Corporate dentistry criticized for unethical practices, unnecessary procedures
by Eddie Burkhalter
eburkhalter@annistonstar.com
Jul 28, 2013 | 8397 views |  0 comments | 53 53 recommendations | email to a friend | print
When Quintoya Seawright’s 3-year-old daughter, Destiny, chipped a baby tooth in November 2010, the young mother took her to the Small Smiles clinic in Montgomery. Quintoya, 25, would end up taking her daughter to the clinic four times that month.

On the last visit on Nov. 9, her daughter was strapped to a board for an hour while the dentist struggled to place two stainless steel caps on baby teeth while her daughter screamed and struggled, saying she could still feel it, the family said.

But without much money, the young mother had to rely on Medicaid to pay for her daughter’s care. Small Smiles specializes in treating children eligible for Medicaid. The company operates another clinic in Dothan.

The large dental chain is owned by a private equity firm and is managed by Nashville-based CSHM LLC. A report released by the U.S. Senate Finance Committee last week claims Small Smiles and clinics like it are motivated by profit, often performing unnecessary procedures, and should be removed from the Medicaid program.

The report also says the clinics are operating in violation of laws in 22 states, including Alabama, that ban anyone other than a licensed dentist from owning a practice. The report states that CSHM actually owns and operates the clinics, and not the “owner” dentists the company enlists to skirt to get around those state laws.

Quintoya said she was never allowed to go back with her daughter to watch the procedures at Small Smiles, but the 3-year-old girl’s grandmother, Sophia, demanded she be allowed on the girl’s last trip.

Destiny began pulling at her mouth, so workers strapped her arms and legs to the board, then the dentist struggled for an hour to place the two caps on the tiny baby teeth while Destiny “kept saying she still felt it. He said, ‘No. She’s numb. It’s just the noise,’” said Sophia.

“Her heart was just beating so fast,” Sophia said. “The lady was holding her head down and was trying to get her to open her mouth by squeezing her nose.”

Destiny had a total of five stainless steel caps placed on baby teeth over four visits. One cap fell out along with the tooth a couple weeks later. Quintoya said she never heard the dentist say her daughter had cavities in those teeth, but he said the caps would help prevent them from forming.

“I’m not sure if it was a necessity to have all those silver things in her mouth,” Sophia said.

Alabama’s Medicaid agency pays nearly double for placing stainless steel caps as opposed to regular fillings, according to the state’s Medicaid pay scale. Other states’ pay scales are similar to Alabama’s in that regard, according to court records. Prior court cases point to that fact as proof the clinics were performing unnecessary procedures and defrauding Medicaid.

The Seawrights are one of about 50 families in several states, represented by Texas attorney Jim Moriarty, who are suing Small Smiles for improper treatment and other harm.

In a statement released last week about the Senate report, CSHM said that the report’s findings were largely based on old information, and that the company had all-new management after coming out of bankruptcy in June 2012.

“Contrary to the portrayal in the report, we adhere to the guidance of our regulators and remain committed to advancing a culture of transparency and clinical responsibility,” the statement read.

Another dental chain with offices in Alabama was also investigated by the Senate Finance Committee.

Aspen Dental, managed by Aspen Dental Management Inc., operates more than 300 clinics in 22 states. The company operates clinics in Dothan, Trussville and Florence, and will open a clinic in Oxford this fall.

ADMI is owned by the private-equity firm Leonard Green & Partners, and is the focus of a 2012 lawsuit that alleges the company illegally owns clinics and deceives patients by targeting mostly low-income adults, forcing patients into debt by performing procedures that are not received or authorized.

Aspen Dental disputes the lawsuits’ claims, and said in a statement to The Star this week that “we’re proud of the access to high quality, affordable dental care the dental practices supported by Aspen Dental Management, Inc. provide to millions of Americans, and we look forward to opening an office in the Oxford community soon.”

Small Smiles and Aspen Dental are not the only dental chains in Alabama with backing from private equity firms. Cumberland Dental operates clinics in Birmingham, Tuscaloosa, Gadsden and Oxford.

Cumberland Dental is managed by American Dental Partners, which operates 280 clinics in 20 states. The New York-based private equity firm JLL Partners bought American Dental Partners for about $390 million in 2012.

In 2007, a jury required American Dental to pay a group of Minnesota dentists at Park Dental $130 million after a month-long trial.

The lawsuit stated that American Dental began in 2004 to control daily operations at the 31 dental clinics of Park Dental, which had been purchased by the private equity-owned American Dental in 1996. The lawsuit stated that American Dental would clear out dentists’ bank accounts and refuse their access to those accounts, and began interfering with patient scheduling and complaints.

Attempts last week to reach Massachusetts-based American Dental Partners for comment were unsuccessful.

Federal oversight

Among the Senate report’s recommendations was that CSHM, “and any other corporate entity that employs a fundamentally deceptive business model resulting in a sustained pattern of substandard care” be excluded by the Health and Human Service Office of Inspector General from receiving Medicaid payments.

The Small Smiles clinic in Montgomery received $2.1 million in Medicaid payments in 2012, which made the location the third highest recipient of Medicaid payments among individual clinics in the state last year, according to the Alabama Medicaid Office.

