PART ONE

PROVIDENCE – Money talks and patients walk. My prediction for 2020: the dynamics of who gets what, when and for how much in health care will dominate the political landscape in Rhode Island, without much input from the voices of patients. Perturbed voters may upend and disrupt the status quo, however.

The gaps in health care coverage [and education and housing, for that matter] reflect the growing wealth and health disparities – and demographic shifts in Rhode Island, including a falling birthrate, a growing “old old” population, and an increasing immigrant population.

From the failed brokered marriage between hospital systems [attempted by Gov. Gina Raimondo and championed by Brown University President Christina Paxson] to the prospect of looming budget shortfalls in the 2020 state budget, sure to be blamed on rising Medicaid costs, the tendency is to treat the symptoms but not the root causes of the disease – the failing business model for health care as a commodity, run by algorithms, with little ability to affect health outcomes in the community.

Can you name the locations of the current Health Equity Zones in Rhode Island? So much has been missing from the media coverage, left out or ignored in the dominant news narrative. Is that an error of omission or commission?

Take, for instance, a number of disturbing trends identified in testimony before the R.I. Senate’s Special Legislative Commission To Study the Impact of Insurer Payments on Access to Health Care, which met for the second time on Tuesday, Dec. 17, by Andrew Gazerro III, D.M.D., chair of the Council on Dental Benefits for the Rhode Island Dental Association.

• The health insurers Delta Dental of RI and Blue Cross Blue Shield of RI have a virtual monopoly on commercial dental insurance health plans in the state; “other dental benefit companies have minimal if any market share in Rhode Island,” according to Gazerro. Delta Dental of RI is the dominant insurance carrier, with eight times as many subscribers and has market control over its competition and its providers, according to Gazerro.

• This lack of competition has resulted in nearly identical rates of reimbursement by both health insurers “because there is no true competition between them and none from other companies,” according to Gazerro.

• The last provider fee allowance increases by the two dental plans, according to Gazerro, occurred in March of 2008, 11 years ago. “Do you know of any other industry that will provide its services at a rate that is over a decade old? Gazerro asked in his presentation, and then answered: “Ask Cardi Corp. to pave the roads at a 2008 rate and see what you get.”

Translated, according to Gazerro, neither Delta Dental of RI nor Blue Cross Blue Shield of RI meets the 40th percentile for reimbursements for any dental procedure, ensuring that “Rhode Island has one of the lowest fee allowance profiles in the nation.”

The consequences of the low reimbursement rates for dental services maintained by the two dominant dental health insurers in the Rhode Island market include reducing the number of private dentists willing to participate in the state dental assistance program under Medicaid, according to Gazerro.

The provider base for the state’s dental assistance program is drawn mostly from eight community health centers and two hospital programs. Rhode Island Medicaid rates for dental services are the fifth lowest in the nation, according to Gazerro, using 2016 data. And, they are still below the low reimbursement rates paid by Dental Dental of RI and Blue Cross and Blue Shield of RI, according to Gazerro.

Many patients with dental coverage under the state’s Medicaid health plan, Gazerro claimed, were receiving “acceptable but not exceptional care, which frustrates patients.”

Another difficult question posed by Gazerro to the Commission members: “Who determines that it costs less to treat a dental patient in Rhode Island?” Good question.

At the breaking point
Gazerro did not mince any words when it came to the consequences of low reimbursements rates on the future of dentistry in Rhode Island.

• The average age of dentists licensed in Rhode Island was increasing.

• No dentists are coming to Rhode Island to take their place.

• There are less than 30 licensed oral surgeons in Rhode Island.

• Older dentists are not investing in new technology for their offices and their skills may be declining.

Further, the average debt of a dental school graduate is $285,000, making it difficult to attract new dentists to the state without creating an incentive program focused on debt reduction, according to Gazerro.

In Gazerro’s opinion, dental care providers in Rhode Island are at the “breaking point,” which is inviting corporate dentistry to move in and take over the market.

Is a dentist in private practice the same as a dentist in a corporate chain? Good question.

Where does the money go?
Gazerro also provided some fascinating data related to the flow of money from Delta Dental of Rhode Island to dental providers under what is called a “Pay for Performance Bonus Program,” which rewarded dental offices that aligned themselves with certain metrics of value.

“We have found that offices which perform less treatment on patients typically received larger bonuses than offices that provide more treatment,” Gazerro testified, adding the caveat that “treatment” was based upon a patient’s needs and conditions and not on what type of bonus a dentist can receive.

Again, according to Gazerro in his testimony, since 2010, Dental Dental has expended more than $30 million to dentists who qualified for this program. During that same period, Dental Dental reported it had a $44 million in profits, according to Gazerro, citing reports from the R.I. Department of Business Regulation.

The question posed by Gazerro in his testimony was: Given there was a total of $74 million to work with [profits plus bonus payments], why was there no room to increase the fee allowances? He expressed hope that the new administration at Delta Dental of Rhode Island would be open to discussing these issues.

