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MassHealth

    HEALTH

    MassHealth Clients Find No Dental Care on Outer Cape

    The OCHS−Harbor Health practice will not reopen

    By

    WELLFLEET — Liberty Schilpp’s middle-school-age children have already had four different dentists and are about to meet number five, this one in South Dennis.

    The problem is not a dearth of dentists, but a lack of those who take MassHealth, the state-subsidized health insurance plan.

    This situation has existed for decades all over Massachusetts, because MassHealth reimburses dentists at a lower rate than private insurers. Only half of Massachusetts cities and towns had a dentist taking MassHealth in 2015, according to a 2016 report by the Mass. Health Policy Commission. In 2014, only 35 percent of dentists in the state treated a MassHealth patient.

    This problem is causing real pain on the Outer Cape.

    No Dental
    Harbor Health’s Ellen Jones Community Dental Center began accepting patients last month, including those covered by MassHealth. It is in Dennis. (Photo courtesy Harbor Health)

    Schilpp, of Wellfleet, used to take her children, who are 11 and 13, to Dental Arts Studios of Cape Cod in Eastham, and then to the Outer Cape Dental Group in Wellfleet. First one and then the other private dental practice stopped taking MassHealth patients. Dentists at those offices did not return calls for comment.

    Schilpp then found another provider to accept the insurance in Provincetown: Outer Cape Health Services.

    OCHS opened a dental practice at its Provincetown clinic in 2010. But it struggled financially, due to the lower reimbursements and also because the volume of patients fluctuated so much from summer to winter that it was difficult to strike a balance in staffing that worked, said Ami Bowen, director of community relations at Harbor Health Services, which later partnered with OCHS to run the dental practice.

    The partnership between the two, both federally qualified health centers, was meant to make the most of federal subsidies that offer care to patients regardless of insurance. And Harbor Health had much more experience with dentistry than Outer Cape Health did.

    Four of the five Harbor Health clinics statewide offer dental care, Bowen said. And 65 percent of Harbor Health patients are on MassHealth, she added.

    But after just two years in Provincetown, Harbor Health shut down that practice, leaving an outfitted Provincetown dental clinic empty in March 2020.

    Though it seemed the practice had closed because of the pandemic, Harbor Heath announced in June that it would not reopen in Provincetown.

    “The hope was we had more scale, we could find efficiencies and shift resources,” said Bowen. That didn’t overcome the seasonal issues, she said.

    The patients from the Outer Cape site, including Schilpp, were directed to the new Ellen Jones Community Dental Center in South Dennis, which is owned by Harbor Health.

    The new location opened in August 2020, replacing Harbor Health’s 21-year-old clinic at the Cape Cod Regional Technical High School in Harwich. Ellen Jones sees 11,000 patients a year, Bowen said.

    A few weeks ago, Schilpp called Ellen Jones and was put on hold for 30 minutes. When she got through, she was relieved that her children were given appointments at the end of September. But it’s stressful, Schilpp said, to have “zero continuity.”

    Since creating a local practice that can work with MassHealth seems impossible, she asked, “Why isn’t there a mandate?”

    MassHealth’s dental coverage is among the most generous in the country, according to a 2019 policy brief published by the University of Massachusetts Medical School. Children, who get the best coverage of any age group, get cleanings and check-ups twice a year, crowns, oral surgery, and root canals.

    But there is no legal requirement for dentists to accept this insurance, and many do not. Over the years, advocates have tried to overcome this hurdle. Most recently, a bill called “An Act Putting Patients First” passed the state senate and is in conference committee. Sen. Julian Cyr voted for it more than once, he said. But since he is a member of the committee now deliberating on it, he could not comment further.

    The bill would allow for mid-level professionals known as dental therapists, who must receive a master’s degree level of education, to see patients for less complex procedures, including cleanings and other basic dental treatments.

    In 2005, the Alaskan Native Tribal Health Consortium pioneered the first dental therapist program in the U.S. Since then more than 40,000 Alaska natives living in 81 previously underserved or unserved communities gained regular access to care. Sixty percent of the procedures done in the program were preventive and evaluative, according to the Mass. Health Policy Commission.

