Fall 2012

Will the Safety Net Hold?

When there’s no other care, hospital-based dental residents pick up the slack, but federal cuts could diminish their numbers

By Gail Bambrick

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Illustration: Richard Mia

Your child has never seen a dentist because you can’t afford to pay outright, and none of the practitioners in your area accepts the only insurance you have, Medicaid. Now she has a toothache and is in so much pain she can’t chew solid food and has missed school. You have just one choice: go to the hospital emergency room and pray there’s a dental resident on staff to treat her.

Across the country, this scenario is far too common. In 2009, for example, more than 830,500 Americans sought hospital treatment for preventable dental conditions, according to a Pew Center study. Now even this stop-gap emergency care could be at risk.

The portion of Medicare that finances residencies for both medical and dental students—the Graduate Medical Education (GME) fund—is in the line of fire as Congress determines how to cut $1.2 trillion from the federal budget over 10 years. The cuts were mandated when the congressional Joint Select Committee on Deficit Reduction, known as the “super committee,” failed in 2011 to agree on its own cost-cutting plan. Washington’s verdict on what will be axed will come in January 2013.

Should GME lose funding, the dental profession could be hard hit, because its slice of the approximately 98,000 total health-care residency positions funded each year is about 2,000 spots, says Huw F. Thomas, dean of Tufts University School of Dental Medicine.

“Dental residencies are serving those who are uninsured or on Medicare and Medicaid who have had limited or no preventative care,” says Thomas. “And residents also provide care for people with complicated medical conditions that must be treated either in a hospital on an outpatient basis.”

One hint as to what may be in store is a recommendation from the Simpson-Bowles Commission, a bipartisan panel created in February 2010 to recommend ways to reduce the federal deficit. That panel suggested a $60 billion cut in GME funding over 10 years. That could translate into the loss of 1,749 residency programs, representing 22,441 individual slots, according to a 2011 survey of hospitals that sponsor about two-thirds of all accredited U.S. residency programs. At least 12 states, including Massachusetts, would lose more than 500 residency positions, according to the survey, conducted by the Accreditation Council for Graduate Medical Education.

Reductions in the number of dental residencies could affect up to 48 percent of the U.S. population—some 152 million people whose access to dental care is already limited, according to a 2011 Census Bureau survey. That includes 50.7 million uninsured, 46 million on Medicare and 56 million on Medicaid, the Census report said.

A Threat to Care for All

It is also anticipated that 7.9 million children who are currently uninsured will become eligible for pediatric dental benefits under the Affordable Care Act, the landmark federal health-care reform law. “A reduction in federal funding for these residencies could become a major impediment to extending care to all Americans as the Affordable Care Act envisions,” Richard Valachovic, executive director of the American Dental Education Association (ADEA), wrote in the December 2011 edition of the organization’s newsletter. Dental educators must remain alert to changes that may be coming down the pike, he wrote.

Reductions in the number of dental residencies could affect up to 48 percent of the U.S. population—some 152 million people whose access to care is already limited.

In addition to providing care to patients with nowhere else to go but the ER, dental residents are equally critical to other kinds of dental emergencies that require specialized care in a hospital, says Mark Gonthier, executive associate dean at Tufts Dental School.

“Imagine you were hit in the face by a bat during a baseball game. You need to align the medical and dental responses to provide adequate treatment,” he says. And there are complex illnesses that require hospitalization, craniofacial surgery and other treatments, he notes. These might include patients with cancer, fibrous dysplasia (abnormal swelling of the bones) or any condition that might cause calcium deficiencies or hormonal imbalances that can lead to gum disease and weakened teeth and bones.

Each year about 30 percent of the 5,000 U.S. dental school graduates pursue a residency. (With the exception of New York state, residencies for dentists are not required.) About half of them choose the General Practice Residency (GPR), working in hospitals with ER patients or those with conditions requiring hospital services. At Tufts, 41 percent of the class of 2012 chose to pursue residency training, with 17 percent opting for the one-year GPR program.

