campaign desk

Golden Teeth

Dallas’s WFAA shows crooked Medicaid spending on orthodontia
September 1, 2011

These days it’s rare for local TV stations to produce anything resembling an expose. With their steady diet of crime, weather, and canned medical news, there just isn’t room for the hard reporting. WFAA, the ABC affiliate in Dallas, has earned a reputation as a notable exception. Throughout the summer, the station and its investigative reporter Byron Harris have taken on the Texas Medicaid agency and its spending spree for braces for poor kids.

Now there’s nothing wrong with these children getting braces. Many, no doubt, will benefit in the long run. The problem, Harris reported, is that last year the state paid more than $184 million—nearly double the amount it spent in 2008—to supply braces for 120,000 kids, some of whom may not have met the state’s criteria for orthodontic work.

The money is supposed to be spent for children between ages 12 and 19, whose teeth are so crooked they could result in a handicap. Medicaid pays some $2,200 monthly per patient for each kid with so-called crisis teeth. Texas law says Medicaid funds can’t be spent for orthodontia merely to improve a child’s appearance. Harris told his viewers: “Judging by the increased payouts, the teeth of Texas children are growing more crooked each year.”

Who’s minding the public purse down there? It appears that the state may not be looking too closely at what it is paying for, or perhaps it is looking the other way. Orthodontists as well as general dentists can determine whether a child simply has crooked teeth or crisis teeth in need of the state’s help. An outside contractor processes Medicaid claims, and apparently rejects the claims only if the paperwork is incomplete—and not on the basis of a medical evaluation.

The contractor uses a score sheet for each case, and a score of twenty-six means a kid will get help. “Any way you fill out that sheet will be approved,” one orthodontist told WFAA. “Providers use that [evaluation] as an excuse to lie on that sheet because there’s no checks on that sheet.”

Because their permanent teeth may not be in yet, Medicaid dollars are not to be spent on braces for kids under age 12. Even so, last year 19,000 kids under that age got braces anyway—that’s twenty-four percent of all Texas children who received braces courtesy of Medicaid, Harris pointed out. The state does allow exceptions to its age rule, but one doctor at the Baylor College of Dentistry said it was unlikely that the state dental director reviewed and approved all 19,000 of these cases.

Sign up for CJR's daily email

What makes Harris’s series so interesting is that he has used government documents to trace where the Medicaid money is going. It’s going, it seems, to clinics, some of them once owned by local dentists but now owned by hedge funds. That makes “Wall Street the ultimate destination for millions of taxpayer dollars,” Harris reported. In one segment, he told of Richard Malouf who, along with his wife, owned All Smiles Dental Centers, a chain of fifty-one clinics that raked in more than $10 million last year. According to tax records, the orthodontia business has been good for them. The Maloufs owned two Dallas mansions valued at more than $14 million. One had a pool house big enough for a family to live in. The Maloufs recently sold the clinics to a Chicago-based hedge fund, and someone who is not a dentist now manages them.

When the new manager didn’t return calls from WFAA, the reporters found a YouTube video where he revealed his management philosophy, honed while running another dental company. Here’s how he defined success: “Are they growing? Are they profitable? And are they exceeding the profitability as well as the growth of the local market?” Apparently they are, according to WFAA. Three years ago All Smiles collected $5.4 million from Medicaid for putting braces on kids’ teeth. Since then billings have doubled.

Over the years there have been countless exposes of health care providers ripping off Medicaid, but it’s always good to remind the public just who is committing the waste and abuse they hear so much about from politicians. These exposes are particularly important right now because Medicaid may be on the chopping block later in the year when the new congressional super-committee looks for cuts to bring down the deficit. Many experts believe Medicaid is a juicy target. Then too, Texas Governor Rick Perry is running for president on platform that includes eliminating government waste. Recently he told a group called Citizens Against Government Waste that “the big spenders in Washington from the president on down need to feel the outrage of the American people.”

Perhaps the people of Texas are outraged too now that WFAA has told them gobs of taxpayer money is going right to the bottom line of for-profit medical enterprises. Predictably, federal auditors have stepped in to look at the books and the state Health and Human Services Commission has announced corrective measures including that full-cast dental molds be submitted with each request for braces. Who knows, maybe the Medicaid gravy train will screech to a halt.

But there’s a larger question that needs exploration, and that brings up the R-word: resources. Who gets health care resources in these times of government scarcity—kids who need braces to improve their appearance or kids with what dentists sometimes call “bombed out” teeth? Harris did dip into the area of rationing dental services. One dentist teaching at Baylor told WFAA “the real dental health threat that we have for our children comes from cavities and gum disease.” Money spent on braces is not being spent on cavities, or for the bridges and other appliances that poor adults often need after a tooth extraction. They go without too.

The larger lesson from the WFAA series to investigate when Medicaid goes under the knife later this year is which mouths, and which people, get the money?

Correction: This story originally reported that Medicaid paid $2,200 monthly to treat children with “crisis teeth.” In fact, Medicaid pays $2,200 per patient. The relevant sentence has been corrected. CJR regrets the error.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.