In Parts 1 and 2 of this series, we reviewed the US dental Medicaid program in crisis stage. We surveyed the collapse and near-collapse of other single-payer government sponsored programs from other nations. An attitude of “it cannot happen here” represents absurd denial.
Part 3 embraces solutions.
The American Dental Association (ADA) has offered highly valuable policies and positions as one basic outline, in an effort to establish a viable dental Medicaid program. Although the ADA has embraced certain highly dubious stakeholders (which is beyond the scope of this article), in its attempt to strengthen the dental Medicaid program, their most valuable contribution may be the document “Medicaid: Considerations When Working with States to Develop an Effective RFP/Dental Contract.”
This toolkit was developed by the ADA’s Council on Dental Benefit Programs. The ADA’s Council addressed multiple crucial factors.
- Need for a state dental Medicaid director.
- The state’s contract with their contracted third-party administrators (TPAs) is critical.
- Enforcement of this contract is essential. “A great contract without enforcement is meaningless. “
- Assuring adequate access for both patients and providers.
- Proper provider enrollment and credentialing.
- Securing the doctor/patient relationship.
- Continuity of patient care and going out-of-network when specialist providers are not available in-network.
- Reasonable fee schedules and provider reimbursement rates. This includes setting medical loss ratios (MLRs) for managed care organizations (MCOs) providing TPA services.
- Rapid claims processing, payments, and an appeal process.
- Utilization of dentist/peers in resolving disputes and overall monitoring.
- Monitor and outreach to Medicaid patients by both the state and MCO.
- Coordination of care and establishment of a “dental home.”
- State to monitor MCO performance and dentist satisfaction with contracted MCOs.
- Monitor and encourage improvements in quality of care.
- State dental Medicaid director to establish clinical treatment benchmarks and to identify “outlier” providers for cases of fraud and abuse.
- Employ mechanisms for dispute resolutions.
- Have a “member handbook” readily available for patients and a “dentist manual” easily accessible. The doctor’s rights and responsibilities must be clearly spelled out and in advance of any contract signing.
- The state must clearly spell out “medical necessity” in all contracts with MCOs and demand compliance with these contractors.
- Any MCO subcontractors must comply with agreements stated in the contract with primary MCO contractor. Performance reviews by the state are essential.
The American Academy of Pediatric Dentistry (AAPD) is another organization advocating for a viable and sustainable dental Medicaid program. In reaction to “one-trick-pony” groups, which promote dental therapists as the quick and easy solution for “access to care,” the AAPD endorses a more thorough and logical path.
In a recent letter of rebuke to US Health Resources and Services Administration, president of the AAPD, Amr M. Moursi, DDS, PhD listed the following as vital elements for enhancing the dental Medicaid program. She forcefully admonished the notion of a “quick fix” with dental therapists.
- The AAPD believes that oral health services to our nation’s highest-risk children should not be provided by non-dentists with less education and experience, especially when there is no evidence-based research to support the safety, efficiency, effectiveness, or sustainability of such an approach.
- Every child in our nation deserves the same high quality of oral health services delivered in the safest way possible. The most vulnerable children should not be treated by the least trained, and certainly not under the guise of promoting “equity.”
- There is no clinical or ethical justification for children with more severe oral health needs to receive lesser care.
- Dental therapists receive significantly less education and training than dentists. (General dentists attend four years of dental school after college; pediatric dentists spend an additional two or more years beyond dental school.)
- The knowledge to perform specific dental procedures does not mean that the providers have the ability to determine whether or when various procedures should be performed, or to safely manage the full range of a child’s oral healthcare.
- Although the few limited studies on the technical quality of procedures performed by dental therapists have found that the resulting work is comparable to that produced by dentists, there is no evidence to suggest that they deliver expertise comparable to a dentist in such fields as diagnosis, pathology, trauma care, pharmacology, and care of special needs patients.
- While nurse practitioners are not allowed to perform major irreversible surgeries, dental therapists with less training would be allowed to perform irreversible surgeries on child patients.
