#4 – Dental Care at a Crossroads: Medicaid and Access to Care

In this episode of Pulse on Carolina Health, host Robert Shaw welcomes Elle Basile, public affairs senior manager with the North Carolina Dental Society, which represents more than 3,900 member dentists in the state and is committed to advancing oral health for North Carolinians. 

Elle discusses the critical role Medicaid plays in providing dental care for North Carolina’s most vulnerable populations, challenges with access to care and the impact of low reimbursement rates on dentists’ ability to serve Medicaid patients. She also shares insights on current legislative efforts, the importance of preserving the adult dental benefit and what policy changes could mean for patients and providers. 

Host - Robert Shaw, Partner, Smith Anderson
Guest – Elle Basile, Public Affairs Senior Manager, North Carolina Dental Society

Smith Anderson is a full-service business and litigation law firm serving regional, national and global companies. Our team of experienced health care lawyers are committed to guiding medical professionals, hospitals, health care facilities and industry organizations through the attendant changes and evolving regulatory environment. We advise on health care policy, legislative advocacy, executive strategy, mergers and acquisitions, privacy and data security, litigation and the complex business requirements of organized medicine. We have been integrally involved in launching innovative health care delivery initiatives such as clinically integrated networks, joint ventures between health systems and practitioners, Community Care of North Carolina and Accountable Care Organizations (ACOs) nationwide.

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Transcript

Welcome to Pulse on Carolina Health, a Smith and Anderson podcast focused on current healthcare trends and policy in North Carolina. In each episode, our host pairs up with industry executives and experts around the state to discuss where their finger is on the pulse of timely healthcare topics and to broadcast issues of importance that affect their business most. If you want to stay informed about the latest developments in healthcare law, policy, and industry trends, this is the show for you. 

Hello, and welcome to Pulse on Carolina Health. I'm your host, Robert Shaw, co-chair of the Healthcare Practice Group at Smith Anderson. I am pleased to welcome Elle Basile, who is the public affairs senior manager with the North Carolina Dental Society. She will be discussing the impact of recent developments in the North Carolina Medicaid program on dental health and policy in our state. Elle, welcome to the podcast. 

Thank you for having me. I really appreciate the opportunity to be part of this podcast. I work for the Dental Society as public affairs senior manager, which means I handle the society's government affairs and advocacy. 

Background on me, I'm a North Carolina native, originally from Greensboro, now living and working in Raleigh. I've been with the Dental Society for a little over two years, and it has been amazing. Prior to joining the staff, I helped handle advocacy for another state association. I also worked as a legislative assistant in the North Carolina Senate for several years, where I was able to meet a lot of great people and get a really good understanding of North Carolina's legislative process. 

Prior to that, and prior to working in North Carolina, I worked in Washington, D.C. for several years on Capitol Hill and in the federal government in various roles. Ironically, I tell my friends and family that in another life, I should have been a dental hygienist, and I regularly keep floss in my purse. So working for the Dental Society has been a great fit. 

That's great. I can certainly understand that. It sounds like your background is a great fit for all the great work that the Dental Society does. So just help us understand what the Dental Society does as a voice for dental health and for dental professionals in the state.  

Yeah, so the North Carolina Dental Society is one of the oldest dental societies in the country, actually. And we represent the majority of dentists in North Carolina. We have a simple but strong mission, which is to connect, protect, and support all members in advancing oral health for North Carolinians. And we do this through a combination of core values that include integrity, member services, creating a space for belonging through science and evidence-based research, and forward thinking policies. And I will say the health and safety of patients is truly at the heart of everything the Dental Society fights for and defends when it comes to policy. 

So what kind of policy trends are you seeing right now these days at the state level in North Carolina? Well, Medicaid is obviously a really big one, and I'm excited to talk about that today. We have a number of other policy priorities at the North Carolina General Assembly. I would say in addition to Medicaid, flouride is probably a big one. 

We've seen some proposals come up more often across North Carolina to consider removing flouride from the community water systems. And I think that issue really comes down to education and understanding the benefits of community water fluoridation as a safe and effective way for preventing tooth decay in children and adults, especially for individuals who already have challenges accessing routine dental care. And I know we can talk about that more related to Medicaid. 

