http://www.journalgazette.net/article/20090802/LOCAL10/308029918
Not everyone’s smiling
Medicaid dental clinic defends itself against critics
Dan Stockman
The Journal Gazette
Kool Smiles patients
Indianapolis 2…7,195
Indianapolis 1…6,949
Fort Wayne…6,013
Evansville…5,733
Highland…2,890
Terre Haute…2,055
Medicaid reimbursements
Indianapolis 2…$2.7 million
Indianapolis 1…$2.5 million
Fort Wayne…$2.4 million
Evansville…$1.7 million
Highland…$1.1 million
Terre Haute…$746,000
Indiana…$11.1 million
Percentages
•Medicaid and CHIP patients treated by Kool Smiles: 7.8 percent
•Medicaid and CHIP claims filed by Kool Smiles: 6.6 percent
•Medicaid and CHIP reimbursements paid to Kool Smiles: 6.8 percent
Deanna Vasquez said she realized something was wrong when she found herself helping a dental assistant hold down her 4-year-old son’s arms and legs as he writhed and screamed.
“You’re basically brushing his teeth,” she said. “I thought, ‘I could do this at home without holding him down.’ ”
But it wasn’t just her son’s screams that left her queasy, she said. It was also the screams of other children – from behind the closed doors of other rooms at Kool Smiles dental clinic, 1852 Bluffton Road.
“Kids were screaming their heads off,” Vasquez said.
She saw one girl emerge. She was 8 or 9 years old, Vasquez said, and had obviously been sobbing. Her parent was in the lobby.
Five sets of parents told The Journal Gazette that Kool Smiles does not allow parents to be with their children during cleanings or procedures. Vasquez’s presence with her son was allowed, she said, only because she insisted she could help calm him down and that they would leave otherwise.
Kool Smiles denies barring parents from its procedure rooms and says its staff acted appropriately.
The national chain of 84 clinics has been accused of overtreating its patients, of prohibiting parents from procedure rooms and of being too quick to restrain the children it treats. Kool Smiles denies any wrongdoing.
Vasquez worries she did the wrong thing in helping Kool Smiles restrain her son – something she now regrets.
Crystal Allen understands.
She had taken her children to the dentist every six months, she said, until financial problems made it impossible. A year after their last appointment, her daughter had a toothache, and Kool Smiles in Fort Wayne was the only practice she could find to see her immediately.
“They made me feel about this tall when they told me how badly I had neglected their teeth,” Allen said. “I left there thinking I didn’t deserve to have kids if I couldn’t take care of them.”
Then came the hard sell, she said.
Kool Smiles said her daughter, 10, needed stainless-steel caps put on four of her baby teeth, and her son, 5, needed six stainless-steel caps. Immediately.
“They were like, ‘This is so important, you need to get it done now. We can make time today; you don’t know when these other teeth are going to go,’ ” Allen said. “I was like, ‘You’re kidding.’ And he was like, ‘No, she’s here, she needs to get it done.’ ”
Then Allen looked around the waiting room.
“There were two kids there, and every tooth in their mouth was stainless-steel caps, including their front teeth,” she said. “Top, bottom, front and back.”
Kool Smiles specializes in treating children on Medicaid, a federal health insurance program for the poor run by individual states.
That means taxpayers cover the cost of most of the care provided.
Kool Smiles, based in Atlanta, lost its authorization to do Medicaid work in its home state two years ago because of allegations it was overtreating its child patients and questions about its practice of strapping children down.
According to WellCare Health Plans, the company that handles Georgia’s Medicaid program, Kool Smiles dentists were performing 17 percent more procedures per patient than other dentists.
When compared with patients of other dentists, WellCare said, a child treated by Kool Smiles was:
•Five times more likely to receive crowns.
•Four times more likely to receive five or more crowns.
•Forty percent more likely to have their teeth pulled or extracted.
•Three times more likely to be physically restrained during dental procedures.
While Kool Smiles patients were about 5 percent of WellCare’s dental clients in Georgia, those patients accounted for about 20 percent of the Medicaid money spent on dental care in the state, WellCare claimed.
