The phones at many dental offices across North Carolina have been ringing repeatedly in recent months with requests for oral health care from newly enrolled Medicaid recipients.
The state's expansion of Medicaid benefits to nearly 600,000 low-income residents on Dec. 1 opened a robust array of services such as dental exams, routine cleanings and more complicated care for many people who previously had little access to a dentist because of the cost.
"The phone's ringing off the hook," said Robert Stowe, a dentist with Winston Smiles Dentistry in Winston-Salem.
One of those calls, Stowe said, was from a woman who had not been to a dentist in 15 years. She needed 12 teeth extracted, he added, and would need partial dentures made to fit between her remaining teeth. She was not yet 50 years old.
Some of the new patients have needed oral surgery. Because no oral surgeons in Forsyth County are taking any new Medicaid patients, Stowe said, he has to refer those clients to other counties.
"I've spoken to oral surgeons in Winston and tried to get them to take some of these people," Stowe told NC Health News in an interview. "They tell me: 'The deal is this. These folks are the sickest.'"
Many of the new beneficiaries are not comfortable with a dentist or oral health provider since such care often was out of reach for them. Many want or need to be sedated when they need extensive work, which can require additional resources.
The problem is, many dentists say, is the state reimbursement rate for dental patients on Medicaid insurance plans is 34 cents on the dollar. That's the same rate that dentists received in 2008.
Two versions of a meeting
Frank Courts, chair of the North Carolina Dental Society Council on Oral Health and Prevention, said the rate has been increased several times during that 16-year period, most recently during the COVID pandemic. Those increases have been temporary, though, and the rate has dropped back to a level that many in the state's private dental industry say is too low for them to accept any new Medicaid patients.
Dentists have tried through the years to get a long-term increase, but “nothing significant has happened," Courts told NC Health News.
Courts and some of his colleagues have been trying again recently to persuade state leaders that a rate increase is the way to get more private dentists to see Medicaid beneficiaries. Only about 45 percent of North Carolina dentists currently do.
Courts, Stowe and Richard Dest, a dental clinic owner who has been treating Medicaid patients since 2007, met recently with Jay Ludlam, deputy secretary for NC Medicaid at the state Department of Health and Human Services. They laid out their concerns for him.
They said Ludlam told them he had sent a budget proposal to the governor's desk that calls for a 30 percent increase of the Medicaid reimbursement rate in the coming fiscal year, but he cautioned them that it was likely to be pared down.
To a request for comment on Tuesday, DHHS sent the following response: “As we see more residents of North Carolina access care through NC Medicaid, it is increasingly important that we maintain provider access.
“Many providers, including dentists, have not seen a sustained rate increase since 2012-14 despite the increases in costs in the last 10 years,” the department statement continues. “NCDHHS is evaluating proposals to increase rates during the short session for providers to account for 2024 costs. Deputy Secretary for NC Medicaid, Jay Ludlam has not sent a letter of recommendations to the Governor about Medicaid reimbursement rates for dental providers. NC Medicaid is in the process of submitting items for potential inclusion in the Governor’s budget proposal. That work is ongoing.”
Dest, who said he doesn’t mind rattling cages, provided NC Health News with his email correspondence with Ludlam that led him to believe that a proposal had been “sent to the governor’s desk.”
In an email sent Feb. 16 to Ludlam, Dest wrote: “Good afternoon. Were you able to put it on the Governors (sic) desk today?” Ludlam responded late that afternoon: “Our budget team submitted to the office of state budget and management.”
Then on Feb. 20, Dest checked in with Ludlam again. “Good morning Jay. Any updates from the governors (sic) desk?,” Dest wrote in an email that also included his plans to hire another dentist. “The rate increase cannot come fast enough.”
Ludlam responded about an hour later: “We met and presented the ask. Short session will start around April 1. Little I can do between now and then other than echo what we discussed last week.”
Developing a budget
Governor Roy Cooper has not yet released his proposed spending plan for the fiscal year that begins July 1.
The state budget office works with the governor to develop a statewide plan. Typically, the governor releases his proposal to the public in mid-March after revenue projections make it clearer how much will be in state coffers. Then it goes to the General Assembly, which might or might not include anything from the governor's proposal in the multibillion-dollar budget that lawmakers put forward.
"This 30 percent increase would be very significant, but we are concerned with how meaningful it is," Courts added.
Some estimates among oral health care providers suggest that reimbursement rates would need to be 75 cents on the dollar to build an adequate private provider network.
The cost of running a dental practice has risen significantly over the past 15 years as X-ray machines and other equipment have gotten more expensive. As the cost of living rises, so do salaries for hygienists and dental assistants.
"We try to take care of our patients out there," Stowe said. "We are trying to pay our staffs. We are small business owners with thousands of workers across the state."
"I'm at the point in my life where I can give back some," added Stowe, whose practice provides care for Medicaid recipients.
Others might not have that luxury, Stowe said.
In need of private practices
Younger dentists often start in private practice while deep in student loan debt. The average debt burden for dental school graduates across the country in 2022 was $293,000, according to the American Dental Education Association.
The state’s subsidized Federally Qualified Health Centers and other publicly funded safety-net clinics couldn’t accommodate all the patients needing care even before expansion took effect in December. They certainly cannot accommodate all the adults and children with new access to Medicaid benefits.
The Medicaid dental program has represented only 2 percent to 3 percent of the overall Medicaid budget, and oral health care advocates say that significantly increasing the reimbursement rate for dentists would be a small change, proportionally. Plus, when the state expanded Medicaid, the federal government agreed to pick up 90 percent of the tab for the new beneficiaries, adding more to program coffers.
Dest and the others who met with Ludlam in mid-February said they were told that a proposal calling for increased reimbursement rates for dentists would include similar requests for at least 30 other health care fields. Furthermore, they were cautioned that even if the governor included a recommended reimbursement rate increase in his proposed spending plan, it might be pared down to 15 percent, or 10 percent.
"Anything would help," Stowe said.
Dest, who has a 10-chair dental clinic in Lincolnton, said his office received 230 new patient calls in January and another 150 through mid-February. He plans to add a dentist to help with the additional load.
Lawmakers, Dest said, "need to get their heads out of the cloud" and allocate more funds for new Medicaid recipients seeking oral health care.
Stowe called on dentists to organize and speak for an underserved population. Medicaid recipients, he said, "don't have a big enough voice."
"There's really a big divide between the haves and the have-nots. This is America. Everybody should be able to have the best health care we can," Stowe added. "We need to continue to fight this fight because it's the right thing to do."
Broadening oral health access
The fight for broader access to oral health care is something that the North Carolina Oral Health Collaborative has been doing for years.
In 2022, the organization partnered with the North Carolina Institute of Medicine and The Duke Endowment to launch the Oral Health Transformation Initiative. (Disclosure: The Duke Endowment sponsors NC Health News to cover children’s health issues.)
The task force, which included members from varied backgrounds in medicine, is expected to release a report in late March or early April with recommendations for lawmakers.
That report is expected to include a broad-brush approach for how to tackle oral health access issues, and Medicaid reimbursement rates are likely to be a part of that, according to Steve Cline, vice president of the collaborative.
Cline said he was glad to hear that a proposed reimbursement rate increase was being discussed. But even if it were 30 percent, he added, more increases would be warranted to get private dentists interested in serving more Medicaid patients.
"They are woefully underfunded," Cline said.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
