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Many Missouri dentists favor single-payer system as more efficient for needy patients

This article first appeared in the St. Louis Beacon, Feb. 14, 2010 - Not all doctors embrace the idea of a single-payer health-care system. But it's exactly what a lot of dentists want for Medicaid patients in Missouri. The Missouri Dental Association argues that putting all Medicaid dollars for dental services in one pot and setting up a single-payer system to run it would produce a more efficient and less costly system.

This change wouldn't be as revolutionary as it seems, says Aaron Washburn, assistant executive director of financial and governmental affairs for MDA. He says 16 states, including Kansas, Virginia and Tennessee, have single-payer dental systems that have allowed them to enroll more needy patients and attract more dentists to the program.

Virginia set up its program in 2005. By the following year, Washburn says, an additional "40,000 eligible children received dental care, and in one year an additional 235 new dentists joined the network."

Washburn argues that Missouri's approach suffers from needless bureaucracy that adds to the cost of dental service. Medicaid patients in 61 Missouri counties get their dental care through fee-for-service programs under which dentists are reimbursed directly by the Department of Social Services.

In addition, Medicaid recipients in St. Louis and in 53 other counties get their subsidized dental care through managed care programs. Under these, the state contracts with managed care companies, paying each a flat rate based on the number of patients enrolled.

Then the bureaucracy kicks in, Washburn says, because companies at the top of the managed care system provide no dental services. They subcontract the services to a second managed care company that creates provider networks to deliver dental services.

The arrangement is complicated further by the fact that dental subcontractors can set rules that apply only to specific networks. A network may require preauthorization for services that might be available with no questions asked if the patient were in a different network, or enrolled in a fee for service program. Washburn argues that this approach leads to more bureaucracy and waste because workers have to be hired to keep track of who's eligible for what and to handle the paperwork.

The MDA is urging Missouri lawmakers to give the Department of Social Services the authority to set up a single statewide dental delivery system that would be administered by a third party with experience in running dental benefit programs.

Scott Rowson, communications director for the Department of Social Services, says the state is doing a generally good job in reaching needy children and other Medicaid eligible residents. At present, he says 182,000 children up to age 17 are being served by managed care and fee-for-service programs in Missouri. The number of dental patients in general in Medicaid in Missouri rose to 91,813 in 2008 from 27,300 in 1999, Rowson says.

"Over nine years, we have more than tripled the number of dental patients and nearly quadrupled the number of dental visits," he says, adding that the number of dental patients grew by more than 38 percent and dental visits rose by nearly 36 percent during the past four years.

Still, Rowson acknowledges there are benefits to shifting to a single-payer system, saying, "We've looked into carving out dental services in the past, and think the approach has some merit. We hope to study it further once the state's budget outlook improves."

Presumably, a single-payer approach would attract more dentists, many of whom do not participate in Missouri Medicaid because of the state's low reimbursement rate, says Dr. Mark Zust, president of the MDA, with a practice in St. Peters. He says the current reimbursement rate covers only about 38 percent of what it costs to provide the service.

"Children are eligible for care under Medicaid, but there are barriers to getting care," he says. "One big one is that reimbursement rates are far lower than what it really needs to be."

"Generally, dentists in private practice have an overhead of about 60 percent, which goes to running the office. You take that and combine it with the fact that the Medicaid reimbursement rate is 38 percent and it means the dentist can't come close to what it costs him to have the office open. Because of that, not very many dentists will accept Medicaid in their practice."

To reach needy children and call attention to the shortcomings in dental services for children, MDA helps to host the Give Kids a Smile program, which is sponsored by Give Kids a Smile, a nonprofit organization of which Dr. Zust is also the vice president.

It took place recently on the campus of the St. Louis University Medical School. Dentists, hygienists, technicians and others provided free care to about 600 children through 8th grade.

The free treatment included X-rays, cleanings, sealants, extractions and, in some rare cases, root canals, according to Dr. Zust.

"We've had kids come in with nearly every one of their teeth decayed all the way up to the gum line," he says. "The cases were just that bad. Toothaches are probably the number one cause of kids missing school."

Asked why the MDA and Give Kids a Smile limited the participation to 8th graders and younger, he says there are enormous needs and "we had to cut it off somewhere" because volunteers wouldn't be able to accommodate every child and teen seeking free care.

He says the bigger issue behind the program is to make the public aware of "a huge unmet need for dental services. We're trying to invite legislators to come to these events, see what we are doing and explain to them this unmet need and why there is a need."

Funding for health reporting is provided in part by The Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.