America Smiles: Restoring Access to Dental Care & Joining Dentistry and Medicine
A federal oral health policy concept draft
Matthew Horan, DMD, MPH
Problem Statement:
Dental pain and oral health problems are universally recognized yet not always managed efficiently by our existing national healthcare systems. Despite years of policy aimed at improvement, critical access to basic dental care remains a challenge, impacting nearly all American communities:
About 108 million people in the US see a medical provider each year, but not a dentist, and an estimated 27 million people see a dentist but not a medical provider. [1]
“In 2022, there were 1.6 million ED [emergency department] visits at a cost of $3.9 billion. The costs were driven by a 29% increase in the mean cost of an ED visit for NTDCs [non-traumatic dental conditions], from $1,887 in 2019 to $2,437 in 2022 — much higher than the average cost of a dental visit.”[2]
This $3.9 billion represents the estimated total cost of those ED visits, with Medicaid and Medicare enrollees alone accounting for nearly 60% of the total visits: 48.1% and 9.5%, respectively.
Medicare only covers dental care for a limited subset of seniors in America, leaving the majority without dental insurance. That’s up to 20% of our population or 69 million people.[3] As most seniors enter retirement, they must pay out of pocket and/or limit themselves to only emergency dental care.
For people living with any intellectual or developmental disability, including conditions like Autism Spectrum Disorder, accessing dental care can require facing nearly insurmountable barriers. Parents or caregivers must navigate coverage limitations, a shortage of providers, long appointment waitlists, limited access to operating rooms, and wasted time due to care coordination challenges.
For adults in general, about 72 million Americans lack dental insurance[4], and they must also choose to pay out of pocket, delay care, or seek dental care only for emergencies.
Additionally, 1 in 5 Americans, or 60 million people[5], are living in rural areas where many lack access to dental providers due to workforce maldistribution or geographic isolation.[6]
Dental and medical education, regulatory policy, practice, health records, and payment systems are still mostly completely separate. As a result, patients, providers, and payers face challenges in working together.
These system failures, rooted in historical practice, have created layers of systemic divisions that prevent Americans from receiving the most efficient care and achieving better oral and overall health outcomes.
Authority:
Our oral health challenges are federal in nature and require national solutions.
Through the Centers for Medicare & Medicaid Services (CMS) and gradual state-by-state efforts to expand Medicaid, American children have seen some improvements in oral health. Health Resources and Services Administration (HRSA) oral health programs have also made some progress in expanding access to care in rural and underserved areas and in supporting workforce development.
Despite the efforts of these federal agencies and several others, our current health systems cannot evolve further to address the remaining challenges without intervention to amend federal policy, as described below.
Intended Outcomes:
These policy changes aim to:
Reduce emergency department visits for dental issues (non-traumatic).
Improve access to dental care for all Americans.
Aid in meaningfully measuring and improving oral health outcomes for all Americans.
Be structured in a way to achieve budget neutrality via the paired reduction in avoidable emergency department utilization.
Key Policy Components to Achieve the Intended Outcomes:
“Dental EMTALA” - In medicine, the Emergency Medical Treatment and Labor Act (EMTALA) requires Medicare-participating hospitals with emergency departments to provide a medical screening examination to any individual requesting care, regardless of their ability to pay. We need a policy change to create something similar in dentistry, with dental professionals leading its creation, implementation, and ongoing maintenance.
When dental emergencies are managed in the medical emergency department, each visit averages about $2,400.[7] This ED-based care is also typically limited to managing symptoms (pain and/or infection) without addressing the underlying problem(s). Given that definitive dental care in a Medicaid-participating dental setting typically costs $300-500, this could save up to $2,100 per visit.
The per-visit potential savings give us a total budget of up to $3.4 billion, of which we can redirect much of the Medicaid/Medicare savings (about 60% of the total savings, or $2 billion) to help address existing oral health care access challenges without increasing overall costs to the care system. The total savings would phase in gradually.
Dentist participation as “emergency referral partners” for hospitals would be voluntary and linked to any participation with Medicaid or Medicare, as incentivized below.
The related expansion in dentists’ participation in Medicare will require assistance via a new CMS oral health support center.
Any eligible and participating dentists, including general dentists, recognized as oral physicians and essential providers, would be subject to “Dental EMTALA” and could participate as “emergency referral partners,” allowing them to directly bill medical insurance using existing medical billing and coding practices. They would have a limited scope of medical coding, confined within a defined subset of preventive and essential care services aligned with dental education and safe practice. These changes are critical for several reasons:
It establishes a more uniform way for dental providers to practice and document healthcare, aiding in more meaningful collaboration with medical peers.
It would require dental electronic health record systems to interact with medical systems, technologies, and payers in a bilateral, uniform, open, and comprehensive manner.
It would provide a pathway for dental professionals to use diagnostic coding, starting with the CPT code set that gets activated for participating dental professionals to bill medical payers.
It helps to maintain readiness in the event of future national emergencies.
This subset of medical codes, enabled for oral physicians, would be reviewed annually and updated to reflect the care needs of Americans. During annual reviews, CMS will emphasize the importance of recognizing that dentists can help address preventive care gaps to aid medical teams in achieving their improved-outcome goals.
Dental billing and coding would otherwise continue uninterrupted as it currently exists.
As managing dental emergencies in dental practices is more financially prudent, CMS would create and administer a dental emergency and essential services carve-out fund. This new carve-out is not a new mandatory appropriation, but a redistribution of Medicare/Medicaid savings from shifting emergency care from the medical to the dental setting.
Only those dentists who opted in and are treating community patients, regardless of their ability to pay, to resolve emergency oral health needs, would enroll and be eligible to bill the carve-out fund at a bundled care rate.
To qualify, dentists would need to use appropriate diagnostic coding and bill for these services via a standard medical claims process from their dental health records systems.
Over time, the total amount of the budgeted carve-out would include annual expenditure caps tied to documented reductions in federal spending on non-traumatic dental emergency department visits as monitored by CMS.
As essential partners, hospitals will be required and incentivized to expand or establish linkages with participating community dentists acting as emergency referral partners. Participating dentists who are also credentialled with Medicaid would access additional benefits:
A pathway for hospital privileging
An established number of operating room hours, based on community needs, for the management of dental patients with special care needs (neurological, intellectual, and/or developmental disorders) in exchange for mutually agreed in-patient and/or on-call coverage.
Scope:
Nearly all Americans would benefit from this policy change. If they or their loved ones are not personally affected by the change in dental access for emergency care, they will likely be affected by the newly established services permitted under the oral physician preventive and essential care scope.
–
We need federal lawmakers, national dental and medical associations, hospital systems, policy leaders within CMS, health economists, patient advocacy organizations, and other partners to collaborate to advance this framework into formal federal legislation.
This effort also still requires consensus building, developing performance metrics, setting federal program targets, and conducting an independent cost analysis.
The time has come to modernize federal health policy to restore access to essential dental services and formally align medicine and dentistry within our national healthcare framework.
References: