Dental benefits widen, waiting lines grow

Some balk at giving care, call subsidized rates too low

Two years into the state's bold healthcare experiment, its early success in expanding dental coverage may be threatened by a shortage of dentists willing to treat newly insured patients.

Since getting free or subsidized dental coverage in 2006, more than 200,000 low-income adults have climbed into Massachusetts dentists' chairs for work on their long-neglected teeth. But increasing numbers of patients are expected to seek care, and advocates fear the wait for appointments, now three months at community health center clinics, will grow.

The problem is that just 17 percent of dentists statewide have been willing to see these newly insured patients, despite reforms intended to boost their ranks. Even some of these dentists are limiting the number of state-subsidized patients they will treat.

Dentists say the state's reimbursement rate for adults covers only about half their costs, and they also cite payment delays and burdensome paperwork.

Without more dentists, said Kerin O'Toole, spokeswoman for the Massachusetts League of Community Health Centers, patients will not be able to get timely preventive care and "we risk treating people with more expensive and serious health issues."

As part of the healthcare law's goal of extending insurance to nearly everyone, dental benefits were restored to roughly 540,000 low-income adults who had lost nearly all dental coverage under Medicaid budget cuts in 2002. The law also expanded eligibility, prompting another 140,000 to sign up through Medicaid or the newly created Commonwealth Care subsidized program for the previously uninsured.

Suddenly, thousands of patients who had not opened wide in years were calling for appointments, and the number of Medicaid patients who saw a dentist more than doubled in the first full year, from about 15 percent of adults to 35 percent, state data show.

Among the newly insured is Pam Anasoulis, a 48-year-old telemarketer from Beverly who has also wired helicopter engines and fixed conveyor belts to make ends meet. For her, entree to the dentist after years of oral neglect was bittersweet. The mother of two grown children, she had broken a front tooth in 2004 and had gone to a dentist who filed down several of her front teeth to make a temporary bridge.

But Anasoulis said she couldn't afford health insurance and could not afford to go back to have the work completed. The bridge broke, decay set in, and Anasoulis was left with stubs for front teeth.

"You really don't think, when you look at someone with missing teeth, how much they're hurting inside," she said. "I got so depressed I didn't go out."

When she finally found her way to the Lynn Community Health Center dental clinic in 2006, many of Anasoulis's front teeth had to be extracted. But Dr. Herlivi Linares, the clinic director, was able to save some of her teeth and make her a partial denture.

Thanks to insurance, Anasoulis got her smile back.

Healthcare advocates expect that thousands more patients will, like Anasoulis, seek care in coming months as community health centers and other groups launch education programs about the need for regular preventive care for children and adults. They say that the one-third of Medicaid patients who saw a dentist in the past year is substantially less than the rate for adults statewide. By the federal government's counting, about three-quarters of all Massachusetts adults go to the dentist at least once a year.

"People who have been chronically uninsured may not understand the nature of primary and preventive medical and oral healthcare, simply because they have never had an ongoing relationship with a physician or dentist," said O'Toole, of the Community Health Centers group.

As part of the healthcare law, the state changed a rule to encourage dentists to treat at least some patients covered by Commonwealth Care or its Medicaid program, called MassHealth. The old rules mandated that dentists who accepted even one subsidized patient had to accept all such patients. Now, the state allows dentists to limit the number of poor patients they accept. That has helped increase the number of practicing dentists who are willing to see poor patients from about 10 percent to 17 percent, according to a Globe analysis of public records.

Of that 17 percent, one in five have already closed their doors to new subsidized patients, said Dr. Catherine Hayes, a professor at Tufts University School of Dental Medicine.

"We need dentists to understand there have been significant improvements in the program," said Hayes, who is also a court-appointed monitor of the state's dental program for children.

But the state's reimbursement rate for treating adults remains at only about 50 percent of what private insurers typically pay, despite small increases in both 2006 and 2007. Dentists contend that makes it financially unfeasible for them to accept many subsidized adults. (Rates for children are more generous, because of a 2005 federal court ruling requiring improved dental care for poor children in Massachusetts.)

"With children, I think the reimbursement is pretty fair now, but the adult fee is still very poor," said Michael Wasserman, a Pittsfield dentist who treats some subsidized patients. "I think if a dentist is going to treat these patients he or she should not be forced to lose money."

Dentists say that in addition to low reimbursements, they are still encountering mountains of paperwork to join the program and delays in getting paid. Jennifer Kritz, spokeswoman for the state Executive Office of Health and Human Services, said the agency is trying to ease the claims and enrollment process, but cannot currently pay dentists higher rates.

The Massachusetts Dental Society has been urging members to join, saying it is the responsible thing to do. But it's been slow going. "It has gotten a little better," said Karen Rafeld, assistant executive director of the dental society, "but it's still a bureaucratic nightmare."

For Dr. Barry Aston, a dentist with offices in Watertown and Hudson, accepting subsidized patients has been a mixed blessing. He signed up about a year ago and was so swamped that he stopped accepting additional needy patients 10 months later. Today, about 40 percent of his caseload is Medicaid or Commonwealth Care.

"I am making more money, but it's a nightmare for my administrative staff," he said. His aides often spend substantial time on the phone with Doral Dental, the company that manages the state's subsidized dental program, to track down lost paperwork.

The dental society's Rafeld said that until the state works out more of the bugs and raises the rates, persuading more dentists to join will be a hard sell. "It comes to a point when you throw up your hands," she said. "People thought instantaneously it would be solved. But it's a process."

Kay Lazar can be reached at klazar@globe.com.