A Closer Look at Dental Care Practices That Specialize in Serving Medicaid Populations Introduction Over the past several years, the Office of Inspector General (OIG) has released a series of reports evaluating Medicaid pediatric dental services in several states. Analyzing claims data in the states of Indiana, Louisiana, New York, and California, the OIG has stated the following concerns: 1.) Certain dental practices may be providing services that are medically unnecessary or do not meet professionally recognized standards of care, 2.) Services may not have been provided to patients by these practices, and 3.) Quality of care and patient safety may have been impacted as a result The OIG’s analysis identifies outlier providers who received high payments per child, performed a substantially higher number of services per day, performed a substantially higher number of services per child per visit, and provided certain procedures to a substantially higher percentage of children. Although the findings do not provide direct evidence of fraudulent billing practices, the OIG notes that dental providers considered to be outliers “warrant further scrutiny”. In recent years, several studies have been completed to investigate the impact of Dental Services Organizations (DSOs) on patient access and fraud, waste and abuse. In an issue brief published by The Children’s Dental Health Project, DSOs were found to contribute to the increase of dental services for children with Medicaid coverage. In addition to exploring the role of DSOs in expanding access to care, Laffer & Associates examined whether issues of fraud and abuse existed among dental practices that specialize in serving Medicaid populations. Their report, sponsored by Kool Smiles, found that DSOs generally do not perform unnecessary services or compromise quality of care. The Benevis Foundation believes it is important to understand the intent and premise of dental practices that specialize in serving Medicaid populations which may not be fully captured by OIG’s recent reports.
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Discussion With poorer health status and greater health needs, Medicaid patients often require more complex care and treatment to maintain or improve their health and well-being. This reality cannot be ignored when examining the patterns of services and billing by dental care providers that serve these vulnerable populations. Health is influenced by many factors—individual, cultural, socioeconomic, political, and environmental-- that together weave an ecological web of health behavior and outcomes. This web is the reality in which dental practices that specialize in serving the Medicaid population operate their business model. Medicaid patients, whom many are part of minority communities and are impoverished, lack appropriate access to care and experience poorer health outcomes. They also mainly reside in geographies that do not have enough dental care providers. Studies have supported the association between these ecological factors and dental care utilization. The Centers for Medicare & Medicaid Services (CMS) analyzed utilization of dental services by children in nine states and found that counties with 30 percent or more African American residents had a lower likelihood of using preventive or any dental care. Moreover, living in a county with more than 20 percent of the population uninsured decreased the likelihood of using preventive and dental treatment services. Overall, children who resided in areas with higher proportion of African American and Hispanic residents had a lower likelihood of using dental care services. All of these determinants – race, location, economic, cultural – play an integral role in shaping health behaviors and outcomes, thus becoming unavoidable parts of the larger examination of the progress made in meeting goals to the Medicaid program: improve access and quality and lower costs. Briefly mentioned by the Office of Inspector General, dentists who participate in the Medicaid program provide “much-needed” access to dental services, especially for children who have difficulty accessing care for issues that, if unaddressed, can worsen and require more serious and expensive dental care in the future. The Children’s Dental Health Project maintains that dental service organizations have contributed to improving access to dental services for children in recent years. In states where they are active, these dental organizations account for a large proportion of Medicaid children treated. These children often have a higher risk of dental disease and require complex care. According to the AAPD, such dentists that provide care for patients with a higher risk of dental disease and a greater need for complex treatment are unfairly deemed to engage in Medicaid overuse. Under this context, measures to identify patterns of fraud and abuse may not capture the reality and determinants of health of Medicaid patients. As described below, the report’s methodology has a difficult task in determining alleged practices of fraud and abuse, especially for dental practices that solely focus on serving underserved populations. The limitations are as follows: 1. Sample size includes all providers who provided services to 50 or more children with Medicaid. “All providers” lumps together dentists including those who have more Medicaid patients (compared to others) and perform more services. The sample size also includes providers whose primary population is not the pediatric Medicaid population. Also included are the providers who are completing clinics, undergoing training, or providing charity care. Within this sample are also dental providers employed by dental service organizations. Compared to non-dental
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service organization providers, these practitioners provide more care to children with Medicaid coverage and as a result will have a higher rate of Medicaid patients served compared to nondental service organization dentists. 2. The services per day metric needs to be thoughtfully examined. Although Medicaid provides dental benefits to low-income beneficiaries such as children, many dentists do not accept Medicaid coverage. According to the American Dental Association’s annual survey of dental practices, an estimated 32 percent of all dentists reported treating patients covered by public assistance. Due to the self-reported nature of the survey, the results may not accurately reflect Medicaid acceptance rates. In fact, according to Scion Dental, a leading Medicaid dental administrator, only an estimated 15 percent of all dentists accept Medicaid patients. The low percentages of Medicaid patients treated by all dentists underscore the scarcity of providers willing to treat this population, thus making dentists who dedicate their practices to provide care for this population a rare subset of providers. Given the need for dental care among Medicaid children and the scarce pool of participating dental providers, the average number of services provided per day may be higher for some of the providers who treat Medicaid children. For instance, if a dentist were to see a number of patients providing only minimal preventive care, he or she may be identified as an outlier in the OIG report, despite providing services that are well within professional norms. 3. The patient population is children whose primary source of dental coverage is Medicaid. The population served by the dentists is comprised of Medicaid enrolled individuals. As discussed previously, Medicaid enrollees tend to have different health status (generally poorer) and complex healthcare needs compared to the general population. The social-ecological determinants surrounding Medicaid children have been shown to adversely impact their health and well-being, thus requiring greater dental care and treatment. 4. The services per patient provided vary and need to be closely examined to identify differences. There are a number of services that a dentist can provide to a patient per visit. For instance, dentists can perform a substantial amount preventive and diagnostic work given a Medicaid patient’s needs. As a result, these providers may have a higher rate of services due to a larger demand of their services by a patient who requires complex and multiple treatments.
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Conclusion Examining fraudulent and abusive dental practices may encounter limitations when applying a “one size fits all” approach for all dental care business models. Certain dental practices specialize in serving Medicaid patients, who are primarily undeserved children. These children traditionally lack appropriate access to dental care and require a larger number of services that commercial populations may not need. The findings of the OIG reports may dissuade current providers and others who accept children and individuals covered by Medicaid from continuing to participate in the program. For dental practices that focus on Medicaid patients, the reports may also produce a “chilling effect” on the willingness of some new providers to treat Medicaid patients. Moreover, using an approach to compare dental providers who only serve a small number of Medicaid patients to those who solely provide services to individuals with Medicaid coverage may undermine the effectiveness of identifying waste, fraud, and abuse of those who require further investigation and monitoring. These challenges may lead dental practices who primarily provide care to Medicaid patients to experience greater difficulty in serving vulnerable populations (such as children) in traditionally underserved areas and providing care to communities with unmet dental needs.