Flares Still Brewing Over Integration of Dental Care

The decision about when and how to integrate dental care into the coordinated care movement is likely to face the legislative assembly

January 30, 2013 -- Mike Shirtcliff insists he’s not trying to derail the transformation process and says that he supports the integration of dental care into coordinated care organizations, better known as CCOs. He just wants to make certain patient care isn’t sidelined by the process. Currently, 650,000 people on Medicaid receive physical and mental health services from the 15 CCOs throughout Oregon.

“I’m not trying to upset people; I’ve been a big supporter of the governor for a long time,” said Shirtcliff, president of Advantage Dental, a collective owned by 300 dentists across the state. “I just don’t want to end up with a disaster and want to make sure the patients we care for don’t get harmed. We created access to dental care when no one else wanted to and now we’re getting penalized for it.”

Legislators were clear about gradually transitioning dental care into the coordinated care organizations, and giving dental care organizations a seat on their governing boards -- Shirtcliff said – pointing to Senate Bill 1580 and House Bill 3650. Currently there are eight DCOs in Oregon. Advantage is among the largest, with 200,000 Oregon Health Plan members. Last year, it took in about $40 million in Medicaid funds.

But where the rubber meets the road is how long that long period will last. Shirtcliff said the statute is clear -- the coordinated care organizations must contract with all the dental care organizations in the regions they serve by July 1, 2014, and the dental care organizations have until July 1, 2017 to provide such services -- on that date all the managed care organizations go away. Until then, the law does not allow CCOs to contract with individual dentists or dental clinics, he believes. 

“All we’re trying to do is keep things viable until we can figure it out; no one knows more about oral health than me, and I’m not owned by a big out-of-town company or influenced by doing medicine,” he said. “We’re a dental-only company that created access to care when no one else wanted to. Not all dental care organizations are as vulnerable as ours. Some are owned by for-profit companies out of Florida (Capitol Dental Care) or affiliated with big companies like ODS.

"I believe the intent of the legislation was for the CCOs to deliver dental care exclusively through the dental care organizations until that later date which would give those organizations five years to exist and time to transition, and would have allowed the CCOs to begin to coordinate and integrate care and do what the transformation legislation intends them to do," he added.   

But Shirtcliff is running into opposition – along with Sen. Alan Bates (D-Medford) and Rep. Tim Freeman (R-Roseburg), he filed a petition last November to amend the administrative rules, saying that CCOs should not be allowed to contract with a dentist or dental clinic – before July 2017.

OHA denies the petition

Dr. Bruce Goldberg, director of the Oregon Health Authority, turned down that petition following a public hearing Nov. 14. Now he intends to re-convene a work group of CCOs and dental care organizations to discuss the policies, procedures and timelines to guide implementation of such contracts led by Barney Speight.

According to Goldberg’s ruling, the CCOs are required to contract with each dental care organization in their service area by July 2014, but are not prohibited from contracting with other dental service providers.

Several provider groups opposed Shirtcliff’s petition – among them the Oregon Primary Care Association, the Oregon Law Center and the Oregon Nurses Association.

“Promulgating an administrative rule that prohibits CCOs from contracting with other dental providers would exceed the Oregon Health Authority’s legally delegated authority and would codify law and policy in conflict with the legal and policy choices made by the legislative assembly,” according to John Hummel, state and federal policy director of the Oregon Primary Care Association, who testified against the petition. “If this petition is granted it would result in dental care organizations (Petitioner Advantage Dental is one of the largest in the state) realizing monopoly powers not granted by the legislature.”

Dr. Rick Kincade, a member of the Trillium Coordinated Care Organization board of directors, who’s a family physician with PeaceHealth Medical Group in Eugene, said there should be “no exclusive arrangements as currently exist with the dental care organizations.”

“Our CCO,” he added, “must be able to contract with multiple providers and not be limited to the few dental care organizations currently providing services in the area, and we must be able to bring them to the table as quickly as possible. The dental providers must be an integral part of the CCO’s care delivery system and cannot remain an ineffective and inaccessible silo.”

