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Covering Medicaid’s orthodontic benefits Date: 08/19/14

By Mary Otto

Sheila Hagar

After a hint from her own dentist, Sheila Hagar started looking into concerns about the rising numbers of Medicaid kids getting braces in Washington. Hagar, who is medical and social services reporter for the Union-Bulletin, in Walla Walla, sought sources and found statistics that made her jaw drop.

“We should be taking care of people who really have a need,” a frustrated Walla Walla orthodontist, Thomas Utt, D.D.S., told her. “While his office – Walla Walla Orthodontics – is authorized to treat Medicaid-eligible children with braces,” Hagar wrote, “Utt grits his teeth at what he sees as misuse of funds and a lack of clarity over just what ‘medically necessary’ means when it comes to correcting kids’ teeth.”

Here, Hagar tells us more about how she tackled the reporting that led to her July 5 package “State Foots Skyrocketing $27 Million Bill for Braces” and what she is learning about orthodontic benefits under Medicaid. She also shares some wisdom on what to do when no one is returning your calls on an uncomfortable subject.

Q: You found that in 2007, Washington spent $884,000 getting braces on the teeth of 1,240 Medicaid kids in Washington State. In 2013, nearly $27 million went to orthodontists for “medically necessary” care for 21,369 youths covered by the program. People you spoke with suggested a variety of reasons for the uptick: increased Medicaid reimbursement rates; growing numbers of eligible young people; dentists “coaching” parents to ask for braces for their children. Utt said parents were clamoring to get them for their kids just because they were “free.” Were you able to get a clearer idea of what factors might be driving the increase?

A: Utt has continued to work on this issue, including the meeting with health care officials mentioned in the article. According to a conversation I had with him on Aug. 5, Utt said he sees the increase as a mix of fear among state officials of violating federal Medicaid rules and a misunderstanding among parents who believe braces are automatic, like vaccinations and dental sealants. They've heard it from their friends and other family members. And word is getting out in general, he said. Utt said in a lot of ways, the state's hands are tied by those federal regulations. But the state appears to be doing its own marketing by encouraging providers to tell families the ACA has changed Medicaid boundaries, he added.

Q: You noted in your story that the term “medically necessary” as it applies to orthodontic work can be “a moving and subjective target.” Can you tell us a little more about how the state determines which Medicaid children need braces? Are there factors besides very severe and obvious conditions that might make braces advisable?

A: There are components such as measuring overbite and underbite to determine chewing problems, but orthodontists are not likely all using the same measuring tool, for example. When an orthodontist sends in the 50-page patient application and required photos for Medicaid, it is subjected to a 10-minute (approximately) review. That reviewer has final say, unless a decision is appealed. Then a health law judge decides, effectively practicing unlicensed dentistry, Utt feels. While the state says only severe and obvious conditions are granted free braces, that is not the case. Utt was able to send me non-identifying pictures of patients applying for the orthodontic work who clearly did not have obvious need but got braces anyway.

Q: You mentioned that the reimbursement rates for braces had been increased in an effort to get more providers to accept Medicaid children. Were reimbursement rates for other kinds of dental care increased too? Are kids getting more of other types of dental care as well?

A: I don't have the answer to this by data, but anecdotally a pediatrician told me that until a few years ago, Medicaid kids in this state could not get into any dentist here. Now we have at least one dental clinic with a pediatric focus that accepts Medicaid. That waiting room is always packed (my own kids go there). We also have a nonprofit dental clinic, however its waiting list is typically months out.

Q: You reported that a task force is looking at the criteria being used to determine which kids get braces. How do you expect that to unfold? Does Washington have different standards than other states?

A: I expect the spotlight on the issue to put some heat on lawmakers, and the task force findings will be better heard and addressed. Every state seems to interpret federal rules a little differently. Oregon, for example, has a more rigid review system and grants far fewer Medicaid-paid braces, I was told by orthodontists. Washington state has a history of being progressive on health care.

Q: What got you started on this story?

A: I was contacted by my own dentist initially. She does not accept Medicaid, but told me she had a friend who was pretty outraged about this situation and wanted to know if I was interested. Eventually Utt and I spoke and I found myself thinking he couldn't be right about the scope of the issue. While Utt did not have everything right, much of what he claimed was indeed backed up by data.

Q: Do you plan a follow-up piece soon?

A: When Utt met with state officials on July 25, he had several suggestions. He was assured some changes were on board, such as reducing the reimbursement rate for braces However, that will likely lead to unintended consequences, such as lowering the number of orthodontists willing to treat these children, Utt pointed out. When changes are formalized, I will do a follow-up. I plan to stay up on the matter and continue to report Medicaid orthodontic care policy.

Q: Have you found sources of data that have been particularly useful to you?

A: The state provided everything I requested with no arm-twisting necessary. I attribute that to a long relationship with Apple Health's (Washington's Medicaid program) spokesman. He knows from working with me that balance is important to me and I will come back as often as I need to for clarification. Also that I am not going away. I noodled around for information about craniofacial birth defects, including begging for search help from pediatricians coast to coast. As you can see from one of my sidebars, I looked at news stories from Texas, where this issue blew things up in a big way. I read articles providers recommended and talked to other orthodontists.

Q: Any advice for other reporters who might want to take a look at this topic in their states?

A: The first thing I would caution is to go slowly. I found dentists here so afraid of losing Medicaid authorization, they would not even return calls to say they couldn't participate. Fear of retribution was palpable. Washington can't be the only state with that problem. Talk to dentists and orthodontists — and those professional associations — on background to learn whatever you can and ask them to tell colleagues what you are working on. Ask them for copies of any correspondence they've had with state officials on the matter. Ask about issues the reader might not know. For example — I didn't even realize kids on Medicaid could get braces, period. I had old data in my head.

I wish I had been able to include the voice of a family, but it became a hurdle I could not jump. That would be less of a problem in a larger metropolitan area, I'm sure. The most logical first step to see if there is indeed a story is to request numbers from a state's Medicaid program. I asked for dollar amounts and patient numbers for the two applicable counties for the past five years. That chart alone was enough to make my jaw drop.

Sheila Hagar is a medical and social servces reporter at the Walla Walla Union-Bulletin in Washington. She has freelanced for newspapers and magazines, joining the Union-Bulletin staff full-time in 2004.