Private-equity driven dentists accused of "dentally abusing" poor kids on Medicaid with painful, unnecessary procedures

Hedge funds in America have backed several dental practices, and Medicaid and parents allege that this has led to a rash of "dental abuse" of poor children, who are seen by dentists at school, without parental consent, for invasive and painful (and expensive) procedures performed by dentists. Critics say the dentists have to meet quotas in order to attain the valuations set by the private equity funds who call the shots. A North Carolina bill aimed at fighting this practice is being fought by three funds (Leonard Green, Court Square Capital Partners, and Levine Leichtman Capital Partners) who've raised $1.1 million to kill it.

Sydney P. Freedberg writes in Bloomberg:

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. A dentist’s statement in his backpack showed he had received two pulpotomies, or baby root canals, along with the crowns and 10 X-rays -- all while he was at school. Isaac, who suffers from seizures from a brain injury in infancy, didn’t need the work, according to his mother, Stacey Gagnon...

In August 2010, Green’s lawyer appeared before the Arizona dental board to answer a complaint that ReachOut did unnecessary drilling on a Phoenix student’s teeth -- even after the student’s mother told the company she was seeing a family dentist and didn’t need any work...

There were two children with the same name at the school, and the work was done on the wrong Sabrina Martinez, Green’s lawyer, Jeff Tonner, told the dental board. Although the board agreed that work was done on the wrong child, it dismissed the case, noting Davila had complained about “the business entity,” not a dentist...

In San Diego, Tina Richardson’s third grader, Alexander Henry, came home in March with four baby teeth missing after a school session with a ReachOut-affiliated dentist that was so painful he “waved his arms frantically,” “pushed everyone off him” and “bled so badly that they had to send him to the nurse’s office,” according to her complaint with the state dental board. Among other things, Richardson said the consent process wasn’t valid.

Richardson said Alexander had seen a dentist nine days earlier who didn’t recommend any teeth pulling. Although she signed a consent form in September covering many procedures including extractions, she said she didn’t sign another one that came in November seeking permission to take out three teeth. No one from ReachOut called to discuss the proposed procedures, she said.

Dental Abuse Seen Driven by Private Equity Investments (via Naked Capitalism)

(Image: Reeve 12265, a Creative Commons Attribution (2.0) image from 27337026@N03's photostream)

• [TooGoodToCheck]

  Did no one ever stop and say, perhaps Marathon Man is not the model we want to emulate in public schools?

  • [CognitiveDissident]

    Who are you to stand in the way of Prof—Progress?
    After all, those Baby Teeth are not going to take of themselves, be sure to take advantage of our full line of baby teeth braces, and even baby teeth bridges to hide those unsightly gaps. For advanced cases, we even have baby dentures.
    Baby Teeth… nature’s way of doubling our pay!

• [Vanco]

  Reach Out Into Your Child’s Mouth And Hurt Him, it should be called.
  Well, I wouldn’t go to the Dental Board, that’s for sure…

• [relawson]

  I decided to change our pediatric dentist practice due to what I thought was some sort of “quota” to do as much work as possible on my kids.  After 2 more opinions confirming my suspicion that they suggested an excessive amount of “needed” procedures, and we weren’t the only parents that came to them with that feeling.

   We dropped the offending dentist quickly.

  There is a “healthy smiles” program at their school which provide checkups and things to kids. I understand it really is to help those that may not be able to have regular dental coverage, but we made it VERY clear that they are NOT to touch our children.  If they ever do, heads will surely roll. 

• [Keith Didion]

  So dentists licensed by the government, practicing under the oversight of government-run schools, and billing a government healthcare program…and this is a failure of “private equity” and, by implication, the free market?

  • [Mike]

     The state and corporations collude to screw-over the working class.  Fuck both of ‘em.

  • [shadowfirebird]

     It *is* the private equity that motivates them to do this.

  • [deaduncledave]

    Yes, Keith. As the article has explained, these are procedures being performed by dentists whom are contracted with private insurance providers that provide management for Medicaid services. This is a trick that GOP have used to divert funds set aside by the government back into for-profit corporations. The argument was that private management will be more economical, as a for-profit company will be more interested in trimming deadwood and improving business procedures. The sad eventuality is that the for-profit companies cost MORE to operate, per procedure, than the government managed plans. How much? Anywhere from %15 to %21 percent more, if the CEO of my practice is to be believed.