- Despite 14 states having some form of dental therapy on the books, Minnesota is the only state with any practicing dental therapists, with the exception of one in Maine (which has no training program). There is no data—none—that suggests that oral health outcomes, access to care, or cost of care improve in any place where dental therapists have practiced. That includes Minnesota, as well as prior tribal pilot programs in Oregon and Washington. Independent assessment of the data on the Minnesota dental therapy program found it has not yet been proven to be as effective as promised. Patient access to care was not meaningfully increased, nor did care become more affordable. Minnesotans continue to experience the same barriers to obtaining good oral health.
- Evidence from Canada and Minnesota shows dental therapists often do not locate in underserved areas. For example, about 3 out of 5 dental therapists licensed in Minnesota were working in the Twin Cities metro area as of April 2016. Only 8 dental therapists were located in the 70 percent of Minnesota’s counties fully or partially designated as Health Professional Shortage Areas.
- Dental Therapy programs are incredibly expensive to start, with little to show for it. Vermont has spent over $2.4 million since 2016 to start a program, including a $1.6 million federal grant, a $400,000 HRSA grant in 2018, and an additional $400,000 from the state. Not a single dental therapist is training or practicing in Vermont.
- Studies from other countries that purport to justify the dental therapist experiment overstate their conclusions and lack adequate data to substantiate them. For example, there has not been a reduction in caries in these countries.
- Although advocates argue that dental therapy model will reduce costs, dental services cost the same amount to the patient – and the state – no matter who performs them. For example, Minnesota Medicaid offers identical reimbursement rates for dentists and dental therapists. Essentially, dental therapy creates a new layer of bureaucracy without delivering any new service or savings to patients.
- There is no shortage of dentists in the United States – and no shortage of care available for children. The number of pediatric and general dentists is growing faster than the child population and the demand for dental services, a trend expected to persist through 2040. It is not dentists that are lacking, but adequate reimbursements in Medicaid. Despite these challenges, over the past 20 years, there has been a near doubling of the pediatric dentist workforce and a significant expansion in children dentally uninsured and receiving treatment under Medicaid and CHIP. It certainly can be improved, but dental therapists are not the answer.
- The best way to provide needed dental care to underserved children is through a Dental Home – the existing model of a dental team working together with the direct supervision (or physical presence) of a dentist.
- Children will be best served by protecting the financial support of dental Medicaid, which will encourage access to care through current providers already prepared to serve, and by expanding loan repayment assistance programs that have the proven result of placing dentists in designated Health Professional Shortage Areas.
A recent report in Dentistry Today “Fixing the Broken Dental Medicaid Program” added the following:
- We need to attract (not coerce) talented and ethical dental providers to the mainstream of care for dental Medicaid. Our disadvantaged citizens deserve no less.
- We must assure taxpayers that their tax dollars are utilized responsibly and not targeted on “welfare for the rich.” That means minimal expenditures for MCOs, which manage dental Medicaid for the states; serious due diligence with oversight of taxpayer expenditures; and a halt to the largess the private equity industry currently enjoys in its position as beneficial owner of so-called dental Medicaid mills.
- We must empower Medicaid recipients and their parents to make positive healthcare decisions in their own self-interests. The present arrogant, paternalistic attitude of government and big business knowing best has failed. True consumer transparency and empowerment is vastly superior to our entrenched model of crony capitalism.
- The failed model of continuously throwing additional taxpayer dollars at the dental Medicaid problem represents flushing good money down a toilet. Seemingly, that’s the best that policymakers in Washington, corporate dentistry, and organized dentistry can come up with. That disturbing policy only serves special interests and not taxpayers or our disadvantaged citizens. Don’t take their bait/refrain of “What about the poor children?” The entire model of dental Medicaid requires a total restructuring.
PUBLIC HEALTH CLINICS AS THE ANSWER
Unfortunately, too often officers and directors of dental federally qualified health centers (FQHCs) are grossly over-compensated. Their incomes may rival the upper echelon of Fortune 500 companies. By contrast, clinical providers generally work diligently for modest compensation. One may ask how this substantial largess is generated.
FQHCs are not usually remunerated for patient services through fee-for-service billings. The government pays through a mechanism of patient “encounter fees.” A set dollar amount is paid to the FQHC for each patient visit.
