Magic Johnson, "the" Magic Johnson, provided keynote remarks on Monday, April 3. Inspirational doesn't begin to describe the buzz felt around the packed 500-person auditorium. It was love. Magic reminded us that love for humanity precedes all else.
In a room full of healthcare executives, payers, hospital systems and non-dentists, he stated a 12 year old passed away from an infected tooth in Washington, D.C. It was one line, and even then many in the audience gasped at the idea of a child dying from tooth decay. This is the story of Deamonte Driver and it happened in 2008. Mary Otto reported and published a book titled Teeth, which shared the state of affairs that created this never ever event. The child had met several dentists, was prescribed multiple courses of antibiotics and had not received treatment due to access challenges of dentists who accept Medicaid. By the time the bacteria spread to the brain, it was too late and the young boy, a child, succumbed.
In 2014, five years after this never ever event occurred, Oregon established a public-private partnership to provide hospital event notifications with physical, behavioral and dental providers through coordinated care organizations and dental care organizations such as Capitol Dental Care. This partnership led to improved interoperability between hospitals and providers (providers can add notes into the system, which then follows the patient to the ED). Oregon has relied upon these systems to prevent a recurrence for all non-traumatic dental infections experienced by the most underserved Oregonians, those who are Medicaid beneficiaries.
A storm is brewing. During the COVID-19 pandemic, hospitals viewed dental care as elective: crippling access for people whose care was relegated to dental services within a hospital setting. Care was delayed and dental disease became more complex. HEN continued to ping DCOs, but the chain of care was fragmented. Today, with hospitals prioritizing advanced surgical care with anesthesiologists to stabilize a challenged economic environment and hospitals limiting credentialing of dentists, access to hospital dentistry is limited and wait times are more excessive. With workforce shortages, hospitals continue to consider dental care elective.
The number of individuals experiencing intellectual disabilities is on the rise, putting further strain on an already strained system. According to the CDC, the percentage of children aged 3-17 diagnosed with a developmental disability increased from 16.2 percent between 2009 and 2011 to 17.8 percent between 2015 and 2017. Resources for these children and their families are unable to keep up with the growing numbers, including dental professionals trained and willing to assist in care. Children with disabilities grow up to be adults with disabilities, and resources to meet their needs are strained even more. Every step of oral health from prevention to treatment is exacerbated by the level of disability a person is impacted by. Home care is difficult and often falls short of other higher priorities such as medications and physical health needs. Dental needs are less visible and often present relatively pain-free until it gets out of control. Finding a provider can be difficult, but traveling to see a provider can be overly cumbersome for people and families experiencing disability. Treatment often needs to be completed under sedation.
As a payer, we can support families by incentivizing providers who see this population through reimbursement and working with the legislature to require hospital time for dental-specific needs. Focus on prevention by utilizing telehealth and mobile units so patients are less burdened by travel. Education and physical support such as specialized toothbrushes and more frequent prevention visits should be abundantly available at no cost.
Lastly, and in my opinion most importantly, as providers we have strayed away from building relationships with these individuals. In some cases, we created a problem rather than solved it. Due to the time, cost and complexity of treating these individuals, we have removed the relationship and jumped straight into sedation. Spending time to create a safe and relaxing space where people can be desensitized in the dental chair takes time and money, and the healthcare industry does not recognize this effort in their reimbursement rates. If they did, providers could eliminate the needs for sedation for several of these individuals, altogether saving resources for those who truly need access to hospital care. By prioritizing a positive dental experience from a young age, we can increase utilization and prevention, reduce the need for sedation and save money by reducing the cost of treatment.
The sum of the solutions (dental workforce diversity, general anesthesia in dental offices, dental providers working at the top of their license, virtual care through teledentistry, access in schools, residence facilities, care coordination with community-based organizations, screening for social determinants of health) do not equate to closing the fragmentation gap. Hopefully, hospitals and payers are able to come to the table with dentists and Medicaid health organizations to provide actionable care for those most underserved and challenged within our health system.
Elevation of humanity may only occur with preferential care of the underserved. Those who are most vulnerable and most underserved — individuals with intellectual and/or developmental disabilities; comorbidities and high BMI; black, indigenous, and people of color; LGBTQ+ individuals; those with varying race, ethnicity, language, to name a few — are at greatest risk. How will we react when another human, a young child, a mother, a brother, loses their life? How many times will leaders like Magic speak of the atrocity that had occurred and create shock and gasps with us?
We, the richest nation in the world, must do all we can to protect those most vulnerable in our society. This is not hard; it is only hard if we make it so. The real question is, are we willing to make it so? Data points to saving the system money as our population health improves. Taking care of the Deamonte Drivers of our nation is a start.