  • [Navin_Johnson]

    It is exactly what happens when you let “the free market” corrupt Democracy and government. It’s a good example of why private interests should be excluded from so many government programs and policies.
    

    Isaac’s case and others like it are under scrutiny by federal lawmakers and state regulators trying to determine whether a popular business model fueled by Wall Street money is soaking taxpayers and having a malign influence on dentistry.

    Isaac’s dentist was dispatched to his school by ReachOut Healthcare America, a dental management services company that’s in the portfolio of Morgan Stanley Private Equity, operates in 22 states and has dealt with 1.5 million patients. Management companies are at the center of a U.S. Senate inquiry, and audits, investigations and civil actions in six states over allegations of unnecessary procedures, low-quality treatment and the unlicensed practice of dentistry.

    • [Antinous / Moderator]

      I switched your italics to a blockquote in the interest of sparing readers a headache. It’s really better to use blockquote if the quote is more than one sentence or so.

  • [YanquiFrank]

    Um.. yeah.  Its the “free market” limitless profit-seeking douchebags in the private equity cesspool that are pushing the quotas.  Sure the dentists are unethical for going along with it, and the state is idiotic for paying for procedures instead of outcomes, but ultimately it is the private equity scumsuckers who are pulling the trigger to increase their profits.  It is the eternal question of skewed incentives.  It was the same story in the housing bubble.  The banks compensate their employees for short term (< 1 year) gains, incentivizing traders, etc. to inflate short term gains at the cost of long term losses (creating and securitizing hordes of crap loans) so as to increase the yearly bonus.  By the time the losses start coming in the traders have all made at least a few years worthy of massive bonuses and don't really care if the bank goes belly up at that point.  The skewed incentives in this instance are the payments per procedure rather than per outcome.  But IN THE FINAL ANALYSIS, its the bankster scum that have the complete lack of ethics it takes to actually push the button that makes them all this money at the expense of  rest of society.  So yes, its the profit-seeking free marketeers predating on a poorly designed system for their gain and our loss.  Just because the gun is on the counter and the security guard is on break, it doesn't mean you should rob the bank.  Its the free market types who want, nay demand, the right to rip people off and take us back to the bad old days of "buyer beware".

  • [Aleknevicus]

    In a word: yes — it’s a failure of “private equity” and the free market. The government (in the various forms you mention) is the one paying for these procedures. Their incentive is to do as little as necessary.

    Private equity, on the other hand, is the one being paid for these procedures so their incentive is to do as much as possible. Given that the problem is that too much is being done, then yes, private equity is to blame.

  • [Rob Gehrke]

    “…and this is a failure of “private equity…?”
    No, Keith. It is a resounding success.

• [shadowfirebird]

  A part of me wants to make a joke about Doctor Oren Scaravello DDS. 

  A part of me just wants to scream.   Doing uneccessary dental work on a FOUR YEAR OLD  — WITHOUT PERMISSION FROM THE PARENT!?! 

  I think that may be the worst thing I have ever heard of.

  • [shadowfirebird]

     I’ve thought it over, America, and this invalidates all those anti-gun-control arguments.  I’m not hearing stories of these dentists being shot*.  You don’t get to keep the guns.

    (* And, ideally, fed to giant singing plants+.)

    [+ The point I'm making here is that the shooting part is a joke.]

    • [IRMO]

      I thnk a truly just retribution here would be something inspired by Marathon Man.

  • [Finnagain]

     then you have lived a very sheltered life.

    Anyway. Don’t we have ambulance-chasing lawyers for this sort of thing?

  • [angusm]

    @shadowfirebird:disqus  ”worst thing you’ve ever heard of”? 
    How about a couple of judges accepting $2.6 million in bribes from the owner of some for-profit juvenile detention centers to send kids to his prisons? http://en.wikipedia.org/wiki/Kids_for_cash_scandal

    Unnecessary dental procedures is up there, sure, but I think taking bribes to jail kids is going to be the one to beat for a long, long time. 

  • [elix]

    I’m not particularly in favour of the Pedos Will Eat Your Babies paranoia/helicopter parenting that society’s increasingly gotten itself into, but…

    Doing uneccessary dental work on a FOUR YEAR OLD  — WITHOUT PERMISSION FROM THE PARENT!?!

    Where’s the lynch mob here? Where are the death threats and eggs and such? (Note: Please do not make death threats.)

