School's decision to cut ties with clinic sparks controversy

A decision by an Alabama dental school to cut ties with a nonprofit dental clinic is raising questions about the proper role of clinics in providing oral healthcare to underserved populations -- especially when they compete with private practitioners.

In a January meeting of the trustees of the Alabama Dental Association (ALDA), participants complained of a lack of a level playing field between nonprofits and private dentists who face business pressures aside from treating patients.

Now the University of Alabama at Birmingham School of Dentistry (UABSOD) has ended a five-year relationship with Sarrell Dental Clinic -- a not-for-profit corporation that is the largest single provider of Medicaid dental services in Alabama -- and the clinic claims it is due to a turf battle with private practitioners.

Jeffrey Parker, CEO of the Sarrell Dental Center, said he was notified April 5 that UABSOD would no longer send its students to work at his clinics in Bessemer and Anniston, where they have treated patients for the past five years. In exchange, the clinic's contract with the dental school called for Sarrell to pay the school at a rate that has increased annually. According to Parker, the center would have paid the school close to $400,000 for the 2010-2011 school year had the contract not been terminated.

Parker said UABSOD bowed to pressure from alumni dentists in its decision to terminate the contract. "We were informed by an official from UAB that, during a closed door meeting held on April 2, 2010, a few influential dentists speaking on behalf of the ALDA threatened the school if they did not cease their working relationship with us," he stated in an e-mail to DrBicuspid.com.

Supervisory issues

But Zack Studstill, D.D.S., interim executive director of the ALDA, said the organization has not discussed this issue with the School of Dentistry -- "nor, to my knowledge, has it made any suggestions to the school relative to its relationship with the Sarrell Regional Dental Clinics," he said. Corporate ownership of dental offices is a relatively new phenomenon in Alabama, where nondentists are the corporate owners and manage the clinics, he added.

"At a recent Board of Trustees meeting, there was discussion concerning the manner in which the Sarrell Clinics are operated, since apparently in some clinics, dental students from the University of Alabama School of Dentistry are treating children outside the confines of the school under Sarrell employee supervision," he told DrBicuspid.com. "It became evident during the debate that it was difficult to separate fact from rumor and fiction. The opinions expressed were very diverse in an open discussion and do not represent any official ALDA policy."

The issue of 501(c)(3) corporate dental care delivery systems has been referred to ALDA's Council on Dental Health and Public Information to gather factual information for a report back to the Board of Trustees, added Dr. Studstill, noting that a Sarrell Clinic dentist-employee is a member of that council "and will be a valuable resource as we seek to fully understand this unique dental care delivery system."

UAB spokesman Dale Turnbough also contends that the conflict stems from a disagreement over the supervision of dental students. "We must ensure that our students and residents receive constant, consistent supervision by faculty with required credentials. We could not determine a mutually agreeable approach to this with Sarrell Clinics despite working on the issue since last fall," he wrote in an e-mail to DrBicuspid.com. "That -- not alumni opinion -- is the reason we are no longer working with them. In fact, Sarrell management indicated that they would not work with any of our predoctoral pediatric dentistry faculty."

But Parker maintains that the university was "very aware" of the clinic's issues regarding a predoctoral faculty member. "In fact, in January the UABSOD sided with us and elected to continue and expand our working relationship with adjunct faculty," he said.

The school also chose to transfer the predoctoral dental students (regarding pediatric care) from the direct supervision of their pediatric faculty to another department under the supervision of Associate Dean Mike McCracken, D.D.S., Ph.D., Parker added. "We have had a very positive working relationship with Dr. McCracken since he has had this responsibility," he said.

Turf war?

A transcript of the January meeting of the Alabama Dental Association trustees -- published by the Anniston Star -- sheds additional light on the issue. In addition to expressing concern about a lack of a level playing field with regard to nonprofit clinics competing with private practitioners, participants at that meeting discussed trying to get legislation passed to control nonprofits.

"The problem in the state of Alabama for the dental profession is nonprofits. In order to protect dentistry, we have to band together in some way to control this," said Roger Smith, D.D.S, of Birmingham, AL, according to the transcript.

