Letters: FQHCs and numbers
October 17, 2016
On Sept. 12, NPR's "Morning Edition" had an incomplete story: "A Good Dentist is Hard to Find in Rural America." By inference, a listener could easily think we dentists could solve the Medicaid/Affordable Care problem by simply opening our doors to those patients. NPR and Pew Charitable Trust lauded the Family Health Center of Marshfield (Wisconsin), for providing much-needed dental and medical care in its 10 locations in Wisconsin. A Pew spokesperson called them "visionary." That was appropriate, but it makes the rest of us look bad for not participating, and they missed the rest of the story.
Federally qualified health centers can provide seemingly low-cost or no-cost dental care by charging an extremely high "per-visit fee," which greatly exceeds the actual procedure fees for most Medicaid dental treatment. For example, when I last participated in Medicaid, I would charge $150 for a simple extraction, and get paid $30, which happens to be 20 percent. FQHCs would also get paid that $30 but additionally receive a per-visit fee of about $345, for a total of $375. A fiscal abuse at some FQHCs has been to focus on the per-visit fee and split up the treatment into more visits, even charging a second per-visit fee if the patient saw two different providers on the same day. Some clinics have had to pay back millions, due to such tactics.
Here's another way to look at the numbers. In my imaginary grocery store, I want to sell bread for $1. It costs me 80 cents to bake, shelve and sell it. Then, the state comes along and wants to buy it for 20 cents. How long can I stay in business, losing 60 cents on each loaf? (Never mind a profit.) Across the street, the FQHC grocer will sell the bread to the state for 20 cents, but with a surcharge of $2.30. (If you want a second loaf, you might need to come back tomorrow.) Thus, the state won't pay me $1 for the bread, but will pay $2.50 to the FQHC grocer. To top it off, we general dentists get bad publicity for not accepting 20 cents.
For many reasons, including fiscal responsibility, I quit all Medicaid as of March 2015, after writing off $100,000 in 2014, and around $1 million in my career.
The general public, NPR, Pew Charitable Trusts and most dentists don't understand this two-tier system of Medicaid reimbursement. Though the Marshfield clinics are doing great work, we general dentists can't try the same without going out of business. NPR and Pew settled for the popular misconception, rather than digging deeper, figuring out the economic realities and telling the complete story.
Stephen L. Kirkpatrick, D.D.S.