Too often an unethical scheduling methodology commonly termed “patient churning” is directed by senior FQHC leadership. A quadrant of three one-surface fillings may be scheduled for three separate patient visits, to maximize encounter fee payments. A standard initial child’s dental visit for exam, x-rays, dental cleaning, and fluoride treatment may again be dragged out, to two or three appointments, to enhance encounter fee production.
More recently, at what was formerly one of the nation’s largest FQHCs, Borrego Health in southern California, an entirely novel approach was employed to swindle our country’s Medicaid program. This rip-off involved multiple poorly monitored contracted providers, an internal contracted payment scheme which enabled fraud, money laundering though a billing company, as well as state regulators and FQHC monitoring willing to look away when presented dentists’ checkered backgrounds.
Obviously, lacking proper oversight and enforcement, FQHCs are not the golden ticket to an enhanced dental Medicaid program.
The US Health and Human Services- Office of Inspector General (HHS-OIG) offers multiple superb concepts for states working with MCOs on Medicaid administration:
- Improve MCO identification and referral of cases of suspected fraud or abuse
- Increase MCO reporting to the state of corrective actions taken against providers suspected of fraud or abuse
- Clarify the information MCOs are required to report regarding providers that are terminated or otherwise leave the MCO network
- Identify and share best practices about payment-retention policies and incentives to increase recoveries
- Improve coordination between MCOs and other state program integrity entities
- Standardize reporting of referrals across all MCOs in the state
- Ensure that MCOs provide complete, accurate, and timely encounter data
- Monitor encounter data and impose penalties on states for submitting inaccurate or incomplete encounter data
What is not working is a government enforcement program of “pay-and-chase.” Violators are often ignored for a period of many years. Many millions of dollars in alleged fraud are allowed to accumulate. By turning a blind eye, government encourages and enables fraud and abuses.
When the government elects to take enforcement action, if ever, violators may no longer be positioned for repayments.
In the intervening time, patients are harmed, and taxpayers cheated.
The US HHS-OIG correctly elucidates, states must demand oversight and whistleblowing by their contracted MCOs which provide TPA for Medicaid.
In reality, MCOs are disincentivized to report larger provider networks like DSOs because they bring in great volumes of member beneficiaries, which is a chief mechanism for payment to the MCOs. If one’s big moneymakers retain several “outlier” provider billers, they are not inclined to “kill the golden goose.”
The dental Medicaid program is well past posibilities for quick and easy problem solving. Pumping more taxpayer money into this abyss is foolhardy. Dental therapists may offer minimal if any benefit. Opening more dental schools and increasing class sizes may benefit the dental education-industrial complex but does almost nothing for alleviating access-to-care.
Corporate rebranding of capitation to the spin of “value-based payments” is similar to the layers of makeup applied to the face of Bette Davis, in the 1962 classic film, “Whatever Happened to Baby Jane?” The look remains hideous regardless.
State governments seem largely unable or unwilling to engage solutions provided by professional groups such as the ADA and AAPD. States also seemingly ignore recommendations by the US HHS-OIG. States also seem oblivious to the wide variety of dental Medicaid swindles prosecuted by the US Department of Justice (USDOJ).
The feds more than tripled moneys recovered from Medicaid fraud prosecutions in the six years between 2004-10. In US HHS-OIG’s “Medicaid Fraud Control Units- Fiscal Year 2021- Annual Report,” Medicaid Control Fraud Units reported collecting $5.36 for every $1.00 spent on prosecution.
One might argue in promoting an effective and ethical dental Medicaid program, if the “carrot or the stick” approach works better. The “carrot” path promoted by elements of organized dentistry appears to offer a solid foundation for a healthy program. The “stick” approach of civil and criminal prosecutions can also function as an effective deterrent for wrongdoing.
Methodologies which fail to serve our disadvantaged citizens and taxpayers are blind trust, apathy, isolated and systemic corruption, laziness, arrogance, and collusion between Medicaid stakeholders based on greed. A Band Aid approach to dental Medicaid will get us to a toxic place as evidenced in Venezuela, the former Soviet Union, or currently in Great Britain.
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 .