The ADA’s Health Policy Institute (HPI) has issued the findings of its study into how many dentists across all 50 states and the District of Columbia participate in Medicaid and the Children’s Health Insurance Program (CHIP)
Analysis demonstrated the highest participation in Iowa at 77.6%, down to a low of 15.6% in New Hampshire. Participation was highest among pediatric specialty dentists (73%), which surpassed participation of general dentists (43%).
The lowest participation rate of the specialists surveyed was 25% among periodontists. Dental service organization (DSO) affiliated doctors generated participation at 63%, versus 41% for those not affiliated with a DSO.
Friedrich Wilhelm Nietzsche was quoted as saying “Der Teufel stecktim Detail,” which means “the devil is in the details.” Stakeholder provider dentists and their representatives in state organized dentistry were questioned to obtain those details.
As one might assume, those closest to provider clinicians expressed views not always witnessed from policymakers in government, the insurance industry, managed care organizations (MCOs), or charitable trusts and foundations.
Iowa
“Iowa is proud of our high participation rate of dentists who provide access to our most vulnerable populations, including children and low-income families. However, there are some very distinct differences between the Medicaid and CHIP programs that should be noted,” said Laurie Traetow, executive director of the Iowa Dental Association.
“The CHIP program, commonly known as Hawki in Iowa, has been extremely successful. The high levels of participation from both dentists and Hawki members speak to the success of the program,” Traetow said.
“In fact, a recent study showed 75% of Iowa dentists are enrolled as Hawki providers, and 89% of these providers saw at least one Hawki patient annually. In addition, nearly 100% of Hawki patients have access to a Hawki provider who is located within 30 miles of their residence,” said Traetow.
“Unfortunately, the Dental Wellness Plan (DWP) and Medicaid programs have not been as successful, and it is becoming increasingly difficult for dentists to continue seeing those patients primarily due to extremely low reimbursement rates,” she said.
“A 2016 ADA study showed that Iowa’s reimbursement rates for Medicaid children rank 40th out of 50 states and the District of Columbia. In many cases, rates are so low that dentists must subsidize dental procedures for these patients. A recent study showed that 91% of dentists enrolled in DWP viewed the reimbursement rates as a major flaw with the program,” Traetow said.
Alabama
The Alabama CHIP program is administered by BlueCrossBlueShield (BCBS) of Alabama. BCBS has about 95% of the practicing dentists in the state in its dental network. This high percentage of dental BCBS providers is accustomed to working with BCBS with their adult insureds and their insureds over the age of 19. Also, the CHIP dental fee schedule provides a reimbursement level that isn’t high but allows for a small profit margin.
“The percentage of CHIP participating dentists would be higher except BCBS will not allow dentists who are out of their dental network to participate in the CHIP program,” said Zack Studstill, executive director of the Alabama Dental Association, which has 72.4% dentist participation.
“BCBS does administer the CHIP program efficiently, and that is certainly an attraction for their in-network dentists,” said Studstill.
“Meanwhile, the Alabama Medicaid program is administered internally by the Alabama Medicaid Agency. The state dental director, retired dentist Dr. Danny Rush, has oversight responsibility for the dental program, and he is very involved in it,” said Studstill.
“Dr. Danny Rush’s interest, direct involvement, and constant contact with providers is a decided asset. Payments are made on a timely basis, and that is a very positive factor with maintaining dentist participation levels,” Studstill said.
Virginia
Virginia’s participation rate for dental Medicaid or CHIP was listed at 31.7%.
“It is my belief that Virginia’s dental Medicaid reform was very helpful and at that time we had one of the more robust programs in the nation, but that was over 15 years ago, and another reform is way overdue,” said Barrett Peters, DDS, MSD, immediate past president of the Virginia Academy of Pediatric Dentistry.
“We owe it to our patients and to our fellow citizens. We also owe it to our practitioners to have a program that is attractive and also addresses the main historic barriers to participation—low reimbursement and high no-show rates,” said Peters.
“The most effective and obvious step would be to substantially raise Medicaid reimbursement. In order to do this, many parties will be involved, most notably our state lawmakers and the Virginia Dental Association,” Peters said.
“The second step would be to develop and implement solutions to reduce the high rates of no-shows of Medicaid recipients, as these missed appointments could benefit other children in need and are quite economically burdensome for a practice,” he said.
“This effort needs to be a collaborative one, between clinical practicing dentists and the Medicaid program, as high rates of no-shows have historically been a major barrier to provider participation and meaningful solutions have yet to be implemented,” said Peters.
“I’m encouraged that Virginia’s Department of Medical Assistance Services (DMAS) is reaching out for input from providers as they plan for implementation of the adult Medicaid dental benefit in 2021 and hope that they will work with us on meaningful solutions,” Peters stated.