    Also, sure, those baby teeth will come out and be replaced with adult ones, but 10 xrays on a toddler without permission? You can’t take that radiation back.

• [hymenopterid]

  I work at a dentist’s office where my dad is the doctor.  I hate to say this but I’ts frightening *some* of the cases we see coming from other offices.  We have seen patients who have been told by other dentists that *all* of their kids baby teeth needed filling or else the decay would infect the roots of the permanent teeth.  This is bullshit scaremongering.  A friend of mine went in to get a cleaning at another office and they told him they could not and would not do a cleaning until after he had some other procedure that involved antibiotics.  The proposed procedure was of course over $1000.  If a dentist ever tells you that your kid needs fillings in their baby teeth you should probably get a second opinion(+edit filling a baby tooth is not unheard of, but it’s usually just to alleviate pain as the baby teeth are not a long-term concern).  If your dentist ever tells you that you need an expensive procedure *before* he will let his hygienist give you a cleaning, then you should probably find a different dentist.  The idea of denying a patient a cleaning just boggles my mind.

  This is so sad, because many dental problems can be prevented with some simple and inexpensive maintenance.  Furthermore it is my perception that there is never a lack of patients in need of the more serious procedures.  There is no need to drum up business by over-treating the patient.  Somebody will always call in with a toothache.

  Lastly I would like to say that one of the challenges we face is dealing with patients who are dental phobics.  This kind of behavior from dentists erodes any trust the public has in dentists.  It’s pretty hard to get someone to trust you when they’ve been subjected to that kind of deceit before, particularly if it occurred at a young age.

  • [Antinous / Moderator]

    My previous veneer salesman dentist felt that the answer to all of my dental problems (of which I had none) was sixteen shiny veneers at $1,500 apiece. After seeing him for a few years, I noticed a little recession on a bottom tooth. I went for a look-see (and mind you, this was two months after my regular visit), OMG all my bottom teeth were going to fall out and needed veneers.

    My new dentist looked at my teeth and X-rays and said, “Yeah, there’s a little recession. No big deal.”

    • [hymenopterid]

      It’s insane.  I don’t know how a patient is supposed to tell the difference between those two docs without actually being put through the ringer first. Yelp I guess.

      • [Antinous / Moderator]

        The bad dentist had chiclet teeth.  I should have recognized that omen.

      • [MetalPorkchop]

        Do your research and then ask lots of specific questions pertaining to what procedures are being suggested.  Ask for alternatives.  There is loads of information online regarding procedures, what terms mean, why certain things are necessary.  If you have radiographs taken, ask to see them and have the provider explain to you what they see and what it means.  Also, it doesn’t hurt to ask if they sterilize their tools, if the room is wiped down between each patient, etc.  Make sure you get a proper lead apron for small radiographs and a proper one for a panoramic radiograph, it should cover your back as well as your front, since the head of the machine goes around your head.  I love when patients ask questions; if the provider gets annoyed or offended with your questions, you should leave.  Their job is to provide health care and educate patients, not rip them off.  Be sure to keep track of what you’re being billed for.  Everything has its own codes.  Cleanings and polishing is done in units of time, a unit being 15 minutes.  If you’re being charged for 3 units of scaling/ cleaning, did the hygienist spend 45 minutes cleaning your teeth.  Polishing is done in half and full units, most people don’t need 15 minutes of polishing, but most clinics bill a full unit.  Do you need fluoride, it depends on how old you are, and more importantly how frequently you get cavities.  Check out dental and dental hygiene regulatory body websites, they should list the most current fee guides, and yes they are guides, so some clinics can and do choose to charge well above the recommended fees.  All this info is out there, but majority of the public doesn’t know.  I’m more than happy to answer with honest, no BS info.  Knowledge is power.  If you are ripped off or mistreated, contact the dental association, in Ontario, Canada it’s RCDSO.org and don’t let them shrug you off.  Google your area’s contact info.

      • [Antinous / Moderator]

        My fundamental dental problem was presbyopia. If I had gotten reading glasses two years earlier and worn them to the bathroom sink, I would have seen that I wasn’t getting optimal care.

