ED Dentists: Why isn't this a thing?

[deleted6669]

Don't get me wrong, I am happy to see folks with legit dental emergencies that require acute interventions, but the endless this tooth hurts, I am out of pain meds, I can't see a dentist, etc gets old. I know small places(like everywhere I work) could not support a dentist in the ED, but what about busy places? Dental procedures pay well. Why not have a dental fast track at every level 1 and 2 trauma center? Hospitals would make money, ED providers would be happy not to deal with meth mouth, patients with legit dental issues would get seen right away and those with BS wouldn't get narcs. Win/win. Has this been tried anywhere? I know there are free standing dental emergency clinics that only take cash and good insurance, but what about the vast majority of folks with state insurance and dental issues? This seems like a no brainer. Maybe 2p-midnight 7 days/week. I bet a dentist at a busy place would see 20-30 pts in those 10 hrs. They would more than pay for their time and make the hospital a chunk of cash.

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[skougess]

You misspelled “lose the hospital a chunk of cash.” The people who come to the ED with dental complaints have to be among the worst reimbursers in the entire health system. Way cheaper to have an ED doc say “no emergency here; discharge.”

 

[gamerEMdoc]

How would hospitals make money? Even a busy ED probably only sees a few dental visits a day. How many truly need to see a dentist that day? One a week? Almost every dental complaint coming to the ED, not all, but almost every one, can be temporarily treated by the ED staff. Paying a fulltime dentist to be in the ED 24/hrs a day to maybe see anywhere from 2-5 dental pains a day... thats gonna cost you way more money than just temporizing things and sending them out.

The closest thing to this is a dental residency. There are sometimes dental residencies attached to hospitals, where the residents can get called out of clinic to come and see a patient in the ED. I've worked at two such places before. Its a luxury, but tbh most of the time the patient still was just temporarily treated in the ED and sent to the dental clinic as an outpatient.

 

[deleted6669]

I have worked at several level one and two trauma centers over the years and only wish I saw just 2-5 dental complaints/shift. That is what a lot of fast tracks are full of. Maybe the physicians are not seeing them, but the PAs/NPs sure are. A dentist could bill for sedation, dental extractions, dental blocks etc. Even medicaid pays ok for these. I have worked at places with OMF residencies, but those folks only wanted to see stuff that needed emergent OR interventions, not the run of the mill dental issues.

 

[The Knife & Gun Club]

We’ve got 24/7 dental coverage at our academic site. They’ll happily come down and schedule people in the resident clinic for urgent follow up, but you’ve gotta pay your $20 co-pay if you want the tooth fixed. That ends up being too steep for most of the people seeking dental care in the ED. Hence why it’s not more common.

It is kinda neat though, they can teach you a lot about the intricacies of teeth, dental pain, and every once in a while, management.

 

[deleted6669]

We’ve got 24/7 dental coverage at our academic site. They’ll happily come down and schedule people in the resident clinic for urgent follow up, but you’ve gotta pay your $20 co-pay if you want the tooth fixed. That ends up being too steep for most of the people seeking dental care in the ED. Hence why it’s not more common.

It is kinda neat though, they can teach you a lot about the intricacies of teeth, dental pain, and every once in a while, management.

Must be nice. I posted this on the dental forum and got this helpful response:

What you want at your hospital is a GPR. The General Practice Residency (GPR) is an intensive postgraduate training program fully accredited by the Commission on Dental Accreditation. The program is designed to train the general dentist in the management of medically complex and special-needs patients in both outpatient and hospital settings, while increasing knowledge in the practice of dentistry and its various disciplines.

The GRP residents would cover your Emergency Department as well as dental problems for the whole hospital. (The Cardio and Ortho departments love GPRs because they can clean up bad dental problem prior to surgery to avoid post-op infections.) Once you have a GPR in place you will find your dental problems disappear. All those repeat dental customers get fixed perennially. Those facial infections are not nearly as bothersome when you can get a dentist into look it over. Those dental pain problems that in your heart you know they are drug seekers have to put up or shut up with a GPR in the hospital.

I believe there are 175 hospitals with these programs around the country. Maybe you can get sell your hospital on starting anew one.