Participants at the meeting were concerned that opposition to Sarrell would be viewed negatively by local communities served by the clinics. Since its founding in 2005, Sarrell's eight clinics in Alabama have treated 130,000 patients, most of whom are Medicaid or Children's Health Insurance Program recipients, Parker said.

During the meeting, Steve Mitchell, D.M.D., director of UABSOD's pediatric dentistry department, warned about the consequences in "the court of public opinion."

Comments from the meeting are part of a slander lawsuit filed by Sarrell in March against Dr. Mitchell. He worked at a Sarrell clinic until recently, according to the suit, and helped line up students to treat children.

Drs. Smith and Mitchell did not respond to requests for comment, nor did Alabama Dental Association (ALDA) Director Zack Studstill, D.D.S., or President Gaines Thomas, D.D.S.

Serving the underserved

About 26 million U.S. children lack dental insurance. But only 38% of the children eligible for Medicaid-funded dental care had at least one dental visit in 2008, according to a 2009 report released by the U.S. Department of Health and Human Services.

John R. Liu, D.D.S., president-elect of the American Academy of Pediatric Dentistry, said the issue is complex and involves more than an insufficient number of dentists or dentists who don't want to take Medicaid patients.

"It ranges from the fact that the Medicaid program is woefully underfunded to parents of the children not understanding the importance of early, preventive oral health practices," he told DrBicuspid.com.

Dr. Liu also acknowledged that some clinics that serve Medicaid patients have raised concerns in the dental community, with some dentists "clearly feeling threatened" by these clinics.

"We would hope that these clinics treat the children within the policies and guidelines that we've established as being the best practices for providing comprehensive and appropriate oral healthcare to all children," he wrote. "As long as this is the case and the children are treated with dignity and respect, we have no problems with these clinics. What concerns us is when some of these clinics, pressured to see more patients because of the low Medicaid reimbursement levels, begin to aggressively treat these children inappropriately and, in some cases, severely traumatize the children by the way they are treated."

Sarrell's revenues in 2009 exceeded $6 million, almost all from Medicaid and other aid payments, Parker said. The company's revenue per patient dropped from $328 per patient in 2005 to only $131 per patient in 2009, which "is a sign that we are not only reducing costs to Medicaid, but making an impact on reducing caries among underserved children," he said.

Image courtesy of the Serrell Dental Center.

Sarrell has 23 dentists, including eight who work full time and help supervise students from UABSOD, the state's only dental school.

The acrimony is similar to turf battles in other states as companies, rather than private dentists, step in to care for young people covered by Medicaid. Some private offices take Medicaid patients, but advocates say there simply aren't enough dentists to treat the needy.

The conflicts, which have been brewing for more than a decade, could become more common with the recent passage of the healthcare reform bill, which includes mandatory dental coverage for kids.

Range of services

Some dentists have complained that dental clinics like Sarrell only do simple procedures such as exams, cleanings, and x-rays, leaving costly treatments with low reimbursement rates to private dentists. But Sarrell provides a range of procedures, including oral surgery, according to Parker. Children who exceed their insurance limits will still receive treatment "whether we get reimbursed or not, if they're a patient of record," he added.

Parker noted that full-time Sarrell dentists are on salary and are not paid based on the number of patients they treat. But he acknowledged that some specialists do get incentive pay.

He also pointed out that no patient complaints have been filed with the Alabama Board of Dental Examiners in the entire time that the Sarrell clinics have been open.

The Anniston Star has written several editorials denouncing UAB's decision to sever ties with Sarrell, noting that a 2008 article published in UAB Dentistry praised Sarrell's services to poor children.

"Some dentists spoke of Sarrell as if its commendable care of the underprivileged was a threat to business," according to an April 13 editorial about the January ALDA meeting.

The remarks "stand out for the callousness of some of the speakers. To hear them tell it, providing dental care to these needy children was a gravy train of benefits for the clinic's seven locations across the state. It sounded as if some members of ALDA were auditioning to take on the role of Ebeneezer Scrooge in a lab coat," the Anniston Star editorial board wrote.

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