YAKIMA, Wash. — For the past several months, the state Medicaid dental program office has been flooded with requests for dentures.
It’s not because all those people suddenly lost their teeth.
This January, Washington Apple Health (the state-operated Medicaid program for low-income residents) restored adult dental benefits, and clients finally got access to care beyond the catch-all tooth extraction that’s been their only option for the past three years.
So dentures are in demand now that they’re covered.
But restoring benefits doesn’t solve what experts say is the main problem with dental coverage under Medicaid.
They say the system is fundamentally flawed in two ways: It historically places dental care outside the scope of overall health care, and it consistently fails to fund preventive care in favor of only paying for emergency services, which are more expensive and less effective.
“For some reason in this country, we feel it’s OK if pain and suffering comes from the tooth, but it’s not OK if it comes from the back, or wherever else ... ” said Dr. Mark Koday, chief dental officer at Yakima Valley Farm Workers Clinic. “More and more studies are showing that oral health can affect overall health, but still, everybody’s behind on this. Funders and legislators on down to even providers.”
Raising reimbursement rates for providers could help boost access for dental patients. But with the state strapped for cash, advocates don’t see that happening anytime soon. In fact, budget cuts could get deeper.
“It’s not outside of the realm of possibility that they start cutting things again,” said Bracken Killpack, senior vice president of government affairs with the Washington State Dental Association.
Adult dental was cut for most Medicaid clients in January 2011 and wasn’t restored until this year. During those three years, preventive and restorative care were not covered at all. Patients could get an exam, some X-rays and a tooth extraction if they were experiencing pain or infection. Anything else, they had to pay out of pocket. A filling for a cavity was not covered, but Medicaid would pay to have the tooth pulled, says Dianne Baum, dental program manager at the Health Care Authority.
Though coverage was maintained for some groups, such as pregnant women or people in nursing homes for developmental disabilities, the vast majority of adults received only emergency coverage — which advocates say is the opposite of how it should be done.
“Almost all dental issues that occur are preventable,” Killpack said. “How the state has set up the system, by only consistently funding emergent care, is deciding that they’re only going to fund when the problems are at their worst.”
Even the restored benefits aren’t comprehensive. Medicaid only covers root canals on front teeth, not molars, Baum said. And it doesn’t cover crowns.
“I don’t think a lot of people get root canals on their front teeth,” she said dryly.
According to the federal government, adult dental care is not an essential benefit. But this nonessential status means dental care — like vision and mental health care, also classified as nonessential — is one of the first things to be targeted for cuts when the budget gets tight, Baum said.
Some providers term this the “Ichabod Crane” medical model, drawn from the tale of the Headless Horseman: Only what’s below the neck is covered.
Koday said the problem is not just the number of adults who need care, but the level of care they require.
“If you have a child come in versus an adult come in, even if the child has a lot of dental problems, it’s still easier,” he said. “The adult’s needs are far more complex. ... There’s more adults, fewer people to take them, (and) their problems are far greater. It’s just sort of a triple whammy, unfortunately, for that population.”
Just like in medicine, emergency dental care ends up being far more expensive than preventive and restorative care.
Some studies show that dental or oral health problems are the No. 1 reason uninsured adults end up in the emergency room. In the Yakima Valley, where there are several clinics that cater to low-income, uninsured and homeless patients, providers say the numbers aren’t quite that high, but the need is still significant.
Yakima Valley Memorial Hospital had 37,500 patient encounters in its emergency department for the first six months of this year. Of those, about 1.3 percent — 502 patients — were there for oral health problems. The most common complaints are dental pain or infection, says Dr. Erik Miller, the director of the emergency department.
A report on emergency room use from the Washington State Hospital Association in 2010 listed “dental disorder” as the 18th most frequent diagnosis code seen in hospital ERs, with 23,459 visits in an 18-month period at an average charge of $532 per visit. Tooth root abscesses were the 35th most common complaint, with 12,998 ER visits at an average charge of $809 each.
Emergency rooms don’t have on-call dentists, so the normal course of action for dental complaints is to prescribe antibiotics if there’s an infection, and pain medication for most everything else. Neither fixes the underlying issue if there’s an abscess due to prolonged infection, or periodontal problems in the roots of teeth.
“Unfortunately, we have some patients that come back time and again because they have trouble getting into a dentist,” Miller said.
Memorial refers patients to Farm Workers or Yakima Neighborhood Health Services, which also has a clinic specifically for homeless patients, or to the Union Gospel Mission’s dental clinic. And the hospital has a few pediatric dental residents through the Northwest Dental Residency, based at Farm Workers, who take calls, but only for kids, and so it’s “few and far between,” Miller said.
Dr. Mike Buehler, director and founder of the dental clinic at the Union Gospel Mission, has strong feelings about dental access after decades as a private dentist in Yakima.
“The real problem with access is money. It is not lack of dentists,” Buehler said.
Existing dentists have room for more patients, but if they took more Medicaid, he says, they wouldn’t be able to keep their doors open. Washington Apple Health — the state’s name for the Medicaid program — reimburses private practitioners at such low rates that hardly any dentist outside of federally qualified health centers like Farm Workers, which are reimbursed differently, can afford to take Medicaid patients.
Buehler says the only way private dentists can afford Medicaid patients is as filler time in their chairs when commercial insurance clients don’t show up for an appointment.
For example, for a regular preventive care visit, which includes teeth cleaning and an exam, a private dentist receives $221 on average from commercial insurance, but only $63 from Medicaid, according to data from the Washington State Dental Association.
Reimbursement rates for federally qualified clinics vary, but they receive the same flat fee for every patient “encounter,” regardless of the service provided, at $203 on average, according to state numbers.
At its Yakima Valley clinics last year, Farm Workers treated 20,031 patients, Neighborhood Health saw 6,000 patients at about 16,000 encounters, and the Union Gospel Mission had 647 patients at 2,058 appointments.
Buehler’s clinic depends on volunteer dentists, but not all of them are certified Medicaid providers, so Buehler can’t accept Medicaid at all without risking being fined by the agency for fraud, he said. Simpler to just keep everyone paying cash. The onerous paperwork from Medicaid adds to private doctors’ reluctance to see patients, a complaint not unique to dental care.
Buehler said the bureaucracy has only gotten worse with health care reform, which doesn’t increase dental access but does increase certain Medicaid requirements for providers.
Until more dentists are willing and able to accept Medicaid patients, which likely means greater reimbursement from the state, patients will continue to suffer and be a burden on the system, providers say.
“I hate the system,” Miller said. “I feel sorry for the people that can’t get care. Ultimately, society pays vastly more than they would if the state would reimburse private dentists decently to see people in the office.”
In the ER, he said, “They spend thousands of dollars, when they could’ve paid the dentist a couple hundred to fix the problem.
“I don’t see anything good coming down the road anytime soon.”
• Molly Rosbach can be reached at 509-577-7728 or firstname.lastname@example.org.