 

[yappy]

How do these patients who cannot afford $20 co pay afford the ED visit?

 

[DeadCactus]

Don't need a dentist in the ED. Need ready access to sliding-scale dental care in the community but for historical reasons we treat dental care as something different from medical care and so it falls outside many of the social safety nets even though it would ultimately likely save a lot of money.

How do these patients who cannot afford $20 co pay afford the ED visit?

Because an emergency department that bills Medicaid must abide by EMTALA meaning patients cannot be turned away on the basis of ability to pay without being evaluated and treated for medical emergencies. This could be done by history and exam alone but frequently a thorough evaluation is done because no one wants to send a patient home when they do have an acute problem. Clinics, dental offices, optometrists, and most other healthcare services are not bound by this regulation.

 

[EctopicFetus]

This is too funny. Anyone who thinks people with dental issues have insurance. Most dentists dont take Medicaid Or medicare And in many states it isnt even covered at all.

I can pay and my dentist will see me same day if i need. If less emergent will see me within 24 hours for sure.

 

[deleted6669]

This is too funny. Anyone who thinks people with dental issues have insurance. Most dentists dont take Medicaid Or medicare And in many states it isnt even covered at all.

I can pay and my dentist will see me same day if i need. If less emergent will see me within 24 hours for sure.

They don't have insurance, they have medicaid. Pretty sure that pays for dental care.
People with good jobs don't go to the ED for dental pain. They have dentists. Mine will see me same day as well.
A few hrs into my shift at a rural, critical access hospital and I have already seen 3 patients with dental pain today. If I was at my old trauma center job that number would probably be 5-6.

 

[dadaddadaBATMAN]

They don't have insurance, they have medicaid. Pretty sure that pays for dental care.
People with good jobs don't go to the ED for dental pain. They have dentists. Mine will see me same day as well.
A few hrs into my shift at a rural, critical access hospital and I have already seen 3 patients with dental pain today. If I was at my old trauma center job that number would probably be 5-6.

Your shops have not been the norm. Have worked in 8-10 different departments, some single coverage, and some without any pa coverage, never been in a place with more than 2-3 per day.

Having said that, everything seems to come in streaks. Also most dental pain patients are not daywalkers

Maybe it’s because you’re in a more math oriented place, or maybe because local practice patterns include opiates (unless it’s obvious fresh break I dont do this, neither do my colleagues).

 

[deleted6669]

Your shops have not been the norm. Have worked in 8-10 different departments, some single coverage, and some without any pa coverage, never been in a place with more than 2-3 per day.

Having said that, everything seems to come in streaks. Also most dental pain patients are not daywalkers

Maybe it’s because you’re in a more math oriented place, or maybe because local practice patterns include opiates (unless it’s obvious fresh break I dont do this, neither do my colleagues).

It might be regional. There is a LOT of meth, even among elderly pts, everywhere I have worked the last 20 years( 8 depts in 2 adjacent states). . I am also stingy with opiates for dental pain. I do a lot of dental blocks.

 

[Zebra Hunter]

I've mostly stopped doing dental blocks mainly because it screws over my partner when the patient checks back in the next night asking for a dental block again which seems to happen all the time with these patients. Most of these patients have had dental pain for weeks to months. They get tylenol and ibuprofen, maybe a toradol shot, information to the local dental school clinic, and discharged immediately.

 

[sylvanthus]

Are there dental midlevels?

 

[d2305]

I've tried to get these patients seen at dental schools with limited success.

 

[emergentmd]

That is almost like saying why don't all hospitals have a trauma team, doesn't it pay well. Sure if they have insurance but the dude that has a bullet in the belly most likely is unbanked and uninsured.

 

[Saddleshoes]

They don't have insurance, they have medicaid. Pretty sure that pays for dental care.
People with good jobs don't go to the ED for dental pain. They have dentists. Mine will see me same day as well.
A few hrs into my shift at a rural, critical access hospital and I have already seen 3 patients with dental pain today. If I was at my old trauma center job that number would probably be 5-6.

