Dr. Stephen T. Skoly Jr., a Cranston oral surgeon, was awakened by a call in the middle of the night last January. A patient at Our Lady of Fatima Hospital needed surgery to repair a broken jaw.
So Skoly climbed out of bed, drove up to the North Providence hospital and performed the two-hour procedure. The next day he checked on the patient during his usual hospital rounds and then followed up with a number of weekly exams at his office.
Skoly’s compensation for four hours of work, spread over eight visits: $84. The patient was covered by Medicaid, which provides dental and other medical services to the poor and disabled, paid by federal and state governments.
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"You just can’t afford to provide a high caliber of care for 84 bucks," Skoly said. Last summer his Cranston office – as well as his satellite offices in East Greenwich and East Providence – joined a growing number of dentists who are limiting the number of Medicaid patients they take.
Most dentists who see Medicaid patients say they do so out of social responsibility, knowing that the fees will be much lower than they normally charge. But the rates paid to dentists by the Medicaid program are so paltry that even state officials admit the situation is curbing access to dental services for low-income patients.
"The state pays at such a low rate, it’s really hard to get dentists to participate," said Sen. Elizabeth H. Roberts, a Cranston Democrat and chairwoman of a special Senate commission that last year studied the issue of limited access to dental care in Rhode Island.
"I think the people making the budgetary decisions, the legislature and the governor, had been unaware of how big a problem this is," Roberts said.
The commission’s report, released last November, found that just 38 percent of the state’s Medicaid population had at least one dental visit during fiscal 2000 – down from 41 percent in 1998 and 62 percent in 1990.
The shrinking access likely has much to do with the state’s swelling Medicaid rolls. Enrollment in RIte Care – the Medicaid supported health program for low-income children and their families – surged from fewer than 80,000 in 1998 to 115,000 at the end of last year, according to the Department of Human Services.
The influx has put added pressure on the dental-care "safety net" of community health centers and private dentists, who say they can’t afford to keep adding Medicaid patients when reimbursement is so low. The fees cover just 45 percent of a private dentist’s normal charges, according to the commission’s study.
For example, the state pays Skoly $65 for a surgical extraction, while his office normally charges $125.
"It’s not a break even," said Dr. Nicholas D. Barone, a North Providence orthodontist and past president of the Rhode Island Dental Association. "It’s money out of a doctor’s pocket to see a Medicaid patient." He said the public payments fall roughly 10 percent short of actual costs.
And administrative hang-ups in the state’s program also are confounding, dentists say. Doctors complain of six-month waits to get paid, conflicts on treatment protocols and a claims system that doesn’t match industry standards.
"It’s so frustrating dealing with the state that we just decided to treat our people for free and not deal with it," said Dr. Kenneth Rawlinson, a dentist in East Providence. Rawlinson said he still sees a small handful of Medicaid patients, but he doesn’t bother filing claims with the state. He stopped taking new Medicaid patients last year.
About 70 percent of Rhode Island dentists – including general and pediatric dentists, periodontists, prosthodontists, endodontists, orthodontists and oral surgeons – see Medicaid patients, according to a September survey by the Rhode Island Dental Association.
But only about 10 percent of those dentists have an open-door policy – most limit the number of Medicaid patients they see to one or two a week, according to the survey.
The state has made some headway to help rectify the dental-access problem, Roberts said. A total of $300,000 is slated to go toward the state’s two hospital-based dental clinics: The Joseph Samuels Dental Center at Rhode Island Hospital and the Pediatric Dental Center at St. Joseph’s Hospital for Specialty Care.
But Roberts admits that the reimbursement issue remains the key problem. Although she has submitted legislation this session to boost dental Medicaid reimbursement, prospects for the bill are dim in light of the state’s budget deficit.
"Now that we’ve drawn people’s attention to the problem, unfortunately it doesn’t look like we’re going to have the luxury of fixing it at this point," Roberts said.
Dental officials say litigation might be a last resort to ensure federally mandated access to dental care for low-income patients, according to Patrick J. Quinlan, the lobbyist and attorney for the Rhode Island Dental Association.
"That’s an avenue we’re exploring with some advocacy groups," Quinlan said. "It may be the only way we can get (the state) to do what (it is) required to do by law."
There is plenty of precedent for dentists or advocacy groups to sue states over Medicaid reimbursement: Such suits have been filed in recent years in Massachusetts, Connecticut, New Hampshire and New York. Those lawsuits charged that low-income residents were being denied their federal right to dental care under Medicaid, largely because the states weren’t paying dentists enough.
In the New York case, the state settled with the state’s dental society in May 2000, agreeing to boost Medicaid payments to dentists by $573 million over four years.
But Barone says the heightened level of attention to the problem shown by the Department of Health, DHS and state officials encourages him.
"(The state) is recognizing that access to oral health care is a problem, and they’re taking steps to address it," Barone said.
