Miami-Dade - Dental HMO flawed, study finds

Dental HMO flawed, study finds

Columbia University reports a Medicaid pilot project is not justifying its budget, while the dental providers complain that the fee level is low.

BY JOHN DORSCHNER

jdorschner@MiamiHerald.com

While Atlantic Dental insists it's doing a good job providing care to poor kids in Miami-Dade County, a study just released by Columbia University concludes the Medicaid pilot project has cost taxpayers ``the same amount for less care and less quality.''

The study by Burton L. Edelstein, a professor of health policy, reports that in the first year of the pilot the dental budget for Medicaid in Miami-Dade increased 1 percent (from $14.9 million to $15.1 million) while the average number of annual dental visits per enrolled child dropped by 61 percent.

Meanwhile, one of the largest providers of dental services under the program, the Community Health of South Dade Inc., known as CHI, said it planned to drop out of the program and no longer serve the dental needs of 6,000 Medicaid kids because the plan pays only $4.25 per child per month.

''We can't continue to provide service for that amount,'' said Brodes Hartley Jr., CHI's chief executive.

Lourdes Tome-Rivas, vice president of operations for Atlantic Dental Inc., or ADI, said the company is being unfairly criticized. The measured drop in services is caused by dentists not reporting all the work they do, she said. They have little motivation to report what they do because they get paid in advance, whether they perform the work or not.

Tome-Rivas pointed to a University of Florida survey, released last month, which found that 80 percent of Medicaid recipients interviewed said they had ''no problem'' getting a dentist they were happy with. She said critics charged unfairly that survey could not be trusted, while at the same time accepting the survey of dentists that showed 57 percent were dissatisfied with the program.

''The biggest difficulty is a funding issue,'' said Marcio Cabrera, an ADI director. ``People say they're upset with ADI. But they are really upset with the funding.''

Cabrera contrasted the Medicaid pilot with Healthy Kids, another state-funded program in which parents pay sliding premiums based on annual income. Though the benefits in the two programs are not directly comparable, ADI gets about $10 a month per kid in Health Kids -- twice the rate for Medicaid. ``And we don't get any complaints with Healthy Kids.''

Under the Medicaid project, each dentist is assigned several hundred kids and gets paid $4.25 a month -- $51 a year -- for each. The Florida Dental Association maintains that's not enough, and critics say the only way the dentists can make money on the plan is to limit their treatment of Medicaid kids.

Still, ADI executives say they're not demanding more money from the state in their new two-year contract, which is scheduled to start next month, and Medicaid official Tom Arnold said increased funding is not a possibility because the basic goal of the pilot project basic was to control soaring Medicaid costs.

That cost-containment has hammered CHI, which says it has lost more than $400,000 a year due to the pilot project, which started July 1, 2004. As a federally qualified health center, serving the uninsured and the poor, CHI used to receive $129 a visit each time a Medicaid child was treated by one of its six full-time dentists or several hygienists.

In effect, the $129 reimbursement served as a subsidy for all the uninsured care the clinics provided, and the $4.25 a month per kid doesn't come anywhere near the salaries of the dentists and hygienists. ''We're struggling every day to make ends meet,'' said CEO Hartley, saying he may have to lay off dentists.

Medicaid spokeswoman Krista Moody said federal regulations state the CHI subsidy didn't apply to programs like ADIs. ``It is a business decision made by CHI as to whether or not they can continue their participation.''

If CHI drops out, the 6,000 children will then be assigned to other dentists in the ADI plan who are willing to do the work for the $4.25 a month.

The Columbia study, funded by the Community Voices Miami project at the Collins Center for Public Policy, relied on data reported by dentists to ADI. It said simple teeth cleanings, which had numbered 75,911 under the old fee-for-service plan, dropped by 59 percent to 31,106 under the new dental plan.

Community Voices acknowledged underreporting might account for part of the drop, but ``it is unlikely that the measurable declines in quality are due solely to poor reporting.''

Cabrera said ADI is trying to do a better job getting dentists to report accurately. ``At the end of the day, it is our responsibility.''

For a month, as a test, ADI offered dentists an extra $30 per cleaning if they reported the service, and there was a huge spike in reported cleanings, but the Medicaid contract doesn't allow that kind of payment regularly, and the test was quickly stopped.

ADI has a call center where operators call Medicaid recipients, urging them to go to dentists and even makes appointments for them, but 35 percent or 40 percent don't show up for the appointments, according to Miguel A. Montilla of ADI.

Moody, the Medicaid spokeswoman, said a contract was being drawn up that will extend the ADI pilot another two years but will require more accurate reporting.