Dr. Luisa Utset-Ward is used to making people scream. As a dentist who specializes in serving children on Medicaid, she regularly pulls rotten teeth out of scared little mouths. But Utset-Ward, 42, wouldn't trade her job for anything because she believes early intervention in the mouths of babes sets them up for a healthier future.
Unfortunately, Utset-Ward may be put out of business this summer if the state Agency for Health Care Administration (AHCA) turns over its Medicaid dental program for children to a managed-care organization as it plans this spring. By legislative mandate, AHCA is starting a pilot project in Miami-Dade County that would require dentists with Medicaid clients to join the managed network, or stop treating them. AHCA's deputy secretary for Medicaid, Bob Sharpe, says the agency may sign a contract with Coral Gables-based company Atlantic Dental, Inc., as soon as May 1.
Atlantic Dental, founded by politically connected healthcare executive Michael Fernandez, 51, was one of only two companies to apply for the contract over the course of a full year. The other was a Wisconsin-based company called Doral Administrative Services, LLC. (Atlantic is also one of three providers for the state's Healthy Kids program.) But several local dentists complain that the application process was kept virtually hidden until recently, when Utset-Ward and her husband Tom Ward (also a dentist) were tipped off by concerned state officials. The Florida Dental Association has issued a statement that the proposed pilot project "does not assure quality dental care and does not provide for a system of ongoing program evaluation."
The main concern of local dentists is that the state agency is simply reacting to a law quietly passed by the legislature, without doing the necessary planning to ensure that the program provides real benefits to patients, not just the company that runs it. The dentists argue that the system of managed healthcare is set up to provide minimal service to most patients, while discouraging dentists from performing more elaborate treatment. That is because, typically, management organizations pay the dentists a small fee per patient each month, regardless of whether they ever see the patient. The HMO would also reimburse dentists for procedures on their list, but the rates are so low that many dentists say it's not worth the trouble. How, they ask, can you take the same amount of money, add a layer of management, and expect to provide more service to patients? AHCA's Sharpe says the answer is that private-sector management will help curb Medicaid fraud, a major problem in South Florida. Sharpe adds that certain issues are still in negotiation and the agency may yet reopen the application process to attract more companies.
But Dr. Alan Friedel, a Hallandale dentist and first vice president of the Florida Dental Association, argues that by its very nature Medicaid is already a managed-care program because the state determines what it will pay dentists for various services. "If they take those dollars and give them to a third-party administrator, then the administrator will take its fee off the top," he explains. "The industry standard is that about 30 percent of fees go to administration. The state is already giving limited funds to this and now they're just adding a whole new layer of bureaucracy."
Utset-Ward is horrified at the prospect because she vividly recalls previous dealings with Medicaid HMOs. She says that there are a thousand tricks unethical dentists can employ to ensure that they make the maximum profit for minimum effort. Two common examples are making patients wait months for appointments, or by not recommending restorative work, such as fillings and surgery. Just doing a quick cleaning and exam isn't going to help children with tooth decay. "About eight years ago they tried an HMO in Medicaid and it was a disaster," Utset-Ward remembers. "Back then, the patients could still opt out of an HMO, so I'd get these kids coming in from the HMOs with a million cavities. The system discourages treatment."
She asked AHCA whether it had developed a study of the current state of the Medicaid dental program, the cost-savings of the new program and how the transfer of patients would occur, or how performance would be evaluated. She says she was told there wasn't anything. Sharpe admits the agency doesn't have the information, but says it will contract with an outside organization, such as a university, to assess the quality of the program. Any assessment will be limited, however, because all the raw numbers will be provided by the HMO itself.
For years the legislature has been looking for ways to clamp down on escalating healthcare costs. This past week, for instance, legislators debated whether to expand KidCare insurance benefits to low-income children, but to exclude noncitizens. In this spirit, the legislature voted in 2001 to initiate a pilot project in Miami-Dade aimed at cost-effective healthcare, but only last year did it add the amendment that opened the door to an HMO: "[AHCA] may contract on a prepaid or fixed-sum basis with appropriately licensed prepaid dental health plans to provide dental services."
