Brian McNicoll

One of my first employers after I moved to Washington, D.C., enrolled us in a Kaiser health maintenance organization. I loved it. I thought it was effective and efficient, convenient and caring.

I was young then. I didn’t know a doctor and didn’t want to know one. My medical issues involved basketball and softball injuries. I needed a quickie X-ray, a pain pill, a brace and a nice form to sign.

But it wasn’t to last. Even then, in the early 1990s, HMOs had become controversial. I wanted my healthcare to be impersonal, but others with more complicated medical needs didn’t. They complained of vending-machine medicine – uncaring, unresponsive, error-prone, focused to an unhealthy degree on cost-containment. The estrangement led to bitterness, the bitterness to piling on by the unwitting media. The media reports, of course, attracted trial lawyers like blood attracts sharks.

By the late-‘90s, corporations were scrambling to get out of the HMO business. A few survived, and there is some evidence the concept is making a comeback. Turns out HMOs had a pretty good business model and did not have a monopoly on uncaring, unresponsive, error-prone medicine.

Today, the same thing is happening with dentistry. Traditional dentists have even less incentive to deal with transient customers, such as the younger me, Medicaid patients and others who seem unlikely to become lucrative and permanent customers. They aren’t often asked to save lives on an emergency basis, so they can pick and choose. And they do.

As a result, a lot of people end up without dental coverage – three times as many kids lack dental coverage as lack health insurance. And since a lot higher percentage of dental bills are paid out of pocket – 40 percent for dentistry, 10 percent for the rest of healthcare – poor kids often miss out.

The dangers of missing out go beyond a little extra brown on the teeth as well. A missing tooth can be the difference between a life in the professions and one spent scrambling to make ends meet in dead-end jobs. Moreover, kids who don’t visit dentists miss school more, access emergency-room care for dental problems far more and run higher risks of diseases such as heart disease, stroke, arteriosclerosis, rheumatoid arthritis and diabetes. Mothers who grew up without proper dental care are significantly less likely to carry children to term.

And every so often, somebody dies.

It happened in Maryland in 2009. Deamonte Driver, a 12-year-old boy, died when an infection that started in his tooth spread to his brain. His mother tried to find a dentist to treat him but couldn’t because fewer than 1 in 5 today will accept Medicaid patients.

Congress responded by adding a dental benefit to the Children’s Health Insurance Program (CHIP) and tailored the legislation to encourage the development of Dental Management Service Organizations – DMSOs – which function basically as HMOs for dental care. DMSOs have figured out a way to do something traditional dentists have not – turn a profit treating those transient customers, particularly disadvantaged children.

Basically, management companies buy up dental practices and bring economies of scale into play. They purchase in bulk, manage for efficiency and survive on the low reimbursement rates of Medicaid. The chains they’ve created are growing in notoriety – Kool Smiles, All Smiles, Reachout American and Aspen are among the big brand names.

It’s working. There are two ways you can tell. The first is a recent Pew study that shows more poor kids are getting to see dentists, fewer are missing school over dental problems and more Medicaid patients are getting regular care. Maryland, which had a bad record on children’s dental health before the Driver tragedy, now gets an A from the Pew study of children’s dental health.

The other way you can tell is that the sharks are out. Trial lawyers are trolling for clients … actively encouraging people to find something wrong with the dental work they had done at a DMSO and sue the firms. One firm, Moriarity-Leyendecker in Houston, devotes its Facebook page to condemnation of all things DMSO.A website called Dentistthemenace.com, hosted by someone claiming to be a grandmother who became enraged at news reports, delivers shrill, crude and suspiciously targeted attacks on the industry. It took to task the mayor of Dallas last year for allowing All Smiles to give free dental exams at a back-to-school event the city holds each year. It actively solicits embittered former employees of DMSOs to report wrongdoing. It is curiously uninterested in such complaints from former staffers of traditional suburban dentists.

DMSOs are where HMOs were back in the ‘90s. They’ve figured out a new way to profitably deliver dental care to patients who otherwise may well go untreated. They are new and still trying to earn the trust of customers, and a few bad apples have made this even more difficult. There are a few business practices that will have to be adjusted – incentivizing volume when it comes to government-paid healthcare is not conducive to good publicity.

But the answer is to fix the industry, not destroy it. Quality dental care is financially out of reach for more Americans now than ever before, and DMSOs are bringing quality care to millions of American children who could not otherwise access it.

Be wary of the way the media presents these businesses. The TV reports are suspiciously similar. A high-volume clinic is shown. An entrenched family dentist who wouldn’t serve any of those patients on a bet is asked if this clinic is operating properly. “No, it’s not,” he intones. “This is tragic.” It’s tragic, all right. It’s tragic that a niche of the massive dental industry, one that exists solely to serve the underprivileged, is under attacks such as these.

But that’s what happens when you start to have a little success.


Brian McNicoll

Brian McNicoll is a conservative columnist and freelance writer based in Alexandria, Va.