  • [ocker3]

     I think most people find it hard to get a same or next-day appointment at a dentist. If their schedule is always full on the day, I reckon that means they’re doing well on the business front, so yeah, not really a need for a good practice to drum up extra work

  • [MetalPorkchop]

    I’ve worked in dental public health as well as the private sector, in Canada.  I mainly do contracts, and form my experience most dentists are slimy money hungry douche bags.  There were a a few I have respect for, mainly in public health (gov’t funded).  A dentist who chooses to work in public health over running her/ his own practice, is not in it for the money.
    Back to those baby teeth, sometimes fillings and crowns are necessary on young kids, if they have large cavities on baby teeth which still should be around for a while.  Baby teeth make the way for adult dentition, so retaining baby teeth secures a proper place for adult ones to grow into and prevents crowding and the possible need for braces later on, though there are other factors involved.  People should take care of their kids’ baby teeth, and not flake off thinking they serve no purpose and will just fall out.

• [human remains]

  When my mum was growing up in the Republic of Ireland in the early 60s, she was taken to the dentist at 16 who advised her to have all her teeth out in one go. Apparently to save the bother of doing it when they eventually did need pulling out, decades later. My Grandma refused and they later found out he was doing it to many other families as he was paid per tooth pulled.

  • [FelixDio]

    Well I can pretty much snap that: replace Ireland with Scotland and 14 for 16 and that’s me. Sadly no-one was going to offend the dentist by denying his judgement.

    To make matters worse, he did a woeful job of extracting the roots of the teeth and some fillings, so I got to spend a fun few days digging into my gums, finding the refuse, and plucking it out by hand.

    Fun stuff, huh?

    • [ocker3]

       My Dad’s teeth are now rotating in his gums because they pulled out too many teeth when he was a kid :( Gov-run dentist in Victoria, Australia, back in the 60s

      • [Vickie Kostecki]

        My mom, about 1950 Ontario when she was 18. She has worn dentures since she was 18. The mind boggles.

        • [MetalPorkchop]

          Pulling out all teeth was a fairly regular practice back in the day.  Often times it was a wedding gift to the bride.

        • [Ultan]

          ->MetalPorkchop
          Yeah, that was in Orwell’s The Road to Wigan Pier, IIRC

    • [MetalPorkchop]

       The sad part is that many people still don’t question dentists and doctors, not wanting to offend and perhaps thinking that they know it all.  They don’t, and many of them don’t care to.  If only people went into the proper professions for the right reasons.

• [bcsizemo]

  How anyone can inflict such things on kids I will never know.   I had the whole bag of orthodontics as a teen: 4 teeth removed, braces, bands, and headgear.  Four years later I had an excellent smile and my wisdom teeth have come in fine….

  But I can assure you on those days when I went for a check up and had my braces and headgear tightened…I just wanted a bottle of pain killed the rest of the day.  I could not imagine subjecting a child to a root canal.

  I’ve been lucky that my parents had good dental coverage and I never had a cavity.
  (The last dentist I went to just stared at my mouth during a cleaning going “Wow”.)

  • [First L]

    Doctors and dentists are desensitized to the sound of children in pain before they leave school to practice.  The desire to maintain the lifestyle of their predecessors in the medical establishment will lead today’s doctors and dentists to even more deplorable acts of barbarity as the rest of the working masses have come to accept that the American dream has been shipped offshore, and all the assets they have left are taken by the hospitals once just one family member ever gets sick.

    For decades doctors have withheld epidural pain medicine from women giving birth while on medicaid – to teach them to have money or insurance for the next time they get pregnant.

    http://www.nytimes.com/1999/03/08/us/mothers-on-medicaid-overcharged-for-pain-relief.html?pagewanted=all&src=pm

    I’ll take European or Canadian “socialized medicine” any day over the American fascist health system we have today.  There is no “free market” in how medicine is practiced in America today anyway, and the arguments against universal health care are absurd.  This is from just some guy who’s voted Republican his whole life, even in the last Presidential election (of which I am now ashamed).

    • [bcsizemo]

      I agree that the greed aspect is really deplorable.  I think universal healthcare is a valiant idea, but the way it is being presented now makes it seem like the same old system with the money just flowing through new hands…

      I figured out a long time ago, voting isn’t about putting the best person in office.  It is really about choosing the lesser of two evils.

    • [Velocirapt42]

       Okay, seriously. I work in a pediatric hospital. Nobody is performing “deplorable acts of barbarity” on these kids.  There is a pain management department comprising of a variety of disciplines, from anesthesiology to acupuncture. Not one of the doctors I work with is okay with a child being in pain that could have been prevented. We take pain seriously and work really hard to decrease and eliminate it. Please don’t label the wonderful, caring doctors and dentists I work with as desensitized or barbarous. There are great doctors and dentists, and doctors and dentists who really don’t care, and not all belong to the latter category.

