Emergency Dept 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.
Cross posted to EM forum for input there.

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[Saddleshoes]

Don't try to reinvent the wheel.

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.

 

[deleted6669]

Love the idea. Wish more places had these. Wish grads of these programs worked in the community...

 

[Big Time Hoosier]

There's not enough money in the world to pay me to work fulltime in the ED dealing with the BS that comes through the doors. I am counting down the days I have left on call in residency as it is.

Big Hoss

 

[oralcare123]

You could be the first one to dedicate yourself to this idea
After my life experiences I have no desire left. People who take things seriously rarely need those services and the ones who are not - don't deserve someone to work such hours

 

[dentistrydmd]

It is estimated in the us that 8% of emergency room visits are dental related. Staggering number imo

 

[oralcare123]

In one famous socialist country dental clinics were large and dentists worked in shifts 8am-2pm and 2pm-8pm. There were a night shift for emergencies and such 8pm to 8am. Keep in mind, that childcare was available 24/7 and education was free
Now tell me who in US wants to work such schedule with children, cranky spouses and other headaches?

 

[TanMan]

Those that go to ED for dental issues usually don't have money, just want meds, trauma and/or go to the ED for everything. In short, theoretically, there should be money in it, but the aforementioned categories don't monetize well for dentists.

 

[MahiMahi]

Speaking strictly "teeth" - this already very much exists. It's called a GPR program, as @Saddleshoes mentioned. OMFS programs also frequently (but not always) do this at their hospitals.

The reason it's not frequently done otherwise - it's a money issue for hospitals. The patients with these issues unfortunately tend to be less well-off, and at most hospitals, keeping dental staff in-house 24/7 for this patient population (when you get less than, say, 3 of these "tooth-specific-issue" patients a day) isn't economical. Even having them on-call, it's likely to end up losing the hospital money given the very low volume of these patients.
You mention dental procedures reimbursing well - this unfortunately isn't the case for state medicaid reimbursement for dentistry (which would be the case with 99% tooth-related ED visits). Think $65 for an extraction for example, and under 3 "tooth" patients a day in the ED (and like you note, some will be drug-seekers).

Dental schools will usually have an "urgent care" section, where they will take care of such urgent issues same-day. The students (working under dental school faculty) pay tuition for this experience though.

 

[TanMan]

It's just cheaper and more profitable for hospitals to give meds and tell them to go see their dentist. I see it all the time: generic report with the same meds over and over and the same handout/pamphlet regarding dental abscesses/infections.

 

[yappy]

People are saying that dental care would be a financial loss for a hospital but isn’t this the case for most emergency departments too? Many community hospitals are non-profit. I think an important question is if limited dental tx in an ED is more or less cost effective for Medicaid/care(tax payers) than the status quo.

 

[Saddleshoes]

People are saying that dental care would be a financial loss for a hospital but isn’t this the case for most emergency departments too? Many community hospitals are non-profit. I think an important question is if limited dental tx in an ED is more or less cost effective for Medicaid/care(tax payers) than the status quo.

Just because the hospital is non-profit does not mean they want to lose money. Adult medicaid dentistry is a money loser in most states.

Case in Point: In my state medicaid payments are... a limited exam is $16.20. A Pano xray is 22.60 a simple extraction is 39.12. So if a person shows up in the emergency department with dental pain and swelling from a perio abscess. The system will get a total of $60.82 to treat that person. That kind of money will not support a hospital trauma center.

 

[PerioDont]

Just because the hospital is non-profit does not mean they want to lose money. Adult medicaid dentistry is a money loser in most states.

Case in Point: In my state medicaid payments are... a limited exam is $16.20. A Pano xray is 22.60 a simple extraction is 39.12. So if a person shows up in the emergency department with dental pain and swelling from a perio abscess. The system will get a total of $60.82 to treat that person. That kind of money will not support a hospital trauma center.

Wow. Those reimbursements are absolutely ridiculous.

 

[MahiMahi]

People are saying that dental care would be a financial loss for a hospital but isn’t this the case for most emergency departments too? Many community hospitals are non-profit. I think an important question is if limited dental tx in an ED is more or less cost effective for Medicaid/care(tax payers) than the status quo.

A quick google search on the topic brought up this paper: Emergency Department Profits Are Likely To Continue As The Affordable Care Act Expands Coverage . See quotes below:

The largest payer group of visits was the private insurance group, representing 35 percent of ED visits; 26 percent were Medicaid, 21 percent were Medicare, and 18 percent were uninsured.

