"The dentist man got me"
May 17, 2012 6:31 AM   Subscribe

ReachOut Healthcare America, a dental management services company, “built its business model on the premise that low-income parents often don’t have time or transportation to take children to the dentist. So mobile teams pack equipment in large cases, load up a minivan, head to schools and set up in gyms, libraries or classrooms.” Services are billed to Medicaid. ReachOut and other dental management services companies are increasingly backed by private equity firms. What could possibly go wrong?

A 4-year-old in Arizona received two "baby root canals," crowns and 10 X-rays -- all while he was at school. And without his mother's knowledge or consent, she says. State investigators are examining complaints that ReachOut-dispatched teams billed Medicaid for unnecessary work on children. ReachOut says what happened is not common practice.
posted by evilmomlady (42 comments total) 7 users marked this as a favorite
Welcome to America - where medicine is based on greed.
posted by Flood at 6:40 AM on May 17, 2012 [19 favorites]

Jesus. I hope that this is just straight up billing fraud, and they didn't actually X-ray a four-year-old's head ten times. To say nothing of the root canals and crowns--I'm not an expert on child dentistry, but would you really put crowns on baby teeth?
posted by Mr. Bad Example at 6:47 AM on May 17, 2012 [2 favorites]

Oh Wow
posted by parmanparman at 6:49 AM on May 17, 2012

Doesn't matter; Had profit
posted by CautionToTheWind at 6:49 AM on May 17, 2012 [4 favorites]

Munchausen by profit.
posted by seanmpuckett at 6:55 AM on May 17, 2012 [24 favorites]

I'm not an expert on child dentistry, but would you really put crowns on baby teeth?

Well, I wouldn't. But, yeah, I have heard of dentists who press for such procedures. I've actually heard of practitioners advising for braces on baby teeth.

Part of me thinks shit like this is the leading edge of what's to come in fields like dentistry...services which aren't typically part of basic healthcare insurance. As more and more people can't afford to add dental coverage to their insurance (let alone afford insurance at all) the dental trades will find themselves with a diminishing clientele (or a clientele that reduces visits to once every couple of years or more), requiring some of them to seek more...creative...means to keep up with the boat payments.
posted by Thorzdad at 6:58 AM on May 17, 2012 [1 favorite]

Pretty interesting. I'd love to learn more about the entire effort. I think it is the case, generally, that there is low take-up of medical care and other in-kind transfers among low income families. The notion that lowering the transaction costs could increase that take-up is something worth considering, particularly given the significant gains to early childhood interventions that I'm constantly reading about in the economics literature these days -- paper after paper finding large returns extending well into adulthood.

That said, I realize the post is focused purely on the efforts of a private group's solution to doing this, but the idea that we maybe could try more push in place of pull policies seems worth experimenting with.
posted by scunning at 7:00 AM on May 17, 2012

I grew up in rural Australia, where dental services were also reasonably sparse. ' One of the solutions to this, was a state run dental van which would travel around and fix children's teeth. The idea was actually noble, much like I think this one is - dental health is important, and can have a dramatic impact in later life.

With all of that said, however, that van kept me from going to a real dentist for twenty years. The problem with a dentist in a van, is they do what they can to get by - you have to, you're a dentist in a van, not in a shiny office with access to rooms full of equipment and anaesthetic. Indeed, my worst experience was when I needed a filling, and they had run out of the days supply of anaesthetic. So they just did without - this had actually become their standard practice. I bit the dentists finger, which is appealing as a kid - but still, it didn't really make up for the horror.

There is always going to be very little oversight in a van. And there is always going to be pressure - even driven internally (these are not the high paying private gigs for the dentists on the ground, these are people who want to make a difference) to perform as much good work as possible. I don't know how to solve these problems... but I am sceptical that a van is the answer.
posted by jaymzjulian at 7:02 AM on May 17, 2012 [3 favorites]

I remember there being a scandal up in Scotland* about some dentists doing more treatment than was necessary. Now they have changed the system of NHS payments to make this much less likely. (Though I only got into my current dentist as the previous dentist there was prosecuted for fiddling the books - at least not the teeth)

*Like the Irish making jokes about Kerrymen being stupid, the Scottish about Aberdonians being tightfisted, the rest of the UK pours scorn on the state of Scottish people's teeth - it's all that Irn-Bru and Tunnocks.
posted by fearfulsymmetry at 7:08 AM on May 17, 2012

You all would be alarmed at how common this kind of stuff is. This is why medicare and medicaid fraud and abuse estimates can be so high.

