In his own polite way, Dr. Michael Dasinger is quick to cuss Medicaid.
He’s the only dentist in the South Alabama town of Brewton who treats children covered by Medicaid, a government health insurance program for the poor. But more than once he has almost quit out of frustration with low reimbursement rates, claims processing hassles and parents who don’t bring kids in for appointments.
What has kept him from being a Medicaid dropout? The children themselves.
“You can’t blame the kids,” he said.
Alabama dentists and Medicaid are in something like a bad marriage, with thousands of children paying the price through delayed or never-received care.
Medicaid has lately sought to make amends to private practice dentists, who provide most of the care to poor kids in Alabama. Alabama’s Medicaid agency has raised the rates it pays to dentists and simplified claims processing.
“Although it’s quite recent, they seem to be trying to get on the right track in Alabama,” said Dr. James Crall, a pediatric dentist at New York’s Columbia University, and a recognized expert on Medicaid and dental care.
But there’s a lot of bad feeling among dentists and a long way to go before Alabama Medicaid achieves its goal of getting care to a much higher percentage of poor kids. Roughly 350,000 Alabamians – from infants to age 20 – are eligible for Medicaid dental care. In the last fiscal year, only 21 percent of those saw a dentist under Medicaid, agency figures show.
Those who did get seen often waited months for an appointment. Many traveled long distances, because 16 of Alabama’s 67 counties have no Medicaid dental provider. In some rural Alabama counties with thousands of “Medicaid eligibles,” virtually no Medicaid claims are filed, because the few dentists there won’t be part of the program.
Use of the program by black children and by children who live in a county without a provider is particularly low, according to a new study by professors at the University of Alabama at Birmingham dental school.
“The bottom line is we have a tremendous problem (in access to dental care) that we have not been able to address,” said Dr. Karen Landers, a state Department of Public Health pediatrician in northwest Alabama.
Medicaid is administered by states, which use their own funds and a federal match. Alabama is hardly the only state that struggles to provide dental care for the poor, and the percentage of kids reached by Medicaid here is right at the national average.
But Alabama’s Medicaid program recently was one of 10 state programs to get an “F” in a report card issued by Oral Health America, a Chicago-based nonprofit group that lobbies for improved dental access for the poor. One reason for the low mark was that Alabama badly lags in the percentage of private practice dentists willing to see Medicaid patients.
In some states, such as Vermont and Nebraska, the majority of dentists see at least some Medicaid patients. In Alabama, only about 18 percent do.
And last year, only 93 of the state’s more than 1,800 licensed dentists were deemed by Medicaid to be “significant providers,” seeing enough patients to claim more than $25,000 in reimbursements.
This tissue-thin reserve of private practitioners, along with a scattering of public health clinics, provides all the dental care Alabama’s poorest children get.
Alabama dentists are the first to say it’s not enough.
“I’m just amazed there’s not a class action lawsuit against the state of Alabama,” said Dr. David Merritt, a pediatric dentist in Florence in northwest Alabama, who noted correctly that Texas and several other states are under federal court order to improve dental care for their poor children.
Dasinger, 65, is one of Alabama Medicaid’s depended-upon dentists. But even he draws limits. He does not treat children under age 5, and he sees Medicaid children mainly on Tuesdays. Still, he has about 800 Medicaid kids on his rolls, from all over southwest Alabama.
Unless it’s an emergency, those children wait months to see him. His office manager has stopped taking names, because the waiting list is so long.
Far from being recruiters for Medicaid, Dasinger and other dentists in the program are quick to discuss its limitations, especially financial ones. They say that until recently the agency was notorious for paying dentists only about half of their “usual and customary” fees.
“You don’t make any money” doing Medicaid cases, he said.
Getting paid at all has been a problem some years, due to Medicaid cash flow problems and claims processing complexities. Indeed, many dentists in Alabama say they have quietly treated some Medicaid children without even filing for reimbursement.
“We would lose money doing the paperwork,” said Dr. Charles Hall, a Huntsville dentist who is a past president of the American Academy of Pediatric Dentistry.
Dentists in Alabama and elsewhere also grumble about problems that aren’t really Medicaid’s fault. They say Medicaid kids are more likely than other kids to misbehave in the dentist chair. Often, dentists insist, one Medicaid child will have an appointment but the parents will show up with all the children in the family, crowding the waiting room. While acknowledging that it’s unfair to generalize, dentists also share stories of Medicaid parents making off with magazines and toilet paper, and changing car oil in the office parking lot.