We estimated that hospital revenue from ED care exceeded costs for that care by $6.1 billion in 2009, representing a profit margin of 7.8 percent (net revenue expressed as a percentage of total revenue). However, this is primarily because hospitals make enough profit on the privately insured ($17 billion) to cover underpayment from all other payer groups, such as Medicare, Medicaid, and unreimbursed care.

Regarding your second question - medical care (of any sort, not just strictly dental) delivered in an emergency room is not cost-effective at all in any healthcare system around the world - it's an environment specifically designed for "emergency" care, at high cost.
Not to mention - setting up a dentist's chair in the hospital emergency room as the new "place" that everyone will know to start stopping by for dental work (that may not actually be urgent) is an absolute nightmare scenario that no emergency medicine physician wants to see.

The correct place for this is a dental clinic - whether it is a public clinic, or a private clinic that accepts state funding.

The real discussion we should be having (and the answer to this overall problem) would be better state Medicaid reimbursement/incentives, and more medicaid clinics, so these patients can be seen before their problems become urgent.

 

[DrJeff]

Just because the hospital is non-profit does not mean they want to lose money. Adult medicaid dentistry is a money loser in most states.

Case in Point: In my state medicaid payments are... a limited exam is $16.20. A Pano xray is 22.60 a simple extraction is 39.12. So if a person shows up in the emergency department with dental pain and swelling from a perio abscess. The system will get a total of $60.82 to treat that person. That kind of money will not support a hospital trauma center.

That's just the reality of medicaid fees.

In my home state of CT, for medicaid patients 21 and under, the reimbursement rates I get from medicaid are in the 65-70% of my usual fees. For those over 21 on medicaid, it's about 30-35% of my typical fees. My overhead is in the 55% range on average.

The reality is that one's feeling of generosity often runs into the reality of running a business and paying yourself and your employees, and if one is seeing a plethora of medicaid patients, that definitely effects the profitability of a practice.

Running a practice, that makes money, in spite of the narrative that some put out there that "profit is bad", isn't a bad thing. It takes an incredible amount of work and effort and time to learn and acquire the skills it takes to provide dental care, we shouldn't under any circumstances, feel "bad" about charging for our services

 

[rsweeney]

Wonderful topic, and an issue my city is striving to solve. I had my own practice for 12 years and have a sobering understanding of the incredible amount of work it takes to run a profitable practice. It’s a constant tug of war between overhead expenses and profit. Charitable work makes me feel good, but it certainly doesn’t pay the bills. I had to take an enormous small business loan to start my practice from scratch, and with a $5500 monthly loan payment (along with other overhead items such as payroll) I needed the work I did to be profitable. You can only pay yourself from overhead for so long...I’m a work horse and have to produce.

Chapter 2 of my career begins working with my local health system to create the very first fully health system-financed hospital dental clinic, unaffiliated with a dental school/GPR. One reason GPRs make sense is the low cost of dental residents...hospitals get more bang for their buck...young gunners willing to wake up to a beeping pager at 2am to drain an abscess.

Our program is very similar to the GPR model. We run a full time off site hospital dental clinic seeing medically compromised patients, Medicaid patients, do work in the OR, and have ED call...I am on call 10 days per month. During the day (from 8-5), ED patients are immediately triaged and transferred directly to dental clinic, which is a huge boon and frees up ED beds.

One way we are trying to solve the financial concerns listed in earlier posts is by marketing our off site clinic as more than a Medicaid clinic. We are credentialed with all third party insurance companies as well, and do the same profitable procedures I did in my practice—most notably crown and bridge, implant restorations, removable, etc. We are much much more than an extraction clinic.

My compensation package is a mixture of guaranteed base pay and bonus pay based on relative value units (RVUs). RVUs are a very common system and measure of reimbursement for hospitals. This is largely a work in progress for the dental field, since RVUs and survey data for dentistry are few and far between. I do have concerns about the sustainability of using RVUs with dentistry, though, and time will tell if it’s fair and accurate for dentistry. I will try to update as the program evolves.

 

[rsweeney]

Wonderful topic, and an issue my city is striving to solve. I had my own practice for 12 years and have a sobering understanding of the incredible amount of work it takes to run a profitable practice. It’s a constant tug of war between overhead expenses and profit. Charitable work makes me feel good, but it certainly doesn’t pay the bills. I had to take an enormous small business loan to start my practice from scratch, and with a $5500 monthly loan payment (along with other overhead items such as payroll) I needed the work I did to be profitable. You can only pay yourself from overhead for so long...I’m a work horse and have to produce.

Chapter 2 of my career begins working with my local health system to create the very first fully health system-financed hospital dental clinic, unaffiliated with a dental school/GPR. One reason GPRs make sense is the low cost of dental residents...hospitals get more bang for their buck...young gunners willing to wake up to a beeping pager at 2am to drain an abscess.