The cuts mandated by the 2011 Budget Control Act that resulted from the failure of the super committee will go into effect on January 2. Even after that, there will be a flurry of legislative activity to remove or alter all or parts of the bill for as long as a year, predicts Yvonne Knight, senior vice president for the Advocacy and Governmental Relations Policy Center at ADEA.

How ADEA will proceed to lobby against GME funding cuts will depend on the outcome of the November elections, the party makeup of the House and Senate and what kinds of legislation are proposed, Knight says. “Pronouncements as to what will happen at this point would be pure speculation,” she said in an interview before to the elections.

It’s still too early to assess the impact of any GME reductions on dental residencies because hospitals receive GME funding and decide how many residencies to offer and in which health-care specialties, Knight said. She did note, however, that ADEA is working with the American Dental Association and other health organizations, including the large and powerful hospital lobbies, to assess all the possible scenarios. “Right now, it is just wait-and-see,” she says.

Gail Bambrick, a senior writer in Tufts’ Office of Publications, can be reached at gail.bambrick@tufts.edu.


The Cost of ER Dentistry 


On any given day a typical hospital emergency room will see its fair share of broken bones, chest pain or cuts and bruises. Increasingly, the ER will also treat an adult or child with a toothache.

In just one three-year period, from 2006 to 2009, the number of emergency room visits in the U.S. for preventable dental conditions rose 16 percent, according to a study released earlier this year by the Pew Center on the States, a nonpartisan research and advocacy organization. In 2009, 830,590 people visited the ER for preventable dental problems, at a cost running into the hundreds of millions of dollars, much of which ends up being charged to Medicaid and other public insurance programs.

Most patients who seek relief from oral pain at the ER do so because they have no other access to dental care: They lack dental insurance or the means to pay out-of-pocket, cannot find a dentist who will accept Medicaid or live too far from a health center that offers dental services, the Pew study says.

Lack of access to care is not a new phenomenon, says Mark Nehring, the Delta Dental of Massachusetts Professor in Public Health and Community Service at Tufts Dental School and a 30-year veteran of the federal public health system. He remembers cases such as the man who, unable to stand the pain of an infected tooth and unable to afford treatment, tried to extract the tooth himself with a pair of automotive pliers, breaking it off at the gum line.

“There has been an access issue for some time,” he says. “But it’s the severity of the disease—the pain and the quality-of-life issues—that are bringing more people to the ER.” Among very young children, for example, there has been an increase in untreated tooth decay, he says. In children and adults, a combination of factors, including poor oral hygiene and excessive consumption of highly refined starchy foods, carbonated or acidic beverages and highly sweetened, gummy snacks are the likely culprits for the rise in severe disease, he says.

With more severe oral disease comes a greater chance of  infection. “It’s this type of pain that results in a swollen face, pain to the point where you have to find some solution, and then the only place to go is the hospital.”

Regrettably, “the emergency room is not a very good place to go for tooth pain,” Nehring says. Often the underlying dental problems cannot be addressed, especially if the hospital does not have a dental residency program. “All the ER doctors can do is offer some medication to ease pain and antibiotics to combat infection, but that’s just relief,” Nehring says. “In the absence of treatment, once the medication regimes are completed, the pain and infection will come back, and it’s an ongoing cycle. And while uncommon, it can be life-threatening.”

The cycle is also costly. In New York state, for example, the cost of treating young children for decay-related ailments in ERs or ambulatory surgery centers increased from $18.5 million in 2004 to $31 million in 2008, according to the Pew report. Florida recorded 115,000 ER visits for children and adults with dental problems in 2010, at a cost of $88 million.

ER treatment for an abscessed tooth costs Medicaid an average of $236, while the same problem treated in a dental office would cost Medicaid $107, according to the American Dental Association’s South Carolina affiliate. And if patients can receive preventive care so that an abscess never develops in the first place, it would cost approximately one-tenth of what ER care does, according to a 2000 study in the journal Pediatric Dentistry.

“Delaying care only results in higher expenses later on,” Nehring says, not to mention the human costs. “For children, in particular, we’re talking about school days missed and compromising their readiness to learn.”

—Helene Ragovin


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