Dental medicaid is state dependent.
In my state the reimbursement rates are so low that most dentists lose money caring for medicaid patients. That and the burdensome regulations involved have caused 95% of the dentists in my state to refuse all adult medicaid patients. --SO-- They end up in the emergency department because they have no other options.

(BTW Low dental medicaid reimbursement, dental care in community health care clinics is often a big financial loser too.)

 

[RoyBasch]

You misspelled “lose the hospital a chunk of cash.” The people who come to the ED with dental complaints have to be among the worst reimbursers in the entire health system. Way cheaper to have an ED doc say “no emergency here; discharge.”

Basically this.

It's a money issue.

Dental ER patients almost uniformly have no insurance and no money.

People who have money and a dental emergency usually actually can see a real regular dentist quite expeditiously and do not wind up in the ER.

One exception, when I was in residency the children's hospital actually did have regular pediatric dentists on call (not OMFS) for handling routine dental emergencies. Since the patient's are all children by definition (children's hospital) they all either had medicaid or SCHIP so there was some payor source if the parents did not have cash or commercial dental insurance.

 

[RoyBasch]

That is almost like saying why don't all hospitals have a trauma team, doesn't it pay well. Sure if they have insurance but the dude that has a bullet in the belly most likely is unbanked and uninsured.

Trauma can be a money maker though.

There are state subsidies for hospitals with a trauma program.

Also having a trauma team allows you to bill for "trauma activations" on patients and rack up huge bills (one hospital in our area that is a level 1 trauma center charges $20,000 once that TRAUMA ALERT button is hit on top of any other consults, imaging, etc.).

Yes a lot of trauma patients (particularly penetrating) are under/no insurance/pay but if you can really soak the ones who do have insurance the no pay patients are kind of loss leaders.

Also motor vehicle trauma usually has a deep payor source from car insurance companies even if the patient has no health insurance.

One community trauma center I worked at, trauma activation did almost nothing (surgeon and anesthesia not present anyways) compared to just seeing the patient as a high acuity patient and moving them through their workup fast (like you would do with any patient you were legitimately worried about). Maybe XR would show up stat with a portable unit (great...) They still charged their insurance another $15,000 for "trauma activation" on top of the regular billing. Of course, to maintain trauma certification the hospital has to be a "trauma center" on paper. But the point is, it can be worth it for them financially to jump through a few hoops (on paper have a trauma surgeon on call, make the ER physicians take ATLS, RNs with ACTN, etc. )

 

[The Knife & Gun Club]

Trauma can be a money maker though.

There are state subsidies for hospitals with a trauma program.

Also having a trauma team allows you to bill for "trauma activations" on patients and rack up huge bills (one hospital in our area that is a level 1 trauma center charges $20,000 once that TRAUMA ALERT button is hit on top of any other consults, imaging, etc.).

Yes a lot of trauma patients (particularly penetrating) are under/no insurance/pay but if you can really soak the ones who do have insurance the no pay patients are kind of loss leaders.

Also motor vehicle trauma usually has a deep payor source from car insurance companies even if the patient has no health insurance.

One community trauma center I worked at, trauma activation did almost nothing (surgeon and anesthesia not present anyways) compared to just seeing the patient as a high acuity patient and moving them through their workup fast (like you would do with any patient you were legitimately worried about). Maybe XR would show up stat with a portable unit (great...) They still charged their insurance another $15,000 for "trauma activation" on top of the regular billing. Of course, to maintain trauma certification the hospital has to be a "trauma center" on paper. But the point is, it can be worth it for them financially to jump through a few hoops (on paper have a trauma surgeon on call, make the ER physicians take ATLS, RNs with ACTN, etc. )

Yea this trauma activation nonsense is going on in Miami now - we used to have one trauma center (Ryder) that saw everything, actually made money, and provided phenomenal training.

Many of the NYC residencies would fly their trainees down to do trauma here.

Then HCA got wise, opened up 5 “trauma centers” in the affluent suburbs, and started billing Medicare $20,000 a pop for BS trauma activations on the plentiful old people that fell down.

I remember interviewing at one of these places and they were all about how their residents get “Excellent Geriatric Trauma Training.” And how the trauma surgeons never really show up to their traumas anyway. I remember feeling like I was taking crazy pills for someone to brag about that.

