NC doesn’t pay dentists enough to treat Medicaid beneficiaries, new report says

Dental care is sometimes an afterthought when it comes to health, but untreated tooth decay can result not just in sore jaws but compromised physical health and lost job opportunities. 

A report released last week by the Oral Health Transformation Task Force envisioned a future in North Carolina where oral health is “comprehensive and seamlessly integrated with overall health.” The task force report was prepared under the auspices of the NC Institute of Medicine and puts a focus on Medicaid beneficiaries and others with low incomes. 

State Medicaid director Jay Ludlam said he hopes the report highlights the importance of dental health and the far-reaching consequences of neglected teeth.

“My hope is that people acknowledge and recognize the importance of dental health and see it as something worth the investment, and conversation about how we can support dentists and the community of dentists and the people of North Carolina with better dental care,” he said in a Friday interview. 

The report comes at a time when more low-income adults who are eligible for insurance coverage under Medicaid expansion are seeking dental care. As of April 1, 400,000 North Carolinians had enrolled in expanded Medicaid, Gov. Roy Cooper announced. Medicaid covered more than $11.2 million in claims for dental services for people covered under expansion since the Dec. 1 launch, according to a press release from his office. 

North Carolina is recognized in the report as offering “some of the most robust adult Medicaid dental coverage in the country.” It’s one of 25 states that offers comprehensive dental coverage to adults. 

Not all Medicaid beneficiaries have access to that care, however.  

Ninety-four of the state’s 100 counties have shortages of dental health care professionals. It’s harder to find dental care in rural areas. Four eastern counties have no dentist, according to UNC’s Sheps Center for Health Services Research. About 40% to 45% of active licensed dentists participate in the Medicaid dental program. Many are not accepting new patients, the report says. In 2022, dental procedures comprised 14% of services to Medicaid beneficiaries. Around 2% of Medicaid payments went to dental providers.

About 15% of kindergarteners have untreated tooth decay. A little more than half of children and young adults ages 1 to 20 who are eligible for Medicaid have had preventive dental care, according to state Department of Health and Human Services data.

Tooth decay can lead to the inability to eat certain foods. Decaying or missing teeth can present stumbling blocks to finding a job. An American Dental Association survey of North Carolinians from 2015 found that 18% of adults said the appearance of their mouth and teeth affected their ability to interview for a job. More than 20% said they avoided smiling because of the condition of their mouth and teeth. 

Dentists want to stay clear of Medicaid managed care

Despite the call for better connections between oral and physical health, the 118-page task force report stops short of recommending that dentists be folded into the Medicaid managed care plans the state launched in 2021. Under Medicaid managed care, insurance companies are paid a set amount per person enrolled and are to provide health care within the limits of the money they collect. 

Dental care remains “fee for service,” meaning that dentists are paid for each procedure they perform.

The task force report explained how dental care was kept outside the Medicaid managed care umbrella. 

“Many oral health professional stakeholders preferred in the past to keep dentistry’s service delivery models separate, autonomous, and tailored to the unique characteristics of dental practice,” the task force report said. “Many advocated for dental services to be carved out when NC Medicaid transitioned from fee-for-service to managed care and shifted state administrative duties to managed care organizations.”

NC Dental Society CEO Jim Goodman said in an interview Thursday that dentists still want to keep the Medicaid dental program separate from managed care. 

The main problem is payment rates have not changed since 2008, he said. 

“We need to make changes that contribute to the long-term sustainability of serving the patients who are now covered by Medicaid in the state,” Goodman said. “The first step for any of that had to be reimbursement rates going up. They haven’t increased since 2008. The problem is the 2008 numbers weren’t great either.”

More dentists would see more Medicaid beneficiaries or add them as patients, but “you can drive yourself out of business seeing more and more Medicaid patients,” Goodman said. “We have well-intentioned and good dentists who want to do this, but they’re also small business owners. We hope people can appreciate that balancing act.”

Support for increased Medicaid payments

Medicaid reimbursement rates for some dental procedures are actually lower now than they were in 2008, the report says. For example, Medicaid paid $29.93 per tooth to put on a sealant in 2008. Now it pays $29.89 per tooth. A payment that kept pace with inflation would be $39.44 per tooth, the report says. 

“This is unsustainable for dental practices,” the report says.

The budget proposal Cooper released last week included a rate increase with a $265 million state appropriation that would allow Medicaid to pay dentists more. 

Ludlam said money for the rate increase proposed in Cooper’s budget would increase payments to dentists for treating patients on regular Medicaid. Dentists would receive the higher rates when treating people under expanded Medicaid too, but none of the money backing the higher rates for them would come from state coffers. The federal government picks up 90% of the cost of care for people covered under Medicaid expansion, with the rest coming from increased assessments on hospitals. 

Even as it acknowledges it’s hard for Medicaid beneficiaries to find dentists to treat them, the report recommends NC Medicaid support “dental homes” for patients, encouraging them to develop relationships with dentists in offices where they would receive comprehensive and continuous care. 

Central to that recommendation is creating compensation rates for dentists that take into account preventive care and complex needs. 

“It’s a good move,” Ludlam said, even though initially there may not be enough dentists. 

“What we need to continue to do is invest in innovations in the way that we provide dental care,” he said. 

As Medicaid rates increase, more dentists will accept the government insurance, he said. “It’s a virtuous cycle that works together.”