Study finds use of hospital emergency departments for dental conditions increased after medicaid expansion in Kentucky

According to a study published in 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, Kentucky is also unique due to its well-documented success in program enrollment. Initially projected to add 188,000 new beneficiaries by 2021, Kentucky's Medicaid expansion led to 440,000 new enrollees receiving coverage once implemented. Although an extensive outreach program existed to help adults understand Medicaid benefits broadly and connect them with primary care options, 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. 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.

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. If the comprehensive adult dental benefit in Kentucky is eliminated, based on another state's previous experience, 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."

Article: After Medicaid Expansion In Kentucky, Use Of Hospital Emergency Departments For Dental Conditions Increased, Natalia Chalmers, Jane Grover & Rob Compton, Health Affairs, doi: 10.1377/hlthaff.2016.0976, published 5 December 2016.