The U.S. Department of Justice sued CSHM, then called FORBA Holding LLC, in 2010 alleging the company defrauded Medicaid by performing unnecessary and substandard medical care. FORBA settled, agreeing to pay $24 million to the U.S. government and participating states, including Alabama.

As part of that settlement, CSHM agreed to sign a corporate integrity agreement with the Office of Inspector General, which required oversight for five years by a government monitor.

The report found that while Small Smiles clinics have made some progress since emerging from bankruptcy in June 2012 with new ownership, “CSHM and Small Smiles clinics continue to operate under fundamentally deceptive contracts that circumvent state laws passed to ensure licensed dentists own dental practices.”

As a result, the report stated that “Small Smiles clinics continue failing to meet basic quality and compliance standards, providing unjustified and deficient procedures, improperly withholding and recklessly administering anesthesia, and performing dubious internal audits. All of these actions strain the Medicaid system.”

But the Inspector General’s office responded to The Star on Wednesday in a statement that the agreement between the office and CSHM gives monitors “unprecedented access,” which helps the office spot problems at the clinics.

“During this oversight we’ve taken action to help CSHM improve its quality of care and management. We will continue to exercise our rights under the CIA, while balancing the significant need for children on Medicaid to have access to quality dental care,” the statement read.

Robin Baskin, director of media communications for the Office of Inspector General, said by phone Wednesday that the office was surprised to not have been notified that the report, which had been years in the making, would be released.

Baskin was first exposed to problems at Small Smiles when she worked as a broadcast reporter at a Washington, D.C., television news station. Although other news agencies had reported on problems at the clinics, Baskin’s 2008 televised report and several follow-ups spurred news agencies nationwide to look into Small Smiles clinics. Baskin was hired to her new position in 2010.

Lawsuits against FORBA in 2007 and 2008 drew the attention of the U.S. Justice Department, and in 2012 the company agreed to the settlement and government monitoring.

“As of a year ago, our (corporate integrity agreement) is dealing with new management in terms of the COO, CFO, compliance officer, etc.,” Baskin wrote in an email to The Star Wednesday.

But the report paints a picture that the structure of corporate dentistry, and not who may be the current CEO, can lead to fraud and substandard work.

“To date, the Independent Monitor has audited and reviewed 60 Small Smiles clinics through an onsite review or desk audit since 2010,” the report states. “Consistently, the Independent Monitor reports reveal that clinic employees had little awareness of the new compliance procedures, and that CSHM was giving its dentists passing grades on chart audits which the Independent Monitor says they clearly failed.”

The report found that 70 of the 14 internal audits by CSHM gave the dentists grades that were on average 44 percent higher than the grade that the government monitor awarded.

The report goes on to say that “the core of the problem appears to be structural. The new CSHM ownership acquired and has maintained their predecessors’ flawed management services agreements, which remove traditional ownership authority from dentists. These agreements fundamentally limit the ability of the dentists to exercise independent clinical judgment.”

The bigger picture

Very little research has been done on the practice of corporate dentistry, said Shelly Gehshan, director of children’s dental policy at Pew Charitable Trust, a nonprofit research organization.

That makes it hard for state regulators to know which companies are providing good care and which aren’t, Gehshan said.

Banning all corporate dental practices may not be the best solution, she explained, as the need for a sufficient workforce to care for low-income children is great.

“And that’s where Sarrell has been good, because they definitely care about quality,” Gehshan said, speaking about the nonprofit Anniston-based Sarrell Dental, which operates 13 offices across Alabama, serving more than 350,000 patients since it opened in 2004.

Legislation passed in Alabama in 2011 allowing Sarrell and other nonprofit dental providers to operate legally, as long as the clinics register with the state’s Board of Dental Examiners and hire a licensed dentist as chief of staff. Prior to that, the Alabama law stated that all dental clinics, including nonprofits, must be owned by a dentist licensed in the state. Today, nonprofits are the only exception to that law.

“They have been open,” Gehshan said of Sarrell Dental. “They have sought evaluations, so whenever there’s transparency you can bet that the people are trying to do the best job they can.”

It’s the lack of transparency among some corporate dental chains, like refusing to let parents stay with their children during procedures, that troubles Gehshan.

“I think that’s a troubling sign. There’s no question about it,” Gehshan said, but she stressed that in dental care overall there are very few quality measures and dentists are almost never paid based upon quality of care.

“They just pay for specific procedures, so with that framework you’ve got a risk of poor care or abuse of a system, like a payment system like Medicaid, by anybody, really. By chains, by private dentists, but at least private dentists have sort of a peer system,” Gehshan said. “Whereas with corporations, I’m not sure what the reporting mechanisms are.”

What is needed, she said, is more research into innovative models of dental care, like the research being done by the Robert Wood Johnson Foundation, a philanthropic organization that studies health and health care-related issues.

“So there is some hope that in the years to come we’ll have some concrete evidence of a model like that that seems to be working,” Gehshan said.

Because whether states have bans on corporate dentistry or not, Gehshan said, there are still companies that “potentially abuse the trust of the public and waste money.”

Staff Writer Eddie Burkhalter: 256-235-3563. On Twitter @burkhalter_star.
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