Our program is very similar to the GPR model. We run a full time off site hospital dental clinic seeing medically compromised patients, Medicaid patients, do work in the OR, and have ED call...I am on call 10 days per month. During the day (from 8-5), ED patients are immediately triaged and transferred directly to dental clinic, which is a huge boon and frees up ED beds.

One way we are trying to solve the financial concerns listed in earlier posts is by marketing our off site clinic as more than a Medicaid clinic. We are credentialed with all third party insurance companies as well, and do the same profitable procedures I did in my practice—most notably crown and bridge, implant restorations, removable, etc. We are much much more than an extraction clinic.

My compensation package is a mixture of guaranteed base pay and bonus pay based on relative value units (RVUs). RVUs are a very common system and measure of reimbursement for hospitals. This is largely a work in progress for the dental field, since RVUs and survey data for dentistry are few and far between. I do have concerns about the sustainability of using RVUs with dentistry, though, and time will tell if it’s fair and accurate for dentistry. I will try to update as the program evolves.

I also want to add that in-patients are part of our practice population, too. As a matter of fact, I have a Zoom meeting this week to discuss how to best serve the in-patient population. In-patients are non-ambulatory patients already admitted to the hospital. The fact that our dental clinic is off-site makes serving this population difficult and will require some strategizing. I completed a GPR years ago, and the dental clinic was onsite within the hospital. I would get paged by various departments during the day and would buzz around the hospital with my assistant between patients. Whether it was draining an abscess bedside, extracting a tooth bedside, extracting teeth pre-anesthesia in the OR, or consults in the psych ward, this was a fantastic setup that can only be emulated with an on-site clinic. Hence, the Zoom meeting this week to discuss options.

 

[rsweeney]

People are saying that dental care would be a financial loss for a hospital but isn’t this the case for most emergency departments too? Many community hospitals are non-profit. I think an important question is if limited dental tx in an ED is more or less cost effective for Medicaid/care(tax payers) than the status quo.

If I could give you a round of applause for this question I would. You are correct, the vast majority of emergency room visits are on uninsured patients who never pay a dime. So, to suggest compensating a dentist in the ED doesn’t make financial sense is, well, nonsense. ED physicians get paid big bucks to do free treatment all day long. These charges get added to the hospital “expunge systems” and the charges are written off. So, how are they able to pay the ED physicians you ask? Probably the same way hospital administrators who make big bucks get paid..from the overhead budget. An ED dentist would be no different. So, any hospital that says they can’t afford to pay an ED dentist is lying to you. If they can afford to pay non-producing administrators’ salaries and benefits, they certainly can afford to pay an ED dentist. But, since most patients in the ED are uninsured and will walk away without paying a dime, it will simply get charged to the overhead budget just like all hospital administrators get paid.

 

[Rsfin54]

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.
Cross posted to EM forum for input there.

I think that is a great idea and in larger cities we have "Emergency Care dentists" that just see emergencies that private practice guys can't or won't see. Trying to get your usual GP to come in "after hours" is almost impossible!

 

[dentistrydmd]

If I could give you a round of applause for this question I would. You are correct, the vast majority of emergency room visits are on uninsured patients who never pay a dime.

No clue where a statement like this would come from, as it is not accurate... The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less


The uninsured do use emergency rooms, but even with Medicaid, ER care can be minutely profitable . It is all about how they bill. They are also not legally allowed to turn patients away in the ER when they have the capacity to treat them. When it comes to dentistry, there just isn't enough reimbursement by Medicaid/Medicare for it to make sense. Hospitals look at metrics for ER's and want to get the patient in and out in the quickest time possible. It is unfortunate but often you'll find MD's draining dental abscesses or prescribing antibiotics for patients with dental issues. From their standpoint they can deal with these issues without having a dentist involved and send the patient to go to a private practice for further treatment if necessary. It does make sense however to have an ENT or OMFS on staff for trauma and these types of issues. Dentist not so much.

The reason why GPR programs exist is not because the residents are cheaper, but because GME dollars exist. Without those dollars, the programs would not survive.

 

[Saddleshoes]

The reason why GPR programs exist is not because the residents are cheaper, but because GME dollars exist. Without those dollars, the programs would not survive.

Truth!!!!
In most hospitals there is a limit to the number of resident specialty positions that get funded via GME dollars. Interestingly, there seems to be no limit on dental resident slots.

 

[dentistrydmd]

Truth!!!!
In most hospitals there is a limit to the number of resident specialty positions that get funded via GME dollars. Interestingly, there seems to be no limit on dental resident slots.

Each GME funded spot is worth about 150k in revenue to the hospital, a portion of which goes to the salary of the resident.