For Immediate Release
Date: Oct 18th, 2011
Contact: Al Pelphrey, DMD, FAAPD
Managed Care and Dentistry in Kentucky: a Dentist’s Dilemma
The year was 1993. I had completed dental school, Pediatric Dental residency, American Board of Pediatric Dentistry board certification, worked at a couple of places in private Pediatric Dental practices and returned to my home in Eastern Kentucky to make an impact in the dental health of the children of Appalachia. I knew that by returning to my home, that I would be called upon to treat the poor and disadvantaged children of Appalachia, who, with the help of Medicaid, had access to care. I accepted the fact that these children would present significant challenges to my dental restorative and management skills. I also accepted the fact that under current Medicaid guidelines I would only be reimbursed about 55% of my actual fee IF I was lucky. And I was correct in all these assumptions….until now!
Currently the State of Kentucky, under the leadership of Governor Steve Beshear has chosen to embark on a total over-haul of the Medicaid system as we know it, replacing the “fee-for-service” model with the Managed Care model that we have been struggling to understand over the past several months. There are a variety of reasons that brought us to this place. Simply put, there is LESS money from the Federal Government available for funding of Medicaid and due to the economic woes of our country, there are MORE Kentucky residents seeking public assistance. In addition to this, the Governor is required by the Kentucky Constitution to balance the budget. These are all easily understandable issues. However, the pace at which these changes are being forced upon us is untenable.
We have been told that we are to accept Medicaid overhaul, sign contracts with entities that we know nothing about, accept terms of these contracts that we cannot even read…and be happy about it!! Really?? Who runs a business this way? We don’t even buy a car or house without knowing the fine print of the contract. So why expect the dentists across this state to agree to contracts that will affect our livelihoods without knowing the fine print? This was my question when I began my task of trying to understand this whole titanic undertaking. When you read this article, I am in hopes that we (those who have been working tirelessly to understand this situation) have been able to surmount the issues that prevent us from being able to “sign on the dotted line” and that the poorest citizens of Kentucky maintain their access to care and the dentists of the state can continue to participate in what they do best…care for the dental needs of our residents.
The problems that we have encountered during this process have been many. The State was not forthcoming with accurate and timely information. The MCO’s were forced (by the Beshear Administration) to implement a Medicaid take-over in six months when past state take-overs have taken 18-24 months. Dentists were expected to sign contracts without knowing the full impact of our contractual obligation…and the patients were caught in the middle. The dental profession was threatened with an across the board 35% cut in fees if we didn’t “play ball” and the Managed Care Organizations were bound by contractual obligations to “convince” providers to participate. Inaccurate information was rampant. And…we were looking at a State imposed deadline of October 1st 2011.
Fast forward to Friday September 16th, 2011…There was a meeting held in Frankfort with Cabinet Secretary Janie Miller, representatives of the MCO’s (Managed Care Organizations), the KDA and representatives from the KDA local societies. Over all I feel the meeting was productive…tense at times…but productive. Secretary Miller did an excellent job at explaining to us just how we got to where we are currently. The dentists present made it LOUD AND CLEAR that certain terms of the newly released “policy and procedure manuals” of the three MCO’s were NOT ACCEPTABLE. Our primary concerns were the increased pre-authorization requirements, restrictions on services and the significant invasiveness of the policies. All along we were told by the State that “the new MCO contracts etc..could be NO more restrictive than current Medicaid policies”. After reading these policy and procedure manuals, we found out that was NOT the case…and we went to work to deal with these issues.
The major result of the meeting was that a Negotiating Committee was formed to work individually with each of the three MCO’s. We were given the task to negotiate, to the best of our ability, the unacceptable terms of the policy and procedure manuals. The members of that committee and their assignments are:
Al Pelphrey-Pediatric Dentistry/Orthodontics
Beverly Largent-Pediatric Dentistry/Orthodontics
John Gray-Oral Surgery
The first step taken was to request that the KDA Office contact each KDA member via email to inform them of this committee, provide them with the latest copy of the MCO’s respective policy and procedure manuals, solicit their concerns and provide them a way to make their concerns known to the respective member of the committee.
This has been done…You may find a copy of all three MCO Manuals and their respective ADA contract analysises and accompanying cover letters on the KDA website at www.kyda.org. Go to the Professional Portal – you will need your Username (Name) and Password (ADA Number). Click on KDA Business, Minutes, Reports & Other Timely Information.
From this, we will have the information needed to negotiate those issues that were unacceptable to the dentists across the state.
I cannot predict what will have occurred as you read this article in the current publication. But, know that you have a group of highly dedicated lay members of your profession looking out for your interests AND the interests of all of our patients. This group was formed to negotiate the unacceptable terms of the MCO’s policy and procedure manuals. I hope that we will have been successful. I hope that we will have represented our profession with diligence and integrity. And I hope that as a result of our hard work…that we can continue to provide for the dental needs of the poor and disadvantaged people across our Commonwealth!
Dr. Pelphrey received his Doctor of Dental Medicine Degree from the University of Louisville School of Dentistry in 1988. He then completed a two-year Pediatric Dental Residency at the University of Kentucky in 1990.
Dr. Pelphrey achieved Diplomat status with the American Board of Pediatric Dentistry in 1999 and holds the distinction of being the only Board Certified Pediatric Dentist in Pike County, Kentucky.
He is a member of the American Academy of Pediatric Dentistry, American Academy of Pediatrics, American Dental Society, American Society of Sports Dentistry, Kentucky Dental Society, Kentucky Academy of Pediatric Dentistry and serves as the President of the Kentucky Mountain Dental Society.
Dr Pelphrey currently practices in Pikeville KY and can be found online at www.YourChildsSmile.com.