The British Dental Association (BDA) issued a statement on May 22, 2022, which “warn(ed) an unprecedented collapse in National Health Service (NHS) commitment among dentists in England could spell the end for the service without radical and urgent action from government.”
The BDA’s advisory spelled out a dire situation for continuation of the NHS’s dental program. Nearly half (45%) of providers report they have reduced their NHS commitment since the onset of the pandemic.
75% of dentist providers say they are now likely to reduce – or further reduce – their NHS commitment in the next 12 months.
45% say they are likely to go fully private. Nearly half (47%) indicate they are likely to change career or seek early retirement.
Over two-thirds (65%) of dental practices have unfulfilled vacancies for dentists.
The overwhelming majority (82%) of these practices cite working under the current discredited NHS contract as a key barrier to filling posts.
Nearly 9 in 10, or 87% of dentists state they have experienced symptoms of stress, burnout, or other mental health problems in the last 12 months, with 86% reporting colleagues in their practice have received physical or verbal abuse from patients.
75% say they are unable to spend sufficient time with patients. Only 25% say they are able to offer the kind of care they want to provide.
“The discredited NHS dental contract, imposed in 2006, puts government targets ahead of patient need, effectively setting a limit on the numbers of NHS treatments a dentist can do in a year. Dubbed ‘unfit for purpose’ by the Health Select Committee fourteen years ago, the system funds care for little over half the population and sets perverse incentives to dentists, rewarding them the same for doing one filling as ten.”
Expanding US Government Funded Dental Programs
In 2021, the American Dental Association (ADA) opposed the expansion of Medicare Part B to include dental coverage. Only inadequate funding of limited duration was offered in the legislative bill, which apparently would have resulted in underfunded and substandard care for seniors.
Additionally opposing Medicare expansion into dental care was the private insurance industry, according to a story in the Wall Street Journal.
Rep. Drew Ferguson (R., GA), also a dentist, argued it made more sense to improve Medicare Advantage. “It’s disingenuous to tell seniors they’re getting a new benefit when it will all be greatly reduced in a few years because of insolvency,” Dr. Ferguson said.
The Medicare program today faces the very real issue of future actuarial insolvency. Yet, some lawmakers attempt to expand coverage into areas such as eye care and dental, as well as reduce the age to receive coverage with “Medicare for All.”
Sen. Bernie Sanders (D., VT) sponsored the US Senate bill, “Medicare for All” in May 2022, along with fourteen Democratic cosponsors. “The American people understand, as I do, that health care is a human right, not a privilege and that we must end the international embarrassment of the United States being the only major country on earth that does not guarantee health care to all of its citizens.” said Sanders.
One might counter Sanders’ point, that while other nations may “guarantee” healthcare for their citizenry, that service may be grossly underfunded and not satisfactorily delivered. One current example is the collapsing dental program under the British NHS. Other examples include guaranteed healthcare delivery in Venezuela and the former Soviet Union, where medical surgeons routinely took cash bribes for anesthesia delivery during surgery.
Former Soviet Healthcare Program
Lessons may be learned from Yuri Maltsev’s, “The Soviet Medical Nightmare.”
“For years, the official Soviet health statistics looked better than any in the West. The only problem is that these institutional statistics do not correlate with vital statistics, which are more reliable and show a desperate state of public health.”
“Physicians are required to study medicine for seven years. Yet their wages are extremely low—about one-third of bus drivers, for example. The state sees this as a way for the physician to “pay back society” for all the resources he took going through “free” schooling. The concept of intellectual capital is as absent as private property.”
“Why then would anyone go into medicine? Partly because they work less (36 hours per week) and hold jobs with high prestige. But the main reason is that the profession offers tremendous access to resalable goods and bribes.”
“The average physician has 3,000-5,000 people assigned to him. The patients have no choice. They must take whoever they are assigned in any given territory. If the local physician is a butcher, that’s too bad. The patient cannot change. If the doctor kills you, relatives have no recourse.”
Managed Care Organizations – Third Party Administrators
In most US states, managed care organizations (MCOs) function as third party administrators (TPAs) for state dental Medicaid programs. They are primarily paid under state contracts as an approved vendor after a competitive bidding process. MCOs receive an established dollar amount per visit of every served Medicaid beneficiary, on a monthly basis.
Depending on the state and size of their Medicaid program, a MCO may annually draw several hundred million dollars for TPA services, per each state contract. Therefore, the more lucrative service in dental Medicaid is usually not as a clinical provider, but as a contracted TPA.
The MCO is responsible for background checks and credentialing of dentist providers. They may also be bonused by a state, for keeping Medicaid payments under a specified dollar figure.
“Value-Based” payment (VBP) dental care focuses on high-volumes of lower cost services such as prevention. Participation numbers will elevate. Like capitation, providers are incentivized to generate high volumes of low-skill dental services. Cost per patient is kept low. Some suggest VBP can save the dental Medicaid program.
Proponents argue, VBP dental healthcare reduces expenses to taxpayers and improves clinical outcomes. A February 2021 report funded by the MCO, DentaQuest states, “The health care system is increasingly moving away from volume-driven fee-for-service payments and toward value-based payment (VBP) arrangements to improve quality, enhance both the patient and providers’ experience of care, and reduce costs.”
Opponents of VBP contend providers ignore dental disease and engage in supervised neglect of patients, in order to make the numbers work under VBD.
This similarly happened historically under capitation programs.
Providers are incentivized to decrease their pool of high-risk patients for dental disease, as more involved therapies such as advanced restorative dental care, endodontic treatment, and prosthetic care become fiscally unviable for providers to deliver.
