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MyView: Don’t call me a churner

October 15, 2012

By Mary Jennings, D.D.S.

One of the unexpected perks I received when I worked for the Indian Health Service was that when I told people that I was an IHS dentist, everyone said "how cool" … and it was! When I moved to Washington state and started telling people that I work for a community health center, I was shocked to find that occasionally someone would sneer disdainfully and call me a churner. I had to ask the hateful person what a churner was.

So let’s start this churning conversation at the beginning. Many, but not all, of the nonprofit clinics in this state—including the four CHCs I have worked for—are federally qualified health centers. That means that the clinics are located in federally-designated, medically-underserved areas. There are strict and extensive program guidelines. The clinics must meet both clinical and financial standards to be able to compete for government grants. The clinics are governed by a board of directors that must be at least 51 percent patient-based. Patients are seen regardless of their ability to pay, and sliding fee scales are provided based on family size and income.

FQHC funding is complex. Some funding is provided by the state. Most of the funding is through Section 330 of the Public Health Services Act grants. They are administered by the Health Resources and Services Administration’s Bureau of Primary Health Care of the Department of Health and Human Services.

There are several types of grants, and no clinic is guaranteed a grant. Grants have time limits and need renewals. Federal reviewers audit clinics to assure that standards are met. FQHCs are larger clinics that draw OSHA and other entities’ attention, so I have always felt FQHCs really excel in providing clean, safe, quality care for our patients.

FQHCs get special Medicaid reimbursement rates called the prospective payment system. The PPS pays FQHCs a per-visit rate for Medicaid patients.

The churning part comes in when someone decides to take a service like sealants and do them in several visits instead of one, thus cheating the system and overcharging for the service.

FQHC detractors argue that this payment system encourages clinics to cheat. Since Medicaid patients comprise only 36 percent of the health center patients nationwide, how prevalent could this possibly be? All procedures and visits are recorded for Medicaid patients. All FQHCs are required to file reports to HRSA. The governing agencies audit. Funding is at stake. I have a hard time believing the system is rife with churners.

Encounter-based funding cuts both ways. For eight years, I provided full-mouth restorative treatment for children under general anesthesia for the same payment we received for an exam. The CHC dentists I know are not paid on an encounter basis and do quadrant dentistry whenever possible. We know many of our patients are not compliant and we may not see them again for a long, long time. We also know that other needy people are clamoring at the door to get in. We are good people doing good work.

But somewhere, some how, someone must be churning because we all know where there is smoke, there is at least a little fire. Churners make me angry because they demean the serious and, yes, noble practice of community health dentistry. Churners have made quite a few more important people than me angry because there is a movement afoot to change these billing practices. Some of these important people are referring to churning as welfare fraud and are insisting on severe penalties for practitioners who churn. I have no issue with this, if it will clean everything up and stop the cheating and sneering. Changing government programs is never easy. There are some huge problems linked to the medical billing system that very well may stymie the issue. But it is still worth trying.

But what really lies beneath this? What makes someone decide to churn? In this economy, I can assure you that money is exquisitely tight in CHCs, and we are worried sick about how we are going to hold the line with less money coming in everyday. Do CHCs have to bark like dogs to get funding? Is churning really a symptom of clinics trying desperately to stay afloat?

In 2009, health centers served more than 3.4 million dental patients with more than 8.4 million visits. Nearly three-fourths of the health center patients are either uninsured (38 percent) or covered by Medicaid (36 percent). Without FQHC/CHCs, our country will look to the private sector to provide these services. It is in the best interest of the dental community for all of us to work together. Do you have problems with the CHC in your town? Then talk to them. Talk to me! Do you churn? Then you better stop. Let’s all just do the right thing and get on with solving the access problem.

Dr. Jennings is the editor of the WSDA News, the publication of the Washington State Dental Association. Her comments, reprinted here with permission, originally appeared in the April 2011 issue of that publication.