Wednesday, August 03, 2016

Economic Turf Wars over Dental Sedation and Public Safety

Dr. Michael Davis
Dr. Michael W. Davis maintains a general dental practice in Santa Fe, NM. He serves as chairperson for Santa Fe District Dental Society Peer-Review. Dr. Davis also provides a fair amount of dental expert legal work for attorneys. He may be contacted via email:
Economic Turf Wars over Dental Sedation and Public Safety
By: Michael W. Davis, DDS

One can’t evaluate the different parties fighting over dental sedation privileges and the vast sums of money involved, without examination in the context of our toxic dental Medicaid program. Medicaid is a social safety net program jointly funded by the federal government and each individual state. However, administration of dental Medicaid is left to the particular state. Each state handles dental Medicaid very different with a complex variety of outcomes.

For example, the state of Florida refuses to authorize hospital-based sedation for dental Medicaid cases. Therefore, many of the most severe dental cases go untreated. Institutionalized patients for severe developmental disorders often go untreated. The potentials for ensuing major medical problems may go unaddressed, until the crisis stage for morbidity and mortality (illness and death).
As a result, numbers of Florida dental Medicaid providers deliver in-office sedation upon patients, who truly should only be seen in a hospital setting. Children, who have a much greater compromised airway than adults, are treated en masse with cocktails of different sedation medications, and in risky dose levels. In order to maximize dollar production under a flawed Medicaid fee schedule, these doctors are notorious for a dangerous lack of patient monitoring.
Authorities rarely deliver more than wrist-slap regulation upon these violators, as their removal from the Medicaid system could hasten the collapse of this broken government program. The poor and disadvantaged are left between a rock and a hard place. They can elect to eat a $hit sandwich or go hungry.

Other providers of Florida dental Medicaid pursue a different scheme. They simply place any “uncooperative” child in restraints (euphemistically called “protective stabilization”). Again because the dental Medicaid fee schedule is so abysmal, these doctors feel justified in maximization of dollar production regardless of a child’s stamina, understandings, and limited abilities. All treatment possible is completed in a single visit. In order not to overdose a child for local anesthesia (generically termed “Novocain”) for their diminutive body weight, these doctors frequently deliver inadequate anesthetic, which generates excruciating patient pain. However, with the child adequately restrained, dental services of extractions, steel crowns and pulpotomies (baby root canals) continue, regardless of a child’s discomfort. Obviously, many of these patients will be in need of extensive psychological counseling for posttraumatic stress. Unfortunately under our programs for the disadvantaged, it’s doubtful this brutal problem of which government bares great responsibility, will ever be addressed. Medicaid dentists too often choose between “juice ‘em (sedate) or papoose ’em (physical restraints)”.
Whistleblowers who step forward in Florida to expose these abuses to authorities are met with institutional roadblocks. These professionals with integrity are forced out of government service by superiors. The rationale is that if the crooks and abusers are severely disciplined and removed as Medicaid dental providers, there will be too few providers to keep the toxic program viable. Government enables the abuse of our most vulnerable citizens and assists in cheating taxpayers.
New Mexico
New Mexico (NM) allows for dental Medicaid hospitalization and sedation coverage, unlike Florida. On paper and in theory, Medicaid patients will be permitted access to hospital operating rooms and nurse anesthetists for necessary dental care. The reality is quite different. Further, the in-fighting between providers and hospitals is in anything but in the interests of patients.
New Mexico paid hospitals for operating room Medicaid sedation services, not logically on an hourly basis, but on a per service basis. Since Governor Susana Martinez (R-NM) declined to appoint a dentist to the position of state dental director, she had no one to advise her on the absurdity and resulting deleterious outcomes of such a payment structure. The governor through letters of NM Human Services Department director and secretary was falsely informed that hospitals, and not the treating doctors, funded most of the facility overhead costs. In reality, doctors brought in their own equipment, supplies and auxiliary staff.

Up until this year, hospitals were paid $694.11 per each accumulating dental service. That means for every x-ray, filling, steel crown, pulpotomy, extraction, etc., the hospital generated an added $694.11 Medicaid billing. An hour of patient services, especially if a pediatric patient, could easily generate many thousands of dollars for the hospital. This fee schedule format not only was a financial boom for many pediatric dentists, but also many hospitals. And, most of the overhead costs were borne by the dentist.

