SALT LAKE CITY — They weren't letters Kenda Thompson relished sending.
But she sent them anyway, at the end of the month, to every last Medicaid patient at the dental clinic in Sandy where she works, to inform them that the office would no longer be accepting Medicaid.
"Some of them we’ve been seeing for years," Thompson said. "You see all their little faces. It's heartbreaking. If we had another way, we would."
Pediatric dentists across the Wasatch Front say they are dropping Medicaid as a result of changes being made by California-based Premier Access — the main provider of dental benefits for Utah's Medicaid program.
Representatives from Premier Access said they are "confident" the changes will not affect services.
But many local dentists say the changes could result in thousands of pregnant women and children losing their providers and being reshuffled to new ones — if they can find someone who will take them.
“I think we're setting ourselves up for a major access-to-care crisis here in the state of Utah,” said Jason Horgesheimer, a pediatric dentist and president of the Utah Academy of Pediatric Dentistry.
Dentists in Utah have resisted the state’s efforts to privatize the Medicaid program for years. In 2013, the state decided to contract with two out-of-state companies — Premier Access and Delta Dental — to provide dental benefits.
Now Premier Access, the larger of the two, is changing its reimbursement methods: Instead of paying dentists a separate fee for each procedure, known as fee-for-service, Premier Access will pay dentists a lump sum per child per month.
The idea is to force providers to rethink whether patients need expensive tests or treatments that may not do much good. This so-called "capitation" model is becoming increasingly popular among insurers, particularly for medical doctors.
But dentists, who rely on procedure-based work more so than medical doctors, have largely resisted the trend. Many local pediatric dentists say they already struggle to break even on Medicaid patients. They claim capitation would pay them even less.
"All of them are now faced with this dilemma: Do we keep taking care of these families that we've been caring for all these years?” Horgesheimer said. “Or do we just drop (Medicaid) altogether?"
Utah Department of Health officials say the only outcry so far has been from providers, not from patients.
"We have been assured by Premier Access that they do not believe there will be an access-to-care issue," said Kolbi Young, a spokeswoman for the Medicaid program. "Until we're made aware of one, they have the ability to structure (their network) how they see fit."
But Horgesheimer estimates as many as half of the pediatric dentists in the state will drop out of the network.
“Up in Weber County and even Davis County, there’s only one or two pediatric dentists who are even considering the capitation model,” he said.
In an effort to trim its provider network, Premier Access also mailed termination notices to 83 providers in July, according to Young.
One of those letters found its way to Thayne Gardner, a pediatric dentist who recently opened a small clinic in South Jordan to be closer to family. According to Gardner, many of his Medicaid patients came to his practice because they were disappointed by the treatment they had received at larger clinics.
“They have limited options already, and now they’re making it harder for them to find someone,” Gardner said. “I don’t make much, but I’ve taken care of these families.”
Even pediatric dentists with large practices — the ones who have the volume to make Medicaid profitable — say they will no longer accept the insurance. Brett Packham, a pediatric dentist with 2,000 Medicaid patients across three practices, said Premier Access cut him loose after he refused to accept capitation.
“They’ll be reassigned,” Packham said of his Medicaid patients. “The sad part for these families is it’s hard enough to find a provider that will do a really good job for their kiddos and treat them the same as anyone else already.”
Others dropped out before the changes were announced. Michael Tew, a pediatric dentist in West Jordan, said he stopped seeing Medicaid patients a year ago because he saw the "writing on the wall."
The decision makes him feel bad, but Premier Access' proposed rates were too low for the amount of risk capitation presents, Tew said.
“When you have to go in and do two little pediatric crowns and a nerve treatment and suddenly you spent $500 on a bunch of work — tell me where the numbers make sense,” he said. “It just doesn’t make sense.
"I don't care how ethical a person you are,” Tew added. “You will run into an ethical dilemma because you'll say, 'Huh, here's the decay. Do I treat it now, or do I watch it?'”
According to its contract with the state, Premier Access must maintain at least one participating provider for every 600 Medicaid enrollees. According to Young, Premier Access will have 391 dentists covering more than 83,400 enrollees starting in October — a 1 to 213 ratio.
In a written statement, Premier Access said the company is "confident our members will continue to experience the quality service and support they have come to expect under the new dental home model."
A representative declined to answer more questions about the changes.
Dentists who are critical about the changes say they fear Medicaid patients will end up at high-volume clinics where they will get lower-quality care — or that they will forgo dental care entirely.
Jessie Mandle, policy analyst at Voices for Utah Children, said access to dental care is a “huge problem” for low-income children.
In 2010, 17 percent of first-, second- and third-graders screened in Utah had obvious untreated decay, according to the Utah Department of Health. And 13.4 percent of parents reported their child needed dental care during the past year but were unable to get it.
Twenty-two percent said they did not have dental insurance.
The disparities between poor and wealthy Utahns can be stark. In a recent survey from the American Dental Association, 77 percent of low-income Utahns cited cost as the reason they put off a dental visit in the past year, compared with 44 percent of high-income Utahns.
They were also twice as likely to report pain, embarrassment and speaking impediments due to their teeth.
Tew said he's worried that widespread lack of access to dental care will become “an epidemic” down the road.
Left untreated, an infected tooth can become a life-threatening facial infection, said Hans Reinemer, the director of the pediatric dental residency program at Primary Children's Hospital.
The problem is "more common than you think," according to Reinemer, who said residents are called into the emergency room at Primary Children's Hospital two or three times a week to take care of children with untreated dental problems.
That "ends up costing them so much more. It ends up costing the taxpayer so much more for a problem that was 100 percent preventable," he said.
Reinemer also expressed concern that the capitation model will incentivize dentists to provide low-quality treatment.
“Realistically, it’s not enough money to do much more than just basic exams,” he said.
Because he works at a hospital, Reinemer said he’s somewhat cushioned from changes happening to private practices, which allows him to recognize that insurers and providers are trying to do the same thing: make their business model work.
"We hope those two things will align," he said. "But at this point, I just don't know."
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Medicaid members with concerns should contact Tracy Barkley, Constituent Services, at 801-538-6417 or Trevor Smith, Bureau of Managed Health Care, at 801-538-7008, according to the Utah Department of Health.