Case Study: Poor Resource Allocation Puts Medicaid Patients at Risk

We’ve all seen patients we wish would have sought care sooner, when their dental issues would have been less expensive to treat, with less discomfort for the patient. Unfortunately, current funding of Medicaid Dental fee-for-service care is limiting access to oral healthcare for the roughly 20 percent of Michigan adults who are covered by Medicaid. Poor resource allocation causes patients to seek dental care later when treatment is more involved, in many cases unnecessarily diverting care to a higher cost environment.

To draw attention to this issue, Richard W. Panek, DDS, MS, an oral surgeon at the Center for Oral Surgery and Dental Implants, authored a case report that was published in the October 2019 issue of the Journal of the Michigan Dental Association. The featured case highlights the adverse outcomes that can result from limited access to routine dental care for adults covered by Medicaid. Dr. Panek makes a compelling case for increasing the Medicaid Dental fee schedule to improve access to care and reduce overall healthcare costs.

A toothache becomes an emergency

J.N. is a 24-year-old male who was referred from War Memorial Hospital in Sault Saint Marie, Michigan, to Spectrum Health Butterworth Hospital in Grand Rapids for treatment of an impending Ludwig’s angina. Ludwig’s angina is an infection of the neck that has the potential to cause airway obstruction and death. Most cases are caused by dental infections, and this patient had a history of inter­mittent pain associated with tooth #31 for several weeks before seeking medical care, as well as swelling around that tooth that extended under the right jaw bone.

The patient did not seek treatment with a dentist due to lack of dental benefits and financial resources, but did go to a local urgent care medical center. He was empirically started on oral clindamycin, with improvement in the swelling around the tooth; however, swelling under the lower jaw persisted. He subsequently went to a dentist who referred him directly to the Emergency Department (ED) at War Memorial Hos­pital.

In the ED, the patient was found to have a fever and an increased white blood cell count indicative of systemic infection. He had no difficulty breathing but did have pain with swallowing. A CT scan revealed submandibular region abscess and necrosis with extension into the tongue. He was started on IV clindamycin.

The advanced stage of the patient’s condition required multidisciplinary medical management that was un­available in the Upper Peninsula or the Northern Lower Peninsula of Michi­gan, so transfer was arranged and the patient flown 300 miles by helicopter to Grand Rapids.

Evaluation and treatment

The inpatient oral surgery consul­tation revealed a firm, tender, non-fluctuant swelling of the submental area with extension into the bilateral submandibular areas. The patient was able to open his mouth normally, but oral evaluation showed elevation of the floor of the mouth with a raised and swollen tongue. The back of the patient’s throat was not visible due to the tongue swelling. The patient could only swallow his saliva when sitting upright. There was no limitation of neck extension or flexion, and the swelling was limited to the area un­der the lower jaw. Dental examination showed caries to the pulp on tooth #31, which was the tooth the patient indicated as the source of his past pain and current infection.

The patient was scheduled for urgent extra-oral incision and drainage of the submental, bilateral submandibu­lar and sublingual spaces, and tooth extraction. Tooth #31 was extracted, and a dressing was placed over the incision and drainage site.

The patient recovered from an­esthesia and was transferred to a regular hospital room. The microbi­ologic report identified Haemophilus parainfluenza, which was resistant to clindamycin. The patient was subsequently started on IV ampicillin-sulbactam, 3 grams every 6 hours. Drainage resolved and the patient was discharged from the hospital after four days.

Commentary: Costlier care and more risk for patients

This report is just one example of how untreated dental disease can put patients at risk. Ironically, the pa­tient had adequate coverage for the nec­essary treatment in the medical sys­tem, but inadequate finances and lack of access to routine dental care that could have prevented hospitalization. Ultimately, this forced the patient from comparatively lower cost early dental intervention into a much high­er-cost, hospital-based treatment en­vironment. Air ambulance transport is estimated to cost $6,000 to $13,000, and in-patient surgical treatment with four days of hospitalization totals more than $11,000.1,2Appropriate dental care to remove the tooth as an outpatient (before the problem esca­lated to the point of infection) would have cost less than $500 in a private dental practice.

How common are cases like this? Dr. Panek analyzed 2015–2016 system-wide emergency department and admission numbers for Spectrum Health, an integrated healthcare system with nine affiliated hospitals in the West Michigan region. He found that more than 7,000 patients per year sought care at Spectrum for oral health prob­lems. During the same time period, more than 120 patients were admitted to the hospital for oral health problems, with a typical one- to two-day length of stay. Although some of these encounters were for traumatic problems, the majority of the cases were toothaches and dental abscesses.

Spectrum’s global per-patient inpa­tient charge for the Cellulitis Diagno­sis Related Group (DRG) is more than $11,000, with Medicaid paying just un­der $6,000.2 In 2011, Michigan hospitals were paid $15 million to treat prevent­able dental problems. That’s only about a quarter of what hospitals say was their actual cost of providing the care.3 The average outpatient ED charge for a dental emergency is estimated nation­ally to be $760; the average charge for a dental examination, routine X-rays, and cleaning is a little less than $235.4

It’s well established that lack of adequate dental coverage leads to increased ED and in-patient hospital care. Increasing Medicaid benefits for dental care would decrease Medicaid expenditures on the medical side. This case report is an excellent example. Had the patient had access to routine dental care, he would likely have accessed the oral healthcare system earlier, thereby prevent­ing the development of the infection and avoiding the costly medical care that became necessary. 

Michigan Medicaid fee-for-service reimbursement is 62 percent of the national average.5 Most participating dentists are losing money treating Medicaid patients at 38.5 percent of the private insurance reimbursement rate. Despite this, Michigan dentists participate with Michigan Medicaid at an above-average rate compared to dentists in other states.

We encourage you to help advocate for greater Dental Medicaid funding by contacting your state representative and senator. This can be as easy as signing up for MDA legislative text alerts. Simply text “MDA” to 52886. Your efforts will help to create a healthier Michigan.

Read the full article (page 34) to learn more about this case and to read further analysis of issues surrounding Michigan Medicaid’s low reimbursement for dental fee-for-service care.


References

  1. Air Ambulance/Data Collection and Transparency Needed to Enhance DOT Oversight. GOA report to the Committee on Transportation and Infrastructure, US House of Representatives. https://www.gao.gov/assets/690/686167.pdf.
  2. https://www.spectrumhealth.org/about-us/average-prices.
  3. Report: Preventable dental problems costing Michigan ERs. Retrieved from https://www.andersoneconomicgroup.com/report-preventable-dental-problems-costing-mich­gan-ers/
  4. Nallia, R. Opinion | To improve health, boost Medicaid dental reimbursement rates. Bridge Magazine. June 25, 2019.
  5. American Dental Association. Medicaid Fee-for-Service (FFS) Reimbursement and Provider Participation for Dentists and Physicians in Every State. Health Policy Institute Infographic. 2017. HPIgraphic_0417_1.pdf.

Map Notes

Source for U.S. map data: Center for Health Care Strategies, Inc. Medicaid Adult Dental Benefits: An Overview. Fact Sheet January 2018. Available from: https://www.chcs.org/media/Adult-Oral-Health-Fact-Sheet_011618.pdf. DC is included as a state. North Dakota offers different categories of benefits to its Medicaid base vs. expansion populations. Idaho offers limited Medicaid dental benefits beyond emergency care to pregnant woman and adults with disabilities and/or other special health care needs. Maryland’s contracted managed care organizations provide a limited dental benefit to adult Medicaid beneficiaries who are enrolled in managed care.