Report: Kool Smiles protocol could save states money

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A recent report issued by the dental service organization Kool Smiles claims that state dental programs could save millions and provide oral care to more children if Medicaid dental providers used the company's care protocol and utilization rates.

Medicaid dental programs in seven states could save more than $550 million annually and provide Medicaid dental care to an additional 1.9 million children if the organization's practices were adopted, according to the report.

The report was paid for by the Benevis Foundation, which was hired by Kool Smiles to provide nonclinical practice support services. Kool Smiles has more than 120 affiliated dental practices in 15 states and the District of Columbia.

The analysis was done by Dobson DaVanzo & Associates using Medicaid claims data for nine states, seven of which were included in the analysis, from 2011 to 2015 and represents utilization and Medicaid expenditures from 164 Kool Smiles dentists and 8,077 non-Kool Smiles dentists.

The analysis found that Kool Smiles dentists performed more conservative, cost-effective care when compared with other Medicaid dental providers in Texas, Indiana, Virginia, Georgia, Mississippi, Louisiana, and South Carolina.

Report focuses on basic services

The report focused on four dental services provided to children:

  • X-rays
  • Extractions
  • Restorative services, including stainless steel crowns, fillings, pulpotomies, and pulpotomy-to-crowns
  • Other dental services, provided to Medicaid patients from all providers

The report's key findings included the following:

D. Ray Gifford, DDS, Kool Smiles managing dental director.D. Ray Gifford, DDS, Kool Smiles managing dental director.
  • Kool Smiles dentists performed 15% fewer services overall, including 40% fewer extractions and 39% fewer pulpotomies.
  • As a result of lower utilization rates, Kool Smiles patients had overall average monthly Medicaid expenditure rates that were 33% lower than non-Kool Smiles patients across all states and years analyzed.
  • The annual Medicaid savings could pay for dental care for as many as 1.9 million more Medicaid children who do not receive care now.

"By providing a dental home to Medicaid children who have historically lacked access to a dentist and addressing needed preventative care early on, we are able to reduce the potential for more expensive, restorative procedures over time," stated D. Ray Gifford, DDS, managing dental director for Kool Smiles, in a statement. "If we can increase access and improve the oral health of these patients while lowering Medicaid costs in the process, we better serve both our patients and taxpayers."

DSO advantages

Quinn Dufurrena, DDS, JD, former executive director of the Association of Dental Support Organizations (ADSO), cited several ways that dental service organizations like Kool Smiles, which is not a member of the ADSO, can save money when treating children.

"The main thing that most DSOs have in common is they create standardized efficiencies," Dr. Dufurrena told "And because of those efficiencies, they provide dental treatment at a reduced cost."

Most DSOs also have quality assurance programs, he said.

"It's very similar to what we did in the Navy," Dr. Dufurrena explained. "We looked at each other's work, and that really can improve clinical quality, especially having another doctor looking over your shoulder."

DSOs also have the advantage of economies of scale.

"They can save on supplies and equipment," Dr. Dufurrena added. "Especially in pediatric dentistry, you don't need as many supplies as general dentists need, like equipment for endodontics, periodontics, and oral surgery." Not having that equipment actually helps drive down costs, he noted.

Investigations of Kool Smiles

Kool Smiles was one of five dental chains that was included in a 2102 U.S. congressional investigation into allegations of abuse by corporate dental chains treating children enrolled in Medicaid. Federal investigators looked at dental chains that allegedly used deceptive business models that gave managers rather than dentists control over the clinics.

Geoffrey Freeman, co-founder of the Benevis Foundation.Geoffrey Freeman, co-founder of the Benevis Foundation.

A 2012 joint investigation by the Center for Public Integrity (CPI) and the PBS "Frontline" program outlined complaints about unnecessary and substandard care at Kool Smiles, which is owned by private-equity investors. In 2007, Kool Smiles was removed from two Medicaid networks in Georgia over complaints about overusing expensive stainless steel crowns to treat primary teeth with caries.

In 2010, Massachusetts officials accused Kool Smiles dentists of billing unnecessary x-rays for Medicaid patients. In 2015, Kool Smiles settled a lawsuit filed by parents of 618 Texas children who claimed its dentists performed unnecessary work and charged it to Medicaid.

"It is indisputable that Kool Smiles dentists perform fewer Medicaid dental services at a lower cost. We believe many allegations were made opportunistically in an attempt to profit from expensive litigation," wrote Geoffrey Freeman, co-founder of the Benevis Foundation, in an email to "Further, these allegations are almost always unsubstantiated, and their methodologies and motives remain undisclosed."

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