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By Lisa Mikkelsen, chief operating officer, Benevis
In a pay-for-performance world, DSOs could improve care, reduce costs and expand access to Medicaid recipients
There is no doubt the state of healthcare in this country is in flux. As states brace for potentially sweeping changes to the Medicaid program, state Medicaid directors and policymakers will need to think strategically and creatively about how best to continue providing needed healthcare services while also improving outcomes and controlling costs.
Dental care is an area that presents unique challenges and opportunities for state Medicaid programs, leaving many to wonder: Is Medicaid dentistry sustainable in the long term?
The answer is yes, but only with appropriate action and reform. This article will explore the need for Medicaid dentistry, some of the access challenges that currently exist, and solutions that will help ensure we continue to build upon the Medicaid dental access gains that are already demonstrating improved health outcomes and increased cost savings in a number of states.
A pressing need
The merits of comprehensive dental healthcare – especially for the tens of millions of children covered by Medicaid – cannot be overstated. According to a 2016 Pew Charitable Trusts report, tooth decay is the most common chronic disease among U.S. children – five times more prevalent than asthma – and dental care is one of the nation’s greatest unmet health needs among children, especially in low-income, minority, and rural communities. In 2012, more than 4 million children did not receive needed dental care because their families could not afford it. Even when controlling for insurance status, low-income and minority children remain less likely than higher-income children to receive preventive dental care, according to the report.
Without access to preventive dental care, many patients are left to seek expensive emergency dental care for unaddressed oral health needs. In 2012, there were more than 2 million dental-related visits to hospital emergency rooms, which accounted for about $1.6 billion in health costs, according to the same report.
Access to care
Access to affordable dental care remains a challenge in many communities throughout the United States. A recent Health Affairs study shows that even though Medicaid expansion has resulted in increased coverage, it has had no impact on decreasing emergency room visits for dental care. The research suggests that coverage alone may not make a difference if patients do not have access to dental providers who accept Medicaid.
A 2014 survey from the American Dental Association confirms this trend: Only about one-third of all dentists accept Medicaid or other public insurance, according to the survey. Many start-up dental practices, which are typically smaller and family-oriented, begin taking all newcomers as patients. But once their commercial insurance and self-pay base is established, many practices begin to reduce – or eliminate – lower reimbursement payers, with Medicaid often being the first to go, as it is typically the lowest payer for dental care.
On average, Medicaid reimburses approximately 60 percent less than commercial insurers. Moreover, inflation is not built into the federal fee structure despite the ever-rising costs of labor, equipment and supplies, resulting in compressed margins year-over-year for Medicaid patients. On top of these challenges, offices serving Medicaid patients must navigate the administrative challenges involved with billing and collecting, including managing eligibility verification, service limit restrictions, and prior and post authorizations for certain services. Moreover, practices face operational challenges of ensuring compliance with Medicaid payor-specific rules and regulations and higher frequencies of missed appointments from Medicaid patients.
All of these factors contribute to a situation that makes it financially untenable for most private practice dentists to accept a significant number of Medicaid patients.
Opportunities
Against this backdrop, group dental providers have risen to meet the access challenge by employing an innovative care delivery model built on the premise of expanding access to care among Medicaid patient populations. They do so by partnering with Dental Support Organizations (DSOs) – practice support firms that specialize in non-clinical services, such as marketing, IT, purchasing, payroll and benefits administration, HR support, finance support and facility management. Medicaid-focused group dental providers attract dentists who want their professional life to fill an urgent societal need or simply want to focus on their clinical skills versus the administrative burden of running a practice. Group practices that have partnered with DSOs are able to provide administrative and operations support, allowing dentists to focus solely on providing compassionate and high-quality dental care to their patients.
How are DSOs helping group dental practices keep their doors open to children and families who depend on their services? They do so by leveraging technology – including integrated practice management systems and economies of scale – to provide transparency and reduce costs, thereby expanding access, improving quality and promoting cost-effective solutions to reduce oral health disparities among children.
In addition to expanding access, certain DSO-affiliated providers are leaders in improving outcomes and reducing costs to Medicaid programs. A recent analysis from national Medicaid research firm Dobson | DaVanzo & Associates looked at CMS data in several states and found that, as a result of Kool Smiles’ focus on preventive dental healthcare, the DSO-affiliated dental provider performed 15 percent fewer services overall and had a Medicaid expenditure 33 percent lower than non-Kool Smiles Medicaid patients. The analysis found that these cost-effective strategies contributed to Medicaid savings that could fund dental services for up to 1.9 million more children nationally who currently do not receive care.
Solutions
Innovative dental providers like Kool Smiles are paving the way for meeting the Medicaid dental challenge. Now it is up to individual states to create an environment where this model can flourish. There is a longstanding issue of depressed Medicaid reimbursement rates. Medicaid rates are determined individually by each state, and in some states the rates are simply too low for Medicaid programs to attract and retain an adequate network of high-quality Medicaid dental providers, DSO-affiliated providers included.
However, the positive impact of DSO-affiliated Medicaid dental providers can be applied nationwide if reimbursement structures and incentives are aligned to reward providers that demonstrate superior outcomes. In other words, states that embrace the shift from fee-for-service to pay-for-performance, at a reimbursement level sufficient to attract providers, can reap the benefits in the form of additional providers, improved access and outcomes, and ultimately reduced costs to their state Medicaid programs.
While there are certainly very real challenges to sustaining Medicaid dental care, innovative group dental providers and care delivery models are the way forward. By effectively aligning incentives and revolutionizing reimbursement models and rate structures, states can help dental providers continue to meet the Medicaid access challenge and improve dental health outcomes for current generations and those to come.
Editor’s note: Lisa Mikkelsen is chief operating officer for Benevis, an Atlanta-based DSO. Benevis provides practice support services to Kool Smiles, a leading Medicaid dental provider for children and families.