    A similar program began in 2009 in Minnesota, and now dental therapists can work in Maine and Vermont. The bill in Massachusetts, similar to Minnesota’s dental therapist licensing, requires that 50 percent of therapists treat MassHealth and other under-insured patients.

    ADDICTION

    State Boosts Telehealth for Drug Therapy

    Baker’s order makes treatment for substance abuse more accessible

    By

    Gov. Charlie Baker signed an executive order on March 15 expanding access to telehealth services for the duration of the Covid-19 crisis. His action has the potential to make Medication Assisted Treatment (MAT) for substance abuse disorder far more accessible, according to several Cape-based addiction specialists.

    The governor’s order prevents private insurers from imposing telehealth restrictions more stringent than those outlined by MassHealth, the state’s health care safety net. This means that all insurers are now covering a wide range of telehealth services at in-person rates.

    Allie Andersen, chief clinical officer at Gosnold, the Falmouth treatment center, welcomed the new policy. “As far as paying for service,” she said, “they’re currently at the same rates as a face-to-face session, and I’m hoping that they will continue to do that. I think it’s a benefit to the patients.”

    Virtual options for behavioral health care, such as substance abuse treatment, teletherapy, and telepsychiatry, have been covered by MassHealth since the start of 2019. But before the pandemic, providers were required to use certain technologies, undergo telehealth-specific training, and “ensure the same rights to confidentiality and security as provided in face-to-face services.” Audio-only telephone conversations were not to be used in isolation.

    That changed in March of this year. MassHealth relaxed its requirements for providers, calling for confidentiality and security rights to be maintained “to the extent feasible.” Telehealth training and technology guidelines are waived, as is the rule about audio-only appointments.

    In addition, a federal rule that requires all new opioid treatment program patients to undergo a complete physical examination has been temporarily waived by the Substance Abuse and Mental Health Services Administration, except in the case of methadone programs, which are more strictly regulated.

    Though some insurance providers covered telemedicine services for behavioral health care prior to the Covid-19 crisis, strict regulations meant that the services gained little traction.

    MAT for opioid addiction, a form of outpatient rehab that uses prescription medications alongside counseling and behavioral therapies, may now be conducted exclusively remotely. Duffy Health Center in Hyannis; Gosnold in Falmouth and Cataumet; and Outer Cape Health Services in Provincetown, Wellfleet, and Harwich Port all provide forms of MAT using medications like buprenorphine and naltrexone (the combination of the two is the common therapeutic Suboxone), which reduce cravings for addictive opioids. Such programs usually require new patients to attend weekly appointments until the patient’s condition is stabilized, at which point meetings may become less frequent.

    Prior to the pandemic, Gosnold mainly prescribed Vivitrol, a monthly injection of the generic drug naltrexone, which can reduce opioid cravings for up to a month. Now, Andersen says, many patients have switched to an oral form of the medication in order to avoid going into a public place. Though in-office injections are still available, most patients have opted for fully remote treatment.

    Duffy Health provides services to people with substance use disorder throughout Barnstable County, as well as those facing housing instability, joblessness, lack of health insurance, and chronic disability. It typically provides MAT for about 330 patients Cape-wide, but that number has increased to 360 since mid-March, when telehealth restrictions were relaxed and in-person visits were severely limited.

    Daniel Rodrigues, the assistant director of substance abuse services at Duffy Health, said that the relaxing of federal regulations has made MAT for substance use disorder more accessible to many patients. “Telehealth restrictions have been a real barrier for the folks we’re serving,” he said.

    Rodrigues said that retention rates in particular have increased with the breakdown of transportation barriers. While Duffy is committed to providing same-day treatment to anyone seeking it because it can be “life or death,” he said, long commutes mean that weekly in-person appointments have proven difficult to maintain for patients outside the Upper and Mid Cape.

    At present, Duffy serves only six patients from the four Outer Cape towns. But Rodrigues said that broader usage of telemedicine services will increase Duffy’s geographic capacity and allow for greater accessibility to Outer Cape residents.

    Andersen hopes that telehealth will find a solid middle ground in a post-coronavirus world.

    “Patients can make their appointments from their homes, anywhere really,” she said. “We have patients who go out on their lunch break and do it from their cars. It’s allowed a lot more people access from a lot more locations.” While she views this increased accessibility positively, she is also looking forward to increased security standards after the pandemic.

