April 12 2007

On a recent afternoon, 3-year-old Jose Ruiz climbed confidently into a dentist’s chair at the Children’s Medical Center in Hartford, despite the howls of protest and sniffles of surrender emanating from children in chairs around him.

Jose, with closely cropped black hair and dark, intelligent eyes, was the picture of calm as he lounged next to Dr. Cheri Cox, a recent Harvard Dental School graduate and first-year resident in pediatric dentistry, who was there to observe.

Dr. Michael Goodman, a pediatric dentist for 35 years, pulled up a chair next to Jose and bantered with him and his mother, Yvette, as he prepared to examine the boy’s mouth.

Inside, Jose’s four front teeth were gone, pink gums left shimmering in their wake. Five teeth were capped with silvery crowns, and five more were filled. Out of the 20 teeth a 3-year-old child has — adults have 32 — only six of Jose’s teeth were left untouched. They sparkled white and pearly, perched in his lower gums.

“Mom is the boss now and doing an excellent job of cleaning the teeth,” Goodman said.

Then turning to Yvette, “He eats more now. Her food bill goes up.”
“Oh my god,” answered Yvette. “He had a hard time chewing food. Now I have no complaints.”

When it’s time to brush his teeth, Jose “runs right to the bathroom,” says Yvette.

Goodman first saw Jose, who lives with his mother in Putnam, nine months earlier in July at the Generations Family Health Clinic of Willimantic. Allowed to keep a bottle in his mouth nearly nonstop from infancy until he was 2 years old, and with no dental care, Jose’s four front teeth were rotted beyond salvation, and problems abounded in his remaining teeth. After Goodman determined Jose needed surgery to correct his dental problems, it took more than six months to get a slot in the operating room at Children’s Medical Center.

“I saw him in July and only completed the work (in late March),” Goodman said. “That’s wrong.”

It’s also common in the state of Connecticut. Poor children like Jose who rely on the state’s Medicaid program for dental care, known as HUSKY A, slip through cracks wide enough to swallow an elephant.

In fact, of the 250,000 Connecticut children enrolled in HUSKY A — one-quarter of all the children in the state — two-thirds receive no dental care at all, according to the Connecticut Health Foundation.

The poor children who do receive dental care are seen by only about 100 dentists who take Medicaid patients, along with a network of privately and publicly owned clinics that provide Connecticut’s dental “safety net.” All told, Connecticut has about 2,900 dentists.

As of 2001, poor Connecticut children had the lowest dental utilization rate in New England, at less than 30 percent. In Massachusetts, just over 50 percent of the children enrolled in Medicaid see a dentist regularly, and among privately insured children, 65 percent go to the dentist.

“It’s very clear that dental care in this state is really in virtually a crisis situation,” said state Sen. Mary Ann Handley, D-Manchester, co-chairman of the Public Health Committee.

At the root of this crisis is a miserly state reimbursement program for dental procedures performed under HUSKY A that is in the 10th percentile of fees, meaning 90 percent of the dentists in the state would charge more for the procedure.

Connecticut’s reimbursement rate was set in 1993, when it was in the 80th percentile, and has not been revisited since. Meanwhile the cost of dental care has gone up by some 60 percent.

At least three bills in the current legislature, including one in Handley’s Public Health Committee, would raise the reimbursement rate to the 70th percentile, meaning 70 percent of the dentists in the state would consider the fee to be fair.

Current HUSKY A fees allow $24 for an initial exam, $33 to extract a single tooth, and $200 to perform a root canal. The 2007 fees at the 70th percentile are $70 for an initial exam, $131 to extract a single tooth, and $599 to perform a root canal.

While the HUSKY A fees are clearly low, one might ask, where’s the altruism? Even attorneys do pro bono work. Why can’t Connecticut dentists suck it up and provide care to the state’s poor children?

Because they would go broke, says the public interest attorney who sued the state seven years ago over its HUSKY A fees, Jamey Bell of Greater Hartford Legal Aid.

“The rates do not cover the cost of providing care,” Bell said. “They’re much lower than anything you see in the marketplace and lower than any organization can sustain, including the safety net of school-based clinics. Often the state tries to sell the problem as greedy dentists. It’s a salable message although it’s not true.”

No one is going to mistake Diane Dimmock for a greedy dentist. She runs Hartford’s school-based dental clinics, which are seen as a model for school systems throughout the country, according to Rep. Vickie O. Nardello, D-Prospect. Nardello, a dental hygienist who serves on the Public Health Committee, said legislators from as far away as Texas have visited to learn about the clinics Dimmock oversees.

