Lakemary Center in Paola has many ways to serve its clients — Kansans with intellectual and developmental disabilities.
But they don’t have a dentist on staff. And after years of stagnant Medicaid reimbursements, finding a dentist who will see their clients for even a normal checkup has become “a significant challenge,” said Lakemary nurse practitioner Mike Herriges.
“Just a basic dental appointment for screening and cleaning is difficult to come by,” Herriges said. “When a child has a dental issue, such as a cavity or broken tooth, we struggle to even find basic emergency care.”
Herriges said Lakemary clients often have to wait several days to get an appointment, even for urgent dental problems, and then staff has to drive them almost an hour up to Olathe or Overland Park.
The Kansas Legislature is close to approving the first Medicaid increase for dentists in almost two decades, a move the state dental association says is crucial to getting more dentists on board with the program. But the proposed increase has shrunk far below the amount the association originally asked for, leaving its impact uncertain.
Currently, less than one-third of the state’s dentists take Medicaid, because the reimbursements only amount to about 35 percent of what they charge.
Johnson County dentist John Fasbinder is one of the few who takes Medicaid patients, including those from Lakemary who need to be sedated during even routine dental work.
Fasbinder said he’s OK with making less money in the late stages of his career, but he’s concerned that it’s getting harder for some of the state’s most vulnerable residents to find someone who will take care of their teeth regularly.
“We can’t get other people to do it, and maybe putting some money in it would make it easier for dentists,” Fasbinder said. “Loan forgiveness and other things have been mentioned, but we’ve got to do something.”
Now that the Legislature appears poised to do something, the question is, will it be enough to lure dentists back?
In expansion’s shadow
Much of the current legislative session has been consumed by a high-profile, high-stakes battle between Democratic Gov. Laura Kelly and the Republican-controlled Legislature over whether the state will expand Medicaid coverage under the Affordable Care Act. But during that time, much quieter discussions have been going on over whether to increase the rates the state pays dentists for the first time since 2001.
That discussion has continued largely without any prodding from Kelly.
“Right now my focus is on expansion,” she said. “And then once we get that in place, then obviously there are a variety of different things in the Medicaid program we need to do.”
Most states have increased their rates for dentists and other medical providers in the last few years, according to the Kaiser Family Foundation.
A 1% bump for Kansas nursing homes is written into the Legislature’s current budget proposal, and Missouri legislators are also mulling an increase for their nursing homes.
But in Kansas, the only increases for dentists since 2001 have been to restore temporary cuts — in 2009 after Democratic Gov. Mark Parkinson squeezed Medicaid by 10 percent to help close a recession-induced budget hole and in 2017 after Republican Gov. Sam Brownback sliced rates by 4 percent to close a hole driven by tax cuts.
“We generally don’t count that as an increase because it was a restoration of a decrease,” said Kevin Robertson, the executive director of the Kansas Dental Association.
Before it was restored, the most recent cut was a breaking point for many dentists. Data compiled by one of them determined that after the cut, about 30 of the state’s 105 counties had no dentists who took Medicaid (including 20 in the western half of the state).
Low reimbursements were just one part of the equation. Dentists, like other medical providers, also expressed frustration with the 2012 switch to KanCare, a privatized Medicaid system run by three insurance companies. Instead of billing just one Medicaid provider (the state), the dentists had to bill three, all with different systems.
Fasbinder said that’s still causing administrative headaches that make the low Medicaid rates even harder to swallow.
“It’s still a real hassle for all the providers,” Fasbinder said. “They keep changing their rules and regulations.”
Two of the three KanCare companies, Amerigroup and UnitedHealthcare, had significant gaps in their dental networks in western Kansas, according to the annual “network adequacy maps” they are required to publish. (Amerigroup has since been replaced by Aetna.)
Even the company with the most robust network, Sunflower State Health Plan, had 431 dentists participating, which is only about 30 percent of the 1,400 dentists practicing statewide.
It remains to be seen whether the rate increase being finalized by the Kansas Legislature will be enough to improve those numbers.
Robertson said data from 2016 pegged Kansas’ Medicaid rates for a variety of dental procedures at about 35% of what the average dentist would charge for them — and it hasn’t gotten any better since then.
His group lobbied for the Legislature to hike that to 60%. But that would have required almost $13 million. Instead the Legislature appears poised to approve about $3 million.
That won’t get the dentists anywhere near 60% of their charges, but Robertson called it a “step in the right direction,” especially given how long it had been since the dentists saw an increase.
“I don’t think very many of us would still be sitting in the same job if they hadn’t had an increase in the last 18 years,” Robertson said.
He said he hoped more rate increases might come in future years.
Herriges said that he fears dentists like Fasbinder who still take Medicaid are becoming overwhelmed, and more needs to be done to bring new providers into the system.
“Just from our experience in the difficulties we have obtaining needed dental care for these children, raising reimbursement rates to a more reasonable level certainly would help,” Herriges said. “That would make a good first step.”