    Could telemedicine increase Gosnold’s often waitlisted outpatient capacity in the future? “Absolutely,” Andersen said.

    The Mass. League of Community Health Centers reported that “telehealth — particularly telephonic — has quickly demonstrated its efficacy in eliminating patient barriers to treatment, including transportation, finding time for frequent visits, care-giving responsibilities, not having a job that offers flexible, paid time off, limited data plans, and ambivalence about coming into a clinic to engage in care.”

    Dr. Matthew Libby at Outer Cape Health Services said that many patients enjoy the convenience of telehealth appointments, but some also miss the in-person experiences of counseling and group therapy. Throughout the pandemic, OCHS has had difficulty obtaining frequent drug screenings. A patient’s internet and cellular connectivity can also pose problems. OCHS currently serves around 200 patients in its Office-Based Addiction Treatment (OBAT) program, a number that has remained stable since before the pandemic.

    OCHS expects telehealth will remain “an important part of how we deliver care in the future,” said Libby.

    Last week the Mass. Senate unanimously passed the Patients First Act, which requires all insurance providers to cover telehealth services “in any case where the same in-person service would be covered” at the same reimbursement rates for at least the next two years.

    “While Covid-19 has stressed healthcare in a myriad of ways, the transition to telemedicine and the expanded practice of providers during the emergency have proven to be extraordinary tools that keep patients healthy, especially in geographically isolated regions like the Cape & Islands,” said Sen. Julian Cyr (D-Truro) in a June 26 press release.

    Olivia Weeks’s summer fellowship with the Independent is supported by the Harvard Alumni Association and the Harvard Club of Cape Cod.

    HEALTH

    Open Enrollment Ends May 25

    How to get help signing up for low-cost health insurance and care

    By

    After multiple extensions, open enrollment for health insurance is set to end on Monday, May 25. It’s not too late to get help with signups for health insurance, and people who have lost income in the last few months may find they qualify to pay lower or no premiums.

    About a quarter of the state’s residents gets nearly free health care through MassHealth. Outer Cape Health Services has health care access specialists who can help people through the applications portal. The Community Action Committee of Cape Cod and the Islands (CACCI) likewise has staff who are specially trained as health care portal navigators, and who can help sign people up.

    Immigrants who have overstayed their visas may not realize they can also get affordable health care. “It’s called Health Safety Net, and it’s not quite the same as health insurance, but it helps with a lot of major health events and other kinds of care at hospitals and community health centers,” said Kelly Hewitt, a health navigator at CACCI.

    “Open enrollment” is an artifact of our complex health system. To prevent insurance companies from rejecting those with pre-existing conditions, Congress required them to accept anyone as a customer. The insurance companies worried that people would wait until they were sick to sign up — like waiting until your house is on fire and then buying fire insurance while it burns — so Congress created a window of time every year, usually December and January, when people are allowed to sign up for the next year of coverage. That’s “open enrollment.”

    If something radically changes during that year, though, you may buy insurance outside that window of time. Losing a job, getting married, getting divorced, moving — even getting paid more, and thereby losing access to MassHealth — all count as “qualifying life events,” and allow you to buy insurance outside of the open enrollment period.

    Because of the pandemic, open enrollment was extended several times, into April and then into May. The current extension ends on May 25. Many people have had a “qualifying life event” as a result of this pandemic, too, so even if you’re reading this after May 25, OCHS or CACCI may be able to help you sign up.

    OCHS Healthcare Access Specialist, Provincetown, 774-538-3321; or Wellfleet, 508-905-2407. Kelly Hewitt, CACCI Healthcare Navigator: [email protected].

     

    RELIEF

    The Cape’s Undocumented Workers on the Margins

    Most pay into the social safety net, but can’t benefit

    By

    PROVINCETOWN — The coronavirus-induced collapse of the economy has people everywhere reaching for lifelines, from unemployment to SBA loans to MassHealth. At the edge of this scene is a group that is often overlooked — the Cape’s undocumented population is not eligible for most of the programs that help people.

    Most of the undocumented people who live and work on the Cape entered the country on legal work visas and then stayed in the U.S. when their visas expired, according to Collin Mickle, an immigration lawyer and coordinator of the Immigrant Resource Center in Hyannis.

