Dental crisis looms

Posted: Sunday, May 27, 2001

Low-income families face a crisis in getting dental care, warned dentists and others Tuesday at a meeting on community dental health.

Without major changes, the crisis will only get worse, they said.

The meeting was organized by the Community Dental Health Project, which has been working for the past year to examine issues interfering with access to dental health care for children on the central Kenai Peninsula. Its surveys found that only one child in five from the central peninsula who is eligible for Medicaid dental benefits actually receives them, and many of those go out of town to get care.

Those at Tuesday's meeting agreed that poor children here are suffering, an emphasis on prevention is vital and that current Medicaid rules are frustrating medical personnel's ability to help. They also agreed that the meeting gave them cause for hope.

About three dozen dentists, physicians, social service providers and patients assembled at the Soldotna Senior Center to start constructive dialogue on improving the situation. Grace Merkes, a member of the Kenai Peninsula Borough Assembly, and Gene Dyson, who sits on the Central Kenai Peninsula Hospital Service Area Board, also attended.

"This has been a smoldering problem for years," said Dr. Dan Pitts, who has practiced dentistry in Soldotna for about 25 years.

"We are upset at the system."

He and his partner stopped providing Medicaid services in the late 1980s, when the federal program shut down its Alaska offices and consolidated administration to California.

"Medicaid was about 10 percent of my practice and about 90 percent of my problems," Pitts said.

Dr. Tom Hipsher, president of the Alaska Dental Society, attended the meeting. His organization was working with the state to reform Medicaid but has been frustrated. The dentists and state health officials were progressing until the state attorney general's office got involved, he said.

"At this point, we are no longer in discussions ...," he said. "We are definitely stalled."

Meanwhile, he stopped providing Medicaid services in January.

Wasilla dentist Dr. Rob Robinson was passionate about the situation.

"Listen to us," he said. "Listen to why the guys who are supporting you are quitting."

The state's largest provider of Medicaid services, in Anchorage, is preparing to withdraw from the program. It is cheaper for dentists to give away their services than to try to get reimbursed through Medicaid. Soon Alaska may not have any dentists at all who take Medicaid, he said.

Meanwhile, the needs for such care are greater than ever, warned other health providers.

Bekkie Jackson, school nurse at Sears Elementary School in Kenai, said she sees three or four children a day in her office with untreated dental problems. Those numbers seem to be escalating, she said.

"I've had children come in who are in such pain they cannot eat," she said.

Patty Little, from the Kenai Public Health Nurse's clinic, agreed. The nurses meet parents who don't know what to do to get help for their children, or who log thousands of miles in travel over time to get care out of town.

"We see quite a few sad things," she said.

Dr. John Kasukonis, an emergency room physician from Central Peninsula General Hospital, said he sees a high percentage of severe dental problems here compared with other parts of the country. About 400 patients per year go to the emergency room with dental problems. About a third to a half of those seen are children. And only about one in eight has a traumatic tooth injury, meaning the rest have problems that could have been avoided by proper dental care.

People tell him they tried to get an appointment with someone who would take Medicaid, but those dentists on the central peninsula are booked up.

"I refer them to Anchorage," Kasukonis said.

"By the time they come to us, there is not a lot we can do. ... I see it as becoming more of a problem year by year."

He faulted Medicaid, saying the rules discourage prevention and encourage negligence by denying benefits except for emergency situations. He decried the system as wasteful.

Family physician Dr. Katy Sheridan described one such case last year at the hospital that bothered her.

A family brought in a child with such a badly abscessed tooth that his face was swollen and he was seriously ill. An oral surgeon from Anchorage was due in town the next day, so she admitted the child overnight. But the next day situations intervened and the surgery was not done.

"I ended up Medevacing him to Anchorage to get his tooth pulled. We paid $5,000 ... and the kid was in pain for 24 hours," she said. "It just seemed wrong."

Hipsher said one place for everyone to start improving the situation is by lobbying the government to change the Medicaid system.

He outlined four key problems driving dentists out of Medicaid:

n The provider agreement: It contains legal clauses that expose dentists to lawsuits, making it more difficult for them to get insurance and penalize them for charity work.

For example, Dr. Todd Wortham of River City Dental said Medicaid rules requiring health providers to charge the government their lowest rates are illogical. If he gave his mother a free filling, Medicaid would require he bill the state for the rest of his patients at that lowest fee, which would be zero. If he did otherwise, he could be found guilty of fraud.

"Those are very scary issues," he said.

n Hassles: Hipsher said Medicaid procedures "make life a pain in the butt for us."

The dentists said Medicaid uses different forms and claims procedures from private insurance companies. Any mistakes it makes are essentially impossible to fix. Preventive care is slighted. Travel is paid at the highest rate, but medical care at the lowest rate.

"There is so much money to be saved," he said.

n Audits: Dentists are up in arms about the way the Alaska attorney general's office has conducted Medicaid audits. Auditors remove many medical records for extended periods of time and charge large fines over what the dentists consider minor procedural points, they said.

Hipsher likened the auditors' manner to the Gestapo.

Said Pitts, "When someone comes to your door and says, 'I'm from the medical fraud division of public assistance,' your heart stops."

n Patient problems: Hipsher said Medicaid patients have a high no-show rate and seem less motivated to take responsibility for their teeth.

Others acknowledged similar frustrations.

Jackson said she has seen school-age children whose parents never taught them to brush their teeth or whose families are so preoccupied with other problems that getting the children's teeth fixed is not a priority.

Participants in the discussion agreed that by working together, the community can improve dental access on the peninsula, even if it means bypassing Medicaid altogether and setting up some creative, grant-funded alternatives. They expressed support for future meetings and setting up a coalition, as recommended by the Community Dental Health Project coordinator Traci Martinson.

Some of the ideas mentioned were:

n Prevention, especially through aggressive education of parents;

n Emergency dental care at Central Peninsula General Hospital, including giving dentists hospital privileges, setting up a dental room there and arranging a rotation of dentists to be on-call;

n More dentists, especially pediatric dentists, to ease the above-normal work load of peninsula dentists;

n Including dental issues in the hospital's long-range plan now under development; and

n Involving retired dental providers in volunteer care projects.

After the meeting, Martinson said she was pleased with the turnout and constructive tone.

"It was a call to action," she said.

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