By contrast, a specialist in oral maxillofacial surgery might wish to treat a Medicaid patient for complicated removal of a cyst in their jaw bone. That represents only a billing for a single service under NM dental Medicaid. A procedure which might require an hour to 1.5 hours of operating room time only generated $694.11 for the hospital. Today, that figure has been reduced to $230.00/ procedure. As a consequence, most New Mexico oral surgeons are not Medicaid providers, and most don’t have hospital privileges. In reality, hospitals can’t afford fiscal losses for advanced oral surgery services under the Medicaid payment structure.
Battles between competing pediatric specialist dentists have become near legendary, in their efforts to secure lucrative hospital operating room (OR) time. Under hospital IV sedation with a nurse anesthetist responsible for patient monitoring, a great deal of dental procedures can be accomplished in a limited time. Children especially are very easily treated for full-mouth dentistry, in a short timeframe.

Doctors and hospitals profited handsomely. In fact, the author was given information from multiple sources, that certain pediatric dentists were not above giving hospital administrators “incentives” to schedule them favorable OR time, and force out competing specialists. In fact, an unethical dentist who generated unnecessary patient treatments also created additional hospital Medicaid moneys, of which the hospital carried no liabilities. Whichever doctor could generate the most Medicaid billings for the hospital obviously became their favorite darling. Ethics and responsible patient care often took a backseat to money.

Specialty Standing for Dental Anesthesiology
We have had an unrecognized specialty in dental anesthesiology for over three decades. These are 2-3 year advanced dental residency programs, which are offered to graduate doctors. These formal academic programs offer extensive training specifically in dental anesthesiology. This doesn’t represent a more limited curriculum, as offered in pediatric dental training or oral maxillofacial dental training, which are quite advanced in their own right. These graduate dental programs are also vastly superior, to weekend anesthesiology training offered to dentists at motels.

Groups such as the American Society of Dental Anesthesiologists (ASDA) have advocated at the American Dental Association (ADA) House of Delegates, year in and year out, to be recognized as a specialty group. Each time attempted, dental anesthesiology has been rejected for specialty standing, and most forcefully by other dental specialty interests. Allegations of economic turf protection, over patient interests, abound.

Dental anesthesiologists have most recently taken to the court system, to gain formal recognition of specialty standing. To date, they have prevailed in Florida, California and Texas.
As a recognized specialty, dental anesthesiologists would be better positioned to help establish clinical standards of care for anesthesiology. We might have a group which actually monitored patient morbidity and mortality associated with dental sedation (not currently done, except informally by the media). We might have a dental specialty group, which could best educate the dental profession and public, on dental sedation matters. Dental sedation can be a godsend to patients who are fearful, exhibit severe anxiety, have compromised health issues (i.e. high blood pressure), emotionally or mentally challenged, etc., all in line with maximizing patient safety.

Private Sedation Training for Dentists
There are private groups which educate dentists on matters of dental sedation. They offer a variety of training levels, for different specific levels of patient sedation. This is in concert with the ADA’s formal sedation guidelines (actually requirements and not “guidelines”, under many state dental licenses), for different levels of sedation.
These guidelines were last updated in 2012 and are currently under review for updating, especially due to numbers of national dental sedation tragedies.
Importantly for the educational course providers, these sedation classes to doctors must obtain approval under ADA Continuing Education Recognition Program (CERP).
A failure to secure ADA CERP course qualification, or more restrictive changes to anesthesiology guidelines to advance patient safety, could potentially damage the financial bottom-line of these private sedation education programs. These groups make little disguise of their intent to influence ADA Executive Director, Dr. Kathleen O’Loughlin, with potential defection of ADA membership (less members equates to reduced dues revenues).
In fact, there are a myriad of groups attempting to influence the ADA in regards to updating sedation guidelines.

The question at hand for dental sedation is: “Who really supports the public interest”? We see strong evidence of the ADA being pressured by special interests. We observe state and federal government as incompetent, and too often complicit in dental sedation abuses as well as waste of taxpayer money. We see smaller special interests, who seemingly appear primarily interested in advancing their self-serving agendas (hospitals, private educational groups, etc.). The welfare of patients seems like low priority lip-service.

To quote Puff Daddy, “It’s all about the Benjamins”. Money will influence the outcome. Money continues to trump possible life and death results of dental patients (especially Medicaid beneficiaries). Money talks, while ethics walks. It’s well past time for change.

This article is dedicated to the work of Senator Chuck Grassley (R-IA), who has championed laws to encourage and protect government whistleblowers and their courage and patriotism.