Dr. David Strange, chief dental officer for Kool Smiles and the company’s national spokesman, said the company has been cleared of all allegations. Doral Dental covers dental work for WellCare.
“We have letters from Doral, the third-party provider in Georgia, really, that we’re quite proud of, stating that they did not have any clinical issues with the charts that had been reviewed,” Strange said.
“We received numerous letters, numerous accounts from Doral stating that they don’t have issues and don’t have concerns with the care provided by Kool Smiles associate dentists.”
But the letters Kool Smiles provided as proof it had been cleared do not refer to the allegations made by WellCare. The letters, written in January, refer only to specific Kool Smiles locations and say they are in response to audits requested by WellCare in September and October 2008.
The allegations that led to Kool Smiles’ contract with WellCare being dropped were made more than a year before, and the audit was being conducted by the Georgia Department of Community Health’s Inspector General.
That audit, according to Georgia Department of Community Health officials, found Kool Smiles had performed a “large number” of tooth restorations on children without anesthesia; excessive treatments during the same visit without some type of sedation; large amounts of local anesthesia given to patients below the proper weight; and one treatment in a Kool Smiles clinic that should have been performed in a hospital. Kool Smiles settled the charges with the state in January 2008 for $193,508.
A follow-up statement from Kool Smiles says its contracts were dropped “without cause” and that the allegations made by WellCare were unfounded. Georgia officials said Kool Smiles as a group is still a Medicaid provider, but the 18 locations involved in the investigation are not.
Kool Smiles was started in 2002 by Dr. Tu Tran and Dr. Thien Pham. Today, the chain of clinics is run by NCDR, a limited-liability corporation formed in Delaware, headquartered in Atlanta and owned by the San Francisco investment firm Friedman Fleischer & Lowe, state records show.
Most states require dental offices to be owned by dentists. Tran and Pham own Kool Smiles – and incorporate a new Kool Smiles company in each state where clinics are located. The clinics are then run by NCDR or DPMS Inc., also owned by Friedman Fleischer & Lowe.
According to Indiana Secretary of State records, NCDR should not be operating in the Hoosier State: It has not paid its annual business license fee in two years, and in February, the secretary of state revoked the company’s authorization to do business here. State law provides for a $10,000 fine for operating without authorization.
Strange said he was unaware NCDR cannot legally do business in the state and would look into the situation. The company later said it appeared to be a paperwork problem that would be resolved.
The corporate structure means Tran is listed as the lead dentist on each of the dozens of Kool Smiles clinics across the country, though he does not practice at any location. Pham is in the process of retiring from the corporation, Strange said.
Kool Smiles’ 84 clinics span the nation, and so do the allegations against the company, especially from parents who say their children were given – at taxpayer expense – dental work they didn’t need (See related story).
Strange said allegations of over-treatment by Kool Smiles are unwarranted, and he says its patients are often children who are not receiving regular dental care and have severe tooth decay.
“I get asked all the time, does my child really need a crown? And the answer to that is very, very often a resounding yes,” Strange said.
“A stainless-steel crown that’s placed on a tooth that’s severely decayed, that has inter-proximal caries (cavities between teeth), on a child that’s at high risk for additional dental (cavities), a stainless-steel crown is oftentimes the most effective, most reliable and most well-suited dental treatment that can be provided.”
Dr. Bradley R. Smith, a Colorado dentist and a spokesman for the American Academy of Pediatric Dentistry, said it is difficult if not impossible to make blanket statements about placing crowns as opposed to fillings on teeth, even on baby teeth that will fall out within a few years.
“If the patient has never been to a dentist and I have very little confidence I’m ever going to see that patient again, I’m much more likely to do a crown because I know it’s more resistant to decay in the future,” Smith said. “That’s a reasonable decision the doctor has to make for each individual patient.”
Smith said it comes down to informed consent: Do the parents understand all the options and the implications of each one?
If not, “then that’s not a good thing,” Smith said.
Strange said the patients Kool Smiles sees might never have been to a dentist and might never return, so it makes sense they would do more crowns.
“We’re seeing children for the first time at age 4, 5 and 6. They have extensive needs without a dental home. … We’re seeing children where the effects are really quite devastating throughout the entire oral cavity,” Strange said. “Crowns are very much a part of routine children’s pediatric dental care.”