Utilization rate
In the conversation that followed during the question-and-answer period following his presentation, Gazerro raised the issue of utilization rates of those who had commercial insurance through Dental Dental of Rhode Island, saying that the health insurer had a 54 percent utilization rate, with only 190,000 out of its roughly 350,000 insured patients seeking dental care, according to the latest statistics available.

With such a low utilization rate, according to Gazerro, “You can’t raise quality access to preventative dentistry.”

A representative from Delta Dental of Rhode Island challenged the accuracy of those numbers, saying that in the last year, some 210,000 out of 298,000 insured patients sought dental care, for a 70 percent utilization rate.

[Editor’s Note: Only the rate of utilization received any pushback from the health insurers who sit as members of the Commission.]

The gap in dental care for adults for insured patients – whether it is 30 percent or 46 percent – has an interesting monetary twist, one not explored during the Commission’s hearing. Potential benefits not used during a calendar year do not carry over to the next year, under most dental health plans. And, there are limitations and restrictions on the kinds of dental work that can be performed, particularly for restoration of crowns, a common dental need for older adults.

Translated, the money paid by companies and individuals for dental health insurance, if the utilization rate is “low,” goes directly into the insurers’ coffers. In other words, the less services provided, the more money the insurers make, the more bonuses paid out to practices that provide fewer services.

In comparison, some $40 million is spent a year, a mixture of federal and state funds, on the state dental assistance program, but utilization rates for the approximately 300,000 individuals, for both children and adults who qualify, is only 50 percent.

Perception vs. reality
In May of 2018, when ConvergenceRI published an interview with Dr. Sam Zwetchkenbaum, the dental director at the R.I. Department of Health, he said the use of dental health services was highly dependent on wealth, according to national data released in 2018. [See link below to ConvergenceRI story, “Moving beyond a state of decay.”]

“People who had money continue to go to the dentist,”
 he said. In terms of dental health literacy, Zwetchkenbaum offered a cautionary note: nationally, some 52 percent of people on Medicare think they have a dental benefit – “which means they haven’t gone to the dentist and asked about Medicare dental benefits.”

“We need to look at the fact that the mouth is part of the body,” Zwetchkenbaum said, agreeing with one of the conclusions in “A State of Decay” report by Oral Health America: to integrate comprehensive dental care in Medicare.

[Editor’s Note: There are new dental benefits that have been added to Medicare Advantage health plans for 2020.]

There is plenty of evidence beyond the testimony of Gazerro that illuminates the growing unmet dental needs of Rhode Islanders:

• The long lines at the seventh Rhode Island Mission of Mercy Free Dental Clinic, held on Sept. 28 and 29, 2019, at the Providence Community Health Centers, provided the visual evidence of the unmet need for dental care in the state.

• Hospital emergency room discharge data from 2017 identified that in Rhode Island, about 6,500 of ED encounters were for non-traumatic dental purposes, according to Zwetchkenbaum. The highest age group being seen in emergency rooms for non-traumatic dental purposes was the 21-34 age group; they were, in turn, the lowest “utilizers” of preventive dental services.

Medicaid coverage for children through RIteSmiles does actually pay well, according to Zwetchkenbaum. “I’ll admit that adult services under Medicaid pay poorly.”

In his testimony on Dec. 17, 2019, Gazerro noted that there were patient-related issues, such as broken appointments or late arrivals and the difficulty in contacting some patients because they may have moved or their voice mail is full.

Zwetchkenbaum, speaking at the end of the commission meeting as part of the public comment, said that it was important not to blame the patient for the poor reimbursement rates.

Connecting mind and body
Gazerro’s presentation was the second during the Commission hearing. If the testimony by Gazerro identified the gaping maw in Rhode Island’s reimbursement rates for dental providers, the first presentation by Susan Storti, the president and CEO of the Substance Use and Mental Health Leadership Council of Rhode Island, looked at the impact of reimbursement rates on the access and delivery of mental health services, highlighting the disparity between physical health and behavioral reimbursement rates.

Translated, Storti’s slide deck sought to show how in terms of money and resources, the head still seems not to be connected to the body when it comes to how providers are reimbursed for health care services.

The problems identified included:

• The large differences between Medicaid and non-Medicaid rate structures, as well as low reimbursement rates from Medicare, that limit the number of providers in Rhode Island willing to accept patients.

• The lack of available local services and coordinated levels of care in Rhode Island has meant that money is flowing out of state, according to Storti. In 2016-2017, the R.I. Department of Children, Youth and Families spent $10 million on out-of-state adolescent residential substance use disorder treatment. The state paid Rhode Island-based agencies at the rate of $180/day, while paying out-of-state agencies at the rate of $900/day, according to Storti.

• Inadequate reimbursement rates are driving providers from the system and deterring the addition of new providers, diminishing the ability of the remaining providers to offer evidence-based practices and high-quality care, according to Storti.

As possible solutions, Storti suggested consideration of cost-of-living adjustments every year in payer contracts, the creation of a Task Force to examine cost-based reimbursement models, and new legislation to establish periodic review of reimbursement rates, following the examples of Nevada, Colorado and Massachusetts.