PERSPECTIVE J Oral Maxillofac Surg -:1-2, 2014
The Unintended Consequence of a ‘‘Cottage Industry’’ Suzanne Morse Buhrow, DHA, RN,* and Jack A. Buhrow, DDS, MSy
in aggregate charges.1 The average length of stay for these admissions was 3 days, with mean charges of $20,875 per admission. Despite a marginal decrease in the length of stay from 3.4 days in 2001 (11%), admission rates, mean charges, and aggregate charges have significantly increased since 2001 (Table 1). Most of these patients were underinsured (eg, Medicaid or uninsured), were aged 18 to 64 years, and sought treatment at metropolitan hospitals. The NTDC admissions increased by 45% from 2001 to 2011. The most frequently admitted primary diagnoses during this 10-year period were periapical abscess (code 522.5) and abscess or cellulitis of the mouth (code 528.3), incurring $90.4 million in aggregate charges in 2001, which increased more than 200% to $286 million in 2011. In 2011, abscess and/or cellulitis diagnoses (codes 522.5, 522.7, and 528.3) accounted for 79% of all NTDC admissions compared with 74% in 2001.
In 2010, more than 1.5 million patients sought treatment in US emergency departments for nontraumatic dental conditions (NTDCs), of which, 4.32% required admission.1 The increase in hospital admissions for odontogenic diseases has been associated with disparities in dental insurance coverage, limited access to services, social deprivation, and age. Overusage of emergency departments and inpatient care as safety nets for the underinsured with NTDCs has become a national epidemic, with significant economic and social implications.2-4 Although emergency department visit data illustrate the safety net usage patterns for dental care in underserved populations,4 the inpatient admission rates, length of stay, and treatment costs for NTDCs may illustrate the potential effect of eliminating hospital-based oral and maxillofacial surgery (OMS) services. No data exist on the effect of limited access to oralmaxillofacial surgeons in US hospitals on patient outcomes and cost; however, it is essential that we understand the economic and social consequences of restricting access to hospital-based OMS care. Hospitalbased oral and maxillofacial surgeons can have a significant impact on improving patient outcomes and controlling healthcare expenditures by providing safe, timely, effective, and efficient treatment.
Implications for Oral-Maxillofacial Surgeons Nearly 80% of all NTDC admissions present with odontogenic infections that require the specialized care of an oral-maxillofacial surgeon. The problem is twofold. First, as the disparities in preventive dental care continue to increase, more patients will seek emergent care in US hospitals for complications of untreated dental conditions. Second, as more oralmaxillofacial surgeons ‘‘retreat to their cottages,’’5 eliminate Medicare and Medicaid provider contracts, and ‘‘baby-boomer’’ oral-maxillofacial surgeons retire from hospital medical staff service, access to hospitalbased OMS care could be compromised. Most compelling is that the ‘‘national bill’’ for hospitalizing patients
Overview of NTDC Admission Trends for 2001 to 2011 In 2011, more than 17,000 patients were admitted to US hospitals for NTDCs (‘‘International Classification of Diseases, 9th revision, Clinical Modification’’ codes 520.0 to 521.09, 522.4 to 522.7, 523.1 to 523.33, 523.8, and 528.3), incurring more than $351 million
*President, Buhrow & Ross Consulting, PLLC, Fountain Hills, AZ.
Received January 13 2014
yProgram Director and Founder, Banner Good Samaritan Medical Center, OMFS Residency Program, Phoenix, AZ.
Accepted January 14 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Address correspondence and reprint requests to Dr Buhrow:
Buhrow & Ross Consulting, PLLC, 15263 East Sage Drive, Fountain
Hills, AZ 85268; e-mail: [email protected]
Table 1. NONTRAUMATIC DENTAL ADMISSIONS FROM 2001 TO 2011
NTDC Diagnosis (Primary and Combined) All diagnoses combined 521.0, Dental caries 521.09, Dental caries 522.4, Apical periodontitis 522.5, Periapical abscess 522.7, Periapical abscess with sinus 523.1, Chronic gingivitis 523.3, Aggressive periodontitis 523.31, Aggressive periodontitis local 523.33, Acute periodontitis 523.8, Periodontal disease 528.3, Cellulitis or abscess in mouth
Mean Charges per Admission
Aggregate Charges for All Admissions (‘‘National Bill’’)
12,010 925 131 607 5,280 198 429 658 NA NA 389 3,393
17,383 916 262 1,001 9,231 254 369 187 70 70 435 4,273
$10,053 $10,390 $13,372 $7,820 $8,147 $12,753 $4,946 $10,344 NA NA $8,087 $13,859
$20,875 $21,798 $21,798 $20,121 $17,821 $25,113 $13,296 $15,025 $22,501 $19,438 $18,422 $28,273
$114,447,427 $9,620,327 $1,769,163 $4,759,951 $43,453,469 $2,554,385 $2,130,793 $6,814,041 NA NA $3,145,182 $46,984,158
$351,579,111 $19,959,976 $5,655,058 $20,128,738 $165,359,546 $63,790,644 $5,186,793 $2,816,793 $1,360,832 $1,360,832 $8,282,841 $120,636,173
Data from Health Care Utilization Project [HCUP].1 Abbreviations: NA, not available; NTDC, nontraumatic dental condition. Buhrow and Buhrow. Unintended Consequences. J Oral Maxillofac Surg 2014.
with preventable complications of untreated dental conditions could exceed $1 billion by 2020. These factors present major economic implications in healthcare expenditures and threaten the health outcomes in vulnerable populations. The question is: If oral and maxillofacial surgeons continue to abandon hospital service, who will ensure the quality of care for this population.and at what cost? It is time that hospitals, insurers, and national health policy makers realize the economic effect and human consequence of diminishing access to hospitalbased OMS care—and halt this retreat.
References 1. Health Care Utilization Project [HCUP]. Available at: http://www. hcupnet.ahrq.gov/HCUPnet.jsp. Accessed December 30, 2013 2. Cohen LA, Manski RJ, Hooper FJ: Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? J Am Dent Assoc 127:605, 1996 3. Cohen LA, Manski RJ, Magder LS, Mullins CD: Dental visits to hospital emergency departments by adults receiving Medicaid: Assessing their use. J Am Dent Assoc 133:715, 2002 4. Cooper LA, Bonito AJ, Eicheldinger C, et al: Behavioral and socioeconomic correlates of dental problem experience and patterns of health care-seeking. J Am Dent Assoc 142:137, 2011 5. Hupp LR: Retreating to our cottages. Oral Surg Oral Med Oral Pathol 99:391, 2005