Tim Leeds Havre Daily News tleeds@havredailynews.com
The local community health center is continuing to try to find more help for people who can’t find or afford dental care, although it is taking longer than hoped. “Were still working on it. We’re not giving up,” said Cindy Smith, executive director of the Bullhook Community Health Center. The health center, started as a county- operated clinic in 2005, reopened as a private nonprofit business last fall, moving to a new location east of Northern Montana Hospital. One of its stated goals before it made that move was to try to add oral health care. The issue is a hot topic on the Hi-Line and most of the rural part of Montana with a shortage of dentists and even fewer dentists accepting payment by Medicaid or the Children's Health Insurance Program causing people to have to travel hundreds of miles to find care. A Havre dentist said there aren’t enough dentists in the area to take care of everyone locally. “We have a tremendous shortage here,” said Dr. Gerald Olson, who has agreed to be a dental consultant for the health center. Olson added that when he started practicing in Havre 30 years ago there were nine dentists in town, two in Chinook and two in Malta. Now there is one in Malta, one in Chinook and five in Havre. “I would believe that at least a third of the people who live in Havre do not have access to a Havre dentist and have to leave town,” he said. Rocky Boy’s and Fort Belknap Indian reservations do have dentists working for their health services. Smith said Bullhook wants to try to fill the gap, including providing service for which people can use Medicaid and CHIP and if they qualify, they would be charged a rate based on a sliding scale depending on their income. A group of volunteers is working to create a fund to collect donations and contributions to help pay for the effort. “Our next step will be to try to get this dental fund started,” Smith said. Trying to fill a gap The search for additional dental care is a continuation of Bullhook’s original mission. The clinic was created after a consortium, the founding of which was spearheaded by Smith while she was director of nursing for Hill County, found significant gaps in health care coverage, especially for un- or underinsured county residents. While the clinic offered, and the private health center continues to offer, services to any who make an appointment, it offers reduced fees on a sliding scale, down to a minimum of $15, for people who qualify depending on their income. Smith has emphasized that while reduced-fee charges are available, the health center is not only for people with low incomes anyone who wishes to use the services provided by Bullhook are welcome, she said. She added that there seems to be a misconception about the target population for the clinic. “People think Bullhook Community Health Center is for poor people who don’t have a job,” she said. “(The patients are) mostly the working poor, people who have health insurance but no dental, people struggling with the price of gas and other problems.” Having a dentist, or dentists, on staff would offer service for people who can’t find a dentist taking new patients now, Smith said. It would provide service for people who are looking for someone who accepts Medicaid and CHIP and would also offer the service on the incomebased sliding scale, she said. Unfortunately, the first round of seeking to add oral health care has not gone perfectly the health center had hoped to have dental care in place by this summer, but grant applications have been denied and no dentist, as yet, has agreed to come work at Bullhook. “We just need to get dental care,” Smith said. “It should be as important as medical care because it leads to a lot of problems down the road.” A lack of service With dental care, there are several problems in finding service in north-central Montana. The first is simply the shortage of dentists. Karen Thomas, director of Child Care Link at the District IV Human Resources Development Council, said it is a major topic. Bullhook bringing in new dentists would be a major benefit, she said, especially for the families Child Care Link serves, which is primarily low-income working families. “It’s huge, absolutely huge,” Thomas said. “At almost every meeting I go to the issue of access to dental care comes up and always that we need more dentists.” Olson said the shortage of dentists is common in rural Montana but it is not just a Montana problem. Much of rural America, including areas in Wyoming and the Dakotas, is suffering a dentist shortage. Areas in Montana seeing population growth, such as Bozeman, Missoula and Kalispell are attracting a fair number of dentists, Olson said. In fact, there are enough that many of the dentists don’t have much work to do, he added. “Everyone wants to live in a beautiful mountain community,” Olson said. But in rural areas like the Havre area there are not enough dentist to go around. Olson said most of Havre’s dentists simply don’t have spaces open to accept new patients, no matter how they will pay for the service. It is difficult finding enough time to provide care for existing patients, he said. Mary McCue, executive director of the Montana Dental Association and formerly of Havre, agreed that the main problem is the lack of practitioners in some areas.