Adults on Medicaid now have dental benefits. Many can’t get appointments.

By ANNMARIE TIMMINS

New Hampshire Bulletin

Published: 07-05-2023 1:00 PM

Three months after the state agreed to cover basic dental care for adults on Medicaid, less than 15 percent of the state’s 850 dentists and oral surgeons have signed on. And fewer are actually taking patients.

Almost half of those 125 providers in the state’s new New Hampshire Smiles Program have set limits on their participation. Some will take only five patients, and others want more time before taking any. 

Some dental practices are scheduling new patients for as early as August, but others have no openings for months or even years; a North Country practice doesn’t expect to be able to accept new patients, even those with commercial insurance, until 2025. 

In interviews with the Bulletin, providers cited staff shortages of dentists, hygienists, and dental assistants, and Medicaid reimbursement rates that cover just half the cost of many procedures. A myriad of efforts to recruit more dental practitioners to the state has promise, advocates say, but won’t bring a quick fix.

For now, that makes the math unfavorable for the 21,000 adults on Medicaid who the state expects to take advantage of the new program in the first year. Previously, New Hampshire was one of about 10 states that gave adults with Medicaid coverage for only emergencies, such as tooth extraction, but not regular preventative care like cleanings, x-rays, and exams. 

Cari Young, a program manager at Aspire Learning and Living, which serves people with disabilities, said a Concord practice offered her appointments in 2025 for her four clients. When Young said she’d take them, the receptionist put her on hold and never returned to the phone. Other practices have not returned her messages.

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“It’s frustrating,” Young said. “They all deserve to have their teeth cleaned at least, even if they don’t have any dental work.”

State officials and oral advocates acknowledged the frustration of people like Young who’ve been unable to find care for their clients. But they are calling the first three months of the program a success.

The state is seeing an increasing number of claims submitted for reimbursement, from 1,000 in April to 2,000 in June, said Dr. Sarah Finne, dental director for the Department of Health and Human Services. That number does not reflect the number of patients seen, she said, because one patient may have multiple procedures.

Recruiting 125 providers this early in the program is also a success, said Finne and other advocates who’ve worked years to get adults on Medicaid dental coverage.  

Providers may be hesitant knowing they will lose money with low Medicaid rates. Some fear that Medicaid patients’ sometimes transient and complicated lives will lead them to miss precious few openings. And because adult Medicaid patients have never had coverage for preventative care, they are expected to have more acute conditions, such as abscesses, infections, and gum disease, which is why the recruitment of oral surgeons has been a focus.

“This (participation rate) is actually encouraging to me because initially, we weren’t sure they were going to go into it,” said Gail Brown, director of the New Hampshire Oral Health Coalition, which lobbied lawmakers for years to approve the program. “We were concerned they would say, ‘This isn’t for me,’ and go on with life as it is because, especially for the traditional private offices, they’re running their businesses.” 

Carrie Duran, a single mother who has Medicaid, was there when Gov. Chris Sununu signed the dental benefit bill after lobbying for the legislation. Duran then visited dental practices with information about the program to encourage them to participate. 

But she’s been unable to get care for herself.

“I live in Wolfeboro, where dentists are more expensive,” Duran said. “They’re great. I’ve heard nothing but wonderful things about the dentists in our area. But none of them take Medicaid.” 

The directory of providers who’ve joined the New Hampshire Smiles Program lists two practices within 25 miles of Wolfeboro. Neither are taking new Medicaid patients. The next nearest provider is in Bristol, nearly 45 miles away. 

“I’m just sort of waiting until it becomes catastrophic,” Duran said. 

‘We don’t want people to go under’

Anticipating providers’ concerns about treating Medicaid patients, the state and Northeast Delta Dental, which won the $33.5 million contract to manage the program for the state, included two key services and financial incentives.

The contract provides eligible patients free transportation to and from appointments. And the program pays for care managers who help patients sort out the barriers causing them to miss appointments. 

“Both of those items are important because they help really give (Medicaid members) the support they need,” said Finne. “And if a dentist (takes on) one of our members, they don’t have to have that concern in the back of their mind that their patient is going to cancel at the last minute or not show because of other issues that are going on. We’re really trying to address that.”

Northeast Delta Dental is offering providers $1,000 to join the program to help with the administrative costs of getting credentialed, said Tom Raffio, president and CEO.

The insurer has hired DentaQuest to handle administrative tasks like billing, transportation, and care management services. Recognizing that providers lose money on Medicaid services, they increased the state’s minimum reimbursement rate for some more costly procedures. 

DentaQuest has arranged “hundreds” of trips for patients, said Dr. Jay Maillet, who oversees the New Hampshire program for the company. Family and friends who transport a patient can also get mileage reimbursement.