There are 10 comprehensive clinics that perform every dental procedure except orthodontics; four clinics that deal in preventive procedures only, and a mobile dental van that goes from school to school.

Dimmock said the comprehensive clinics see 5,000 to 7,000 children yearly in 22 schools. The system’s four dentists, 10 hygienists and seven assistants also see 3- and 4-year-old children on a regular basis. In 2006, the school-based clinics performed a total of 56,000 dental procedures, all under the HUSKY A fee schedule. Fortunately, the school board is willing to support the program despite its losses.

“Clearly the reimbursement fees, which have not risen in 13 years, are not adequate to run this program or any program,” Dimmock said. “Every year we are really scrambling to try to scooch out enough money to pay bills.”

Dimmock estimated the school-based clinics lose between $150,000 and $400,000 every year.
Behind the numbers that define the state’s dental crisis are children in pain.

“One of the main reasons children end up in the emergency room is because of problems with teeth,” Handley said. “We’ve heard this from people in dental clinics and from the children’s hospital in Hartford.”

Marty Milkovic of the Connecticut Oral Health Initiative said dental pain is the “number one cause” of school absences in Connecticut.

“It’s just wrong kids should have to suffer like that,” said Milkovic.

Yet, the situation has not exactly lit a fire under the state.

The class-action lawsuit filed by Bell in June 2000 was brought to force the state to comply with the provisions of the Medicaid Act, which requires access to dental care. The lawsuit was filed against the Department of Social Services. The next couple of years were taken up with discovery. It took until 2006 for a decision from the court, which agreed with a technical legal argument made by DSS that adults covered by Medicaid should be excluded from the lawsuit.

So the state’s poor children remained as plaintiffs, which led to a major legislative push last year to pass a bill raising the reimbursement rates to the 70th percentile.

At the last minute during final budget negotiations, says Bell, the governor’s Office of Policy and Management and the DSS convinced the Legislature to back off, and wait for a settlement of the lawsuit. But so far the DSS and the plaintiffs haven’t been able to agree to a solution.

“Suffice it to say we have not reached an agreement on settling the case,” said Bell.
Michael P. Starkowski, the recently confirmed commissioner of the DSS, confirms negotiations in the lawsuit broke down last fall, when the agency was under the leadership of his predecessor, Patricia Wilson-Coker.

Instead of trying to figure out how to pay dentists more based on the percentage of dentists who would take the fee — the 70th percentile criterion — the state suggested raising the dollar value of each dental procedure. The DSS said it would spend $20 million for increased fees.

Starkowski pointed out the 70th percentile fees were based on numbers “reported by the dentists.” In other words, the problem with the 70th percentile is that it is a standard set by whatever dentists say the fees should be, and couldn’t in effect, be managed properly.

Nevertheless, Starkowski maintains the DSS is negotiating in good faith.

“We wouldn’t have put $20 million on the table if we hadn’t recognized we need to increase the rates,” said Starkowski.

But Bell says that rather than trying to solve the problem, the DSS is “looking to spend a certain amount of money they’ve been told they can spend.” She said the solution is a simple matter of supply and demand.

“In order to get enough supply you have to set rates at a level that will attract suppliers,” Bell said. The state has to accept the 70th percentile standard.

Meanwhile, the Legislature has grown impatient with DSS. Feeling somewhat duped by the promise of a lawsuit settlement that never came, Nardello said the Legislature is now determined this year to push through a bill raising the reimbursement rate to the 70th percentile.

And when that happens, the state’s dentists will be very much on the hook.

If the current anemic reimbursement rate justifies their nearly nonexistent participation in providing care to Medicaid patients, that excuse will be gone once the rate is raised.

Carol Dingeldey, executive director of the Connecticut State Dental Association, said a recent informal poll by the organization showed that with rates at the 70th percentile, an additional 300 dentists would begin seeing HUSKY A children, and 90 who are currently taking care of the children would take on more patients.

“Another thing we could surmise is there are additional members waiting in the wings, watching this and seeing how it plays out,” Dingeldey said. “We could have more once they see and believe the program is going to work.”

That’s not good enough for Nardello, who wants to see at least 50 percent of the state’s 2,900 dentists taking care of Husky A kids — and not just one or two — once the 70th percentile fees are put in place.

In 2000 in Georgia, the number of dentists providing care to Medicaid patients jumped by 423 percent, from 259 to 1,355, when the state increased the reimbursement rate from the 75th percentile to the 85th percentile.

Nardello said she believes the first year of a revamped HUSKY A program will cost about $20 million. She said it’s hard to predict expenses in the following years, but that eventually they will plateau as the dental health of poor children improves.