You:
Hi Dr. Mertz, thank you so much for taking the time to speak with me today.

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Participant:
Of course — happy to be here.

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You:
I’ve been really looking forward to talking with you, especially because so much of your work focuses on the policy side of dental care, which is exactly what I’m researching.

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Participant:
Great, I’m glad it’s useful. I love talking about this stuff.

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You:
So before we get into some of the bigger questions, I was really struck by something you said earlier — about how once certain systems and policies get built, they become very hard to undo, even when we know they're not working.

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Participant:
Yes, exactly. Some things are well understood, but once they're embedded into big systems with layers of structure and decision-makers, it becomes incredibly hard to reverse them.

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You:
Right, that makes sense.

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Participant:
like you know some things but it's really it's just sort of got entrenched in these big systems with these and structured people on them. And once that once that sort of gets laid down and cemented, it's very hard to, you know, kind of go back, do it.

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You:
Yeah, exactly. Yeah. So building off of, obviously, even though Medicaid has been, and what, it definitely has improved, especially for the coverage of dentistry. It obviously still allows these specific dental disparities to persist because a lot of underserved and, you know, populations that are that like require Medicaid, especially for their families and children. If obviously dentistry isn't covered in that, they're not going to have the means or the money to go out of their way and seek private dental care. So do you have any thoughts on how Medicaid has specifically contributed to the disparities, especially within minority and underserved populations?

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Participant:
Yeah, I mean, it does it a whole bunch of ways. I mean, the structure of Medicaid is actually, if you think about Medicaid, I mean, it's aged blind and disabled and poor. So, but it's the vast majority of people who are on Medicaid, it's because of income requirements, right? It's because they're very, very poor and not just a little bit poor, like very, very poor. And so once you are eligible for Medicaid, you're already like disadvantage. And so the idea would be to, okay, we're going to give you a state- covered benefit. So at least you don't have to worry about healthcare. Like you can, you can, you know, get these healthcare covered, your healthcare covered. Usually, like ventistry, there's no co-pays or anything. It should be, you know, it should be pretty straightforward.

Having said that, unlike the way that it contributes to the disparities is that it pays very poorly compared to commercial insurance. For the most part, some states are better, some states are worse. Pardon me. But because it does that, and there's no no policy structure to ensure an adequate number of providers who will accept Medicaid. So it's just up to the provider. They can choose to do it or not choose to do it. Whereas with physicians, physicians are generally employed by large systems in large groups, and most of those large systems and groups, except Medicaid, because it's the second largest pair in the country. It's a huge patient base, of people. And it doesn't pay as good as Medicare, but it pays.

So the and you see the same issue in medicine in that there's each state is allowed to create their benefit package under certain sort of like minimum set of federal standards. And so for kids, that's set by EPSTD, which is their early periodic screening deduction, EPSTD, whatever that he has yet. Screening testing a deduction. So that mandates the minimum set of things that kids could get and the access for children has improved, especially since the affordable Care Act, because that really pushed the pediatric dental care as a essential health benefit and so all of the marketplaces were forced into sort of bundling or actually coupling dental assurance that people are buying through the affffordable Care Act marketplace mechanism with dental. They were getting their dental.

But for adults had still completely optional and there are, you know, a third, maybe a half of the states that don't provide any dental services whatsoever for adults on Medicaid. So that could just, it just, even though in theory, the individuals, if it didn't have Medicaid, they would have no dental coverage at all, which would be getting even worse. The idea of Medicaid is sort of like, you know, for these individuals that are already extremely vulnerable, either through poverty or through disability, would be to give them a benefit that makes the getting this essential healthcare easy. Yeah. But because there's no companion that that says, dent have to accept this or there has to be an emergency dental room. So in medical care, you have M Tala, which is the emergency medical, it's EMTALA. It's essentially it was passed in the 80s and it was to get emergency words to stop dumping patients. And basically said, if you go to the emergency room, anywhere, any emergency room, they have to treat you. They can't just say, no, we're not saying you.

So what's happened is because there's nothing, there's no guaranteed like place of last resort for dental, almost people end up in actual emergency rooms. There's like a billions of dollars. They get spent an emergency rooms on preventable dental issues, and they don't get resolution because they' no dentists in the emergency room. Yeah, they kind of do get sent away. Yeah, they get antibiotics and they get opioids and they get, you know, that, and then they, and then they go back. So it's, it's it's the fact that there's not, there's not a balance in it. And so you sort of say, well, here's a benefit, but in the real world, that benefit is not useful at all to you. If you can't find a provider who's willing to give you care. So, I mean, I'm sure you've read this word about DMonte Driver and what happened to that child. Yeah.

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You:
Yes.

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Participant:
Yeah. So he was on Medicaid. I mean, he's he is the example. Like, his mom went to three different dentists trying to take care for him before, you know, he actually got the abscess and then the brain infection and then he died.

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You:
Yeah. So building off of that sins Medicaid has such low reimbursement rates, which obviously ends up discouraging dentists from accepting these Medicaid patients because they're obviously thinking, why should they sacrifice, you know, the income that they're making? But are there any specific policy solutions that could make Medicaid participation more of an option for providers? Would it just be increasing reimbursement rates or anything else that could possibly be added?