“I believe without significant reform of the pediatric dental Medicaid system in Virginia, provider participation rates will continue to decrease as rates of early childhood caries will continue to increase. This divide will only be further exacerbated by the confluence of factors that are affecting our profession as a result of the COVID-19 pandemic,” he said.
Maine
The ADA HPI survey listed Maine’s participation at 31.2%. Angela Westoff, executive director of the Maine Dental Association, disputed the figures generated by the HPI for Maine dentist participation. She firmly stated that number should be 42% (2014 numbers) based on data she supplied state authorities.
“The HPI team (subsequently) contacted MaineCare and communicated with an official who shared raw claims data with HPI. Following HPI’s analysis, the MaineCare official acknowledged that the information provided to CMS was indeed inaccurate. Ultimately, the participation rate for Maine dentists in 2014 proved to be 42%,” Westoff said.
“Unfortunately, the manner in which data is reported to Centers for Medicare and Medicaid Services (CMS) by the State of Maine has not been corrected. And, unfortunately as well, it is absolutely not the researchers’ (ADA’s HPI) responsibility to assess and correct data submitted by states and subsequently posted by CMS,” added Westoff.
Westoff cited differing focus at the level of state government between administrations.
“The current administration is undertaking yeomen’s work in undoing the decimation of Maine’s public health infrastructure during the last administration, which spanned eight years, and, at the same time, dealing with Maine’s COVID-19 crises,” she said.
“We are hopeful that the analysis of MaineCare reimbursement for dental services will result in significant improvement,” Westoff said.
Highlight Summary
It is clear that significant differences between dental Medicaid and CHIP exist. Remuneration for dental services under CHIP is generally greater than Medicaid and therefore offers greater inducement for dentist participation.
Eligible patients (or their parents) generally pay a small premium fee to participate in CHIP. With skin in the game, they have incentive to show for scheduled appointments. In some states, patients may also be required to submit a small copayment for services under CHIP. The insurance industry learned long ago that copays are of merit in enlisting patients as additional watchdogs over potential fraud and abuses.
Research findings are only as accurate as the data supplied to them. No one faults the ADA’s HPI when it is given flawed or outdated numbers. However, later decisions based upon imperfect research findings risk adverse outcomes.
State dental directors who exhibit motivation, communication, and knowledge can be invaluable in greasing the wheels in running functioning CHIP and Medicaid programs. Dentists serving in these capacities benefit from prior firsthand experience as former CHIP and Medicaid providers. States need administrators who directly comprehend frustrations and roadblocks experienced by providers and have the authority to work viable solutions, often via unconventional channels.
State governors and state legislators must view dental care for the disadvantaged as essential and be willing to appropriately fund such dental care. Inclusive must be oversight of provider doctors, Medicaid-focused dental service organizations (DSOs), and managed care organizations (MCOs).
Fee schedules that are only updated every 15 to 20 years have been too common under dental CHIP and dental Medicaid. They represent a disincentive for better clinicians to participate, except perhaps on an extremely limited charitable basis. A high state participation rate may be deceiving in that doctor beneficence may be restricted to only one or two cases per month.
If remuneration fees are below overhead costs to deliver dental services within the standard of care, superior clinicians will restrict their participation. CHIP and dental Medicaid programs will in turn attract many of the lowest common denominator providers.
Dog That Won’t Hunt
Policymakers too frequently ignore or minimize the two most important stakeholders in dental care for the disadvantaged, doctors and patients. In alleged advocacy for cost savings and superior outcomes, big business, big healthcare, and government are promoting value-based dentistry and alternative payment models (APMs).
The spun platitudes expressed by policymakers in their bubbles often discount realities faced by doctors and patients. Superior healthcare outcomes and less costly treatments are virtually guaranteed by restriction of a pool of patients to those least at risk. In fact, researchers at Harvard Medical School contend that value-based healthcare can exhibit systemic racism.
“APMs financially penalize practices that disproportionately care for patients with high social risk factors. The underrepresentation of Black patients in accountable care organizations is also concerning as their exclusion can widen the health gap,” the researchers said.
APMs all too often break down to resurrection of our failed old capitation programs. Vapid fanfare generated by government officials and public health subordinates working for corporate dentistry or Medicaid MCOs can apply only so much lipstick to on the pig called capitation.
Conclusion
To ensure dentist participation in CHIP and Medicaid, critical stakeholders (wet-gloved provider dentists and their representatives in state organized dentistry) must have a prominent seat at the table. Top-down policy for CHIP and Medicaid that largely excludes provider doctors is nearly certain to fail. That failure is currently on full display in many states.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.
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