Better documented, and probably more serious, is the high rate of broken appointments. While other patients fail to honor appointments, too, the American Dental Association estimates from surveys that a full third of Medicaid patients don’t show as scheduled.
That’s a serious disruption for a solo practitioner like Dasinger, who has dental hygienists to pay and expensive equipment to maintain. “We have had seven or eight that haven’t shown up today,” Dasinger said one recent Tuesday. “We’re shot to hell.”
Dr. Roy Smith understands such frustrations. As a dentist practicing in Prichard, a hard-pressed city on Mobile’s northern border, Smith is better aware than most people that poor children often don’t get adequate dental care. But after years of holding firm, he dropped out as a regular Medicaid provider last year.
Reimbursement rates and trouble getting paid contributed to his decision. So did broken appointments and what he called the “low dental IQ” of young patients and parents who seemed not to know about good nutrition or the importance of brushing and flossing.
Smith bridled, too, at clinical decisions forced on him by Medicaid policy. For example, only in certain situations will Medicaid pay for a crown that’s not stainless steel.
“Blue Cross will pay for a composite crown that looks natural and white,” Smith said. “So the poor kids are the ones walking around with a mouth full of silver. I see these kids. They’re embarrassed. They’re walking around holding their mouths so people won’t see all the silver in there. A teen-age girl doesn’t need that.”
State Medicaid officials don’t strongly challenge the validity of such complaints by dentists. Instead, they point to changes made.
Gov. Don Siegelman announced in October that, with the help of the state’s share of the national tobacco lawsuit settlement, Alabama would spend an extra $6.5 million a year to raise reimbursement rates to what Blue Cross and Blue Shield of Alabama pays for dental procedures. For example, an extraction bumped from $34 to $53. Dentists now get $22, as opposed to $15, for a comprehensive oral exam.
Medicaid officials plan to capitalize on the rate hikes with a broad-based campaign for enlisting more dentists and minimizing broken appointments through “targeted case management.” Social workers at county health departments are supposed to remind parents of appointments, and help arrange transportation as necessary.
Agency officials say they have worked hard for the last year to simplify claims processing, even sending technicians to dentists’ offices to install free software and train office employees in how to use it. Dr. Mary McIntyre, a physician who oversees the dental program for Medicaid, has gone herself to dentist offices to investigate complaints and look for solutions.
“We’re trying to sell this program,” said Dr. John Searcy, medical director for Alabama Medicaid.
Since rates were raised, 10 dentists have signed up to be Medicaid providers, and another 39 have asked for applications. As well, some South Alabama dentists and their office managers confirm that Medicaid claims processing has been faster and easier in recent months.
“They’re trying hard,” said Dr. Gary Silbernagel, a Flomaton dentist who sees children on Medicaid.
Unfortunately for the agency, its reforms come when most Alabama dentists have all the work they need from patients who pay out-of-pocket or through private insurance. Dentists can afford to be critical of the new, improved Medicaid – even of its rate hikes.
Wayne McMahan, executive director of the Alabama Dental Association (which lobbies for private practice dentists), noted that Medicaid still hasn’t reached dentists’ usual and customary fees. Blue Cross, he said, pays 15 to 20 percent below those fees, and a patient “co-pay” usually makes up the difference. With Medicaid patients, there is no co-pay.
McMahan also pointed out that Medicaid raised most but not all of its rates. A handful of procedures, including the rate for installation of stainless steel crowns, were held back. McIntyre confirmed that the agency is waiting with the stainless steel crown procedure because of concerns that it is being overused by dentists.
“I know dentists who got offended by that, because it was like Medicaid was saying, ‘Just because you use this (procedure) code, you’re a crook,'” said Dr. Noel K. Childers, a pediatric dentist on the faculty of the dental school at the University of Alabama at Birmingham.
Such comments by dentists are common, and reflect the difficulty the agency is having in patching things up. Some dentists, including Florence’s Merritt, believe there’s just a basic incompatibility between Medicaid and private practitioners that higher rates and quicker payment won’t fix. He’s not giving up on Medicaid, but he thinks more public clinics are a better answer for delivering dental care to poor kids.
Merritt has lots of reasons, but one is the reaction he gets when he asks fellow dentists to join him as an occasional Medicaid provider.
“They look at me,” he said, “like I’ve asked them to walk on hot coals.”
(Register Staff Reporter William Rabb contributed to this report.)