    That means the majority of the Cape’s undocumented population pays payroll and income taxes, Mickle added. “Employment visa holders are assigned Social Security numbers when they first arrive,” Mickle explained. Even after their visas expire, they can generally work under those numbers, he said. When they do, employer and employee both pay Social Security, Medicare, unemployment, and state family and medical leave taxes.

    “In addition, most of the overstay immigrants we see are paying income taxes, state and federal,” said Mickle. The IRS knows about immigrants and their wages and expects them to file tax returns, but is not allowed to refer people to immigration enforcement. “They want people to pay — not to discourage them from paying,” Mickle said.

    Visa overstays may pay into the American social safety net, but that doesn’t mean they can receive its benefits.

    Unemployment Closed

    Congress has radically expanded the unemployment system. It is the principal economic support for people who have lost work because of the pandemic. Benefits were increased, and the pool of people who are eligible for them has nearly doubled. But that expanded UI system is closed to the undocumented.

    There are some classes of immigrants who can file for unemployment in Massachusetts, according to Monica Halas, an unemployment law expert at Greater Boston Legal Services. Green card holders and people with an employment authorization document (EAD) can file. Those eligible for an EAD include refugees, asylum seekers, and persons with Temporary Protected Status or deferred action agreements.

    Still, the most common work visas used on the Cape, the J-1 and the H2-B, never result in this kind of categorical employment authorization. Rather, those visas are tied to specific employers and industries, and convey much more limited privileges.

    Access to at least some relief could come for people in mixed-immigration-status families, if one person qualifies for unemployment. For example, the expanded UI system allows students who work part-time to apply.

    MassHealth No, but a Safety Net

    MassHealth provides comprehensive, nearly-free health care to about a quarter of the state’s residents. It’s part of the federal Medicaid program, it’s mostly paid for with federal funds, and federal rules bar undocumented people from the program. But undocumented residents of Massachusetts can enroll in the Health Safety Net and get at least some of the advantages of health insurance.

    “For Health Safety Net, you prove that you live in the state, and you prove your identity, but you don’t prove your immigration status,” said Kelly Hewitt, program coordinator for access to health care at the Community Action Committee of Cape Cod and the Islands. Health Safety Net is not insurance, and it doesn’t pay for everything that insurance does. But it pays for a lot of things, and it can also help avoid a tangled snarl of medical bills, appeals, and complex paperwork after a hospital trip. Hewitt says people should sign up for Health Safety Net before they wind up needing it.

    The Community Action Committtee does not report information about people to ICE. “It’s safe for anyone to call us,” said Caronanne Procaccini, a director there.

    Another form of relief could eventually find its way to the Cape’s undocumented population, after taking a circuitous route from Congress through the SBA to local lenders and then local employers. The Payroll Protection Program, which now amounts to $660 billion in forgivable loans, specifically encourages employers to bring back their entire staff. The application requires employers to certify that the employees they are including reside primarily in the U.S., but does not ask that they verify citizenship.

    Rules for the program have changed often, and are still changing. But Mickle does not think this rule will. “The SBA is totally overwhelmed by the complexity and volume of these loans,” he said. “Is it likely that they’re going to put some kind of new, above-and-beyond scrutiny on everyone’s payroll, now? Particularly when the IRS doesn’t apply that scrutiny? Even if they did want to, I don’t think the bandwidth is there.”

    The Payroll Protection Program was intended to keep people employed. For the visa overstays who live on the edge in our economy, being employed has always been the only reliable plan.

     

    HEALTH

    For Outer Cape Kids, Healthy Teeth Take Extra Effort

    Care needs to start early, but awareness and access vary

    By

    Tooth decay is preventable but it’s still the most common chronic disease of children and adolescents, according to the Centers for Disease Control. With February being Children’s Dental Health Month, the Independent went to local dentists and school nurses for a checkup. Their diagnoses were mixed, and came with doses of advice on prevention.

    Truro Central School Nurse Helen Grimm said that it is “not unusual” to see students who are distracted from their lessons, and not just because they’re wiggling their loose baby teeth. They’re distracted by mouth pain. Although students generally have good hygiene, she said, there’s “huge room for improvement” when it comes to their teeth.