But, L.M. Reese, a community advisory council member of Trillium, agreed with Kincade, saying he was concerned about the availability of qualified dentists in Lane County, which could lead to access problems unless the dental care organizations were involved.

Dr. Jennifer Frankel, a dentist in Keizer, who supported the petition, indicated she could be “economically harmed and suffer the loss of patients” if CCOs were able to contract outside the dental care organizations prior to July 2017.

“The move toward CCOs in Oregon is something I very much support,” according to her testimony. “These organizations are still in their infancy with many issues to tackle. I see no reason to add another level of complication to the process by adding dental health right now.”

For his part, Shirtcliff said he’s not trying to get the governor, the legislature or any of the CCOs in trouble. “If we don’t do this right, and the current system comes apart, people will lose access to care.”

Of the Oregon Health Plan budget, only 6 percent of the money is spent on dental care, he added.

“Why aren’t the CCOs worried about the big money – mental health integration, hospital care, premature babies – why are they so worried about dental care? We don’t understand this. In the past, no one was paying any attention to dental because it was such a small part. But now the CCOs want to control dental too. I certainly hope we can work this out and finish transformation in an orderly fashion. I’m trying to be a good citizen and just take care of peoples’ teeth and not go broke in the interim or damage an Oregon company.”

But now it appears the legislature will have the final say on the outcome of integrating dental care.


To review the decision by Dr. Bruce Goldberg on the petition filed by Mike Shirtcliff, click here.

Image by Mattes (public domain) via Wikimedia Commons.

News source: 


An inacurate statement was made in this story regarding the testimony of L.M. Reese at the OHA public hearing. There was no disagreement between L.M. Reese, CAC member, and Rick Kincade, MD, Trillium Board member regarding dental integration into the CCO. Mr. Reese spoke in opposition to the petition to change administrative rule and never stated anywhere in his testimony DCOs are needed to ensure access. In fact his testimony states the contrary. See his comments below. My name is L.M. Reese. I am an Oregon Health Plan (OHP) member and have been going to Willamette Dental for several years. I have an oral health problem because I am unable to get my jaws open wide enough to adequately brush my teeth. I go to the dentist twice a year and have my teeth cleaned to prevent gum disease. I am fortunate that I have preventive care available to me. As a member of the Community Advisory Council (CAC) for Trillium, the Coordinated Care Organization (CCO) in Lane County, and one of two CAC representatives to the Trillium CCO Board, I attend regular board meetings. At a meeting recently an ER physician talked about seeing patients with dental related problems in the ER because those patients didn’t have access to a dentist. As a CAC member I am responsible for helping in the achievement of the triple aim: better health, better care and lower cost. I don’t see how we can do that without improved access to oral healthcare. If the Dental Care Organizations are allowed to limit dental access to providers who are members of their organization it will limit the availability of qualified dentists to provide services to OHP members in Lane County. I feel strongly that the Legislation that required a contract between the CCOs and a DCO in their service area on or before July 1, 2014, should move forward as originally intended and without restrictions that prohibit a contract with dental providers who aren’t members of a DCO.

It is somewhat ironic that Shirtcliff is concerned with patient care given I just sent Advantage Dental Services a complaint about a women with cancer not getting her teeth issues dealt with in a timely manner. Shirtcliff is President and CEO of Advantage Dental Services who have been violating patients rights under medicaid law for many years in Douglas County. They have a pattern of failing to provide services to medicaid patients in a timely manner and doing anything else they can so they reap the profits for the capitated payments they receive. They have made themselves, including Dr. Shirtcliff a lot of money, while failing to provide services to the dental patients in our community. Regarding the current issue: an Advantage Dental provider pulled all the person's teeth in May, but no teeth until December. Teeth did not fit so still no teeth. After the person's family complained, the patient was terminated as a patient from the practice. I am not necessarily a fan of CCOs, but when it comes to the reputation of Advantage Dental, if other dental care providers are like them, they need to be accountable to someone other than the state of Oregon, which has done little to address their abuses in our community.