No Smiles Here ; Dentists: Shrinking Reimbursements Force Them To Drop Low-Income Patients

Two large Lancaster County dental practices say a major insurer's newly reduced fees are too low for them to continue seeing low- income patients.

The practices, Smilebuilderz and Children's Dental Health Associates, are telling families covered by Pittsburgh-based Gateway Health Plan to switch to higher-paying plans or find another dentist. Finding a dentist that would take Gateway coverage could require traveling as far away as Philadelphia, the dentists say.

Thousands of patients will be affected, including Lillybeth Samsel of Lebanon. She is disappointed a Smilebuilderz oral surgeon won't be available to pull her 15-year-old son's impacted wisdom teeth.

Samsel said finding care in Philadelphia poses a major inconvenience and switching insurance plans is not a reasonable option because it may require changing her family doctor and other medical specialists.

Cost containment

Gateway Health, a managed care plan for the state's Medical Assistance program for the poor and disabled, informed dental practices last month it would reduce reimbursement to providers July 1 because of the state's "increased pressure for cost containment."

Comment from the state Department of Human Services was not immediately available Monday.

Few dentists in Lancaster County and across Pennsylvania see Medical Assistance patients because of low reimbursement rates and other reasons.

"What it comes down to is these people are not going to have access to care," said Christi Binder, Smilebuilderz's director of talent management. "There aren't going to be people saying, 'I'll see these patients for free.' "

In 2014, Smilebuilderz, which has three offices in Lancaster County, provided 72,796 procedures to 6,451 Gateway Health patients.

Dr. Eric Felix of Children's Dental Health Associates, with an office in Manheim Township and 12 other communities between Philadelphia and York, said he is terminating care for Gateway patients because he can't meet increasing costs if reimbursement shrinks.

"I can't provide services if I'm going bankrupt," Felix said. "It's as simple as that."

Cheri Brubaker, Smilebuilderz's operations director, said Gateway patients often need significant dental work, and the fee reductions "make it impossible for providers to care for these patients."

As an example, Smilebuilderz said, reimbursement for pre- orthodontic treatment falls from $466 to $35. Reimbursement for a surgical extraction falls from $117 to $65. And reimbursement for a root canal falls from $597 to $275.

Smilebuilderz said its revenue for 18 kinds of procedures would decline by $1.3 million annually.

'Responsible stewards'

Gateway Health spokeswoman Paula Yurkovich said in an email to LNP that the health plan seeks to ensure access to comprehensive dental care, "yet we also need to be responsible stewards of the Commonwealth's dollars."

Yurkovich said rates were adjusted to be consistent with the government's fee schedule.

"We have discussions planned with Smilebuilderz and are hopeful that we can reach a solution that is acceptable to all parties," Yurkovich said.

Christi Binder, Smilebuilderz's director of talent management, said the practice is asking a Gateway Health vice president to reconsider.

Smilebuilderz doesn't make a profit caring for Gateway patients, Brubaker said, but has accepted them "because we care."

"Now they're cutting their fees for specialists to the point that we won't be able to provide the care that we want to provide," she said. "We would have to change our level of care, which we're not willing to do."

Binder said Smilebuilderz continues to accept Medical Assistance- paid plans provided by Amerihealth Caritas, United Healthcare Community Plan, and University of Pittsburgh Medical Center.

Shone Busha of Airville, York County, a Gateway member for almost 10 years, said having to travel to Philadelphia for dental care "is certainly not acceptable."

"I actually have enjoyed Smilebuilderz," Busha said, "and now I'm going to have to switch to another (insurance) carrier or possibly find somebody else."