USA - Like pulling teeth

Like pulling teeth
By David Jacobs (Contact)
Monday, December 17, 2007
Nelson Daly has been a practicing dentist in Baton Rouge since 1994, and business is booming. But he doesn’t accept patients who rely on Medicaid, the government program that covers certain kinds of medical expenses for the poor.
And it’s not because he’s greedy; he’s one of the founders of the Greater Baton Rouge Community Clinic, a “virtual clinic” by which providers offer free care to the working poor in their own offices.
“I’d love to help out more people,” he says. But Medicaid in Louisiana pays less than 60% of the average fee that a dentist would charge for most services. At that rate, most dentists, who generally own their own practices, can’t even cover their overhead.
“If I don’t run it like a business, I’m going to lose it,” Daly says. With the community clinic, he can decide ahead of time how many people he will treat and work them into his schedule. But if he opened the floodgates to Medicaid patients, he wouldn’t have that kind of control. And even Medicaid generally only covers dental care for pregnant women and people under the age of 21; other needy people rely either on a hodgepodge of private efforts and government clinics, or do without.
“There’s definitely a real problem,” Daly says. “Unfortunately, you cannot take care of everybody. There are so many people out there, you can’t come up with a plan to cover all of them.”
Medicaid is funded by the federal government and the state at a 70/30 ratio, and administered by the state. Last year, the program cost about $62.3 million. The state has raised the reimbursement rates each of the last five years, cheering dental health advocates.
“Louisiana is going in the right direction, but we still have a significant way to go,” says Ward Blackwell, executive director of the Louisiana Dental Association. He says if reimbursement rates could be brought up to about 70% of a dentist’s typical fee, most would be able to at least cover their expenses.
Just over half of the state’s 1,950 dentists are signed up for Medicaid, although only 663 actually saw even a single Medicaid patient in fiscal year 2006-07. The administrative burden the system imposes, along with what dentists say is a tendency by Medicaid patients to miss appointments, help discourage dentists from serving that population, says Dionne Richardson, director of the state’s Oral Health Program. But finding a dentist also is a problem in many rural areas; Richardson says 73% of Louisiana’s 64 parishes are officially designated as “dental health professional shortage” areas.
Richardson says when the Office of Public Health provides dental sealants to children in central Louisiana schools, they often recruit providers from other areas. And of roughly 30,000 pregnant women eligible for Medicaid dental services, only 4,129 participated in fiscal year 2006-07, which represents a three-fold increase from the year before, she says.
One way to increase access, used in the United Kingdom, New Zealand and about 40 other nations but implemented in this country only in Alaska, is the use of dental therapists, who provide primary dental care to children and adults in poor, rural areas.
The Alaskan therapists receive two years of training in the state, explains Peter Milgrom, the director of the Northwest/Alaska Center to Reduce Oral Health Disparities and a professor in the University of Washington’s Department of Dental Public Health Sciences. Therapists can pull teeth, drill and fill and, perhaps more important, promote preventive care among an Alaskan population where most children have significant tooth decay by their second birthday, he says.
Milgrom argues that such a system, staunchly opposed by the American Dental Association, could do a lot of good in the lower 48 where he says only about a third of the population gets regular dental care and nearly two-thirds of children on Medicaid don’t have a dental visit in any given year.
Blackwell, the head of the LDA, calls the use of dental therapists a “scary prospect.” How can therapists with limited training stand in for dentists with four-year college degrees and four years of dental school?
“There’s no way you can begin to equate the quality of care,” Blackwell says. “I think that’s not a very good solution. Why should you have a second tier of care for the poor?”
“There is already a two-tiered system and always has been,” Milgrom says. “The goal is to actually provide something other than expensive emergency care.” He stresses that therapists are not independent practitioners; rather, they are considered primary caregivers at the remote sites where they operate, and consult with and make referrals to a regional dentist supervisor.
Blackwell does say that better education about the importance of primary dental care is needed. And many dental professionals say fluoridated water can make a huge difference. Blackwell says less than half of the state’s population has fluoridated tap water, and says that for every dollar spent on fluoridation, perhaps $40 can be saved in Medicaid costs.
But as Robert Barsley, director of the Dental Health Resources Program at the LSU School of Dentistry, points out, fluoridation can be very expensive on the front end. Hays Owen, senior vice president and chief administrative officer of the Baton Rouge Water Company, says the company has never estimated how much it would cost to add fluoride at each of its 80 wells parish wide, but says it would be cost-prohibitive.
And there is care out there for the less fortunate. Most metropolitan areas, including Baton Rouge, do have clinics that charge on a sliding scale, although fully staffing those clinics can be a problem. There are specific programs to provide donated services to the handicapped and elderly. The Baton Rouge Clinic program caters to those that are employed but uninsured, and make up to twice the federal poverty rate; the program has a waiting list of three to six months, executive director Pat Alford says.
But people still seem to fall through the cracks. Blair Gremillion is a Prairieville dentist who volunteers on the “Dental Bus” that belongs to Healing Place Church of Baton Rouge. The bus visits the church’s satellite campuses in Donaldsonville, St. Francisville and Gonzales three Saturdays a month. Gremillion and two other dentist volunteers take turns doing tooth extractions, which he says is the biggest need.
“I think we all could do a little more,” he says, stressing that he had nothing bad to say about his profession. “There’s definitely a problem, and there’s not an easy answer. This is what God put in my heart, and it’s one way I can help. We’re not trying to solve the health care crisis by ourselves.”

Comments
Posted by nyscof (anonymous) on January 28, 2008 at 8:18 a.m. (Suggest removal)
Poor diets create poor teeth. Fluoridation is not a factor in it at all. Fluoride is neither a nutrient nor essential for healthy teeth.
No Louisiana resident is , or ever was, fluoride deficient. In fact, they may be fluoride overdosed as the Centers for Disease Control show that up to 41% of US school children have dental fluorosis - white spotted, yellow, brown and/or pitted enamel.
Dentists must be mandated to treat children on Medicaid. They didn't get rich on their own. The government subsidized their education and their unions, such as the American Dental Association, garner them perks through their influence in creating legislation favoring dentists.
The Dental Health Aide Therapists are a wonderful idea but the ADA is fighting it because they don't want anyone infringing on their lucrative monopoly - even if low-income Americans have to suffer so dentists can stay rich.