Study Finds Use of Hospital Emergency Departments for Dental Conditions Increased After Medicaid Expansion in Kentucky
For largely preventable conditions, results signal need for additional outreach efforts
BOSTON – According to a study published today in the December issue of Health Affairs, increased access to adult dental coverage through Medicaid exposed a largely unmet need for oral health care services in Kentucky and the potential implications when this care is sought in hospital emergency departments (EDs) instead of through a dental provider. Following the state’s expansion of Medicaid and addition of an adult dental benefit on Jan. 1 2014, researchers found that the newly-eligible population was in poorer oral and general health compared to previously covered beneficiaries and faced challenges accessing the dental health care delivery system. The findings point to the need for educational outreach and other access improvements in addition to coverage.
In the study, “After Medicaid Expansion In Kentucky, Use Of Hospital Emergency Departments For Dental Conditions Increased,” authors Dr. Natalia Chalmers, director of analytics and publication at the DentaQuest Institute; Dr. Jane Grover, director of the Council on Advocacy for Access and Prevention at the American Dental Association (ADA); and Dr. Rob Compton, president of the DentaQuest Institute, explored the costly use of EDs for treatment of dental needs, many of which could have been prevented.
Using data from the State Emergency Department Databases of the Healthcare Cost and Utilization Project, the Kentucky Cabinet for Health and Family Services, the Area Health Resource Files, and the Commonwealth of Kentucky, the researchers found:
- From 2013 to 2014, the number of adult Medicaid discharges for conditions related to dental or oral health in Kentucky increased from 6,328 to 18,884, while the number of discharges for the uninsured decreased from 20,453 to 7,796.
- Among adult Medicaid enrollees, the proportion of discharges for conditions related to dental or oral health that could be classified as preventable with primary dental care rose from 22 percent in 2010 to 33 percent in 2014.
- The share of Medicaid enrollees discharged for a condition related to dental or oral health who also had a chronic comorbid condition – like tobacco use or diabetes – increased from 41 percent in 2010 to 51 percent in 2014.
- From 2013 to 2014, inflation-adjusted costs for ED discharges for adults with Medicaid and conditions related to dental or oral health increased by over $4.2 million or 219 percent.
“In a state where – according to the ADA’s Health Policy Institute – 1 in 5 low-income adults said their mouth and teeth were in poor condition, this increased use of EDs for dental care likely stems from unmet oral health needs that can also greatly affect overall health,” Dr. Chalmers said. “While expanding coverage is an important first step in improving health outcomes, our findings suggest that this must be paired with appropriate support to increase opportunities for beneficiaries to more easily access the right dental care from the right provider.”
One of only 12 states to include adult dental coverage as part of its Medicaid expansion,1 Kentucky is also unique due to its well-documented success in program enrollment.2-6 Initially projected to add 188,000 new beneficiaries by 2021, Kentucky’s Medicaid expansion led to 440,000 new enrollees receiving coverage once implemented.7 Although an extensive outreach program existed to help adults understand Medicaid benefits broadly and connect them with primary care options,8 the researchers did not find evidence that similar efforts existed for dental coverage. That finding suggests outreach targeting dental health may reduce inappropriate use of EDs for preventable oral health conditions.
“While research shows that states should anticipate at least some initial increase in the use of the ED for dental care after adding a Medicaid benefit, strategies must be implemented to better connect members with providers, increase oral health education and ensure that ongoing, routine care focuses on prevention rather than the palliative treatment received in the ED,” Dr. Grover said. “At the same time, an influx of members can strain the delivery system, so states should consider solutions that encourage and incentivize greater provider participation, thus better aligning coverage with access.”
Researchers also point to evidence suggesting the increase in ED discharges for conditions related to dental or oral health may be temporary, as ED visits for all conditions decreased in low-income Kentuckians in 2015.4,9 Other states have seen the use of the ED and safety-net clinics decrease with Medicaid expansion when consumer education is comprehensive and capacity is sufficient.4,10
The study comes at a key time for Kentucky’s Medicaid program. In August 2016, Gov. Matt Bevin applied for a section 1115 waiver that proposes eliminating the adult Medicaid dental benefit as it currently exists and replacing it with a rewards account enabling members to accrue funds for this and other types of coverage.11 If the comprehensive adult dental benefit in Kentucky is eliminated, based on another state’s previous experience,12 this may lead to additional immediate increases in dental ED visits, resulting in higher annual costs for Medicaid.
