LEWISTON – Paul Carrao needs dental care.

Because his old bridges and crowns have failed, the 69-year-old retired medical auditor has problems eating and can no longer speak properly. He’s so embarrassed by his teeth that he rarely goes out in public. His poor oral health has begun to affect his overall physical health.

But when Carrao, who is on MaineCare, tried to find a dentist to take care of his teeth, he ran into a problem. None would take him.

More specifically, none would take MaineCare.

His best option: Forget the expensive bridges and get full dentures. He was advised to have the rest of his teeth pulled, including the healthy ones.

“That’s down and dirty dentistry,” Carrao said. “It’s unethical.”

Maine’s shortage of dentists is well-known. With one dentist for every 2,100 people, experts say Maine has the lowest ratio in the country. Those numbers get even worse in northern Maine, where there’s one dentist for every 4,000 people.

But what’s less well-known is the plight of poor adults trying to access those few dentists. Of the 585 Maine dentists the state surveyed in 2006 – the last year for which such data is available – only 275 said they accepted MaineCare. Of those, 135 said they were not taking new patients.

In Androscoggin County, seven dentists took new MaineCare patients in 2006. In Franklin County, four did. In Oxford County, three.

Dentists say MaineCare reimbursements are so low and the paperwork so cumbersome that they lose money. So they won’t see those patients. Instead, some offer discounts to current patients who have fallen on hard times. They participate in charity programs. They give away care in a one-day annual event.

But what of the people who don’t have regular dentists and need care on one of the 364 days a year when there isn’t a free event?

Their options are limited.

‘This cannot go on’

MaineCare is a government health insurance program for low-income Mainers. For children up to 21, MaineCare provides full dental care, including cleanings and fillings.

For adults, MaineCare pays for emergency dental care and for services needed to relieve pain, prevent imminent tooth loss and address issues that affect patients’ health.

So, some root canals and extractions, yes. Dentures, possibly. Fluoride treatment, no.

Dentists do not have to accept MaineCare patients, and those who do may limit the number they take.

A few months ago, Carrao found Community Dental, a nonprofit organization that runs six dental centers with the mission to, according to its Web site, provide “affordable, accessible, quality dental health services.” It is one of the few to take new MaineCare patients.

Carrao went to Community Dental in Lewiston and the doctor came up with a treatment plan. Then, Carrao was told by staff members that his regular doctor had to sign off on the procedures as medically necessary if he wanted MaineCare to cover it. Carrao’s Veterans Administration doctor did, and Carrao submitted the required forms to Community Dental.

Then waited.

And waited.

Eventually, Community Dental told him they never submitted the forms to the state. Carrao said he was told the dental office didn’t forward the paperwork because they didn’t want any more MaineCare patients. The center’s supervisor, Debbie Littlefield, disputes that. Littlefield, who also serves on the MaineCare board, said she looked at Carrao’s paperwork as the office supervisor and realized he wouldn’t be approved for the work in the treatment plan, so she didn’t send it in.

The dentist, Littlefield said, hadn’t known about Carrao’s payment situation when he came up with treatment. That is a front office responsibility.

When Carrao told the clinic he was going to file a complaint with the Maine Board of Dental Examiners, Community Dental told him it would be willing to accept him as a patient if he paid on his own. They also referred him to a denturist in case he wanted to get dentures rather than deal with more expensive care, but Littlefield said she warned him MaineCare likely wouldn’t cover that, either.

Carrao, who spent his career investigating Medicaid fraud and abuse in California, was livid about the delays and his inability to get the care he needed.

“Obviously, I care about my teeth, but more than that, I care about social justice and this cannot go on,” he said.

Carrao called eight other clinics and dental offices across the state looking for someone who would see him. One by one, they said they didn’t take MaineCare. While the state has a list of dentists who provide MaineCare, it only provides numbers, not names or addresses, on its Web site And it does not publish the list because the names on it change so frequently, a spokesman said. MaineCare recipients must call a hotline number to get the information.

A money issue

Local dentists say they know there’s a dire need for dental care for the poor in Maine. They point to the roughly 200 people who waited for hours for free dental care one day last month.

But of the six Lewiston-Auburn dental offices that participated in that Dentistry with a Heart day, at least half don’t accept MaineCare, including Lewiston dentist Robert Limoges, who initiated the charity event.

“If I’m going to do it for free, I’d just as soon give it for free,” Limoges said.

