Specialty dental care remains out of reach for many poor Illinois children [Chicago Tribune]

Jan. 04--A smile revealing rows of healthy white teeth spreads across 8-year-old Maria McCarthy's face.

Confident and poised, the Skokie girl smiles easily. But five years ago, when she arrived as a foster child at the home of Michael and Ana McCarthy, her baby teeth were practically rotting out of her mouth.

As one of roughly 1.6 million children in Illinois covered by Medicaid, Maria waited for months, teeth aching, to undergo surgery. She might have waited longer had a pediatric dentist in Buffalo Grove not agreed to waive thousands of dollars in fees to treat her.

"Her teeth were black, and she hardly ever smiled or spoke. She was in pain," said Ana McCarthy, who has since become the adoptive mother to Maria and her two sisters, Sofia and Veronica. "We couldn't find a dentist willing to treat the children. What we were told is, 'You need a surgeon.'"

Many Illinois children who are covered by government-sponsored insurance programs often go without much-needed specialty dental treatment or wait for extended periods because of an ailing Medicaid system.

The biggest issues, advocates say, are Medicaid reimbursement rates in Illinois that are among the lowest in the country for specialized care and administrative hassles that go along with treating low-income patients. Dentists say they can't make ends meet.

"Nobody wants to make a profit on (Medicaid patients), but they have to allow us to pay the bills," said Indru Punwani, head of the pediatric dentistry department at the University of Illinois Medical Center in Chicago, the largest provider to Medicaid-covered children in the state.

Barriers to specialty dental care for low-income children remain a problem almost seven years after a federal judge ruled that the state had violated the rights of several hundred thousand poor children in Cook County.

The class-action lawsuit, filed in 1992, argued that Illinois had violated federal law mandating that children covered by Medicaid have equal access to medical and dental services as those children covered by private insurance.

Forced to take action, the state settled the lawsuit and agreed to increase Medicaid payments for various preventive care procedures, including the amount it pays dentists for cleanings, which went from $25.40 to $41, and the rate for sealants, which jumped from $14.10 to $36.

The changes made a difference: The number of Medicaid-enrolled dentists increased from 1,845 in 2006, the year the increased rates went into effect, to 2,625 in 2011, according to the Illinois Department of Healthcare and Family Services, which administers the Medicaid program. That's out of roughly 8,500 practicing dentists in Illinois.

But specialty care, including more expensive and complicated procedures like the oral surgery Maria needed, remain out of reach for some children covered by Medicaid.

Punwani, who also is executive director of the Illinois Society of Pediatric Dentists, said the fact that almost half of children in the U.S. starting kindergarten suffer from tooth decay is proof that the state has not gone far enough.

According to the Illinois State Dental Society, the average funding rate for the five most frequently performed specialty dental procedures covers 16 percent of the dentist's costs.

Illinois is among the lowest-ranking states for procedures categorized as specialty care, including a one-surface resin -- a type of filling -- and an anterior root canal, for teeth located in the front of the mouth.

The health department does not track how long children who need specialty care have to wait to see a dentist. However, by law, dentists who receive Medicaid payments are required to see patients who are suffering from pain, infection, swelling or traumatic injury within 24 hours.

But because demand greatly exceeds supply, Medicaid patients in Cook County wait an average of three months for a follow-up visit and three weeks for emergency care, according to Bridge to Healthy Smiles. The advocacy organization has been lobbying the Legislature to increase reimbursement rates.

For young children with complex dental problems, options are more limited.

Out of about 240 licensed pediatric dentists in the state, only 83 are enrolled in Medicaid, according to figures from the Department of Healthcare and Family Services and the Illinois State Dental Society.

While general dentists provide the majority of care to children, most lack the training or the equipment and facilities to safely treat infants and very young children or children with special needs, according to advocates.

The shortage of pediatric dentists willing to treat Medicaid patients is of particular concern in low-income communities, which have higher rates of tooth decay and other oral diseases.

Before being placed with the McCarthys, Maria, Sofia and Veronica had been removed from the home of their biological father by the Illinois Department of Children and Family Services and then relinquished to state child protection officials by their mother, who said she could not care for them, according to records.

After several months during which the McCarthys accompanied the children to therapy sessions and doctor visits, the girls slowly started to thrive. But the pain in Maria's mouth persisted.

One of the first dentists to examine Maria's teeth found 23 cavities, her mother said. But the child would wait seven months, until July 2007, to undergo oral surgery at Loyola University Health Systems' Maguire Center.

The wait was especially protracted for Maria because her status as a foster child required the McCarthys to obtain approval from the Illinois Department of Children and Family Services before any of the girls could be treated by a doctor or dentist.

Because almost all of the 45,000 children who are in state custody or have been adopted are covered by public insurance, DCFS struggles with some of the same issues facing families.

"Many pediatric dentists don't accept Medicaid because the reimbursement rates are unsustainable," said Dr. James Mitchell, interim medical director of DCFS and associate professor of pediatrics at the University of Chicago. "When it's below the cost of doing business, it's a problem."

Results of a recent study, commissioned by the state, confirm that dentists in Illinois are often unwilling to accept Medicaid patients.

Posing as parents, researchers from the University of Chicago called 85 dental practices in Illinois to request an appointment for a child with a fractured front tooth.

Of the fictitious children covered by Blue Cross Blue Shield PPO, more than 95 percent got appointments, compared with about 37 percent of the kids with Medicaid. And, even though the state reimburses any dentist for emergency treatment, only 7 percent of the children with public insurance were able to schedule an appointment with a dentist who opts not to participate in Medicaid. After the study, the authors learned that some dentists in Illinois may not have been aware that Medicaid reimburses for emergency treatment regardless of whether the dentist is enrolled.

Using results of the study, the health department and lawyers representing the children in the case are working to improve access without increasing rates.

"HFS is aware that access to care is an issue and it has taken a number of steps, at (a) time when the state has faced an enormous fiscal crisis, to improve access to dental care in recent years," said Mike Claffey, an agency spokesman.

The department has bolstered financial support for some publicly funded clinics that serve low-income patients while working to better coordinate care through the "medical home" program, also established in 2006, he said. The program connects people enrolled in Medicaid to a clinic or doctor's office where treatment and patient referrals are handled.

While officials acknowledge that access to specialty care remains a "concern," the state cannot afford to increase reimbursement rates, Claffey said.

McCarthy said the trials her family has endured to obtain treatment were worth it to give her daughters the best chances for good health and happiness.

"Did you brush your teeth?" said McCarthy to her daughters, on a recent night before herding them to bed. "Let me see those pearly whites."

Tribune reporter Deborah Shelton contributed.

efmeyer@tribune.com

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