Published in Pawtucket Times on March 3, 2003

According to Alfred Santos, executive director of the Rhode Island Health Care Association (RIHCA), one company’s business decision has left Rhode Island nursing homes scrambling to bring dental coverage to thousands of nursing home residents.

Over the last two months, Santos has met with state regulatory officials to inform them of this latest health-care access problem.

Here’s the scoop:

Access Dental Care, a major provider of dental services to nursing facilities, announced in a Nov. 4 member to its 40 nursing home clients that it would no longer offer onsite dental care, beginning Jan 1, 2003. The brief memo cited the extreme physical challenge to dental staff who provided dental services to residents outside the normal dentistry setting as the rationale for dropping onsite dental care.

But a nursing home trade group says that there may be a bigger issue behind Access Dental Care’s decision to not provide onsite dental services to nursing home residents.

RIHCA’s Dental Services Committee believes the actual reason for this business decision may well be tied to a low Medicaid reimbursement for dental care services, said Chair john Gage, who also serves as the trade group’s vice-president. Currently, Gage is the administrator at Riverview Heatlh Center in Coventry.

Gage said 80 percent of nursing home residents rely on Medicaid to pay for their dental services. Access Dental Care’s decision to not perform dental services on site will force m any frail, bedridden residents to be transported outside the facility for treatment, causing needless pain and suffering to them, he said.

“With a severe staffing shortage facing many facilities it will be even more difficult to assign a staff person to accompany the resident,” Gage noted.

According to Gage, it’s not so easy for nursing homes to find other providers to deliver onsite dental services. Complicating this health care access issue, Geage said, is HealthDrive’s policy not to contract with any nursing home to only provide dental services.

At press time, state officials from the Department of Health and Human Services were unavailable for comment about this payment issue.

State Sen. H. Elizabeth Roberts

(D-Cranston), who is chairing a subcommittee of the state’s Long-Term Care Coordinating Council (LTCCC) is currently looking at Medicaid issues, said Access Dental Care’s decision to not provide treatment to Medicaid recipients in the nursing home setting only exacerbates an ongoing problem. That Is, low Medicaid reimbursement  keeps low income seniors from receiving the appropriate preventative and restorative dental care they need.

Roberts said, “inadequate Medicaid rates make it hard for dentists to see residents, because the rates are so far below their costs. When combined with the medical complexity of nursing home patients, the low reimbursement is even more of a barrier, she said.

Robert’s LTCCC subcommittee plans to turn their attention to investigating the obstacles that keep dental care from being provided to Medicaid-eligible seniors in nursing homes and in their homes.

Bringing dental services to low-income children and seniors became an important issue to Roberts when care to a young constituent in the Rlte Care program required the use of an operating room for dental work because of severe tooth decay.

This operation could have been prevented with ongoing dental care, she said, noting that it “took the attention of state government to locale a provider who would accept the low Medicaid provider rate.”

Roberts is working to ratchet up the Medicaid reimbursement for dental care and to streamline the payment process through legislation she has recently introduced. The senator intends to bring together the state’s Dental Society and nursing homes to develop a plan to bring dental care to facilities that no longer received onsite dental service.

Robert Hawkins, state ombudsman and executive director of the Alliance for Better Nursing Home Care, agreed with Roberts’ assessment that there has been limited access to dental services in nursing homes over the past couple of years.

Hawkins has been pushing for appropriate dental treatment for nursing home residents for more than 25 years.

“Medicaid-eligible seniors who are mobile can more easy travel to dental clinics, if they can find treatment, especially with the low Medicaid rates,” Hawkins said. “For the old, sick and feeble, why should they have to go to through the turmoil of leaving the facility to get their dental care?

“Lack of access to dental care is a form of discrimination for those unfortunate to be lower-income and on Medicaid, Hawkins charged.

The Medicaid system has always been “penny wise and pound foolish,” Hawkins said. “When you don’t treat a dental problem early, residents don’t eat, they lose weight, develop bed sores, ultimately requiring costly hospital care.

“Can any one remember having a tooth ach all night long with no where to go?,” Hawkins asked.

Susan Sweet, a consultant to nonprofit groups and a longtime elder rights advocate, added there is also a lack of dental care for low-income seniors that extends into the community as well.

“For some reason, dental care is treated in the health care community as less important as other medical care,” she said, adding that reimbursement for dental care has lagged behind reimbursement for other medical care.

So where do we go from here?

Roberts’ plans to bring the state’s Dental Society together with nursing homes to craft a short-term solution is the first step in removing the obstacles of providing dental services to Medicaid-eligible residents. But a more permanent solution is needed.

With Gov. Don Carcieri poised to shortly release his budget, I hope he and the General Assembly counter Medicaid’s traditional “penny wide and pound foolish,” philosophy by increasing Medicaid payments for dental services. An inadequate reimbursement rate will ultimately reduce the needless pain and suffering that dental problems cause in nursing homes across the state.