RI dentists warn of looming shortage 'superstorm.' Here's what's driving it.

When David Mastrostefano's daughter asked him for career advice, he told her not to become a dentist like him.

That's because his industry has descended into what he's calling a "superstorm."

"In five, six years, we’re all going to retire and no one’s coming into the state," Mastrostefano said.

Mastrostefano was describing a dentist shortage well known to those in the industry. It has impacted the nation, including Rhode Island, where patients face a dizzying obstacle course, from an aging workforce to insurance plans that leave them with crippling out-of-pocket costs, causing them to forgo badly needed care.

Aging workforce means retirements threaten to worsen crisis

Could Mastrostefano's dire forecast come true? According to Rhode Island Dental Association President Fred Hartman, about 45% of the state's dentists are age 55 and older.

"Year after year, they’re going to start retiring," Hartman said. "And it’s a hard job, especially when margins are shrinking."

That's because of chronically low reimbursement rates from insurers – the same issue primary care providers are saddled with, and the same reason Rhode Island has failed to attract enough doctors to efficiently serve its population.

It's also the same issue that keeps patients from being able to afford critical procedures.

That results in situations like Mastrostefano saw with one of his patients, who couldn't afford to have a tooth pulled in June, went to an emergency room for antibiotics, and as of February still had the tooth in place.

"When he came to me two weeks ago, he had a larger infection," Mastrostefano said in a recent interview. "It was borderline a super infection."

As a result, the extraction took an hour and a half – far more than the typical time allotted – and required a large surgical incision, plus more antibiotics.

More: The doctor shortage is crippling health care. Could pharmacists help?

Without sufficient coverage, patients pay out of pocket or skip care

Sarah Eager, president of the Rhode Island chapter of the Academy of General Dentistry, represents about 90 general dentists who typically see Medicare patients. But for complicated procedures requiring an oral surgeon, those patients find themselves out of luck. Eager said virtually all oral surgeons in the state have dropped Medicare plans because of a combination of excessive paperwork, required approvals and low insurance payouts. (A brief search on Zocdoc – an online physician locator – found only two oral surgeons in Rhode Island taking Medicare.)

"I’ve been here for 20 years and when I came to Rhode Island, the insurance problem was always a problem," Eager said. "We were always the lowest reimbursement … And I think in 20 years we’ve just been plugging along, making do."

Eager said getting necessary approvals for procedures is "a full-time job and almost not worth it" for dental practices.

Other dentists The Providence Journal interviewed described the same situation – one that also affects Medicaid patients with low incomes. For doctors, the financial strain is worsening, and it's becoming harder to break even at their practices.

"The biggest issue that we see is that, as costs to provide the services have increased over the years, and especially post-COVID, the allowances we receive are actually not considerate of the costs that it takes to provide those services," said dentist Andrew Gazerro, who practices in West Warwick.

More: 'How did this happen?' Primary care shortage keeps hitting RI hard

The Rhode Island Executive Office of Health and Human Services, or OHHS, acknowledged the difficulty of Medicare and Medicaid patients in accessing care. It noted that Medicare "does not routinely cover dental care except in some cases" and "there are a limited number of private dental practices in Rhode Island that participate" in Medicaid. However, some patients may find care at federally qualified health centers.

A spokesperson said the department "is currently working on an oral health transformation project in hopes of increasing the number of providers who care for Medicaid members." The project would include assessing workforce gaps, investing in residency programs to attract more dentists, and encouraging "tele-dentistry," which may be used for consultations or educational purposes.

Dentists pushing for legislation, warning of looming crisis

The Rhode Island Dental Association is hoping it can make headway with a House bill on which Rep. Joseph McNamara is the lead sponsor. (As of early February, a Senate version was not yet introduced.) The Rhode Island Fair Share for Dental Care Act, as it's called, would force insurers to spend more money on patient care instead of marketing, executive salaries, and other costs not directly related to patients.

The bill would require insurers to submit financial information each year, including their income and expenses. If they're not spending 85% of their premiums on patient care, they would owe refunds to their customers.

For now, dentists hope lawmakers are listening.

"There’s a big crisis that’s looming on the horizon that we’ve really been trying to point out," Gazzero said, "both to the legislature and the powers that be that if we don’t change things and change them soon the quality of dental care is really going to take a hit."

This article originally appeared on The Providence Journal: RI dentist shortage, expensive costs leading to many putting off care