That fluoride could be a topic for an entirely different podcast. I will say as a research and evidence-based organization, we truly support the continued use of fluoride based on decades of research experience and thousands of peer-reviewed scientific journals. But I look forward to talking more about Medicaid. 

That sounds good. Let me go save fluoride for another podcast. While we tackle Medicaid today, what role does North Carolina Medicaid play in providing dental care in North Carolina? How does it fit into the dental health service provision? Yeah, that's a great question. 

Medicaid is the foundation of dental care for many of North Carolina's most vulnerable patients. And for kids, the dental Medicaid benefit is required by law and includes preventive and restorative services. And that coverage has made a huge difference. Access to this care means the difference between a kid sitting in class distracted and in pain from a toothache or being able to really fully focus and learn and thrive as they grow. And for adults, dental care is an optional benefit under Medicaid. Some states don't cover it at all. 

Some states have enhanced or limited benefits or benefits for emergency services. North Carolina has an enhanced adult dental Medicaid benefit, and that's made a huge positive difference. Oral health is essential for overall health and well-being. 

And without this Medicaid benefit, many adults might otherwise not receive care or wind up in emergency rooms for preventable dental disease.  

So when you say it is an optional benefit, help me there, does that mean that the federal government's Medicaid program provides that the states can or cannot provide the dental benefit at their discretion? Is that sort of a good summary? 

That's correct. Yeah, that's correct. 

Now, how many dental practices are accepting Medicaid patients? What's the sort of market penetration for the Medicaid plan?  

Yeah, here's where the access to care challenge really lies. Only about 30% of active licensed dentists in the state participate in Medicaid, which means that the majority don't. And even among those who do, many are not accepting new patients or they have to limit the number they're able to serve. 

However, that's not because dentists don't want to treat these individuals. Most dentists that I talk to say they'd love to do more. And in fact, I often hear from many providers that say they do these services pro bono. But the reality is low Medicaid reimbursement rates for dental care have made it really nearly impossible for dentists in our state to treat these patients on a regular basis. The fact is reimbursement rates are still at levels they were in 2008, meaning you're getting reimbursed at about 35% of your actual cost of care. And so frankly, you can't just keep your practice open by saying yes to everyone. 

North Carolina's Medicaid rates are some of the lowest in the region, and that's a big part of why access to care is limited. And the most effective way to improve this issue is to increase reimbursement rates for dental care and make it more feasible for more dentists to treat Medicaid patients. And I'll give a great example of how Medicaid reimbursement rate increases have actually increased provider participation. 

In our most close northern state in Virginia, they increased their reimbursement rates by 30% in 2022. And within two years, they saw a 20% increase in provider participation. So we have a great anecdote from a nearby state about how reimbursement rate increases actually increase provider participation. 

What's your sense of what the North Carolina reimbursement rate is as compared to other peer states?  

So like I said, it's about 35% of the actual cost of care. When you compare that to our surrounding southern states, most of our surrounding southern states are reimbursing at a rate of about 46%, 47%, 48%. So we are lagging behind our surrounding southern states in that reimbursement rate for both kids and adults. 

And when you say total cost of care, what goes into that? I'm guessing there's salary, real estate, how does that work?  

That's a great question. So the total cost of care is how much it is to run your business. It's the procedure, the usual and customary rate of a procedure, but it's also paying your staff, rent and utilities, it's supplies, it's updating equipment. 

It's a whole combination of factors that go into cost of care. 

Understand, okay. And so I'm surprised to hear you say that it's 35% of the cost of care. So that sounds to me like if you are providing Medicaid services, then you are by definition taking a loss. Is that a fair summary?  

I think that's very fair. Yes, that's exactly right. 

And are there enough dentists currently that serve the Medicaid patients to meet the need of the Medicaid eligible population?  

You know, it's complicated. North Carolina has more than 6,000 active licensed dentists. And while our state has plenty of dentists, not enough are able to treat enough Medicaid patients. For example, there are entire counties that don't have a dentist who accepts Medicaid. And we hear anecdotes from both providers and patients about families sometimes driving hours across the state just to find somebody who accepts Medicaid. And even in our urban areas where there are a higher concentration of dentists, the number of open Medicaid slots is often limited because practices simply can't sustain the losses. 

