Alone in a meeting room, trustees of the Alabama Dental Association complained about Sarrell Dental Center, a nonprofit corporation that treats thousands of needy children on Medicaid.
In a rambling exchange, leaders of the 1,800-member professional organization said they were concerned about Sarrell's quality of care, and they lamented that for-profit dentists face tough business demands. Something needed to be done, they agreed.
The comments — made public after Sarrell Dental obtained a transcript of the session — helped blow the lid off a simmering dispute between the nonprofit chain of clinics and Alabama's traditional dentists. Sarrell Dental has since filed a slander lawsuit against one of the board members, and the state's only dental school this week pulled its students out of two Sarrell clinics where they saw patients.
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. The private offices typically take Medicaid patients, but advocates say there simply aren't enough dentists to treat the needy across the country.
The conflicts, which have been brewing over a decade, could become more common with the passage of President Barack Obama's health care bill, which includes mandatory dental coverage for kids, said Meg Booth of the Washington-based advocacy group Children's Dental Health Project.
"The safety net is not large enough to absorb the number of children who are not able to get into private dental care," Booth said. "This is very much because of the lack of access to dental care."
Nationally, some 26 million children lack dental insurance coverage. But only 37 percent of the children eligible for Medicaid-funded dental care visit a dentist at least once a year, according to a report released last year by the federal Department of Health and Human Services.
The interim executive director of the Alabama Dental Association, Dr. Zack Studstill, doesn't deny there's a problem with needy children getting adequate dental treatment in the state. But the idea of a corporation or nonprofit organization owning dental clinics is new in Alabama, and established dentists aren't sure what it will mean in the long-term, he said.
Sarrell Dental counters that Alabama's dental establishment is endangering care for thousands of poor children by trying to limit the growth of corporate and nonprofit chains.
To illustrate what it called attack by the state dental association, Sarrell Dental released a transcript of the Jan. 31 trustees meeting to the public. Comments from the meeting are part of the lawsuit filed by Sarrell in March against one of the participants, Dr. Steve Mitchell, who teaches at the University of Alabama at Birmingham.
This week, UAB said its dental students no longer would work at Sarrell clinics, where they have treated patients under a $400,000 contract. Sarrell's chief marketing officer, Brandi Mangum Parris, said the school acted under pressure from alumni and private dentists.
University spokeswoman Dale Turnbough said students and dental residents have to receive constant supervision by credentialed teachers.
"We could not determine a mutually agreeable approach to this with Sarrell clinics," she said.
During the trustees meeting, participants spoke of the lack of a level playing field between the nonprofits and private dentists, who typically buy or lease their own offices and face business pressures aside from fixing teeth. There was discussion of legislation to control nonprofits.
Mitchell noted that local leaders are happy someone is treating the poor, who can receive services from cleanings to fillings at Sarrell clinics.
"And you need to be very careful you don't give the impression that we're just trying to protect our turf if we try to do something about this," added Mitchell, who is in charge of undergraduate pediatric dentistry at UAB.
Studstill, in an interview and statement, said the trustees debated how Sarrell clinics operated because dental students were working there outside the auspices of their school.
The nonprofit has treated 130,000 patients since its founding in 2005 and has eight clinics statewide. A huge lack of access to dental care for the needy has fueled its growth, and the state's dental establishment is simply intimidated, said Parris.
"I think it is that growth that scares them," she said. "They don't understand it."
Mitchell worked at a Sarrell Dental clinic until recently, according to the suit, and he helped line up students to help treat kids.
But Mitchell's tone changed, the suit claims, and he has gone down a road of "malicious conduct" by accusing the company of providing substandard care and of letting students treat patients without the supervision that is required by law. Parris said Sarrell has 23 staff dentists who help supervise students.
Mitchell didn't return messages seeking comment.
The friction isn't confined to Alabama. Dentists complained when three private companies opened clinics to treat Medicaid patients in Massachusetts five or six years ago, said Mary E. Foley, who was in charge of the state's Medicaid dental program at the time.
"I was getting calls from all over. It was, `Who are these people, and what are they doing?'" said Foley, now executive director of the Medicaid/SCHIP Dental Association, composed of state officials dealing with Medicaid dental care.
Similar questions arose across New England and in Western states including Arizona and Colorado, she said.
While as many as 70 percent of Alabama's dentists accept Medicaid, there still aren't enough to treat those most at risk for serious problems with their teeth: Children under 2 years of age living in poverty.
"The dental associations are right in ensuring quality of care," said Booth, from the Children's Dental Health Project. "At the same time, I would hate to see a state where the dental association doesn't have a strong participation in Medicaid and also doesn't want others to see those kids."
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