But, this can be stopped. All you need to do is embrace the vilified trial lawyers who have the answer: qui tam pro domino rege quam pro se ipso in hac parte sequitur. 31 USC § 3730. Support trial lawyers. They help guard society and can help end abuse.
posted by dios at 7:27 AM on May 17, 2012 [1 favorite]

But... but... but... WELFARE QUEEN!
posted by PenDevil at 7:33 AM on May 17, 2012

It's almost as if, sometime around the end of the Carter administration, the US decided to start taking the last line of the Gettysburg Address as a challenge rather than an ideal.
posted by R. Schlock at 7:38 AM on May 17, 2012 [4 favorites]

Since my daughter had a crown on a baby tooth; yeah, they do that.
posted by NiteMayr at 7:47 AM on May 17, 2012

Medicare/medicaid fraud goes back as far as the programs themselves. The shitty part, at least when I had a view into the system, was that payouts were glacial, and the procedures approved not always realistic. As a result, billing had to get creative for appropriate reimbursement and juggle the system just so the business could remain viable. Which could be viewed as a shaky practice in itself, even if it resulted in good medical practice. It was also a very highly regulated game, where savvy billers working in conjunction with medical providers are the key to staying afloat. In my area, the shrinking pool of solo/independent practices choose to stay out of the system altogether in favor of cash pay/self insured patients because who needs that kind of headache?

The interesting thing here isn't that these practices are run by their private equity bean counters, but that the article describes those bean counters being easily able to recruit so many dentists willing to go along. Which makes me wonder if it's as outrageous as it's made out to be. I can easily believe medicaid payouts tend to be standardized hammer treatments for a variety of routine nail dental problems. But what amounts to widespread malpractice, as a matter of culture, across different companies, would be incredible indeed.

And yeah, baby tooth crowns are a thing. They seem to be regarded as temporary(since the tooth will be shed soon enough), relative trouble free solutions for particular tooth problems.
posted by 2N2222 at 8:08 AM on May 17, 2012 [1 favorite]

This is why I have an adversarial relationship with dentists, generally speaking. Pressuring me to submit to procedures that are either unnecessary, or that I have expressly told them I don't want.

If they are doing that to a grown woman with a full-time job and health benefits in Canada, I can't even begin to imagine what they're doing to little kids who don't know any better and who don't have a parent nearby to advocate for them.
posted by LN at 8:10 AM on May 17, 2012

This story is horrible, and the narrative terribly obvious, and I think that Capitalism and health care go together like... well, Medieval populations and plague... but is it wrong of me that "The All Smiles collapse" sounds like a plot point in a China Miéville story?
posted by GenjiandProust at 8:35 AM on May 17, 2012

We built their mobile unit if you want to take a look inside (self-link).

We also build trauma-free bookmobiles. Helps me sleep at night.
posted by hal9k at 9:10 AM on May 17, 2012 [1 favorite]

hal9k: "Helps me sleep at night."

You shouldn't have to feel that way. There's nothing about the idea of a mobile dentistry van that bills Medicaid that's problematic: in fact, there's a lot right about it. Where we seem to have gone wrong here is medical procedures without a parent's consent (illegal) and over-charging Medicaid (technically illegal, but with CMS as underfunded as it is, who's there to check).
posted by Apropos of Something at 9:22 AM on May 17, 2012 [4 favorites]

When I was a young schoolchild in the USSR in the late 1980s and then in post-Soviet Ukraine in the early 1990s, children's dental health services were administered through schools and preschool facilities ("детский сад," usually separate from schools, but also based on a grade school model). As I recall, at some point each year there'd be a rumor in the hallway that the dentist had come. I would sit in class, dreading the inevitable, until my name was called and I'd go over to the nurse's office. There I'd see that hideous chair, and the drill on its articulated arm, and the little emesis bowl, or whatever. A small group of children would huddle on chairs by the door. One at a time, they would be directed to the chair and examined by the indifferent, businesslike dentist. To the young me it was, in a word, terrifying.