Noah Fedele-Woodley, 4, went to the procedure room alone at Kool Smiles’ location in Newport News, Va., because his mother and grandmother were not allowed to accompany him, said his grandmother, Carol Fedele.
“They brought him out screaming. He was soaking wet,” Fedele said. “He was literally saturated from head to toe from crying and sweating. … Once his mother was holding him, he collapsed. He passed out in her arms.”
Burst blood vessels were found on Noah’s face and neck, known as petechial hemorrhaging clusters, which can be caused by trauma to the skin or stresses such as intense vomiting.
“(The dentist) said it happens all the time; they get it from crying,” Fedele said. “He said, ‘They all do that; they just showed up on him because he’s light-skinned.’ ”
Noah’s Kool Smiles records from that visit show the boy was restrained for 25 minutes. Noah’s mother had signed a consent form six months before, in July 2008, but had no idea she was giving permission for Noah to be strapped down, she said. The form is labeled “Pediatric Dental Patient Guidance Techniques.”
Noah also had bruises on his cheeks, Carol Fedele said, as if his mouth had been squeezed open.
Kool Smiles employees reviewed Noah’s records “and continue to believe we provided medically necessary dental treatment,” the organization said in a written response. “Kool Smiles adheres to the treatment policies and guidelines of the American Academy of Pediatric Dentistry and the American Dental Association.”
The American Academy of Pediatric Dentists’ guidelines say restraints should be used only as a last resort and are meant only for medically necessary treatment.
“The use of protective stabilization has the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, and violation of a patient’s rights,” the guidelines warn.
Strange did not deny that Kool Smiles patients are three times more likely to be restrained but said it was “an apples-to-oranges comparison” because Kool Smiles sees only children.
“We see a patient population that is, generally speaking, younger than the other dentists’ in the community,” Strange said. “It’s kind of like saying a preschool compared to grade school uses more crayons and that using more crayons is somehow inappropriate.”
So younger patients are going to require more restraints?
“Younger patients require different types of treatment. Protective stabilization happens to be that type of treatment,” Strange said.
Strange said that with parental consent, it can be appropriate to restrain a child for any treatment, even an exam.
“This needs to get back to the focus, and the focus is really on the children, and if you can’t do an exam, then you’re not focusing on the child,” Strange said. “From my perspective, from a clinician’s perspective, that’s key.”
For years, advocates for the poor have complained it is difficult to get dental care because so few dentists are willing to accept Medicaid patients, at least in part because of low reimbursement rates.
But Kool Smiles has found a business model specializing in Medicaid patients. The corporate information Web site Hoovers.com estimates NCDR has 500 employees at its Atlanta headquarters and did $20.1 million in sales nationally in 2008.
In 2008, the Indiana Family & Social Services Administration, which administers Medicaid, reimbursed $2.4 million to Kool Smiles in Fort Wayne. Statewide, the six Kool Smiles locations were paid $11.1 million in Medicaid reimbursement last year.
Unlike the statistics in Georgia, Indiana FSSA figures show reimbursements to Kool Smiles in line with their number of patients.
Still, the Kool Smiles business model thrives on volume. FSSA said the Fort Wayne clinic had more than 6,000 separate patients in 2008.
Dr. Todd Parco, a dentist in New Mexico, even placed a help-wanted ad for dentists tired of the fast pace at Kool Smiles.
“If you are wanting to get out of the dental mill scene like Kool Smiles … and want to find something infinitely better, give us a call,” the ad said.
The Fort Wayne Kool Smiles hygiene bay contains six dental chairs, so six cleanings can be performed at a time.
Kool Smiles rewards its dentists for working fast – they can earn bonuses of more than $10 an hour for production, according to a help-wanted ad the company placed in a trade publication.
“In any profession, the more productive you are, the higher your compensation,” Strange said. “The point that really needs to be made is at Kool Smiles, we are very, very particular and very committed to ensuring that all of the dentistry that’s provided is quality dentistry.”
Strange also disputes claims the company keeps parents out of Kool Smiles treatment rooms.