      • [cdh1971]

        I agree with you, your last line in particular – there are more docs and dentists that care than do not. 

        Any doctor or dentist, like your colleagues who work in a pediatric  hospital have self-selected to work there because they care more about children and youths than the average doc. My understanding is that these folks make at least a little less than the average doc/dentist and require extra training. 

        The present entry discussing the quacks employed by private-equity firms who commit malpractice to pad the bottom line doesn’t diminish the many good  docs and I think most readers should understand this. 

        These threads always have a lot of hyperbole don’t they :)

• [chgoliz]

  There seems to be an inverse relationship between The Free Market and the rights enshrined in the U.S. Constitution.  One of them is going to have to back down.

  Silly me, putting that thought into the future tense.

• [WillieNelsonMandela]

  The ghouls that perform these procedures need to be named and shamed. Revoking their dental licenses would be even better.

  • [hymenopterid]

    The worst part is it’s nothing new.  I honestly think that some dentists are unwilling to speak out about this because they already perceive that the public doesn’t like dentists.  A lot of dentists have self esteem issues because the public regards them with such suspicion.  The result, I think, is an “us versus them” mentality not unlike what you see with cops or bankers.  There needs to be some enforcement of standards coming from the dentists themselves while the industry still has some credibility to save.  Dentists have got to start calling out these bozos.

    • [Donald Petersen]

      A lot of dentists have self esteem issues because the public regards them with such suspicion.

      I used to have a nine-fingered dentist.  He always seemed like a swell guy, friendly and professional, but in the back of my mind I always wondered what happened to that missing digit.

  • [First L]

    Revoke their teeth and the teeth of the PE firm’s directors and CEOs while they’re at it!  The fact that they are fighting back against the legislation is blatantly deplorable.  Not even 100 years ago the “dentists” and business men associated with them would have been tarred and feathered – a painful and shameful process – while the local sheriff set up a perimeter to contain the mob violence and keep it from spreading out of control.  They would have been literally driven out of town.  The ubiquitous presence of cameras, the certainty of prosecution, and the career limiting effects of a criminal record have taken the fun out of democracy “of the people”.

• [robert feller]

  This same thing happened to me and my family by a crooked dentist and a mother who is gullible. The doctor drilled every tooth in my brother and my head…yet I’ve never had another cavity after I turned 16…for the last 30 years. Scam artists…

• [Hans]

  Although she signed a consent form in September covering many procedures including extractions, she said she didn’t sign another one that came in November seeking permission to take out three teeth.

  I question whether that could possibly be informed consent.  If the parent is asked to consent to a wide range of procedures, it seems unlikely the provider has explained the necessity and risks of the procedures which are specific to the case. Indeed, it sounds as if they are asking consent to perform procedures which have not yet been diagnosed as medically necessary.  That sounds quite at odds with conventional medical ethics.

• [wibbled_pig]

  I guess a few people took Steve Martin’s role from Little Shop of Horrors as a model..

• [raymondjacksone]

  By learning from “Penny Health” When it comes to medical insurance, never use the words “experimental” or “investigational” or tell them that you want them to pay for a clinical trial.

• [IronEdithKidd]

  Right about now, I’m thanking His Noodly Goodness that I have dental insurance for my little one and that my dentist’s day job is being a professor at the local Big Ten university dental school.  Ramen.

  Fuck everyone participating in the oral butchery of our underserved youth.

  • [Antinous / Moderator]

    I used to go to the dental school at UCSF for my dental care. It’s really cheap. A student does the work, but there’s a professor there double-checking everything. It does take about twice as long as going to a regular dentist, but a great option if you don’t have much money.

• [Cazmonster]

  It really sucks that I came up with evil dentists in a dystopian RPG. They aren’t nearly as evil as these guys.

• [blueprairie]

  Interesting.  Not one single dentist in our county (I’m in Illinois) will take Medicaid patients because the reimbursement doesn’t even cover the cost of sterilizing instruments.  Where is all this $$$ coming from?

  (Not that it’s more than a drop in the bucket, but the county  health dept has a dental clinic for children, and one dentist in the county takes need-based patients one day per month, for free.  He says it costs less than the extra billing paperwork would if he invoiced Medicaid.