“In general you would say there is a shortage but it is more of a maldistribution, because it is the rural areas where there is the greatest shortage,” she said. “Havre is one place in the state that definitely has a shortage. We actually feature it on our Web page” as a place in need of dentists. She said that while there is also a shortage of dentists who accept Medicaid and CHIP less than half the dentists in Montana accept Medicaid at this point the problem in the Havre area is simpler. “The difficulty in Havre is the shortage of dentists,” McCue said. “No one is able to get in as a new patient.” Medicaid and CHIP The problem seems to be highlighted for those who need to use Medicaid or CHIP, however. Petersen, health information coordinator for Bullhook Community Health Center, said the lack of dentists accepting CHIP and Medicaid can lead to serious problems. She said families have had to take their children as far as Great Falls or Helena to find dentists who accept new patients using the coverage, and the delay has led to complications including dentists needing to pull several teeth from young children. The problem affects many in the area. The application Bullhook submitted to the state for a grant to create new dental services said of the county’s 16,248 residents 21. 4 percent, or more than 3,475, utilize Medicaid, compared to a state average of 12. 3 percent. Of those residents, 63 percent are younger than 21 and 12 percent are 65 or older. State figures show the usage of CHIP: the latest figures for Hill County show 348 children enrolled June 1, up from 321 on May 1. In Hill, Blaine, Chouteau and Liberty counties the total enrolled in CHIP is 641, up 32 from May 1. Olson said most dentists won’t accept those coverages simply because of finances the payment by Medicaid and CHIP is so low that it generally won’t cover the cost of working on a patient, he said. “Every time a Medicaid patient sits in my chair I am literally donating my time or paying them,” he said. He said the problem is exacerbated for new dentists. The low payment makes it difficult or impossible for dentists fresh out of school to be able to afford paying their education expenses and the cost of setting up a new practice, he said. “They can’t afford to accept Medicaid,” Olson said. He added that Havre dentists do work with the programs in his office, the dentists have worked with Medicaid patients from Head Start, the Havre Day Activity group homes and the Northern Montana Long Term Care Center, he said. Thomas said the local dentists have been very helpful when they can. Olson, Dr. Robert Jestrab, Dr. Michael Shelby and Dr. Lee Laeupple donated their time April 2 and 3 to screen 50 children for dental health issues, for example. “They really have stepped up to help us as a community,” she said. Jan Paulsen, Medicaid dental program officer at the state Department of Public Health and Human Services, said about 250 dentists in the state now accept Medicaid, but that number fluctuates as dentists drop out or add the coverage. “It’s kind of a moving target,” Paulsen said. She said there are several problems dentists usually list with participating in Medicaid, which Medicaid officials hear nationwide. “The main one being people not showing for appointments,” she said. “A dentist doesn’t like to have a half-hour of no income whether it’s Medicaid or Blue Cross or whatever.” Another is the hassle of dealing with the paperwork involved. “Proper forms, pre-approvals, it’s just another system to navigate,” Paulsen said. “Many of them have had a bad experience and don’t want to go there again.” The reimbursement rate is another issue Paulsen said, but bookkeeping can be part of that hassle and dentists often dispute the rate Medicaid says it is paying in the state. She said the program in general pays about 85 percent of a customary dental fee, but dentists often submit a lower figure, closer to what they expect the program will pay, to avoid having to go back and redo their books. That leads to the Medicaid workers using that lower figure to decide how much can be paid, and leads to a lower amount than the 85 percent of the customary fee, she said. “We can only work with the figures we are given,” Paulsen said. Funding sought Smith said Bullhook Community Health Center has unsuccessfully applied for 20 grants to help pay for bringing in dental service since it moved in to its new location, leased from Northern Montana Health Care, last September. Those applications included to the state government for a share of the money approved by the state Legislature to help provide dental care all of those grants went to places that already had some service, she said. Bullhook has $89,000 in its budget for dental care she hopes to use to help set up a program, Smith said, and the health center will continue to try to raise funds, including the committee formed to work on that and by applying for more grants including the next round of state funding. The health center has worked with dentists, including offering to provide vouchers to help pay for services, trying to get dentists to block out times to work with Bullhook patients and trying to schedule appointments for patients. “We’re actively trying to recruit a dentist in practice to team up with us,” she said. Smith said Dr. Michael Veseth in Malta has helped, providing care for patients using Bullhook vouchers, which sometimes includes vouchers to help pay for the travel to Malta. Olson said the issue with working with Bullhook, such as blocking out time to see its patients, is the same as accepting any new patients. “The real problem is, if you’re not an existing patient we’re not able to block out time ,” he said. “Our own patients are not getting time.” He said the Havre dental community in general would welcome new dentists. He said he supports Bullhook’s efforts, as well. “I think it’s a great idea to try to recruit a dentist, particularly to try to care for the low-income (people),” Olson said. “The ones who are really in trouble are those people.”
