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{ tooth & nail } 


Hospital dental clinics I


n 2013, several Missouri hospitals have begun to investigate putting dental clinics in their facilities to treat patients going to their emergency departments


for dental pain. Bringing the treatment of dental patients under the umbrella of services provided by hospital systems alarms and reminds me of the same process by which private medical offices and services were absorbed into the big hospital system model of care. Several groups are evaluat- ing patients who go to emergency rooms for dental pain. You can view a report by the Dental Advisory Board to the Greene County Health Commission where, as a member, I obtained some of the statistics following (go to www.modental.org/focusissues). Numbers of dental patients in ERs can be shocking when measured on a yearly or nationwide scale. When broken down to a day-to-day set of numbers for an individual clinic, reality may mean that emergency dental clinics in hospitals are not a good idea.


Before you can evaluate a solution for dental ER patients, you must first investigate the problem and the people you are trying to help. We need to know if dental clinics in emergency departments would work to ef- ficiently help people in dental pain at the ER in a cost effective way. Too often, there are false assumptions about dental ER patients. It is a fact that many people go to emergency departments at hospitals with dental pain as their chief complaint and do not receive definitive treatment. It is assumed that the ERs are inundated with dental patients. Thousands of dental patients a year go to emergency rooms, and they can account for 2.4 to 3.4 percent of all ER patients.


If the ER clinics see an average of 225 patients a day, that is fewer than six dental pain patients in a 24-hour period, 7 days a week. If you break it down even further to when pa- tients go to the ER, only 41 percent of dental


6 focus | JUL/AUG 2013 | ISSUE 4


patients went to the ER Monday through Fri- day between 8 and 5. If you employ one den- tist and one assistant 24 hours a day, 7 days a week to treat every single dental patient in an ER as they come in, they will see around 42 patients a week. The same employees, Monday through Friday 8 to 5, will see 17 or 18 patients a week. In my experience, in a dedicated emergency dental clinic, the magic number was 16 patients a day, or two an hour to operate at a minimal loss. In order to run a hospital dental clinic purely off of ER visit patients, you would have to successfully refer three out of four of all ER dental patients to a clinic that could be open only two days a week. I find it difficult to assume that many of these patients would accept referral to the hospital dental clinic.


Let us assume, for argument sake, you established the referral system and got the patients into the hospital clinic. It is assumed that the majority of ER dental patients are low-income and use Medicaid to pay for their hospital bill. This would mean that the imminent 2014 return of adult Medicaid coverage for extractions and exams will pay for some ER patients to have their painful teeth extracted. However, only 36 to 37 percent of ER patients with dental pain have Medicaid; 2014 will not see Medicaid expanded in Missouri, so we can expect levels to remain about the same for now. The largest payer group for dental pain patients in the ER is classified as self-pay, meaning individuals without Medicaid and no medical insurance. This group accounts for 42 to 46 percent of ER dental pain patients. No one will ever confirm this, but I would


not be surprised to find that “self-pay” may inevitably mean “no pay” for the hospitals. Rules in place dictate that a hospital must provide care to anyone needing emergency healthcare treatment regardless of citi- zenship, legal status or ability to pay (the Emergency Medical Treatment and Labor Act or EMTALA, passed in 1986). Reality could mean that barely more than one out of three patients will have limited Medicaid dollars for reimbursement, and almost half of patients might pay out of pocket for treat- ment, but they might not because they may not have to.


In my limited time at an emergency dental clinic, the magic number for production was around $200 an hour to operate at a minimal loss and pay for staff (a dentist, two assistants, front-desk person) and equip- ment/disposables. As a Medicaid provider, reimbursement would be fixed for around a third of all patients at what is estimated to be currently around 38 percent of UCR. Using our previous model of two days a week with two patients an hour, you would need to collect an average of $100 per pa- tient on some Medicaid money and mostly self-pay patients with a dentist and staff who only work part-time. With many patients not produc- ing $100, rates on self-pay patients would have to be more than $100, and would approach what


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