So the workforce exists, but without reimbursement rates that come closer to the actual cost of care, many dentists are left in this tough position of limiting how many vulnerable patients they can serve if seeing them at all.  

Are there waiting times for getting into practices for Medicaid patients? What's your sense on how that affects the market?  

Yes, we do hear from patients and providers that there are significant wait times for Medicaid appointments. And that's just a fact of the limited ability for our providers to actually provide services to these patients and the reimbursement rate that kind of coincides with that. 

Let's turn to the legislative trends. What's going on in the legislature regarding the adult dental benefit?  

Great question. What we were at the start of legislative session, we were so ecstatic to see a bill filed to increase dental Medicaid reimbursement rates for both children and adults by 30% across the board. 

Since that bill was filed in, I think it was February at this point, the Medicaid landscape has, at both the federal and state level, has shifted dramatically. And right now we're hoping legislators and the Department of Health and Human Services will be able to work out a compromise to avoid a 3% rate cut to dental services. We also know that when Medicaid shifts happen in funding, optional services are often looped into conversations about potential cost savings. 

And we want to emphasize that preserving the adult dental benefit will actually save the state money in the long run. When individuals don't have access to dental care, they often turn to emergency departments where they're receiving treatment for immediate pain, but the underlying issue is often remaining. And that cost often falls on the state to pick up at a much higher cost when these people don't pay their emergency room bills. 

And just this year, the Health Policy Institute, which is a research arm of the American Dental Association, published a research brief on what happens when adult dental benefits are removed. And it estimates that in North Carolina, specifically, if the adult dental benefit were removed, there would result in a one-year increase in health care costs in the state of over $61 million. And if you broaden that over five years, the total projected cost would be about $307 million. So a huge impact to the state in increased costs by removing that optional benefit. 

So is that 3% cut that you referred to earlier, is that flowing from federal trends or is that a state trend? What's the basis of that? 

My understanding is that is a state-concentrated issue alone. We understand that there's been some back and forth discussion about what it takes to actually fund the Medicaid program. And that's resulted in a looming 3% rate cut. Dental is included in 3%. We've heard that some providers are actually higher at 8% or 10%. But we are really hoping that the department and the General Assembly can work out a compromise to that before this October 1st deadline.  

And what's the October 1st deadline? Help us with that.  

So the October 1st deadline is what the Department of Health and Human Services has proposed. If they don't receive a fully funded Medicaid rebase, they have said that they'll need to start implementing rate cuts by that October 1st date.  

I understand. Do you think we'll get a movement before then or is this going to go through the fall? What's your crystal ball tell you?  

You know, we have our fingers crossed between now and then. We're really hopeful the legislators and leaders within the department will be able to make that, you know, make some sort of agreement. The legislature does have a period of a couple days that they're scheduled to come back at the end of September, which will be really close to right up at the goal line there. But we're really hopeful that they can work it out because really, you know, at the end of the day, who suffers the most is the patients and punishing providers for trying to do the right thing and serve these patients. So we're really hoping to avoid that.  

Very good. Well, it sounds like you probably have a busy schedule coming up in the next couple of weeks. 

Yes, absolutely. But nothing short of interesting.  

Isn't that the truth? Anything else about the Medicaid adult dental benefit that you'd like to share for our podcast listeners today?  

You know, I think at the end of the day, our providers are really trying to just provide quality access to oral health care in North Carolina. And so the best way to do that and improve access to care for these patients is to raise reimbursement rates. And I really appreciate your opportunity to provide a space to talk about that today. It's something that our providers and our members of the Dental Society feel really passionate about. And so the more that we can provide education and raise awareness of this issue is great. And I really appreciate the opportunity today. So thank you. 

Sure. Well, thank you, Elle. Thanks very much for talking with us today. 

We hope that everybody enjoyed the podcast and see you next time. 

The views expressed in this podcast are those of the individuals only. This podcast is not intended as legal advice and does not create an attorney-client relationship between you and Smithy Anderson. If legal advice is sought, please contact qualified legal counsel.