He accepted state-aid clients until about 1990. He stopped because the state’s reimbursement rates were too low. Factoring in overhead and staff costs, he was losing money on every patient he saw.

“I wouldn’t mind just breaking even,” he said.

Except for a couple of minor boosts in the early 1990s, MaineCare dental reimbursements have stayed stagnant for at least a decade, according to the state. The Maine Dental Association said rates have remained largely unchanged for 20 years and no longer come close to what dentists normally charge.

State officials have long discussed the lack of dental care for Maine’s poor and the need to increase MaineCare reimbursements to draw in more dentists. Everyone agrees there’s a major problem and believes raising reimbursements would help, but one thing always crops up.

“It’s a money issue,” said Brenda McCormick, director of the Division of Health Care Management for the Maine Department of Health and Human Services.

An increase would cost Maine millions of dollars a year, and the state has never had the extra money. So reimbursements stay unchanged.

An analysis by the Maine Dental Association shows Maine’s reimbursement rates are now among the lowest in New England.

Unlike with private insurance, Maine dentists are forbidden by MaineCare from asking patients to pay additional out-of-pocket amounts. For example, if the doctor charges $300 to pull an impacted tooth but MaineCare only reimburses $100, that doctor cannot ask the patient to pay any of the remaining $200. So once dentists take MaineCare, they must accept whatever amount the state is willing to pay, even if the procedure costs them more to do than they’re going to get back.

“If you were a dentist and you could see everybody in your practice for full price, how many MaineCare patients would you take?” asked McCormick.

Paperwork is another problem. Dentists say MaineCare’s reporting requirements are cumbersome and time-consuming, and their office personnel constantly have to deal with claims that they feel have been wrongly denied.

Auburn dentist Jim Helmkamp called the situation a “nightmare.” He stopped accepting MaineCare patients at the beginning of the year, because of the low reimbursement and the paperwork.

“My administrative person couldn’t stand it,” Helmkamp said. “She was faxing and talking (to the state) and it just ended up a waste. I think for the last while we just didn’t charge them. We just did the work and didn’t even try to collect it from MaineCare.”

Medical duty

Carrao believes dentists have a duty as medical professionals to help their patients, regardless of a patient’s income. And that means participating in MaineCare.

“They are violating their oaths as dentists,” he said.

The Maine Dental Association balks at the notion that dentists don’t care about the suffering of poor patients.

The association points to its analysis that shows Maine is 20th in the country for the percentage of dentists who participate in their state’s dental program and ninth for dentists who do more than $10,000 in charity work each year.

And, according to the association, Maine dentists give away $8.5 million worth of care per year on their own, not including organized efforts like Donated Dental Services, which helps disabled patients.

“Their ethic isn’t, frankly, very different (from primary care physicians),” said John Bastey, director of government relations for the association. “They want to cure people. That’s why they went to dental school.”

Still, dentists say, they run small businesses, with expensive equipment and highly trained workers who need to be paid. They can’t keep providing services that make them lose money.

“It’s purely a business decision,” said Lewiston dentist Peter Drews. “Unlike the government, we can’t work in a deficit.”

Solutions?

The state is working on ways to get poor adults more dental care, but so far there is no grand solution.

Rep. Meredith Strang Burgess, R-Cumberland, has sponsored a bill to increase MaineCare reimbursements on 12 common dental procedures, putting Maine more in line with other New England states.

In its report in December, the Governor’s Task Force on Expanding Access to Oral Health Care for Maine People recommended a major increase for all dental procedures, but such a jump would have cost the state about $14 million. Burgess’ more modest proposal would cost $2.8 million.

The problem? Most of the 12 are children’s procedures. MaineCare adults would see little benefit.

Some dentists are willing to consider a change if the bill passes.

“I would participate in MaineCare if they did that,” Limoges said.

The Health and Human Services Committee held a public hearing on the bill last week. A work session is scheduled for Tuesday.

The state is also changing its computer reporting system in an effort to make it easier for doctors. And both the state and the dental association are working on ways to get more dentists to practice in Maine.

Carrao can’t wait to see if the changes help. He’s still looking for a dentist who will accept MaineCare. He still isn’t sure whether MaineCare will approve the dental work that his doctor says is medically needed.

“That’s the only thing I can do at the moment,” he said. “I must get dental care, above all for my health. But the other thing is, it’s no kind of life when you’re too embarrassed to socialize.”

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