Another problem, according to local providers, is the state didn't bother to include local dentists in the process. Miami Children's Hospital is one of the largest providers of dental care for Medicaid patients in the county, yet the state hasn't approached dentists there about this dramatic change, according to Mark Webman, a pediatric dentist and chief of dentistry at Miami Children's. Webman says he doesn't know a lot about Atlantic Dental, but, in general, any change that would limit the Medicaid dentist pool is worrying. "Every dentist worth their salt believes that freedom of choice is extremely important. By the state going to a program where they limit the choice, that's not a good thing."
Elise Linder, program manager of Community Voices Miami, advocates for oral health access. She says the current Medicaid program is already problematic because although many people qualify, reimbursements to dentists are so unremunerative, there aren't many willing to accept Medicaid. "If the legislature is doing to oral care what they're doing to Medicaid and KidCare in general, it's pretty scary," she warns.
Healthcare exec Michael Fernandez is a principal in Atlantic Dental; among the other companies he owns is CarePlus Medical Centers, Inc. HMOs have been good to Fernandez. Early this year he spent $26.8 million to buy a home and waterfront property in Gables Estates. He's also been magnanimous to his friends, giving enormous amounts of money to many politicians through his various companies. Last year, his generosity embarrassed Alex Penelas, county mayor and Senate hopeful, when an e-mail a Fernandez associate sent out compelling employees to donate to the Penelas campaign became public. A Miami Herald analysis later found that Penelas took at least $68,000 from the company's employees, their relatives, and business associates.
Fernandez also served as vice chair for Penelas's Sixth Annual Mayor's Ball, a charity schmoozefest held on a cruise ship in December 2002. Atlantic Dental was an event sponsor. Fernandez was appointed to a county task force created by Penelas to study ways to improve healthcare access for the poor, in part by using private providers.
But Fernandez has been generous to other politicians as well. Last year, the Republican Party of Florida got a $25,000 check from Healthcare Atlantic Inc., an affiliated company run by Atlantic Dental CEO Leila Chang. And he keeps state Rep. Rene Garcia in kibble by employing him as an "outreach coordinator" for CAC Careplus (and before that Physicians Healthcare Plans, Inc., a company Fernandez sold in 2002). Garcia sits on the House subcommittee on health services, the subcommittee on health appropriations, and the select committee on affordable healthcare for Floridians. And he sat in on the conference committee between the House and the Senate, during which the amendment was inserted. Garcia asserts that he had nothing to do with the amendment, noting that the original legislative mandate for a pilot project was approved in 2001, before he worked for Fernandez.
A five-year-old with her front teeth eaten away almost to the gumline and a nasty abscess just above them lies back in rigid terror against the vinyl chair. Her numerous black braids with clear beads on the ends dangle onto a white and pink flowered T-shirt that says, ironically, "Sweet."
"It hurts!" she cries, twisting her body so that her white sandals knock against each other.
"I know some of your teeth hurt," Dr. Luisa replies, rubbing a cherry-flavored gel on the girl's gums before numbing them with an injection. "I'm going to make it better."
With swift efficiency and a distracting banter, the doctor pulls out two front teeth with miniature pliers. Fresh screams fill the office.
"Okay, Mommy got you," the girl's mother soothes. A four-year-old boy in the next chair weeps in silent anticipation. His mother wipes his face.
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"Her teeth gonna grow back?" the girl's mother asks, tapping a pink bedroom slipper lightly against the floor.
"Yes," Dr. Luisa answers sternly, smoothing a bright sticker onto the girl's shirt. "but not until she's about seven. This isn't her fault, as much as you don't want to hear that."
Mother and daughter are sent off with a new toothbrush and an appointment to have more teeth removed next week. Utset-Ward says baby bottle syndrome is common among poor children because their parents often don't know that it's not good to let them constantly sip juice or milk. The result, without proper brushing and dentist appointments, is numerous cavities. "I see kids like this four, five times a day," she laments. "This girl will be okay, but younger kids who lose their teeth while they're learning to speak can end up with a speech impediment."
Other drawbacks for children with too many rotten teeth are the risk of developing an infection that could send them to the hospital, and malnutrition because it hurts to eat.