The dentist administered basic services, most commonly fillings. I imagine these were of porcelain enamel (I did not encounter mercury amalgam before I arrived in the US). Occasionally, the dentist would also extract baby teeth using simple dental forceps. Pretty much everything was done without local anesthetic. I'm not sure what was done for more complex cases: undescended canines, and so on. Dental clinics existed, and regularly saw pediatric patients (including me as a toddler, after I had a nasty bout of stomatitis after sucking on a hairbrush). Braces were certainly available, though far, far less common than they are in the US. I think the school-based dentistry was just there to provide some minimal threshold of care.

As a child, I had terrible teeth. I attribute it to the simple fact that preventative treatment just wasn't part of the Soviet model. It was all restorative. Every year brought another round of fillings. There was also no contact with parents, no permission notes sent home. Decisions about care were made by the dentist on the spot. There was no concept of dental cleaning, or tooth whitening, or sealants, or any of that fancy high-tech stuff that's common in the US now. I don't think it's uncommon for Soviet immigrants to consider preventative services superfluous, clearly an effort made by American dentists to rip them off. We respect aggressive dentistry with clear, visible outcomes: fillings, crowns. Root canals.

But for all I know, back in the 80s dental care in the US may have been on par with Soviet dental care. And I'm sure that some residents of the former Soviet republics these days receive care on par with that in the US — if they have the money.

Of course, that's not to say that US pediatric dentistry today is head and shoulders above the care I got as a child in the USSR. My younger brother had fairly extensive "baby bottle" decay and tartar buildup as a young child. The Medicaid dentist's suggested solution was to put him under complete anesthesia, extract all eight incisors, and put crowns on the remaining teeth. She sounded very insistent and authoritative. We eventually decided not to follow her recommendation. We found a dentist with a specifically pediatric practice who was more familiar with the problem and recommended a much more reasonable course of care. In the end, my brother's teeth are, on the whole, doing much better than mine.
posted by Nomyte at 9:24 AM on May 17, 2012 [2 favorites]

hal9k: "We also build trauma-free bookmobiles. "

OMG. Dude, you have my dream job.
posted by notsnot at 9:25 AM on May 17, 2012 [1 favorite]

If kids are traumatized by brutal dentistry, this can hurt the rest of their life: I have 2 relatives who were both traumatized by dentists as children, which made them unable to see a dentist as adults without being sedated completely, and so they didn't have dental care for 20+ years. One now lacks her front teeth; the other has full dentures at the age of 54.
posted by jb at 9:32 AM on May 17, 2012 [1 favorite]

American Dental refused to replace defective anesthesia equipment

Jesus Fucking Christ. I am appalled by the stories in this thread of dental procedures done without anesthesia. What kind of sadistic dentist (who is not later eaten by a giant plant) does this?
posted by cereselle at 9:37 AM on May 17, 2012 [1 favorite]

I am appalled by the stories in this thread of dental procedures done without anesthesia. What kind of sadistic dentist (who is not later eaten by a giant plant) does this?

The one I had when I was a kid.

posted by R. Schlock at 9:45 AM on May 17, 2012 [1 favorite]

This makes me SO FURIOUS. Aside from the ugliness of the for-profit healthcare fraud angle, to do that to those children just makes my blood boil. I want those dentists (the ones who treated kids without parental consent, without anesthesia, for no reason) to be prosecuted for child abuse. Seriously. Prosecuted and jailed. FURIOUS.
posted by Joh at 9:58 AM on May 17, 2012 [3 favorites]

For some reason dentists used to believe that kids' teeth didn't have nerves in them, or something. I had several fillings as a child and was never offered anesthetic. Once I was an adult it took me until my early 30's to get up the nerve to see a dentist.
posted by Daily Alice at 10:00 AM on May 17, 2012

I am 35 and have never been afraid of dentists. After reading this article and your comments, however, I may be reconsidering that notion.

