Everyone remembers the Frew case back in 2004 when the Supreme Court forced Texas to provide basic healthcare services including dental care for Medicaid-eligible children.
Reason for fee increase in 2007
For those that don't remember, let's recap. Linda Frew, on behalf of her daughter, and with others filed a class action lawsuit against the state in 1993 because it was not providing federally mandated Early and Periodic Screening, Diagnosis and Treatment for underprivileged children. There was a settlement agreement brokered by a federal court in 1996 but the state refused to have their compliance with the agreement or lack thereof monitored by the court. That fight ultimately went to the Supreme Court which threw out the state's arguments in 2004.
As a result of the Court's decision, Texas found itself having to increase fees for basic dental services to attract more dentists to service the more than 1.5 million Medicaid eligible children at that time.
Dental rates had been so low that few dentists serviced this community. The increase served its purpose and many more dentists joined the program. These rate increases came into effect in September of 2007 as part of the Frew Expenditure Plan. Those 2007 rate increases are shown in the PDF to the right.
Fees decrease by 2% since 2007
As we fast forward to today, some 15 years later, what do we find? Unsurprisingly perhaps we discover that these 2007 fees have been decreased by on average 2% for those basic dental services.
Yet provider expenses have increased by 36% since 2007, the inflation rate from 2007 to 2022 before this current inflationary spiral. Providers have a knife to their throats. Expenses are going up, up, up but rates decrease. Something has to give.
It reminds one of the story about how you boil a frog. If you throw the frog into a pot of boiling water, he will jump out. But if you put the frog in the pot with temperate water and slowly increase the heat, you boil that frog real nice.
2007 Rate Increase from the Frew Expenditure Plan
Financial pressure on providers
Fortunately or unfortunately, many dental practices in Texas are now dedicated to servicing the Medicaid-eligible community as difficult as that sometimes is. They are in the pot of slowly heating water that is nearing boiling as far as fees are concerned, not to mention onerous restrictions such as the three-year rule and the problems with the Texas Medicaid Fraud Prevention Act.
We understand that the Medicaid-eligible population has grown to some 3.9 million underprivileged children which puts pressure on the state's healthcare budget. So it is understandable that the state would want to keep dental rates as low as possible.
But a fee schedule that is 2% lower than 2007? It's worse than that.
HHS graciously directed us to the Texas Medicaid dental fee schedule shown below and is available on the TMHP website.
Think getting lower 2007 fees are bad? There are fees that originated in 1992 that have gone down!
Can providers survive?
Is this fair to providers who service this community because of need not just money? We don't think so.
How can providers survive when their expenses are climbing but fees are stagnant? Providers are coming to the boiling point on fees.
Trying to survive on a fee schedule lower than it was 15 years ago or longer is unfairly asking a lot of any healthcare professional.
Fee schedule review needed
The first step that could be taken is a review of the fee schedule by HHS. As shown in the PDF below, dental rates have not been reviewed by the agency since October 2017. That's almost five years ago.
The executive commissioner of HHS, who presides over these reviews we are told, could start a dialogue with the dental provider community on the fee schedule.
It would be an excellent starting place for Texas Medicaid dentists and bode well for future cooperation.
Heaven forbid the matter should go back to the Supreme Court.
Since 2015 I have had the opportunity to serve patients with Texas Medicaid. There have been many changes since that time and none appear to be in the interest of the patient or provider. Costs have been skyrocketing, especially in the last two years. The three year rule places a significant burden on treating dentists. Three years is a very long time to essentially be required to ‘warranty’ a restoration for a patient that may not adhere to any guidance involving diet and home care. Supply chain and runaway inflation issues are driving up costs of nearly every piece of equipment, material, and disposable required to properly treat patients. Inflation and rising gas costs are being felt by staff and new hires. This has lead to rapidly increasing pay rates to retain or hire new staff. Soon, it may be necessary to reduce staff as wages and costs of doing Medicaid dentistry continue to increase while putting increased burden on the provider without even reviewing the current fee schedules.
I am a texas dentist and have been largely serving the Medicaid population for many years. Every year our overhead has been increasing substantially and more recently, with runaway inflation, its really getting out of control. It is reaching an inflection point in which it is becoming financial infeasible to keep treating the Medicaid population. On top of the low reimbursement, there are also additional hurdles such as the ridiculous 3yr rule which makes it near impossible to properly treat this underserved population. Please consider increasing fees, at a minimum, back to the 2007 levels, to allow providers to continue care without unnecessary financial strain. Thank you!
I started practicing dentistry in Texas in 2012 and provided care to the Medicaid community. Each year I’ve seen the increases in prices and overhead while there has been decreases in fees. Covid-19 had even a greater impact on the supply price increases. Now we are facing some of the worst inflation numbers in years and are expected to survive with the current fees. I personally have had to reduce my staff size. It’s a privilege to serve the underserved Medicaid community but without some help, it will be difficult to continue. What is happening will actually hurt the patients that need the care.
This is disturbing to see the actual numbers. Unfortunately, these nonstop decreases in fees will only hurt the patient and also create an environment where many dentists are put in terrible situations in having to see more and more patients just to stay afloat. Nothing good can come of that. Regulate all you want, but pay fair and reasonable fees. I have been a Medicaid provider for 15 years and every single year they have reduced them. I just don’t see how I can continue if this trend doesn’t end.
I have been a Medicaid provider in Texas since 2014 and it honestly has been disheartening to try to provide the same level of care this patient population deserves with these decreasing fees. I have had to decrease my staff numbers and cut back on supply orders due to increasing costs of wages and materials which greatly limits how many patients can be treated. I feel like my hands are tied and at this point I am not sure how much longer I can stay on as a Medicaid provider. Please consider increasing fees so that we can continue to provide care to these deserving patients.
I remember years ago in dental school I attended a lecture on supervised neglect. My professor repeatedly reminded us of our oath to do no harm. The three year rule is the ultimate definition of supervised neglect. These dangerous and unethical rules keep hard working doctors from providing patients with the care they need and deserve. This coupled with skyrocketing costs will soon prohibit an entire demographic of children from receiving basic dental care.
I have been providing dental care to largely medicaid population here in Texas for a number of years now. And unfortunately as this article states, I have only seen the fees decrease over time. With inflation rising; office leases soaring; supply shortages and bottlenecks (esp last couple years due to covid), and thus increased pricing; staffing shortages, and then directly/indirectly increased staff wages… I am very concerned about how much longer I can remain a medicaid provider–I am seriously needing to consider switching to only private insurance and/or fee-for-service. How am I and other dentists supposed to practically and realistically keep on providing good, continuous care for an already underserved population? If Medicaid fees continue to decrease, we will soon have a major crisis on our hands: fewer and fewer dentists being able and willing to logistically care for a large portion of our population that need our help and services; and medicaid children suffering the negative impact of this through no direct fault of their own.