Dentists fear state’s Medicaid policy changes may delay kids’ care
By Megan Gannon
On December 1, the Dunleavy administration rolled out changes to Medicaid coverage for dental services in Alaska that some practitioners fear will lead to delays in treatment for children.
The new regulations are intended to combat “overuse” of dental services for patients 21 and under, according to the Alaska Department of Health. Now dentists must seek prior authorization for Medicaid coverage when three or more teeth are to be extracted and when three or more crowns are to be placed in a single appointment. Providers will also need prior authorization when a Medicaid recipient needs more than four extractions in a single year and when a patient needs four or more crowns in a single year.
“These regulations will not compromise the ability to provide treatment within a few days of the initial visit,” said Clinton Bennett, a spokesperson for the Department of Health. “Currently, over 99.5 percent of prior authorizations are processed within 3 days of receipt.” Bennett added that in urgent cases, an expedited review can be requested.
But critics of the changes told the Nugget about their concerns with the new policies. They worry the changes could limit access to care for the state’s most vulnerable patients and increase the paperwork burden for practitioners who accept Medicaid. They also note that a few days of a delay to get approved for care could have significant implications for patients who are in pain, who must travel for treatment or who are treated by traveling dentists, as is often the case in Alaska’s remote communities.
“Rather than correct the problems and go after the very, very limited number of dentists that are taking advantage of the system, they come up with arcane rules and expect everybody to comply,” said Dave Logan, executive director of the Alaska Dental Society. “And they add to the administrative burden for the dentists that are in the system so greatly that it’s been a death of 1,000 cuts.”
The DOH says the regulation change is a “necessary corrective action” in response to recent legislative audits, which found instances of apparent overuse that went undetected by the Medicaid system’s surveillance procedures. For example, the 2019 audit pointed to cases like a 19-year-old who got 26 crowns in one visit. It also highlighted claims data that showed 60 cases of recipients getting five or more crowns on the same day.
But some dentists say the audits failed to look at the reasons behind these procedures, noting tooth decay rates are so high in Alaska that such figures are not surprising.
A kid in need of five crowns is “a run-of-the-mill case for us,” said Meghan Foster, of Denali Pediatric Dentistry in Anchorage. “Very frequently, it’s a minimum of eight crowns and four extractions,” Foster said. “Frequently, it’ll be 12 to 16 crowns and four extractions. I personally believe, and I think most of us in the dental community believe, that there’s just some disconnect on the reality of the decay rate that we’re actually faced with and overtreatment concerns that the state has.”
Robert MacArthur, a dentist who works in remote communities in Alaska, also feared the new pre-authorizations could lead to delays in care, leaving patients waiting with painful infections and antibiotic prescriptions that could have been avoided.
He described a case of a young man who had tried three times in the last six months to come to Bethel for pain on a wisdom tooth but was delayed by bad weather and holiday closures.
“Let’s say he actually got into Bethel and we had to wait for a pre-authorization,” MacArthur said. “He’s already been waiting in this situation for months in pain with an abscessed tooth and then we have to tell him, ‘I’m sorry, there’s nothing I can do other than giving you antibiotics or pain medications, and I can’t actually get to the root of the problem and take out the tooth because now I have to wait for pre-authorization for Medicaid.’ For our patients in our community, it’s just contrary to what I feel like we were taught in school—to do no harm.”
Dentists who treat kids and young people from remote parts of Alaska tend to err on the side of more definitive treatment, said Christine Roalofs, who founded the Anchorage-based pediatric practice Just Kids and still works as a visiting dentist in villages in the Norton Sound and Bering Strait area.
“We are in the trenches taking care of these kids because we have such a high decay rate in Alaska,” Roalofs said.
Roalofs saw another flaw in the legislative audits the DOH used to craft its new policies: it did not distinguish between those custom-made crowns—like the ones adults typically receive, which may cost upwards of $1,000 each and may be a sign of overtreatment in pediatric cases—and the prefabricated stainless-steel crowns that dentists regularly use to cap kids’ baby teeth, which cost about $300 each. Dentists will often opt for longer-lasting stainless-steel crowns over fillings, because they know they know the risks of giving fillings that might fall out and require urgent care, she said.
Bennett, the DOH spokesperson, could not say whether overtreatment was a major issue in rural Alaska dentistry and confirmed that the state’s analysis did not take geographic differences into consideration.
When the state released a draft of the changes in early 2021, health authorities initially proposed mandating pre-authorizations for all extractions, which was “next-level ridiculous,” said Logan. The slightly revised version of the changes was signed by former DOH Commissioner Adam Crum in October 2022, a month before he was appointed commissioner of the Alaska Department of Revenue.
In response to the original draft of the new regulations, the state had received dozens of public comments from dentists, with most of them in opposition. Several were especially worried about the potential consequences for kids who are too young or anxious to receive treatment or even have X-rays taken without sedation. Practitioners note the scope of necessary care may be unknown until a patient is under general anesthesia, and doctors want to avoid putting children through multiple rounds of sedation.
“Ethical dentists are going to be doing the exact treatment that needs to get done, whether the authorization on a tooth happens or not after the fact,” Foster said. “The treatment is going to get done once we have the kid asleep.”
But she and Roalofs separately explained that the burden of risk will instead fall on the small providers who may not get paid if they perform treatments that must be retroactively authorized.
“They’re tying our hands on whether or not we want to potentially do things pro bono, if the Medicaid reviewers decide that [a treatment] wasn’t appropriate,” Roalofs said. She worries about what will happen to kids in villages who need to wait days for pre-authorizations if they only have access to a visiting dentist like her for a week at a time.
For patients who need to be flown into a bigger hub for care, doctors will be in situations where they have to make guesses for treatment plans for kids they’ve never met in order to get the treatment pre-authorized, Foster said. “Unfortunately, when you finish the case, if you make any changes…the change authorization form only allows four changes per page.”
Logan also worries smaller dental offices will not have the capacity to handle the added administrative complications, and that the change may disincentivize practices from accepting Medicaid.
“Really the only reason that the system is still functioning at all is the number of dentists that feel a social responsibility to take Medicaid,” Logan said. “I know from back when I was in practice, Medicaid was maybe five percent of my practice, and it was easily 80 percent of the headaches.”
Large healthcare institutions may be more insulated from those financial risks and the paperwork hassles.
Representatives from Norton Sound Health Corporation in Nome said the new Medicaid changes should not affect how the hospital administers dental care. They said the Indian Health Service would fill gaps in Medicaid coverage for its beneficiaries. For those who are not IHS beneficiaries and can’t pay out of pocket, NSHC would work to offer discounted payment plans, according to a spokesperson.
Last month, the DOH held a Medicaid Care Advisory Committee meeting to hear provider concerns about the changes. Roalofs says she wasn’t assured that the state was prepared to handle the influx of paperwork, especially since there is still no online system to apply for prior authorizations.
The state has said that by eliminating other prior authorizations for most adult enhanced services, the DOH should expect a significant reduction in paperwork overall.
“Online submission is not currently available, but the new regulation changes result in an overall decrease in administrative burdens and paperwork submission,” Bennett said. “The new regulation changes are estimated to result in a decrease of approximately 4,200 service authorizations per month down to 950 per month for dental services requiring service authorizations (inclusive of all ages and all dental services, based on an analysis of prior claims data).”
Dentists will learn whether that’s true over the next several months. Roalofs said she hoped the department will continually evaluate and adjust these regulations based on any problems that crop up now that the new policies are in effect.
Foster expressed a similar sentiment.
“I have faith that this is all going to shake out in an acceptable fashion,” Foster said. “I just don’t know how long it’s going to take to get to that point.”