Cleaning up DSO's is Essential to Increasing Access to Dental Care for Low-Income Children

For most Americans, going to the dentist isn't at the top of the list of things we want to do, but we go anyway, because dental care is necessary for our health and well-being. However, many of the poorest children in America don't have the luxury of dreading a trip to the dentist.
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For most Americans, going to the dentist isn't at the top of the list of things we want to do, but we go anyway, because dental care is necessary for our health and well-being. However, many of the poorest children in America don't have the luxury of dreading a trip to the dentist.

According to the Centers for Medicare and Medicaid Services (CMS), 43 million children in the U.S., including half of all low-income children, receive health coverage through Medicaid. This coverage includes dental services as part of the Early and Periodic Screening, Diagnostic, and Treatment benefit.

At a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services. Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health.

For millions of American children, the Medicaid dental benefit is the only path they have to receiving necessary dental care. Despite this benefit, many low-income children still lack access to dental care, because there are no dental practices in the neighborhood where they live. Because of low Medicaid reimbursement rates, it isn't financially prudent for a dentist to open a practice in areas where virtually all potential patients are on Medicaid.

In recent years, however, larger dental practices known as Dental Service Organizations (DSO) have filled that void. These large practices are able to see more patients, making it more viable to treat children on Medicaid. The DSO model is producing positive results. According to the Children's Dental Health Project, the number of children seeing a dentist at least once a year has risen significantly - from 21.4 percent in 1993 to 40.2 percent in 2011.

While the DSO model has been successful, there remain areas of concern. A 2012 joint investigation by PBS's Frontline and the Center for Public Integrity (CPI) uncovered the questionable practices of some DSO's that raise red flags with state Medicaid officials.

The piece did, however, hold up one particular DSO as an ideal model that is "showing hope." Sarrell Dental, a nonprofit dental practice with 17 locations throughout Alabama, received a glowing review. However, some unsettling changes have occurred at Sarrell Dental since that Frontline broadcast.

In 2013, Sarrell Dental was acquired by Massachusetts-based DentaQuest. DentaQuest's President of Care delivery is Todd Cruse, who previously ran a company called FORBA Holdings LLC, a dental management company that provides business management and administrative services to 69 clinics nationwide known as "Small Smiles Centers."

In 2011, FORBA changed its name to Church Street Health Management (CSHM). In 2013, the Senate investigated CSHM for "deceptive business practices."

Following that investigation, the Office of the Inspector General (OIG) of the Department Health and Human Services notified CSHM it will no longer be eligible for reimbursement from Medicaid. OIG's letter to CSHM cited "multiple breaches to a compliance agreement, which mandates quality of care measures."

Following allegations that it was bilking taxpayers by doing unnecessary and substandard procedures, the company reached a 2010 settlement with the Department of Justice. Without admitting wrongdoing, the management company agreed to pay $24 million to the federal government and several states and to significantly change its practices.

But its problems didn't end there. An NBC News investigation of Small Smiles in 2012 found persistent allegations of abuse, including unnecessary root canals, shoddy work and insufficient anesthesia, from families of patients, former employees and government investigators.

And the company received a series of warnings and penalties as government and independent investigators monitored the company's activities as part of the five-year agreement...

...But the Inspector General's Office said last week it issued the exclusion because CSHM failed to satisfactorily remedy issues it raised in December 2013 and January of this year, including failure to report incidents related to patient care. While government monitors perform onsite visits, CSHM is also required to notify the agency of any breaches of its compliance agreement.

Given that Sarrell Dental has been held up as an example of the best the DSO model has to offer, its affiliation with DentaQuest threatens to cast the entire model in a bad light, which could have a devastating impact. If state governments begin to suspect DSO's of deceptive business practices, it could result in increased red tape and reduced reimbursement rates that would have the ripple effect of knocking out many practices that are above board, cutting off access to dental care for millions of low-income children.

DSO's are a beacon of hope for poor children in need of dental care. If the bad actors aren't weeded out, it will be these children who suffer the consequences.

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