Concurrently, many dental specialists disconnect from Medicaid service, leaving many states with few if any doctors in certain dental specialty areas.
In a moment of stark candor, DentaQuest created a 2021 communication with the State of Hawaii “Dental Third Party Administrator (TPA) Services for the State of Hawai’i Medicaid Population.” DentaQuest stated, “Recommendation to consider full capitation – In the upcoming procurement, Hawaii has an opportunity to shift from fee-for-service (FFS) program using a third party administrator (TPA) to a full-risk capitated model for its dental program. There could be significant benefits for Hawaii in moving to full capitation.”
“(T)he models would provide managed dental plans with the flexibility to use different provider compensation levels and strategies such as value-based payment (capitation) to improve access to care and outcomes, whereas in FFS, the state must pay every participating provider the same fees.”
Further, disadvantaged socioeconomic groups frequently are represented by persons of minority groups. This patient population often demonstrates the highest rates of dental disease. VBP for dental services is not compatible with equity outcomes, as this demographic generally requires more involved and extensive dental treatment.
Yet, CareQuest, a direct affiliate of the MCO, DentaQuest which espouses VBP, is also apparently an advocate for “health equity.”
It is seemingly incongruent to simultaneously advocate for both equity in dental healthcare and VBP.
Expanding Adult Medicaid Coverage
Not surprisingly, the push for expanding adult dental Medicaid coverage again comes often from the MCO industry. CareQuest, an affiliate of DentaQuest sponsored the report “Expanding Dental Benefits is Good for States.” It was demonstrated again, unsurprisingly, that when adult dental Medicaid benefits were financially elevated in Colorado, utilization rates increased.
Expanding the pool of Medicaid-eligible beneficiaries increases potential revenues for MCOs, with minimal additional outlay of capital. By contrast, a dental provider must generate additional clinical and non-clinical staffing, supplies, equipment, dental treatment operatories, and training specific for newly acquired services provided.
Moreover, clinically serving the adult Medicaid population can be highly challenging with their possible compromises in physical and mental health, risks associated with elevated rates of tobacco, alcohol, and drug abuse, potential transportation problems, many years of neglected dental disease, and a potential lack of value for dental care with resulting cancelled and no-show appointments. The dental provider faces some of the most difficult clinical cases in the dental profession, all for pennies on the dollar of remuneration.
CareQuest estimates 56 million Americans lack access to dental care.
That figure is disputed by the ADA’s Health Policy Institute in “Rethinking Dentist Shortages” by Marko Vujicic, PhD.
Vujicic states, “The fact that there is significant unused capacity within the dental care system and that the most important barriers to dental care are financial leads to an important policy implication. In the current situation, adding additional dental care providers to the market is unlikely to address the most critical issues concerning access to dental care. Rather, the evidence strongly suggests that policy makers ought to focus on solutions that address the demand-side constraints the US population faces—especially low income Americans—in accessing dental care.”
In other words, in the USA, like Great Britain, there exists more than an adequate supply of well-trained dentists to serve the population. Unfortunately, healthcare programs offer too little incentive for dentists to participate in dysfunctional failing government programs.
Many doctors continue to serve on an increasingly limited basis, both in US dental Medicaid and British NHS programs, as a beneficent community charity. Alleging a lack of dentists, or dentists too greedy to serve, are misrepresentations by the ignorant or certain self-serving parties.
Dentistry Today obtained an exclusive interview with past-vice president (2017-19) of the ADA, Richard Huot, DDS, who today serves as CEO of Beachside Dental Consultants, Inc. Huot opined on when political aspirations clash with clinical reality.
Huot said, “The recent Medicaid extension by some states for adult dental care with some incentive money from the Families First Coronavirus Response Act (FFCRA) initially looks promising for dental providers, but as with all government programs that are shared at a federal/state level, financial incentives for states by the federal government to extend Medicaid will end when the Covid Virus emergency is considered no longer.”
“After extending the program and treating adult dental patients for a while, states may find themselves in a funding quandary, once the “federal carrot” is taken away.” continued Huot.
“One only has to go to the medical side and see hospital systems that are pressuring states for more reimbursement for the large increase in medical patients seen in the expansion of Medicaid, and we have yet to have a full blown recession that would potentially qualify citizens for Medicaid funding.”
Huot warned, “At some point, and when we go into a recession, state budget cuts will have to be enacted, and Medicaid dental benefits are a likely target.”
“One can travel “across the pond” to see the results of a single payer system that has reached its breaking point and is endangering their existing network. In an article outlining the dental crisis, years of underfunding and lack of fee increases to providers has come to a crux. NHS dentists are leaving the system, citing inflation, years of no fee increases translating to stagnant income, and the tremendous backlog of patients waiting to be processed in the system, despite qualifying for care,” Huot concluded.
CONCLUSION – PART 1
Government funded single-payer dental program is on the verge of collapse in Britain. Such programs catastrophically failed in Venezuela and the former Soviet Union. The US dental Medicaid program may also be in a death spiral.
The various stakeholders in US dental Medicaid all carry obligations for a successful turnaround. Citizens and especially disadvantaged persons, deserve considerations beyond gratuitous lip-service. Positive outcomes for the nation’s dental Medicaid program depend on responsible and motivated dentist providers, honest legitimate MCOs, reasonable oversight mechanisms, and taxpayers willing to fund services they see of value.
Part 2 will elucidate how some dental Medicaid scams have been foisted upon the public, and the apparent collusion between participating nefarious parties. Dental Medicaid cannot survive as a “golden goose” which primarily serves interests of the moneyed few, at the expense of the disadvantaged and taxpayers.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee. He can be reached at MWDavisDDS@Comcast.net .