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Participant:
Yeah, I mean, there's a ton of research on this. I just did a big study, so California, increased their reimbursement rate from essentially 30 cents on the dollar to 86 cents on the dollar. So basically got very close to sort of like a usual and customary fees. And there was no change in dental participation in the years after that change. And in fact, what we found in our study was that it actually led to dentists leading the program. And there's a reason for that.

So a lot of dentists, about 40% of the dentist in California are enrolled in Medicaid, meaning they've filled out the paperwork so that they can fill Medicaid. They've like gone. They're sort of MPI number, all the various things. But onlyent of them, like, I'll just use the sample, or sample year that means uses 2019. 2019, only 25% of the dentist actually even saw one patient. And then among those, only like, so we were at 40% now we not 25% all the dennis, only 15% of all the dentists in California, some more than 100 patients in a given year.

And so when they raise the riates, you have this 10% of dentists that are seeing less than 100 patients, and about half of them are seeing like less than 10 patient. So they're doing something in Medicaid, but I don't know what it is. Like, I don't know why five patients. So if you think about it, you're paying me fee for service. I see five patients. You increase my rates. That does nothing for me. Like, I've already written it off as charity care.

It only helps you if your practice. If you're seeing Medicaid patients at volume, right? And then that's a lot more money for your practice. Yeah. But if you' what you saw, we saw that all these dentists that were in that category of like, they would see in occasional medication, but they weren't really a Medicaid provider. They, the incentive program, we're going to pay you more their minds. They'd thought, oh, good, someone else is going to do this now. And so they exited the program. Oh, he's actually. Yeah. leaving an unenrolling in the program.

So, which, as I've just explained, makes sense if you put it together. Right. So we should be paying much more on Medicaid. Like, it should pay the same as it should payave what it needs to pay in order to cover the services. So I'm not saying that's not, like, that should happen. That's a nobrainer. But that's like what we call like sort of like, um like in leadership studies, there are things that in a workplace are kind of like hygiene. Like if they're bad, things are really bad, but they're not motivators. They're like baseline things that have to happen. So the payment stuff is like a baseline thing. And then there's like what has to happen on top of that.

And you hear the same things over and over again. There's, you know, they want less paperwork, they want, they want more, less pre-authorizations that they need, less-authorization requests. So there's all this stuff that they have to go through that's and to be really frank, there's just a lot of straight up bias and racism. The, you know, dentist population is primarily middle and upper income and still very white male, even though it's getting more diverse and like, in the corner, that's not the population that's on Medicaid. Right. So there's, there's just a lot of, you know, they don't want to deal with those people kind of stuff that happens.

No, they're not going to say that. And they'll say that. They'll say that very clearly behind closed doors. They want to stop Right. They won't say it directly. Yeah, exactly, because they they've got to, you know, keep their social contract and their monopoly with the state. But, but I think so. Now, having settled that, I think there are examples of ways that you can do this differently, but it requires sort of an entire system change.

So we just finished a study up in the Pacific Northwest with a group called the Willamete demo Group and they have 30 offices around three states, and they're full incapitated model. So they have have dental practice and they own. They have a dentist group so that like it's a step it's within this like pool of companies that they have. So the dental practice is owned by the dentist and run by the dentist, because that's part of the state law is that you have to have a dentist owner. And then you have then they have an insurance product that they sell and the insurance is capitated, meaning that they pay up per member per month.

So if I'm a laminate, if I'm a laminate patient, so my company chooses laminate is one of buying potential dental insurance companies, and I' go with that. Then I go in and their incentive structures is totally flipped. So they make money if I stay healthy. Whereas for service, they make money if I need a lot of dental work. So the more crowns you do want me, the more money you make, But in Lamt, the healthier you can keep me, the more money they make, because they get paid paid for my enrollment per member per month, regardless of whether I use services.

Okay. So they've actually completely flipped the model and they haven't evidence-based protocols they use. It's really incredible. They have a fully integrated electronic health worker with using diagnostic codes and they do, they essentially do risk-based demry. So if you come in with high risk, they're going to see you a bunch of times, get you cleaned up, get you to health, and then, you know, off you go. Yeah, I coming in that low risk and I'm healthy and I don't they're like, come back in two years, maybe three, you know, like why are, why, why are we wasting my time in their time coming in, if I don't have any risk forlenies and I have no other issues that need to be dressed.

So I think that's when you talk about how good men can't be successful and how can they get it? And this company sees Medicaid. Like they Medicaid, they see medicating a commercially insured 50% of their pediatric population on Medicaid, and they're managing those kids and actually reducing health disparities between Medicaid kids and unmercially injured kids.

So you have to do it all like, it's almost like you have to flip the whole thing and then you have to do, you have to do multiple things at once and there's no like, we'll just raise the fees and then everything will be good, right? So multiple different factors. Yeah. Yeah. So, under the affordable Care Act, Medicaid expansion has has improved for low income individuals, but did this expansion. Yeah, who did the expansion, yeah.