My dentist as a kid was actually really gentle and pretty nice. Unfortunately, when I had a minor bout of TMJ and he immediately started pushing for an extensive and expensive long-term treatment plan involving MRIs and orthodontia--none of which would be covered by insurance, of course--I switched dentists and never went back (my current dentist, who is also my uncle, successfully "treated" my TMJ by recommending that I take an aspirin and avoiding hamburgers, subway sandwiches and anything else that would force me to really stretch out my jaw for a week or so).
posted by infinitywaltz at 10:02 AM on May 17, 2012

What kind of sadistic dentist (who is not later eaten by a giant plant) does this?

Pretty much all of them in the 1970s when I was getting my head filled with almalgam. Unplesant to be sure, but unless you're having a root canal (or someone's trying to get information out of you as in Marathon Man) it's tolerable. Also a great incentive to brush and floss. So toughen up kids. We did it so can you.

If you're gonna have government health care, I think you just need to accept that there will be enormous fraud across the board - just like at the Defense Department - the idea that you can have it any other way is fantasy. People who receive services they do not pay for generally don't give a damn about cost and that opens the door big and wide to waste, fraud, and abuse.
posted by three blind mice at 10:07 AM on May 17, 2012

three blind mice: It is actually possible to largely prevent this kind of fraud through effective regulation. The US is so riddled with governmental corruption and regulatory capture, though, that it's created a downright toxic environment where people are convinced that effective regulation is an impossibility. It's the sort of attitude that makes people settle for absolute shit because they're convinced that nothing else is possible; like the domestic abuse victim who believes that nightly beatings are the only possible reality. And then every once in a while someone takes a trip through the French healthcare system (or equivalent) and can't believe what they've been putting up with.
posted by kaibutsu at 10:41 AM on May 17, 2012 [2 favorites]

damnit nomyte, I typed in "undescended canines" and google gave me something completely different than I was expecting and seeing a pair of dog nuts on my lunch break (at work nonetheless) is something I don't want to ever have to have happen again.

I have shitty teeth. I haven't seen a dentist since 1993. I've had one tooth outright collapse on me (I thought it was a kernel of popcorn at first, then after fussing with it, I realized what it was). It's not a pretty site, my mouth.

And I have a decent paying job right now, but no dental care. And we did have AFLAC, but that was confusing as hell (find a provider that will take it, pay and then they reimburse or something utterly ridiculous).

I looked for a dentist recently (and saw what looked like a dental mill or two in the area -- my ex once went to a place in Cleveland that's well known as a big dental scam, and I have a feeling some of these places are like that). I finally found a small office that looks legit, and it's near me. I still dread it. But I know my heart health is part of the equation and I already have way too many risk factors.

And of course, I dread "the lecture". Meh. Dental Care, like "Health Care" (as if they're not the same thing) should be universal single-payer.

Fuck America and Fuck Capitalism.
posted by symbioid at 10:43 AM on May 17, 2012 [1 favorite]

Seconding kaibutsu. We have very tight controls/regulations on health care provided in France. They're pretty good at rooting out abuses – not perfect, but good.

Indeed, the opposite argument is a lot more likely: health care that's not overseen by an entity directly influenced by democratic process (voting, ie. government) is a lot more prone to abusive pricing. I mean, who needs a few crowns on baby teeth when a hospital can bill $23,700 to an insurance company for a hospital visit (nothing else), get $9,000 from it, and the patient has to pay $900 of that? (Using a cousin who had to go to a Nevada hospital last week as an example.) Hell, if you have no insurance here in France, which is only possible if you're a non-EU citizen who doesn't pay taxes, a hospital visit costs 100-200 euros (there are no missing zeroes, it's in the low hundreds).
posted by fraula at 10:45 AM on May 17, 2012 [2 favorites]

Daily Alice: " I had several fillings as a child and was never offered anesthetic. Once I was an adult it took me until my early 30's to get up the nerve to see a dentist."

I see what you did there.
posted by symbioid at 10:47 AM on May 17, 2012

Baby Root Canal is the name of my new band.
posted by aeshnid at 10:48 AM on May 17, 2012

My son also needed the pulpotomy(baby root canal) and crowns for his baby teeth. Here in San Diego, the dentists wanted $1000 for two pulpotomies and crowns and to fill his other teeth. We visited a dentist in Tijuana and it only cost $300 for all that work. We have been driving the family down for our dentistry ever since. The last time my dentist's office here called, I told them I was now being treated in Mexico, they sounded very wary, like 'Are you SURE?'
posted by cherryflute at 10:51 AM on May 17, 2012 [1 favorite]

Its not just in Scotland, fearfulsymmetry.

