164 million work hours and 51 million school hours lost in the U.S in 1989 (Gift et. al, 1992) Costs associated with avoidable ER dental visits: –In 1997 Medicaid spent $1,686,565 on 62,000 avoidable ER dental visits in North Carolina (Slifkin et. al., 2004) –When the Maryland Medicaid program stopped reimbursing dentists for adult emergency services, a study found an increase of 12% in ER visits by adult Medicaid patients (Cohen et. al., 2002) –Pettinato et al. (2000) using data on Medicaid patients (children only) found that it is 10 times more costly to provide care to children admitted from the ER for dental-related problems than the estimated costs for preventive care.

5. Data Data were collected from 5 hospital systems (7 hospitals in total) in the Minneapolis-St. Paul metropolitan area and cover the period July 1, 2004 to June 30, 2005. Data collected include date of visit, age of patient, dental-related ICD-9 diagnostic codes, sources of payment, facility and physician charges, and frequency of repeat visits.

6. Definition of dental-related ER visit The hospitals were asked to identify visits with a primary diagnosis based on a list of ICD-9 codes selected in consultation with a dentist. The selected ICD-9 codes were intended to include visits most likely to reflect preventable dental problems or those related to lack of regular dental care. The selected codes were intended to exclude, as much as possible, dental diagnoses related to accidents or trauma, and dental conditions complicated by diabetes, HIV or other underlying chronic health conditions. Cases with a primary diagnosis of broken tooth (ICD-9 code 873.0), for example, were not included in the selected cases.

7. Analysis We computed the number of visits, total and average charges by hospital, by age group by hospital and by type of payor. We also computed the percentages of repeat visits by hospital. We grouped visits and charges into 4 categories of payors (public programs such as Medicaid and SCHIP, commercial insurance, Medicare and self-pay).

8. Results Table 1: Number of Dental-Related ER Visits and Total Charges by Hospital (between July 1, 2004 and June 30, 2005)

9. Table 2: Number of Dental-Related ER Visits by Age (between July 1, 2004 and June 30, 2005)

10. Table 3: Average Charges for Dental-Related ER Visit by Age Group (between July 1, 2004 and June 30, 2005)

11. Table 4: Repeat Visits for Dental-Related Problems (between July 1, 2004 and June 30, 2005)

12. Table 5: Charges for Dental-Related Visits by Type of Payor (between July 1, 2004 and June 30, 2005)

13. Summary of the results During a one-year period, the five hospital systems charged $4,743,519 for a total of 10,325 emergency visits to their emergency departments. The average charge per patient across all hospitals was $459 and the majority of patients were between 20 and 50 years of age. Roughly 20% of the patients had between 2 and 11 visits to hospitals ERs and the repeat visits represent about 40% of all visits. Across all hospitals, public programs paid for more than 55% of the charges and about 75% in two of the hospitals. The most common primary diagnosis was dental disorder NOS (ICD-9 code 525.9) followed by periapical abscess (ICD-9 code 522.5) and dental caries (ICD-9 code 521.0).

14. Discussion ER care is costly (nearly $ 5 million spent in one year) and is not definitive because ER physicians treat pain and infection but do not perform routine surgical procedures of dentistry (e.g., pull teeth or do root canals). Nearly 40% of the visits in the one-year period were repeat visits, suggesting that many of these patients could not get access to a dentist. The majority of care for dental-related ER visits was paid by public programs, which raises issues of cost-effectiveness. An urgent-care style dental clinic might be an alternative to costly ER care and could also address the issue of completeness of care. The large number of visits by children between 0 and 5 years of age raises concerns about long-run dental and health problems. Dental insurance and preventive care might be cost-effective for this group.

15. Conclusion Limitations of the study: –The data represent one metropolitan area in a single state, therefore the results are not generalizable to the whole country or to more rural areas. –We cannot guarantee that all visits were truly for preventable dental conditions because of the way the hospitals do their diagnostic coding. –Given data limitations, several assumptions had to be made about classifying the charges by payor type (distinction between public and commercial was not clear in all cases). Given the limited literature on dental-related emergency departments visits, this study provides unique information and may stimulate public policy discussion on an important public health problem.