Dentist Garth Bobrowski gives away thousands of dollars in free dental care for patients who can’t afford it in his small town of Greensburg, Kentucky.
“Dentists serve patients in their communities in these rural towns because these folks are our folks. We go to church with them, we go to school with them,” Bobrowski said. “So we do it as a service to the community.”
But the state’s low-income dental insurance program will change this summer. Last month, the federal government approved Gov. Matt Bevin’s changes to the Medicaid health insurance program for low-income and disabled people. The changes are worrisome for advocates and patients in a state where dental care is already inadequate.
And the new plan will also mean big changes for dentists, who already accept lower reimbursements for the services they give Medicaid patients. Dentists like Bobrowski fear the new system will leave them offering more care for free.
The Medicaid Waiver
Currently, Kentucky’s Medicaid enrollees have automatic access to dental insurance. But the new plan requires patients to earn what the state calls “My Rewards” account dollars to pay for dental services, like a dental cleaning or filling. An enrollee can earn those My Rewards dollars a few different ways, including by getting a comprehensive dental exam or vision exam, avoiding unnecessary emergency room visits for a 12-month period or taking a health literacy course.
If patients don’t have enough rewards dollars, dentists can send accounts into negative balance, and recoup future payment as dollars accrue. Or, they have the option of sending patients away until they can pay.
These Medicaid changes apply to individuals who earn up to $16,642 a year or $42,435 for a qualifying family of four. To keep their coverage, these same people will also have to fulfill a so-called community-engagement requirement: 80 hours a month of work, volunteering, taking a GED course or other activities. Some groups, including pregnant women, people deemed “medically frail,” caregivers or people with a disability will be exempt.
And a spokesman for the Kentucky Cabinet for Health and Family Services said the plan has sufficient safeguards to make sure anyone who needs dental care will get it.
“Less than 10 percent of [the] expansion population is getting preventive dental care. By focusing rewards and policies that incentivize preventive care, Kentucky HEALTH aims to drive down the need for more expensive dental services,” Doug Hogan wrote in an email.
But Dustin Pugel, a policy analyst at the progressive Kentucky Center for Economic Policy, is worried that putting more focus on preventive care won’t drive down the need for more advanced dental services, like fillings. Instead, it’ll make those services harder to get, he said.
“This gives options for folks to earn credit that they can use for specific services like a dental cleaning or filling, but in terms of comprehensive dental coverage, that’s gone,” Pugel said.
Bad Oral Health, Poor Access To Care
Kentuckians lag behind most of the country in tooth and gum health. In 2012, Kentucky was ranked eighth highest in the U.S. for the percentage of adults who’ve had a tooth extracted, according to data from the Centers for Disease Control and Prevention. Extracted teeth result from cavities or gum problems that have gotten so bad that the only way to fix it is to pull the tooth. Gum diseases also have strong ties to heart problems, diabetes and other chronic health issues.
Add this to the fact that only about a quarter of Kentucky dentists even take Medicaid patients. These few dentists say they’re preparing for an influx of patients who can’t pay their bills.
Somerset dentist Henry Coffey said around 80 percent of his patients have Medicaid coverage. And even though there are more than 20 dentistry practices in Somerset, Coffey said only a handful accept Medicaid.
“I got people driving to me from two, three hours away because they can’t get anybody to work on them, that’s crazy,” Coffey said. “The other dentists, I don’t know if they think they’re too good, but somebody has to work on these people.”
Medicaid pays dentists the lowest reimbursement of any sort of insurance, below Medicare or employer-based insurance. Coffey said the federal government pays him 30 percent of what he actually charges for these patients. And Medicaid paperwork is already a little more complicated, he said.
“For me, it’s just about to the end. I’m paying two full-time office people, and their job is eight hours a day, dealing with filing Medicaid reports,” Coffey said. “And now they’re telling us they’re going to give us more to do? It’s just becoming unfeasible.”
Educating Patients Gets Complicated
The change is only affecting the Medicaid expansion population, and some groups — like pregnant women, people deemed ‘medically frail’ or caregivers — will keep their automatic dental coverage, bypassing the My Rewards program. But dentists don’t have access to information about which patients will be affected.
Dentist Garth Bobrowski said even though most of his patients have Medicaid coverage, he doesn’t know who he has to educate about their changing benefits.
“It doesn’t just pop up: ‘You’re Medicaid expansion!’ You don’t know. Doctors just know you have ‘X’ insurance,” Bobrowski said.
With the waiver set to go into effect on July 1, dentists are going to have to start knowing why a patient has Medicaid. And advocates say outreach needs to start soon to let patients know how they’ll get care going forward.
Family Health Centers Louisville spokeswoman Melissa Mather said it’ll take the efforts of the state, advocacy groups and providers to make sure people know how to earn those My Rewards dollars and keep their coverage. She said that means knowing which people need to earn dollars even before the patient makes an appointment.
“We have to start looking at that because we’re going to educate people under this category in a different way, we’re going to start teaching you about how to accrue my rewards virtual dollars,” Mather said. “Before we could just say, ‘you have Medicaid, great.’”
How exactly service providers are going to do that is still unclear to them. Doug Hogan, a spokesman for the state, said the system to identify people and help dentists redeem My Rewards dollars is still being developed. But, he said there will be online and in-person training for dentists when the system is ready.
What If There Aren’t Enough Rewards Dollars?
What if all this work goes into checking if patients have enough “dollars” for services, but the account is too bare for a dental cleaning or cavity filling?
That’s the part that troubles Bobrowski, the dentist in Greensburg.
“It becomes an ethical situation of, say somebody needs a tooth pulled, and they’ve only got $15 in their account,” he said.
Hogan noted that when services are needed, providers will be able to make a patient’s My Rewards account be overdrawn up to $150. Hogan also said that if a patient needs urgent care, medical insurance may pick up the tab. The federal government’s program for older Americans, Medicare, pays for certain dental care procedures provided in a hospital or emergency room.
“If services are medical in nature, they may be a covered medical service and not be considered a My Rewards dental service,” Hogan said.
Bobrowski said he plans to serve patients using the My Rewards account. But he’s spoken with other dentists who won’t.
‘A moral obligation’
At Family Health Centers Louisville, Medicaid reimburses $150 for a dental exam, a set of x-rays and a cleaning. That’s about half of what it actually costs the clinic to provide those services — accounting for the doctors, the dental hygienists, the tools and equipment. This $150 for an exam is a set amount Mather said Family Health Centers can count on to keep their nonprofit going — but now that consistency is gone.
If a patient doesn’t have enough My Rewards dollars, Mather said that person will be able to pay a sliding scale fee for a dental service. That rate will range between $30 to $130 for what Medicaid used to pay $150.
“It’s the long-term sustainability that we’re concerned about,” Mather said. “If we have all these patients that need this care at least before we could get some of it reimbursed under Medicaid.”
Coffey, the dentist in Somerset, said he knows the state is trying to rein in the costs of Medicaid, and he understands the need. But he also knows that if he doesn’t provide the cleanings, the fillings, the gum treatments, there are few others that will.
“I feel I have a moral obligation to try and help these people,” he said. “And there’s just a few of us in this town that feel this way.”