 

[deleted645092]

I got spoiled once and had a dental resident show me how to use that calcium epoxy with the UV light to temporarily cap a fractured tooth or cavity to reduce pain, but they made it sound like it would be expensive to stock all that stuff.

 

[deleted6669]

Are there dental midlevels?

Yes, but they currently work in only very remote settings:

UW Department of Family Medicine

depts.washington.edu

 

[sylvanthus]

Yes, but they currently work in only very remote settings:

UW Department of Family Medicine

depts.washington.edu

For now.

 

[nexus73]

There is no money in it compared to what dentists can make in private dental practice with commercially insured patients. Plus the ED is high liability just by the nature of people waiting too long to get something addressed. And the mouths coming into the ED are probably a lot funkier than private practice. Why would a dentist do this unless there was a premium paid to do it?

The reason you have most specialists (surgeons, cardiologists, etc) coming to the ED is they need access to the hospital to do their jobs (surgeries, stents, etc) and are obligated to be on call to maintain privileges. If an orthopod could do their surgeries in a private surgery center all day and not deal with EMTALA and the uninsured, they will do it. A general dentist does not need the hospital in this way.

 

[GassYous]

Maybe you can start a ed dental fellowship and then all the people who can't find a job will be able to work

 

[thegenius]

Don't get me wrong, I am happy to see folks with legit dental emergencies that require acute interventions, but the endless this tooth hurts, I am out of pain meds, I can't see a dentist, etc gets old. I know small places(like everywhere I work) could not support a dentist in the ED, but what about busy places? Dental procedures pay well. Why not have a dental fast track at every level 1 and 2 trauma center? Hospitals would make money, ED providers would be happy not to deal with meth mouth, patients with legit dental issues would get seen right away and those with BS wouldn't get narcs. Win/win. Has this been tried anywhere? I know there are free standing dental emergency clinics that only take cash and good insurance, but what about the vast majority of folks with state insurance and dental issues? This seems like a no brainer. Maybe 2p-midnight 7 days/week. I bet a dentist at a busy place would see 20-30 pts in those 10 hrs. They would more than pay for their time and make the hospital a chunk of cash.

Who is going to pay for the dentist to hang out in the ED? Where is that money going to come from?

Can a dentist in the ER bill for doing root canals, periapical abscess drainage, and other crap like that?

 

[thegenius]

Are there dental midlevels?

oh god yes that's what we need!

and dermatology midlevels
and rheumatology midlevels
and ophtho midlevels. Or better yet optimetrists.

 

[sylvanthus]

Its all about the money, would not be surprised whatsoever if such a thing existed.

 

[gryffindor]

A dentist could bill for sedation, dental extractions, dental blocks etc. Even medicaid pays ok for these.

I saw your post on the dental forum but couldn't respond. Many states do not have adult Medicaid. But in general, you can not bill dental blocks to any insurance. It is considered inclusive to the procedure. An OMFS in private practice recently shared that some of the Medicaid HMOs we have here won't reimburse him more than $65 for sedation. He tried to reach out to them to negotiate and they wouldn't, told him he was already at the highest reimbursement in the state. That's horrible. He dropped those HMOs and I don't blame him. Extraction of the kind of tooth that usually sends people to the ER will net under $50 with Medicaid. They will reimburse maybe $20 for the consult. So that's a cool $135 for dealing with all of that at 2 am.

I did a GPR before I became an orthodontist. The only case I remember seeing that probably was a big money loser for the ER was the 20 year old who had been seen in the regular dental clinic, told he needed an extraction and he refused to do it. I think it was a financial issue, maybe he didn't want to pay the co-pay but I'm sure the GPR clinic would have charged under $100 at most to take the tooth out. He returned a few days later in the ER after the GPR clinic had already closed with difficulty breathing. I got to go to the ER with the OMFS resident on call to take that tooth out under general anesthesia. We tried to treat him in the regular clinic and eliminate the possibility of this happening but we can't force someone to do a procedure. He probably never paid that copay and got his extraction for free.

Medicaid for dental is a big money loser which is why most private practices won't touch it.