Editor’s Note: This story was first published on New Hampshire Bulletin.
The Granite State’s victory this year in finally getting lawmaker approval to provide nearly 85,000 adults on Medicaid basic dental benefits will be short-lived if it can’t find more dentists like Chris and Derek Blackwelder.
The two are among the approximately 16% of New Hampshire dentists who take Medicaid, a percentage some oral health advocates say needs to at least double to truly expand access to dental care.
“It’s going to be a challenge,” said Michael Auerbach, executive director of the New Hampshire Dental Society. “We’ve passed the bill, which is fantastic. It’s taken us decades to get this through. Now the real work comes.”
For the Blackwelders, their commitment to public service, which they’ve prioritized since working with American Indians after dental school, outweighs the downsides of taking on Medicaid patients: the tedious paperwork, low reimbursement rates and challenges caring for a population with significant health issues and difficulty showing for appointments.
But passion for public health alone won’t be enough to sufficiently boost that 16% participation rate. Facing an April deadline to begin benefits, the state and oral health advocates have another strategy. They’re expanding recruitment efforts and offering providers an incentive to take on adult Medicaid patients: Someone else will deal with the paperwork, scheduling and rescheduling appointments and transporting patients when they can’t get to an appointment. They’ll also be responsible for arranging language services and connecting patients with other services when needed.
Chris Blackwelder, who like most dentists currently sees pediatric Medicaid patients, is optimistic. But she says it will also take reasonable reimbursement rates that don’t bankrupt a practice to get those 16% and others to add adults on Medicaid to their caseload.
“I don’t think the limiting factor to dentist participation is philosophical,” she said. “I think if those things are in place our colleagues are willing, just currently not able.”
The state has long provided basic dental benefits to children on Medicaid. But unlike most states, it had limited care for adults to emergencies, such as tooth extractions. As a result, most dentists who take Medicaid have restricted services to children.
Public health advocates pushed lawmakers for years to expand coverage to include preventative care, such as cleanings and X-rays, as well as restorative care like replacing a chipped or missing tooth. They’ve argued that basic care would reduce the need for costly emergency services, lower risks of diseases associated with poor oral health and increase job prospects for recipients held back by dental problems.
Those arguments finally overcame disputes and concerns about costs and the scope of benefits this year when the House and Senate each passed bills expanding benefits. The state will cover costs for the first three years with $21 million in settlement money the state secured in January against a company hired to manage Medicaid pharmacy benefits.
Sununu signed both in July, flanked by an elbow-to-elbow crowd that included lawmakers from both parties and dozens of oral health advocates. Among them was Dr. Sarah Finne, a retired dentist and the state’s Medicaid dental director.
“I’ve been at this a long time,” she said in an interview Monday. “I’ve been out of dental school for 38 years. This is in my blood. I firmly believe that we need to include oral health with overall health.”
Also in the crowd was Tom Raffio, president and CEO of Northeast Delta Dental, who recalled in an interview a time when many thought seeing a dentist was good, but not necessary. It took years of education to persuade lawmakers otherwise.
“More and more, there was a recognition that … the mouth is part of the body and that you can’t have good overall health without good oral health,” Raffio said.
With the legislative challenge behind them, Raffio and others are focused on the next hurdle: persuading more dentists to accept Medicaid. “It’s one thing to have the benefit, but not if it’s unavailable because (too few dentists) are in the network,” he said.
Increasing the number of dentists who accept Medicaid will require increasing the number of dentists practicing in New Hampshire.
Auerbach said there are about 1,200 licensed dentists in the state but there’s not a good count of how many are practicing. And the latter are declining. Last month, the Valley News reported the closing of at least four dental practices in the Upper Valley, some of which took Medicaid, due to retirements or staff shortages.
Gail Brown, director of the New Hampshire Oral Health Coalition, said they know of just 17 programs that serve individuals and families who have limited incomes, few resources, or rely on Medicaid for dental coverage. That’s down from 19 a few months ago
“Those 17 programs are already stretched to their maximum capacities, many have had to limit or restrict new patients and create waiting lists,” Brown said. “These public-focused programs are unable to handle the current demand.”
That demand is soon to increase. Brown said other states have seen 21% to 24% of their new Medicaid patients seek care in the first year.
Concord’s community college offers a dental hygiene program that’s been a valuable workforce pipeline for dental offices and health centers. But the state is without its own dental school. The Bi-State Primary Care Association, which is leading dental workforce development for the state, is addressing that gap with help from the College of Dental Medicine at the University of New England in Maine and the Harvard School of Dental Medicine.
The first provides about a dozen New Hampshire public health centers and private practices students for 10- to 12-week rotations. Harvard is currently sending one student to New Hampshire for a rural-based residency and expects to send four more students under a pending program.
If those numbers sound small, they aren’t, said Stephanie Pagliuca.
“We are not California,” she said. “We can have an impact with a steady, small number of folks coming through.”
Nicole Kimmes, interim dean at the UNE College of Dental Medicine, said the federal government’s latest report on workforce needs said New Hampshire could address its shortage with nine new dental providers, enough to expand care to 35,000 people. Some of those sites take Medicaid.
“Students who serve in our established network of community-based education sites have enabled clinics to increase the number of patients insured by Medicaid who can receive care; reduced patient wait times for appointments; and allowed for more donated dental care or reduced fees for high-cost procedures,” Kimmes said in an email. She said some graduates have returned to practice in the communities where they spent their rotation or in other dental health professional shortage areas.
She added, “Despite these successes, there is more work to do.”
Finne, who is leading the state Department of Health and Human Services’ work on getting the expanded dental benefit in place, agrees. Dentists have shared their hiring challenges with her.
“Their time is constrained,” Finne said. “Practices are not able to do what they could do three or four years ago. If you don’t have enough staff, it can definitely cut down on your availability to see patients.”
Brown said more public-private partnerships that bring dental care into the community, such as nursing homes and schools, and the use of lower cost and less invasive services may be part of the solution – if Medicaid and private insurers agree to cover them. She said they could include new fluoride treatments to stop tooth decay, restorations that don’t require drilling, teledentistry and greater use of certified public health dental hygienists who can practice in a traditional practice and community.
“Both patients and providers need to shift from utilizing the emergency room to putting the right care in the right place at the right time,” Brown said.
Pagliuca and Raffio validated dentists’ hesitancy to take on adult Medicaid patients.
They may not have seen a dentist for years and arrive with significant dental needs. Their inconsistent work schedules and lack of paid time off can make it hard to keep an appointment. Unreliable transportation and language barriers are not small challenges.
“A lot of (dentists) really have great intentions and want to do right by the community,” Pagliuca said. “But it can be intimidating.”
The state expects to issue a call for bids this month seeking one or more dental managed care companies or Medicaid managed care companies to provide that administrative support and patient case management, which Raffio said is crucial. He expects Northeast Delta Dental will submit a bid, highlighting its existing relationship with nearly 851 New Hampshire dentists, 93% of all dentists in the state.
Raffio said Delta Dental would leverage those relationships, urging them to take on adults on Medicaid, and reach out to the 16% of dentists who’ve been taking Medicaid for their pediatric patients. He thinks increasing participation to between 40 and 47% is realistic.
“It should be oral health for all,” Raffio said. “One of our expressions is, ‘Everyone deserves a healthy smile, not just the people with commercial insurance.’ ”