“We don’t want people to go under on this thing,” said Maillet, who practiced dentistry in the state for nearly five years before joining DentaQuest. “So we listened to providers.” 

‘We need the workforce’

Providers who’ve begun taking Medicaid patients are busy and will remain so until more join the program.

Allure Dentistry and Braces in Manchester is one of the approximately 50 practices that are participating without a limit on how many patients they will see.

“Our phone requests have pretty much tripled,” said office manager Jennifer Williams. They are currently giving new patients August appointments. “This is a corporate company and they are pretty open with trying to open up access as much as possible,” Williams said.

That’s much harder for smaller practices.

One dentist who has long worked with vulnerable populations began getting 80 calls a day when she said in a media interview that she planned to participate in the New Hampshire Smiles Program. “It was disabling our practice,” she said, asking not to be identified for fear the calls would resume if her name was publicly associated with the program again. 

She said she’s reconsidered her intentions to participate for two reasons: Her office is too small to meet the demand, and the financial losses would be too high. 

“Even the crown (reimbursement) fee is barely covering my lab fee, let alone my two hours of chair time, or my assistant, or the building and insurance,” she said. “Do you want to work the next hour at 25 percent of what you make because it’s the right thing?”

Raffio, who hopes to grow the network to 200 to 250 providers, is counting on more dentists to answer yes to that question. 

“It has to be what I call ‘Level Five Leadership,’” he said. “From the heart, you know? In the final analysis, you have to be willing to do a good deed for society because none of us want to get 50 cents on a dollar. I really do think you have to know that you’re doing this for the betterment of society.”

Coos County Family Dental is one of two North Country providers in the program but the only one taking patients. It is struggling to find appointments for a different reason: workforce shortages.

Ken Gordon, CEO of Coos County Family Health Services, which includes the dental clinic in Berlin, said they don’t expect to book new patients, even those with commercial insurance, until 2025. The nonprofit has partnered with Upper Connecticut Valley Hospital in Colebrook to open a second clinic there in September to meet demand. And it’s received a grant to double the size of the Berlin site.

“But there’s still the workforce issues we’ve got to contend with here,” he said. “We have the facility space, but we still need the workforce to join us.”

Expanding treatment with mobile clinics, teledentistry

While there is recognition the Medicaid reimbursement rate is an obstacle for some providers, it’s the access to dental care that state officials, oral health advocates, and dental training programs are trying the hardest to tackle now.

Those efforts include not only bringing more practitioners to New Hampshire but also expanding access to care in new ways.

Dentists may be eligible for help with student loans if they commit to taking Medicaid patients or practicing in rural areas. NHTI, which has the only hygienist and dental assistant training programs in New Hampshire, is collaborating with the state and advocacy groups to understand where expanded training or support is most needed.

Lisa Scott, chair of the school’s dental education department, said they’ve had about 20 people complete the hygienist program each of the last two years. The number of dental assistants, who can perform fewer procedures than a hygienist and must work under the direct supervision of a dentist, has gone from 16 last year to 12 this year, she said.

The Harvard School of Dental Medicine and College of Dental Medicine at the University of New England are placing students in public health centers, private practices, or rural areas of the state as part of their training. The hope is they’ll stay in the state. 

Sununu signed legislation on June 28 that will lift state licensing laws by allowing out-of-state professionals to practice in the state if their credential requirements are “substantially similar” to New Hampshire’s.

DentaQuest is referring people who cannot get an appointment but need care quickly to teledentistry.com, which will connect a Medicaid patient with a dentist able to consult virtually and prescribe antibiotics and some pain medication.

Solvere Health’s mobile health clinics in Concord and Colebrook have been another new resource for adult Medicaid patients. Care includes diagnostic exams, x-rays, fillings, extractions, restorations, and antibiotics for infection.

Edward Lorch, the company’s CEO, said the state and Northeast Delta Dental have asked to continue those visits as a resource for people unable to find care in a traditional practice. The mobile clinic has done 120 appointments over the course of eight stops, in Concord, Berlin, and Colebrook, said Jackie Skorvanek, chief of staff. The number of patients is a bit less, she said, because some made a return visit.

“We really believe that the mobile unit, because of the comprehensive care, should be seen as a dental home,” Lorch said. “A lot of these rural areas are dental deserts. To think brick-and-mortar buildings are the only solution is a little bit foolhardy.” 

But brick and mortar is a solution Solvere Health is considering. Lorch said once the company better understands where the mobile clinic is most needed and would be most used, it will consider opening a dental office. 

“Workforce is the primary issue, but I think we have the wherewithal fiscally and culturally,” Lorch said.  “I feel really good about New Hampshire.”

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