Perfect Storm Hitting Medicaid Dentists in Texas

Over the last several months, TDMR has been receiving anecdotal comments from Medicaid dental providers that they have found themselves truly between a rock and a hard place at this time. Although we have reported on a number of negative factors affecting dental practices in Texas for months now, it appears a terrible confluence of factors has led a few dentists to tell us that this is no-holds-barred the worst time they have ever experienced as a Medicaid dentist.

The fact of the matter is that the survival of their practices is at stake.

In evidence, we have been told that there have been significant layoffs in some large dental practices with multiple offices and even some have closed offices. Out of deference to those affected, we will not mention names.

But the inability to hire staff because there are fewer now available, the increased cost to retain those they have, the lowered Medicaid rolls due to the “Great Unwinding,” and the continued low fees have impacted dental practices, rural offices especially, leading to further staffing cuts and office closures.

We are told there are fully built-out dental offices now lying vacant around the state.

So let’s look at these factors:

Staffing crisis!

Medicaid dental offices in Texas face challenges in finding dental assistants and dental hygiene staff due to a combination of factors exacerbated by the COVID-19 pandemic and pre-existing conditions in the dental care sector. The American Dental Association (ADA) recognized this as a significant issue a few years ago, with a reported four out of ten dental practices in the country trying to hire dental assistants or dental hygienists at any given time. This indicates a serious workforce shortage within the dental sector.

Several key issues contribute to these staffing challenges:

1. Impact of the COVID-19 Pandemic: The pandemic has led to staff shortages across many industries, including dental care. Dental practices have reported losing staff during the pandemic, and the inconsistency in the applicant response to job ads has made recruitment unpredictable. Some applicants prefer part-time positions, requiring additional on-the-job training, which can be challenging to manage alongside patient care.
2. Educational Requirements and Shortages: The field of dental hygiene requires licensure, which in turn requires several years of education. This has led to a long-standing shortage of hygienists. Additionally, closures of educational programs for dental assistants and hygienists have exacerbated the issue, resulting in fewer trained professionals entering the workforce.
3. Competition and Compensation: Intense competition for dental staff has led to increased pay rates, but dental practices are also facing financial pressures from lost revenue during the pandemic and increased costs for protective equipment and other COVID-19-related expenditures. This makes it difficult for dental offices to match compensation expectations, particularly in a tight labor market where potential employees have many options.
4. Changing Work Preferences: The pandemic has also shifted work preferences, with some dental professionals seeking part-time positions or leaving the profession due to COVID-19 exposure and workplace safety concerns. This shift in workforce availability and preferences has made finding and retaining staff challenging for dental practices.

The Great Unwinding crisis!

The end of the COVID-19 Public Health Emergency (PHE) in May of 2023 and the ending of continuous Medicaid coverage on March 31, 2023, have posed significant challenges for Medicaid dental offices in Texas. Children’s Medicaid numbers in Texas have plummeted from 4,327,679 last May to the latest reported figure by HHSC of 3,350,000 in November 2023. We are not sure where they stand today.

Continuous Medicaid coverage prevented states from disenrolling individuals from Medicaid, ensuring continuous coverage for enrollees regardless of changes in their eligibility status during the pandemic. As part of the unwinding of continuous Medicaid coverage, the federal government requires HHSC to redetermine Medicaid eligibility for approximately 6 million Texans over a 12-month period, according to HHSC.

As reported by various news agencies, the re-enrollment process has not gone smoothly with many eligible Texans not figuring out the re-enrollment process. As reported by Axios and the Kaiser Family Foundation,

• About 65% of Texans undergoing the redetermination process have been removed from Medicaid, the highest disenrollment rate in the nation, per KFF.
• Of those who lost coverage, about 68% were removed for clerical reasons like unreturned paperwork — not because they were ineligible.

So over the last few years, dentists have sought to accommodate the dental needs of 4.3 million children and increased their resources to do so.  Now 1/4 of these children are gone from the system. Dentists are reporting dwindling numbers of patients coming for treatment so offices are closing, staff retention is difficult.

Inflation crisis!
The impact of inflation on Medicaid dentists, particularly regarding the prices of Personal Protective Equipment (PPE) and other items, is part of a broader challenge faced by the healthcare sector due to rising costs. The healthcare industry, including dental care providers, has been significantly affected by increased nonlabor costs, which were particularly pronounced in the early stages of the COVID-19 pandemic. These costs were driven by supply chain difficulties and global bottlenecks, leading to higher expenses for essential supplies such as PPE. The continuation of these supply chain issues is expected to push nonlabor costs above what would have been projected before the pandemic, with an anticipated increase of up to $110 billion in additional nonlabor costs by 2027. These costs are likely to become permanent, affecting all healthcare providers, including Medicaid dental offices.

For Medicaid dental providers specifically, managing these increased costs within the constraints of Medicaid reimbursement rates poses a significant challenge. The financial pressures from inflation and increased supply costs are impacting the ability of these providers to maintain service levels without additional support or adjustments in reimbursement rates to account for the higher operating costs.

Fee schedule crisis!
There are a number of articles on TDMR on the fee schedule that hasn’t been updated since 2007 and has only had a 2% reduction rather than a raise since that time.

• Time to Review Medicaid Dental Fees? Expenses Skyrocket While Fees Decrease Over 15 Years
• 72% of Private Practice Dentists Plan to Raise Fees This Year, Will Texas Do the Same for Medicaid Dentists With $32.7 Billion Extra in the Kitty?
• Texas Pays $950.45 While Private Insurance Is Billed $2,052.81 For Same Services
• No Fee Increase for Medicaid Dentists in Texas Budget
• Inflation and Low Fees Driving Medicaid Dental Providers Out of the Program
• Comments Show Problems with Current Medicaid Dental Fees

Just a casual comparison between the current TMHP fee-for-service THSteps dental fee schedule and the THSteps medical fee schedule for fee updates shows that a number of Medicaid rates were last reviewed and revised in 2023 for medical services.  One can only wonder why dental rates have been ignored for so long.

In what is good news for this particular problem, we are told a fee review is coming this year.  More on this later.

With all this being said, we hope dental providers can weather this storm and come into calmer seas so the population of Medicaid-eligible children in Texas continue to get the high-quality, necessary dental care they deserve.