“The company doesn’t have a policy where parents are excluded from participating in treatment with their children,” Strange told The Journal Gazette. “The company does have a philosophy that most children do well without the presence of the parent. However, we do have an open door when it comes to treating children, and our parents are actively encouraged to participate in the Kool Smiles dental experience.”
But parents from five different families contacted by The Journal Gazette said they were told it was company policy they could not accompany their children and that children whose parents insisted on staying with them would not be treated.
A sign in the waiting room of the Fort Wayne Kool Smiles on July 21 stated: “Parents MUST remain in the waiting room while your child is being treated or they will NOT receive treatment.”
Strange said the sign meant only that if parents choose not to accompany their child during treatment, they cannot leave the premises. That sign has since been removed.
“I was not allowed to go back” to the treatment room, Crystal Allen said of her children’s visits to Fort Wayne Kool Smiles. “I was unable to see anything.”
Christina Bergbower took her children to the Terre Haute Kool Smiles and was told it was company policy that she could not accompany her children.
“I said, they’re a minor, and by law I can be there with them, and they told me it was their policy – it was on the wall that it was their policy,” Bergbower said. “They make it very clear to you that parents are not allowed in the back.”
Strange said that is not true at any Kool Smiles location.
“The short answer is absolutely no, we do not have a policy that precludes parents from being in the back or in the operating treatment facilities with their children,” he said.
A dentist at the Terre Haute Kool Smiles told Bergbower that her 6-year-old son Cody’s tooth was so decayed he had to have a stainless-steel cap put on it. When she took him to another dentist, however, the cavity was found to be so small they were able to fill it without using Novocaine.
Bergbower’s 16-year-old daughter, Shauna, was told by Kool Smiles she needed fillings for four cavities. Another dentist could not find any.
“I showed them the paper from Kool Smiles,” Bergbower said. “She said if she would have had those teeth filled, it would have caused pain and discomfort and set her bite off.”
Strange said Kool Smiles has a vigorous internal-review process that investigates any complaints made, but it gets few – just one-half of 1 percent of their patients complain, he said.
The Better Business Bureau in Fort Wayne gave the Fort Wayne Kool Smiles a grade of F because a customer had filed a complaint and the BBB never got a response from the company.
“An unanswered complaint is a big deal in the BBB system,” said Michael Coil, president of the BBB of Northern Indiana. “All you have to do is respond. We’re not saying they’re wrong or right. All we’re trying to do is get their side of the story.”
Kool Smiles says it did respond, but the BBB somehow never received it. It refiled its response after being asked about it by The Journal Gazette, and the grade was changed to a B-. It was later changed to a B+ when the company responded to a BBB survey asking for basic company information.
Strange said the situation appeared to be an oversight.
“That’s certainly uncharacteristic that we wouldn’t have responded,” Strange said. “We really, truly are people interested in doing the right thing.”
Kool Smiles has dozens of children’s dental clinics across the nation, but the company has also been the subject of complaints across the nation.
The dental licenses of Kool Smiles founders Dr. Tu Tran and Dr. Thien Pham, and Kool Smiles’ regional director of dental operations, Dr. David Vieth, were put on one-year probation in Massachusetts. The probations ended in June.
All three were disciplined for violations including that three clinics failed to perform required weekly biological testing, failed to maintain sterile instruments and didn’t maintain hepatitis vaccination records for employees, and that one clinic allowed an unqualified dental assistant to place dental sealants on a patient.
In addition, Pham was disciplined for anesthesia violations.
“That was an opportunity for us to learn and improve, and we’ve done so,” said Dr. David Strange, Kool Smiles’ chief dental officer and national spokesman.
Allegations also have been made by parents and news organizations.
In Hampton Roads, Va., WAVY-TV reported in November that one parent was told by Kool Smiles that her daughter needed eight stainless-steel crowns on her teeth. After four were put on, she got a second opinion from a dentist who said she didn’t need any.
Another parent was told by Kool Smiles his son had seven cavities that needed to be filled; a second opinion found none.
In Atlanta, WAGA-TV interviewed a former Kool Smiles employee in November who used her cell phone to film the office manager cleaning children’s teeth, though the manager was not a licensed dental hygienist. Strange told the TV station the employee had been dealt with internally.