“We cannot forget that the need to improve the oral health of Americans remains critical,” Dr. Compton said. “As Medicaid and other public health insurance programs continue to evolve, and policymakers assess the future of these programs nationwide, we hope this study demonstrates the many factors that can bolster access to care and the need to more collectively align efforts to achieve the Triple Aim of better health outcomes, lower costs and better patient experience.”
The full study can be found in the December Oral Health issue of Health Affairs. On Dec. 7, 2016, the publication will also host a forum in Washington, D.C., where panelists will be discussing these findings and other papers from the December issue. Visit Health Affairs’ website to learn more, and follow the event live via Twitter @Health_Affairs using #OralHealth.
About the DentaQuest Institute
The DentaQuest Institute (www.dentaquestinstitute.org) is a not-for-profit organization focused on improving efficiency, effectiveness and quality in dental care. Through its work to align clinical practice with science-based research, the DentaQuest Institute is helping oral health professionals find new ways to partner with patients to prevent and manage oral diseases. This work ensures patients get the right care, at the right time, with the right outcome. The DentaQuest Institute is an affiliate of DentaQuest (www.dentaquest.com), a leading U.S. oral health enterprise.
1 Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion [Internet]. Chicago (IL): American Dental Association; 2014 Feb [cited 2016 Oct 21]. (Health Policy Institute Research Brief). Available from: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0214_1.ashx.
2 Witters D. Arkansas, Kentucky see most improvement in uninsured rates. Gallup [serial on the Internet]. 2015 Feb 24 [cited 2016 Oct 21]. Available from: http://www.gallup.com/poll/181664/arkansaskentucky-improvement-uninsuredrates.aspx.
3 Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. 2015;314(4):366–74.
4 Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Intern Med. 2016;176(10):1501–9.
5 Sommers BD, Blendon RJ, Orav EJ. Both the “private option” and traditional Medicaid expansions improved access to care for low-income adults. Health Aff (Millwood). 2016; 35(1):96–105.
6 Benitez JA, Creel L. Kentucky’s Medicaid expansion showing early promise on coverage and access to care. Health Aff (Millwood). 2016; 35(3):528–34.
7 Miller SP. Statement of Stephen P. Miller, commissioner, Department of Medicaid, on Medicaid Transformation, before the Interim Joint Committee on Appropriations and Revenue [Internet]. Frankfort (KY): Joint House and Senate Committee; 2015 Jul 23 [cited 2016 Oct 21]. Available from: http://www.klsreports.com/ShowDocument.aspx?CDocID=4983.
8 Rosenbaum S, Schmucker S, Rothenberg S. Will Kentucky roll back its Medicaid expansion? [Internet]. New York (NY): Commonwealth Fund; 2016 Jul 8 [cited 2016 Oct 21]. Available from: http://www.commonwealthfund.org/publications/blog/2016/jul/will-kentucky-roll-back-its-medicaid-expansion.
9 Sommers BE, Epstein A, Orav EJ, Blendon R, Medicaid expansion, the “private option,” and changes in utilization and health. Paper presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
10 Angier H, Hoopes M, Gold R, Bailey SR, Cottrell EK, Heintzman J, et al. An early look at rates of uninsured safety net clinic visits after the Affordable Care Act. Ann Fam Med. 2015;13(1):10–6.
11 Ky.gov. Governor Matt Bevin submits innovative, transformative plan to improve health outcomes to federal government [Internet]. Frankfort (KY): Kentucky Cabinet for Health and Family Services; [last updated 2016 Aug 24; cited 2016 Oct 21]. Available from: http://chfs.ky.gov/dms/kh.
12 Singhal A, Caplan DJ, Jones MP, Momany ET, Kuthy RA, Buresh CT, et al. Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs. Health Aff (Millwood). 2015;34(5):749–56.