More Here. Dentistry.co.uk has a politicised version.
posted by marienbad at 11:07 AM on May 17, 2012

How much of this could have been avoided if a non-profit driven entity dedicated to strengthening the nation had been more willing to fund basic medical care for 'those people'.
posted by Slackermagee at 11:42 AM on May 17, 2012

damnit nomyte, I typed in "undescended canines" and google gave me something completely different than I was expecting and seeing a pair of dog nuts on my lunch break (at work nonetheless) is something I don't want to ever have to have happen again.

I think "impacted" is the more accepted term, but its meaning is less transparent. But never mind that, just don't google anything pertaining to dental disasters and you'll be better off in the end.
posted by Nomyte at 12:00 PM on May 17, 2012

Slightly off topic but in the US fluoridated water and toothpaste has massively reduced the number of cavities people get and as a result dental profits plummeted. To compensate they've found other services to push and are now profitable again, but at the cost of making a visit to the dentist feel more like a time share pitch than a medical procedure. I went to one dentist in Silicon Valley (once) where there were *four* non-technicians in the room pitching me cosmetic and other non-necessary services. The second one I tried sold me on root planing and had me come in for it enough that my insurance finally put their foot down. I miss the old "one dentist, one tech, one receptionist" offices.

Back on topic the idea of mobile dental offices delivering services to poor kids is wonderful and I hope that we find a way of doing this that doesn't reward scum like these outfits.
posted by Blue Meanie at 12:00 PM on May 17, 2012 [1 favorite]

All this crap seems pretty common in the dental industry. This is just a new twist on it. When I moved to Atlanta I went looking for a dentist. The first place I tried told me I needed a couple of horribly expensive procedures done and then had the audacity to offer me financing. This was before they even did a routine cleaning, which was all I had come in for. I told them to go fuck themselves and found an honest dentist. Doing this to kids who aren't likely to stand up to an authority figure and then billing the government for it, is a new low, though.
posted by dortmunder at 12:36 PM on May 17, 2012

Why would baby teeth be root canaled or crowned? They fall out and adult teeth grow in a couple of years.
posted by bystander at 12:55 AM on May 18, 2012 [1 favorite]

And how do you administer the treatment? My 4yro won't even sit in the chair, let alone let a dentist drill in her mouth.
Surely the risks of anesthetic (you know, possible death) far outweigh any benefit the dental work might provide.
posted by bystander at 12:57 AM on May 18, 2012

Isaac Gagnon stepped off the school bus sobbing last October and opened his mouth to show his mother where it hurt.

She saw steel crowns on two of the 4-year-old’s back teeth.

Steel crowns?!?

A couple of years ago, I was in the process of getting a crown when power went out in the dentist's building. They couldn't form a temporary crown without electricity, but "thankfully" they had a few stainless steel temporaries still on hand ("oh, we were about to throw these out!").

The next two weeks were a study in increasing misery as the crown became more and more sensitive to changes in temperature. At the end, I couldn't tolerate any solids or liquids that hadn't been warmed/cooled to the temperature of my mouth. (In the meantime, my pleas to the dentist to replace the crown with a proper temporary, or to write me a scrip to deal with the pain went completely unheeded.)

Needless to say, I've changed dentists. And if I found steel crowns in my child's mouth, my first call would be to another dentist to get them the hell out. My second call would be to a malpractice attorney.
posted by malocchio at 6:44 AM on May 18, 2012 [1 favorite]

I am appalled by the stories in this thread of dental procedures done without anesthesia. What kind of sadistic dentist (who is not later eaten by a giant plant) does this?

I had a lot of cavities as a kid. The dentist I went to never used anything on me. No novocaine. No nothing. I became scared shitless of going to a dentist. It wasn't until I was well into my 20's that I had to see a dentist again (because my wisdom teeth were killing me) and I was introduced to the wonderful world of nitrous oxide, along with some crazy numbing agent swabbed along my gums before the needle went in.
posted by Thorzdad at 6:35 PM on May 18, 2012

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