    Kacey Kachtick-Anders at the dentist
    Fearless at age five, Kacey Kachtick-Anders of Provincetown tunes up her smile at the dentist’s office. (Photos Tracy Kachtick-Anders)

    At Wellfleet Elementary School, nurse Claudia Cope said the situation is different. “It’s rare that kids don’t get dental care,” Cope said.

    Cope believes the difference between her experience in Wellfleet and Grimm’s observations in Truro arise from greater numbers of people facing cultural and socioeconomic barriers there.

    At Truro Central, 34.9 percent of students are economically disadvantaged, 45.3 percent are “high need,” and 64.2 percent are white. At Wellfleet Elementary, 28.6 percent of students are economically disadvantaged, 37.1 percent are high need, and 82.9 percent are white. These statistics are from the Mass. Dept. of Education.

    The differences are small, but they are there: Truro has more special needs students, more disadvantaged students, and fewer white students.

    Grimm sees those differences affecting awareness and time. “For families without a car,” she said, “transportation to dentist appointments can be a challenge.”

    As far as insurance coverage for dental care, Cope thinks the existing system is meeting the needs of the community. Even those covered only by MassHealth, she said, will be able to get the care they need without leaving the Cape. Harbor Community Dental Center in Provincetown and Ellen Jones Community Dental Center in Harwich both accept MassHealth and Health Safety Net.

    For more complex cases, patients need to get to the Ellen Jones center or to Hyannis for a specialist. The Outer Cape does not have a pediatric dentist.

    “As a general dentist, I have training in pediatric dentistry,” said Dr. Gerard Kinahan of Truro. “But it’s not nearly as advanced or in depth as someone who focuses on it.” The specialty requires two years of study beyond dental school. “Pediatric dentists are trained in behavior modification and pharmacology,” which, Kinahan said, “makes the children’s experience easier on everybody.”

    Should the Outer Cape have its own pediatric dentist? Grimm thinks there “absolutely” should be one. But the consensus seems to be that the population of children here is not large enough to make that work.

    Both Kinahan and Dr. Cheryl Andrews, who practices in Provincetown, said only a small number of their patients are under 15 years old. They both refer their youngest patients with extensive needs to specialists. Kinahan suggested that a pediatric dentist here would be “lovely,” and said it might succeed as a satellite office of one of the up-Cape practices.

    Kacey’s sister Alaina
    Kacey’s sister Alaina, age eight, is missing a few, temporarily.

    Good dental care in childhood can set kids up for a lifetime of healthy teeth, said Elise Cozzi, who retired as a clinical professor of pediatric dentistry at Yale New Haven Hospital and lives in Provincetown.

    “Tooth decay is actually caused by a bacterial infection, caries,” Cozzi said, and a little-known fact is that a pregnant woman with untreated dental issues can pass the decay-causing bacteria on to her child. “Teeth are at risk as soon as they come into the mouth,” she said.

    In general, kids should avoid very sugary foods, like juice boxes. Going to bed with a bottle of milk can also pose problems, as the natural sugars in milk can lead to decay.

    Tap water on the Cape is not fluoridated. And although Andrews is not a proponent of fluoridating town water supplies, “the stats are astonishing,” she said, adding that a tiny increase in the amount of fluoride in teeth can make them much more resistant to decay. “I’m a big proponent of using fluoride as needed.

    “If I had kids, they’d be on fluoride until age seven or eight,” Andrews said. “If you want to put me out of business, that’s what you do.”

    There are two types of fluoride and, for children, dentists recommend both. The first is systemic: you ingest it so that fluoride ions actually grow into the teeth, replacing a tiny fraction of calcium ions there, making them stronger. Once children’s teeth stop forming, they don’t need to take systemic fluoride anymore; brushing with fluoride toothpaste is enough.

    In terms of timing, kids should see dentists at around one year old, when their first teeth begin coming in. Once you’ve got a general dentist, you can make a plan for care.

    All Outer Cape schools offer free clinics twice a year with dental hygienists who come into the school to provide quick cleanings and fluoride sealants. They can check to make sure there aren’t any problems. It’s optional, however, and not all parents sign up.

    “Every child should see a dentist twice a year — no matter what,” Andrews said.

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