For those on Medicaid, it can be a struggle to find dental care in the Twin Ports
Zymrie Bekteshi is doing the best she can in the world. She's a single mother raising a boy and girl, both under the age of 10. She sews for a local company serving the aviation industry. Her employer lets her work from home.
"Work from home is good," she said. "I have nobody to help me, no family if kids get sick. So they give me a machine to work with in my home."
Even with the job she's held for 11 years, she described herself as "low-income." Not long ago, Bekteshi, of Duluth, experienced one of the risks concomitant with living near the poverty line: trouble finding a dentist for her kids.
Bekteshi's kids lost their private practice dentist when she lost the health insurance she was buying through the state after her particular insurer couldn't agree on a contract with Minnesota in 2016. Bekteshi turned to Medicaid, the state and federally funded program which serves low-income families.
"Everything changed," she said.
Of dentists and Medicaid, she found, "They don't like it; they don't accept it."
A News Tribune examination of the dental industry in the Twin Ports found some truth to Bekteshi's claim. Local dentists don't seem to like Medicaid, as sources say there are only a handful of private practices among the dozens locally that accept it as a form of payment. In Wisconsin, only 37 percent of surveyed dental association members said they accept Medicaid. A 2014 American Dental Association study put the number at 69 percent in Minnesota compared to 42 percent nationwide. But the state figure would appear to be an exaggeration if only applied locally.
Local dentists and the state dental associations explained there is a valid reason for the aversion to Medicaid, namely some of the lowest reimbursement rates in the country. In Wisconsin, Medicaid reimburses 32.1 percent on every dollar charged, according to figures from the American Dental Association; in Minnesota, it's 31.1 percent.
Because of the low return rates, dentists in the Twin Ports often don't enroll to accept Medicaid as a payment. The ones that do are mostly clinic-style providers set up with multiple dentists and a lineup of chairs so they can cost shift and spread their financial risk across many patients in the way medical doctors do.
For traditional dental offices — solo practitioners operating a small business — the return from Medicaid is so low in Minnesota and Wisconsin that it doesn't pay for them to offer their services to everyone in their communities, even children.
"The answer to this is money," said Dr. Jon Nelson, a Superior dentist. "Everyone wants to seem to dance around that and find different solutions to it."
'A child can't decide'
When it comes to a person's dental care, a universal rule of two applies: brush at least twice a day and visit the dentist twice a year.
But for children who are underprivileged in the Twin Ports, a complimentary toothbrush and the polite reinforcement from a hygienist to brush their teeth isn't a sure thing. For some, routine trips to see the dentist don't happen at all.
Evidence from state dental associations, legislatures and health departments shows that children whose families are on free or low-cost health coverage can have a difficult time seeing a dentist. They're discouraged because of trouble they have finding private practice dentists enrolled to take payments from publically funded insurance programs, most prominently Medicaid.
In Minnesota in 2015, only 41 percent of all Medicaid-enrolled children ages 1-20 received any dental service, according to a Centers for Medicare and Medicaid Services letter sent last year to the state's Department of Health and Human Services.
In the Twin Ports, there is some confusion about exactly how many children face barriers to routine dental care. But related statistics and stories from the front lines tell of hundreds of children locally who experience life along a fine line between having dental care and none at all.
The Lake Superior Community Health Center took in 2,264 dental patients 19 or younger between its Duluth and Superior locations in 2017. Of those, 1,750 belonged to Medicaid-paying families.
"Many of those are kids who might have gone without dental care if we weren't here to serve," said CEO Dayle Patterson.
The confluence of few providers to serve what is a growing roster of Medicaid-enrolled children has created what is described within the industry and state health departments as an "access to care" issue. Children who are underprivileged bottleneck into only a few dental health providers. When it comes to routine care, they can be made to endure months-long waiting lists. Or their families can pay cash to see dentists who aren't enrolled to accept Medicaid. Missing an appointment to a private dentist comes with opportunity costs for families experiencing poverty, sources said, because for them a no-show under any circumstances usually means there's no welcome back.
"A child can't decide if they go to the dentist or not," said health manager Jackie Majerle of Family Forum, which operates Head Start programs throughout Northwestern Wisconsin. "If they don't have the means to get there, that's grownups. That's not fair. A poor adult choice is filtering down to a child who ultimately is the person suffering the consequences."
The Family Forum Head Start Program serves families with the lowest incomes first. In Superior, it used to shuttle 200 kids twice a year to receive basic preventative dental services at the Lake Superior Community Health Center. The health center now saves them the trip by coming to Head Start twice a year. On its visits, the health center's staff of dentists and associates can seal children's most at-risk permanent teeth to protect them from decay, as well as do things such as examine and clean teeth and make referrals for corrective care.
For some children it can be their only interaction with dentistry. But it's also not ideal. Majerle said she's seen it where a child was diagnosed with an abscessed tooth and their family given a referral for corrective care, only to have the same child's abscess reviewed again the next time the health center came to Head Start. Other children have been referred to places 100 miles away or more, such as Wausau or Eau Claire, Majerle said, in an effort to find open appointments. Options in the Twin Ports are limited, said sources, including dentists themselves.
