Finding a dentist who takes Medicaid can be difficult. Only about one in three Georgia dentists accept payment from the state-run program. Dentists say money, no-shows and paperwork keep them from participating.
Jasmine is doing "so-so" keeping her kids from getting cavities. The mother of three, who didn't want her real name used, is at Dr. Edward Green's office in Albany.
"Excluding a couple of cavities that I'm not too thrilled about, it's been okay. It's getting better because I try to substitute a lot of their sugary sodas with either milk or fruit juices without the sugar in it."
Two of her kids, nine and twelve, were in today for fillings. She says she tries to have them brush twice a day, but struggles. As for paying for today's visit, however, the Medicaid recipient will have no difficulty. She calls the state-issued card she'll take to the front desk "a lifeline" for her and her husband.
"I'm a stay-at-home mom and right now, he's in between jobs. He's leaving one to the next. As with that, you know, you lose company benefits, including dental. So, the Medicaid has really been right there when we needed it."
One million five hundred thousand low-income and disabled Georgians rely on Medicaid. Last year, the program paid for about one million four hundred thousand dental visits, the vast majority of them for children. But in a state with about 4,700 dentists, only about 1,600 take Medicaid, and still many of those aren't taking new Medicaid patients. The problem is most acute outside Metro Atlanta. Dr. Green, a past president of the Georgia Dental Association, is among the minority.
"With the current fee structure, we are probably at a break-even point. But, I feel a responsibility to the community. I attended the Medical College of Georgia, which is a state school. I live in a town where there are needy recipients. And I feel a responsibility to participate."
Green says the state pays only about 70 percent of the costs of treating Medicaid patients, and when Medicaid reimbursements were adjusted up three years ago, the state saw its highest level of dentist participation. The number then dropped and has slowly risen since. Even so, fees are far from Medicaid's only problem. After all, the majority of patients are privately insured, in effect, subsidizing the rest. But...
"When one allocates an appointment time for a Medicaid recipient, it's already at a break-even fee. If that person chooses not to come, or cancels the appointment, then that's a loss for that practitioner who's trying to help."
There are no statistics on how many Medicaid patients are no-shows in Georgia, but the American Dental Association says nationally, it's about 24 percent compared to 14 percent for the privately insured. It's a vexing problem costing doctors hundreds of dollars a week, thousands a year. And that's not all. Georgia Medicaid has been plagued with paperwork problems. Dr. Jay Alderman, Georgia's Medicaid dental director for 22 years ending in 2003, says it got so bad that the state had to stop using one of its private administrators.
"They were double-billing and then they were figuring a mathematical formula based on the past and going back and saying they wanted more proof and they wanted payback. It was just a real mess."
The bureaucratic nightmare cost dentists hundreds of hours in valuable office time. Many now want nothing to do with Medicaid, and that's a problem for state Medicaid director Mark Trail. He's trying to convince dentists the issues with fees, no-shows and paperwork are being addressed.
"Claims are paying extremely well. In fact, many providers tell us that with things like our web-based claims adjudication system, they find that we're actually one of the administratively simplest payees to deal with."
Trail calls claims of paperwork problems "ancient history" and a "temporary glitch" that came with a change of administrators. This year, Medicaid is changing again, this time to a managed care company, something toward which many dentists are taking a wait-and-see approach. Trail believes the HMO will improve service, even for troublesome no-shows.
"We think the managed care organizations are going to help us do that. We actually have some contractual requirements for a certain percentage of the kids in particular to actually get dental care. So they're going to be financially motivated to make sure that the kids get dental care by doing follow-up phone calls and letters."
The importance of getting kids to the dentist is shown in numerous reports linking good oral health to good overall health later in life. Still, dental benefits are optional in Medicaid and many states don't offer them. It's often the first to go when the budget axe falls. States with the strongest commitment to Medicaid dental benefits, however, are clustered in the South, a fact some attribute to the region's poverty. Dr. Alderman, who's now a dental health advocate and a private consultant, says he believes it's also an education issue.
"When I was state dental director, when you talked with teachers, they said that dental problems and vision problems were the most significant problems that they had. This is what kept kids out of school. So obviously, a child in pain cannot learn. Many of the kids that we target in our program had never been to the dentist before."
The Georgia Department of Community Health will roll-out HMOs for Medicaid recipients in Metro Atlanta and Middle Georgia next month and the rest of the state in September. The switch was delayed from last year. DCH says that was to make sure everything was right.