The fact that access to dental care is lacking for under- and uninsured central Kenai Peninsula residents is not an issue that garners much debate. What is debated, however, is why access to dental care is lacking and what can and should be done about it.
Central peninsula private practice dentists point to problems with the Alaska Medicaid Program as the reason why they don't participate in the program.
"The private practice dentists have been forced out of Medicaid," said Dan Pitts of the Soldotna Dental Clinic, who has been a practicing dentist in Soldotna for 26 years.
However, that doesn't mean those patients don't get any care, he said. He has treated Medicaid patients for free, and is on call every two months at Central Peninsula General Hospital, as are other dentists in town, to deal with dental emergencies.
"I don't know anybody that turns anybody away that comes into their office in pain," Pitts said. "If someone is in pain or in need, nobody gets turned away. We do the work for free."
Pitts and other local dentists may donate their services when the need arises, but they don't participate in the Medicaid program. The main reasons they and other dentists in the state don't are laid out in a report about provider participation in the Alaska Medicaid Program done in 2001 by the Alaska Division of Medical Assistance.
One of the complaints listed in the report is that the reimbursement rate Medicaid pays providers for services given to Medicaid recipients is too low. In Alaska, Medicaid pays providers 67 percent of the amount billed.
If a private dentist runs their practice with a 50 to 60 percent overhead -- the cost of renting office space, paying bills, buying equipment, etc. -- that 67 percent reimbursement rate barely covers the cost the dentist incurs to treat a Medicaid patient and leaves little, if any, money left over for profit.
"The reimbursement is not coming close to what private pay (people with private insurance) is reimbursing at," said Paul Engibous, a pediatric dentist from Anchorage who operates a biweekly dental clinic in Soldotna that accepts Medicaid and Denali KidCare patients.
"... You're basically trading money, you're not making anything. Any profitability is gone and you're taking a reduced fee."
Engibous said he is able to participate in the Medicaid program because he also has a practice in Anchorage with another dentist who continues to see patients while Engibous is running the Soldotna clinic. That way the practice can make money, even thought seeing Medicaid patients is not a source of much profit.
"I know the dentists on the peninsula would love to see lots and lots of kids and adults (on Medicaid), but if they're potentially losing money seeing them, you can't do it," Engibous said. "You can't go to Safeway and say, 'I only want to pay 60 cents on a dollar Coke.' It won't work. It won't happen because you have to pay the overhead."
Another complaint providers have against the Medicaid program is that the billing process and business aspect of the program is overly complicated and not user-friendly. Providers also complain that the financial audits Medicaid conducts and the audits done by the Medicaid Fraud Unit can be onerous.
According to the report, providers did not question the need for the audits, but they did question the intent and methods of audits in recent years.
"I'm sure there are people out there who tweak the system a little bit and I think auditors are absolutely needed, but there has to be a little bit of a balance," Engibous said. "It doesn't have to be a rancorous type of relationship. It can be a win-win relationship and, unfortunately, sometimes it's not."
A third headache for providers who participate in the Medicaid program is dealing with patients who miss appointments. A lack of transportation, child care needs, not having a telephone and other reasons are frequently cited.
A fourth concern dentists have is a "hold harmless" clause found in the Medicaid provider enrollment form. The clause basically stipulates the state is to be held harmless in the event litigation arises between a Medicaid recipient and a provider. For instance, if a client brings a malpractice suit against a provider, the hold harmless clause would protect the state from being brought into the ligation.
"The state just pays for the care, we're not the provider giving the care," said Brad Whistler, oral health program manager for the state Division of Public Health.
There is some question over whether the clause could be interpreted to mean that if a client were to bring a suit against the state, the dentist who treated that client could be held responsible for the state's litigation expenses. That is a theoretical situation, Whistler said, and not the intended purpose of the clause. However, the Division of Medical Assistance has heard some concern over the matter, so the division is looking into it.
Pitts listed the hold harmless clause as one of the main reasons he does not participate in the Medicaid program.
"I've been told I'll be unable to get malpractice insurance if I do Medicaid work," he said.
Pitts said an added frustration with the program is that he doesn't think these concerns have been addressed.
"It all started going haywire about 10 years ago," he said. "... I just got a Medicaid provider agreement in the mail and it hasn't changed."
Bob Labbe, director of the Division of Medical Assistance, and Whistler disagree. They say there have been changes made in the last two years that address some of these areas of concern.
"We've taken a lot of steps to improve the (program) for providers to participate," Labbe said. "... There's a whole list of things that I think people who are more engaged with us have been aware of."
Among this list are adopting unified claims forms and streamlining the dental claims process, improving communication between providers and auditors so the process is less confrontational and getting a state waiver that allows Medicaid to track down third-party payment services, rather than having the provider bill other payment services first and then bill Medicaid.
One issue that has not been changed, however, is the Medicaid reimbursement rate.
"I know this issues has come up, and the rate issue is a budget issue," Labbe said. "I'd like to do some improvement in that area, I would like to make sure we're covering the costs (of treatment) as best we can, but there are costs associated with it."
Whether Medicaid needs to make more changes to encourage more providers to participate in the program or whether more providers need to be made aware of the changes that already have been made is a matter of opinion. The need for greater access to care, however, is not.
"There's a need, there's no question," Engibous said. "There's a need (in Anchorage), there's a need in the peninsula, there's a need in Fairbanks, in Kotzebue and Bethel and Juneau, and honestly there's a need in probably every major and not-so-major metropolitan area in the country. That's the bottom line. It's not unique to this area.
"Part of the reason is it's difficult working through the Medicaid and Denali KidCare system. We're obligated to treat the kids and do the best we can, but sometimes it's difficult. A lot of people decide the headache of working within the system is just a little bit overwhelming -- throughout the country."
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