Trends in Emergency Department Utilization for Dental and Oral Health Related ConditionsDentaQuest Institute Office of Analytics and Publication

Natalia I. Chalmers DDS, PhD - UCSF DPH175 seminar, June 6th 2017

@ChalmersDDSPhD

Opportunity for Improvement in Dentistry

Oral Health

Learning Objectives• Describe the difference between ED utilization for dental and

non-dental conditions• Identify specific factors that are significantly associated with ED

utilization for dental conditions• Describe the gender, race and income disparities in ED

utilization for dental conditions• Define the challenges and opportunities for achieving health

equity in ED utilization for dental/oral health related conditions• Identify specific factors associated with the high level of return

ED visits for DOHRC

Oral Health and Systemic Health

Monsarrat et al. Journal of Clinical Periodontology 2016

Association between Overall Health and Oral Health

55

60

65

70

75

80

85

10 12.5 15 17.5 20 22.5 25

Data Value of Subset of Subset of Behavioral Risk Factor Data Health-Related Quality of Life HRQOLAdul

ts a

ged

18+

who

hav

e vi

sited

a d

entis

t or

dent

al c

linic

in th

e pa

st y

ear

Adults aged 18+ with fair or poor self-rated overall health

National Oral Health Surveillance System (NOHSS) and HRQOL: Percentage with fair or poor self-rated health Each data point is state

Chalmers et al JADA 2017

2013 Health Care Spending in the United States

Dieleman et al. JAMA Dec 17 2016 US spending on personal health care and public health, 1996–2013

2013 Health Care Spending in the United States

Dieleman et al JAMA Dec 17 2016 US spending on personal health care and public health, 1996–2013

National Health Expendituresand Dental Services ExpendituresAggregate and per Capita Amounts, Percent Distribution and Annual Percent Change by Source of Funds: Calendar Years 2009-2025

2,296

3,029 3,206 3,358 3,5393,966

5,549

15.9%17.4% 17.8% 18.1% 18.3% 18.6%

19.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

2007 2014 2015 2016 2017 2019 2025

% o

f Gro

ss D

omes

tic P

rodu

ct

Expe

nditu

re in

Bill

ions

of D

olla

rsNational Health Expenditure NHE as a % of GDP

Note: Data from 2016-20205 is projected. Source: Keehan SP, Stone DA, Poisal JA, et al. National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy. Health Affairs. 2017.

97113 118 122 128

141

185

4.5%

3.9% 3.9% 3.8% 3.8% 3.7%3.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

$0

$20

$40

$60

$80

$100

$120

$140

$160

$180

$200

2007 2014 2015 2016 2017 2019 2025 % o

f Tot

al H

ealth

Con

sum

ptio

n Ex

pend

iture

s

Expe

nditu

re in

Bill

ions

of D

olla

rs

Expenditure on Dental Services % of Total Health Consumption Expenditures

Note: Data from 2016-20205 is projected. Source: Keehan SP, Stone DA, Poisal JA, et al. National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy. Health Affairs. 2017.

Dental Services Expenditures by Sources of Funds

$43 $43 $44 $45 $46 $46 $47 $48 $50 $52 $55$59 $62 $66 $69 $73

$76

$49 $50 $51 $52 $52 $54 $57 $59 $62 $65 $68 $71$75

$79 $82 $86 $90

$0.3 $0.2 $0.3 $0.4 $0.5 $0.4 $0.4 $0.5 $0.5 $0.5 $0.6 $0.6 $0.7 $0.7 $0.8 $0.9 $0.9$8 $8 $9 $9 $9 $10 $12 $13 $14 $15 $16 $17 $19 $20 $22 $24 $26

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Expe

nditu

re in

Bill

ions

of D

olla

rs

Out of Pocket Payment Private Health Insurance Medicare Medicaid

Distribution of Dental Services Expenditures by Sources of Funds

DentaQuest Institute © Confidential | Not for Distribution

41.6% 41.3% 41.2% 41.5% 41.3% 40.3% 39.3% 38.7% 38.4% 38.2% 38.0% 38.5% 38.5% 38.5% 38.4% 38.4% 38.4%

48.3% 47.8% 47.8% 47.4% 47.3% 47.6% 47.7% 47.7% 47.7% 47.6% 47.4% 46.7% 46.4% 46.2% 45.8% 45.5% 45.1%

0.3% 0.2% 0.3% 0.3% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% 0.5% 0.5% 0.5%

7.5% 8.0% 7.9% 7.9% 8.0% 8.9% 9.7% 10.2% 10.5% 10.8% 11.1% 11.4% 11.7% 11.9% 12.3% 12.7% 13.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Out of Pocket Payment Private Health Insurance Medicare Medicaid

1996 Dental Spending in the United States

Dieleman et al JAMA Dec 17 2016 US spending on personal health care and public health, 1996–2013

2013 Dental Spending in the United States

Dieleman et al JAMA Dec 17 2016 US spending on personal health care and public health, 1996–2013

2013 Access to Dental Service (0-20 years)

The Problem

DentaQuest Institute © Confidential | Not for Distribution

National Trends in ED utilization for Dental

2,548,423

2,136,839 2,095,195 2,229,651

817.90

680.30 666.35 699.15

0.00100.00200.00300.00400.00500.00600.00700.00800.00900.00

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2011 2012 2013 2014

Rate

s of D

OH

RC

Coun

ts o

f DO

HRC

Count of DOHRC Discharges Rate Per 100K of DOHRC Discharges

Most Commonly Diagnosed Dental Conditions

The following slides are part of manuscript in progress and can not be distributed or published online

DentaQuest Institute © Confidential | Not for Distribution

Maryland: The Patients

http://www.usatoday.com/story/news/local/2015/06/24/er-visits-dental-problems-rising/29242113

Why are Maryland’s Cost Lower?• The Hospital Rate Regulation

Model (from 1974/1977) and the All-Payer Model (from 2014).

– Sets identical hospital service rates for all payers

– From 2014, includes outpatient costs.

– 2014 CMS waiver includes goals in line with the Triple Aim

• 2016 progression plan to extend to chronic care management

– http://healthaffairs.org/blog/2017/01/31/marylands-all-payer-model-achievements-challenges-and-next-steps/

Repeat Visits

DentaQuest Institute © Confidential | Not for Distribution

The following slides are part of manuscript in progress and can not be distributed or published online

Dental Care in the Emergency Departments

• Costs are high $820 per visit• For Dental Medicaid bears the burden• Age and gender disparities • Racial disparities (state)• Income disparities • Majority of patients are healthy• Nondefinitive care with high return rate (state)

Learning Objectives• Describe the difference between ED utilization for dental and

non-dental conditions• Identify specific factors that are significantly associated with ED

utilization for dental conditions• Describe the gender, race and income disparities in ED

utilization for dental conditions• Define the challenges and opportunities for achieving health

equity in ED utilization for dental/oral health related conditions• Identify specific factors associated with the high level of return

ED visits for DOHRC

Natalia I. Chalmers DDS, PhDDiplomate, American Board of Pediatric Dentistry Director, Analytics and Publication DentaQuest Institute, 10320 Little Patuxent Pkwy, Suite 231Columbia MD, 21044Natalia.Chalmers@DentaQuestInstitute.org (202) 579-5801