"There is a problem with access to care — it is real and I can honestly tell you we are working on it tirelessly," said Nelson, the ranking member of the local branch of the Wisconsin Dental Association and a longtime practitioner in south Superior, where his office shares a building with a laundromat.
Nelson is like most of his peers locally in that he does not accept Medicaid. His shop is what a person thinks of as a traditional dental office — a small business owned by a solo practicing dentist and staffed by a small team of experts. It's a model currently not well-equipped to handle some of the Minnesota and Wisconsin children in poverty. According to the American Dental Association, most states return 45 cents or more on the dollar submitted to Medicaid, while some go up to 75 or 80 and have dentists clamoring to take on new families on Medicaid, sources said.
But the low reimbursement rates set by the Minnesota and Wisconsin legislatures are in conflict with the costs of operating a small business, Nelson explained. Solo practitioners use between 60-65 cents on every dollar made to operate their small business. That's paying rent, taxes, employees, laboratories, light bills, supplies and more. For some, expenses include paying down up to a quarter million dollars in student debt recent generations of dentists can now accrue on their way into the career. Low reimbursement rates become the financial impediment which prevents community dentists from being able to see all of the different children in their neighborhoods, Nelson said.
"There are ethical concerns," Nelson said of the access to care issue. "But there are business concerns, too. You can't see anybody if you can't keep the doors open."
A working model
Locally, it's clinic-style dental offices that are equipped to field children in poverty. Shops such as the Lake Superior Community Health Center and the private practice Eversmiles Pediatric Dentistry in Duluth serve high volumes of children from families with low incomes.
Eversmiles' Dr. Mark Bruzek spoke with the News Tribune about access to care. Bruzek specializes in pediatric dentistry and is in a partnership with another dentist. Bruzek described serving children with difficult dental situations and advanced diseases which can be exacerbated by prolonged undertreatment.
"My training was I serve the hardest children to treat," he said.
Going back to the start of his career in 1985, he used to see 12 percent of his patients on Medicaid. After 23 years in Wausau and now the last nine in Duluth, he said that number of patients has increased to more than 50 percent.
"We're seeing more and more children on government-funded insurance programs," he said. "It's getting worse not better, and I think we'll see (the trend) continue."
As currently situated, Bruzek believes the Twin Ports is serving children as well as could be expected within a 60-mile radius. Waiting lists for routine care are part of the deal, he said.
"But if I have a child with a facial infection, swollen neck or something like that," he said, "I'll get them in tomorrow."
Patterson, the CEO at the Lake Superior Community Health Center, said 81 percent of its more than 7,000 annual dental patients can be described as households which come in under 200 percent of the federal poverty guidelines — meaning a family of four bringing in $48,600 a year or less.
Federally qualified health centers such as Lake Superior Community Health Center were created as part of the 1960s war on poverty to address care gaps in rural communities. FQHCs are required to accept all patients regardless of ability to pay. Folks at 200 percent of the poverty level or below pay on a sliding scale.
"We provide quality care and cost-effective care," Patterson said.
The health center is where Bekteshi ended up taking her children for dental care.
"They take good care of us," she said. "When they said, 'We accept Medicaid here,' I made check-up appointments."
Nelson and sources from the dental associations in Minnesota and Wisconsin say there are remedies in the works to address the access to care issue.
The Minnesota health department wrote a legislative report in 2015 calling for a 15 percent increase in reimbursement rates, saying current rates are based on dental fees which are 20 years old. Wisconsin is studying a pilot program by increasing Medicaid rates in four counties. The state also legally expanded the functions of hygienists and licensed dental assistants so that dental offices can absorb a higher volume of patients.
"My members want to see Medicaid patients," said Mark Rossetto, the director of government services for the Wisconsin Dental Association. "It's not that they even want to make money on them, but they need to cover their overhead."
Many dentists give back by working pro bono in their own offices and at auditorium-style events designed to bring in large volumes of people who are poor and undertreated. A two-day Mission of Mercy event in 2015 at the Duluth Entertainment Convention Center served more than 1,100 patients free of charge — services valued at $1 million, according to the event sponsors, which included the Minnesota Dental Association.
Commercially, the industry is shifting toward a solution with the rise of direct service organizations. They're dental operations that break from the traditional model for the way an owner, who may or may not be a dentist, operates multiple practices in a group-based fashion, Nelson said.
But at a time when the social safety net is being re-examined in Washington, D.C., it's hard for anyone to be confident reimbursements rates will be increased dramatically or that attention will be paid given how other issues can be viewed as higher priority.
"Out of a total medical/dental yearly budget, at least for Wisconsin," Nelson said, "98 percent goes to medical and 2 percent goes to dental."
For many years, Nelson said, he accepted Medicaid at his practice. He's considering doing so again. His exposure to the access to care issue from his trustee position in the state dental association weighs on him.
"When you're off on your own, you're in your own little world and you make your own decisions," he said. "I may be changing my decision. I'm older now. Things are getting paid for. Even though I have given back in many ways internally within our practice, it may be time for me to look at that a little closer."