Yeah, so did the expansion actually have a meaningful impact on access to dental services or has this divide remain pretty steady or gotten better or worse throughout the years? Yeah, I mean, it all depends because adultult dental coverage is optional, regardless of whether this state is a Medicaid expansion state or not. So the expansion state was that they expanded who's eligible for Medicaid so they made a bigger pool of people in order to pull in federal matching funds to be able to support their program.

So if they included dental in that, they should have pulled in those dental matching funds and been able to actually do more. I'm sure somebody's done the study on this. But if you expanded, if you expanded AXI 4 healthcare, but you said, nope, we still don't do dental, then at least for the adult population, you wouldn't have seen any difference because for kids again, it's Mary, the expansion, what has definitely been credited with expanded access for kids. but not for adults. for adults, it's mixed. It depends. You know, the expansion is the dense those are two different policy choices.

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You

Yeah. Yeah. And so kind of bringing it like a little bit more personally, but has UCSF kind of ever researched or talked about shaping or even just like their stance on medical dental policy for the future, like, such as through just informing their students are actually enacting specific like policy goals that they'd like to see happen.

 

Participant

I mean, has to no, I think going to wisdom so that they would be integrated and epic was very expensive and very big undertaking and the goal of that was like a more medical dental integration to really bring dental in under UC health.

The problem is, is that UC health is sort of a high-end health plan and does take Medicaid, but is the dental clinics in the dental school almost almost entirely only seen Medicaid patients. Okay. Because you're getting treatedes students. especially you're practicing on people people who actually have money don't want to go sit with G Dam on their Facebook three hours to save for a few bucks.

You know, that's not going to be a fun thing. But the problem is that we can integrate, but what they wanted to do was essentially make dental services at the dental center at UCSF available for people who are in UC Health, who are getting this like high-end healthcare.. But there's no one at the dental center to see them.

The faculty practice is like three people and the clinics are almost all student run. And so they haven't even figured that part out. It was like a huge mismatch in terms of the patient populations, in terms of thinking like, oh, okay, we're going to integrate this service, right? Yeah.

So, I think there's a lot of, there's a lot of talk about the importance. There's a lot of research, like research than I do, that looks at policy and looks at, you know, folks out in the community that are doing various things. But I will tell you that we take Medicaid in our pre-Doc clinic, but we do not take Medicaid in any other clinics. None of the specialty clinics except Medicaid, and the faculty practice doesn't accept Medicaid.

faculty practice doesn't even accept Delta dental, which is the insurance UCSM provides to their faculty and staff. So I cannot even use my own insurance that UCSM provides an incidental in the faculty practice at the dental school.

So what happens is, if you're in the pre-doc and you get, you need specialty care, we actually, even though we have specialty clinics in the same building, we're training people in every single, every single specialty in the building, including moral surgery. We refer our Medicaid patients back out to the community for specialty care rather than letting them go upstairs and get seen in our own clinics. Because and were Republic University and we don't accept Medicaid in two thirds of the clinics in.

So I'd say the idea and then like the reality are Yeah, they're very different.

 

You

Yeah. Exactly. Yeah, and to kind of like wrap everything up, this is kind of a far stretch, but if you could change one aspect of US Dental healthcare overnight, what would it be?

 

Participant

I would start with I don' not use that word anymore or whatever. Which is in behavior. when they had mental health parity, the law that was passed, essentially, it said, you can't can't strip out mental health.

Now they're not there yet in terms of practice, that they are there in terms of policy. So I would say that, you know, federal governments as we need to have universal coverage of dental. And so all private, all private health insurance companies need to either partner with or start a dental benefit and provide dental benefits in the undated part of the Medicaid needs to have full coverage for dental for anyone in Medicaid and Medicare needs to have full coverage for dental for anyone in Medicare.

So in theory, in the VA, the VA don't forget the VA hasn't horrible dental coverage. Like, our veterans have almost no dental coverage at all. And then there's trindcare, which is sort of this other. I have another another talk right of I'll finish up here. that I have so those things together, if you just said, and the federal government has the authority to do this, right, this isn't not just an essential benefit for pediatric, but an essential benefit. Dental is a essential benefit. It's mandated.

It's mandated all the way through Medicaid and it's mandated Medicare. That's when Bernie Sanders keeps putting forward, just starting with the coverage and making the money flows with the first thing, then you can starting the next step, which would be like how the delivery system responds. Right. It's multiple different layers. Yeah. Exactly. Yeah. Yeah. Yeah.

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Participant:
How are you going to use this information?

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You:
So, this summer, I'm planning on compiling on a lot of different interviews with different dental professionals and, you know, the paper would mainly focus on Medicaid aspects and I kind of did a much more historical paper in the previous year and kind of taking your input as well as many others into framing the future of dental policy and I think it's, like, pretty impactful to hear from real people who have worked in this field and know what it's like, especially dealing with Medicaid and dental patients themselves. You know, yeah.

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Participant:
Well, good luck. Make sure you send me whatever you do.

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You:
Thank you.

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Participant:
Yeah, thank you so much for talking with me today. And I loved your website. Feel free to reach out again.

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You:
Thank you so much.

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Participant:
Thank you so much. All right, I'll talk to you soon. Bye.