Orthodontist vs. insurer: How Question 2 could bring sweeping changes to dental industry

Question 2 would require dental insurers to devote a higher share of premiums to patient care than many currently do.

Dr. Ximena Venegas inside the first Boston location of Tend, a technology-driven dental company.David L. Ryan/Globe Staff

When Massachusetts voters head to the polls in November, they’ll get the chance to settle an arcane dispute that could upend the dental industry.

To boil it down: Question 2 would require dental insurers to spend no less for patient care than 83 percent of premiums they collect. It would be a sweeping change for an industry with no minimum threshold today, and one that could affect not just the insurers that do business here, but also the state’s dentists — not to mention anyone with dental insurance. It might even become a model that’s replicated in other states.

But take a look at who has funded this fight so far and something curious emerges: a one-on-one slugfest between orthodontist Mouhab Rizkallah and insurer Delta Dental of Massachusetts.

Rizkallah essentially bankrolled the initiative from the start. He paid $500,000 last year to hire signature gatherers to get it on the ballot. This year, roughly 40 dentists chipped in, mostly anywhere from $100 to $1,000 apiece, along with about three dozen other individuals. But Rizkallah contributed the bulk of the nearly $1 million the ballot committee raised so far in 2022, according to state campaign finance records published last week.

The pool of contributors on the opposing side is even smaller. Nearly $5 million has come so far from seven donors, most of it from one: Boston-based nonprofit insurer Delta Dental, which kicked in $4.5 million. A few other insurers — including MetLife, Concordia, and Sun Life — provided the rest.

The rift between Delta Dental and Rizkallah has been building for years. In the past decade, Rizkallah has sued the state’s Medicaid program, MassHealth, three times, alleging among other assertions that it did not provide adequate orthodontic coverage to children in low-income families. Much of Rizkallah’s beef was with DentaQuest, a Delta Dental affiliate that served Medicaid patients and was sold to Sun Life for nearly $2.5 billion, in a deal announced last year after Rizkallah began his Question 2 campaign. (A spokeswoman says Delta Dental gets no revenue from MassHealth today.)

A container of alcohol wipes rest next a to a tray of dental tools at a pop-up dental program created by ForsythKids in 2020.Erin Clark/Globe Staff

In March 2021, Attorney General Maura Healey came after Rizkallah, suing him for allegedly overbilling MassHealth and keeping kids in braces for far longer than they should have been. Rizkallah portrays this case as payback for his advocacy, saying Healey’s investigation was prompted by his critics at Delta Dental/DentaQuest. That lawsuit remains unresolved.

In the early stages of his ballot campaign, executives at Delta Dental HQ in Charlestown might have been able to dismiss Rizkallah as a lone disgruntled protagonist. But now the Massachusetts Dental Society and the American Dental Association have joined his crusade, together contributing more than $100,000 as of Sept. 20. Big money could be on the way: The ADA this month committed $5 million. The ADA believes Question 2 can set the stage for dental insurance reform across the country, by prompting insurers to be more accountable and transparent. (The measure would require insurers to submit loss ratios and other financial information to the state, making them public.)

So what’s motivating these huge outlays of cash? Neither Rizkallah nor Delta Dental would get on the phone. Both answered questions via e-mail, Delta Dental through a PR agency.

To sum up their responses: It’s for the patients.

Rizkallah stressed that medical loss ratios, as they’re known, are already in place for health insurers. Dental insurance, he said, needs to be more highly regulated, too. He points to Delta Dental as a prime example of what he calls a misallocation of consumers’ premium dollars. Delta Dental received $240 million in revenue from premiums, to cover its nearly 2.5 million members, in 2019 and paid out $177.5 million in benefits — a loss ratio of 74 percent. Rizkallah said that if the 83 percent minimum becomes law, it would redirect what he calls the “wastefulness” of insurers such as Delta Dental “back to patient pockets” through decreased premiums and copays.

The Mass. Dental Society e-mailed members last week, encouraging them to get involved with the ballot fight in part because it could spark patient-friendly reforms across the country. Andrew Tonelli, a dentist in North Reading who co-chairs the state association’s government affairs committee, said if Question 2 succeeds, he would feel more comfortable that patients are getting a good value for their insurance premiums. He said his group previously pushed for legislation on Beacon Hill that would require insurers to disclose their medical loss ratios, to no avail, and in June voted to endorse Question 2.

A restroom in Tend, a dental office in Post Office Square. David L. Ryan/Globe Staff

But Delta Dental sees higher costs on the horizon for patients. The company points to a recent industry-funded report that shows some insurers may end up raising premiums, while also increasing benefits or reimbursements to dentists, to hit the 83 percent requirement. Increased premiums, Delta Dental warns, could prompt people to drop their insurance entirely and make them less likely to visit a dentist, an outcome neither side wants. Delta Dental argues that Question 2 doesn’t allow dental carriers to exclude investments in digital customer interfaces, disease management, or fraud prevention from the loss ratio calculations — unlike the rules for health insurers — and could discourage carriers from investing in those programs as a result.

So who’s right?

Evan Horowitz, executive director of Tufts University’s Center for State Policy Analysis, took a stab at answering that one. Horowitz issued a report last week that predicted a mix of outcomes should Question 2 get approved: Insurers may lower monthly premiums, streamline operations to spend less on administrative overhead, or reduce profits, or pay more in dental claims by covering more procedures or allowing dentists to bill higher prices.

Horowitz also believes the new financial reporting mandates included in Question 2 would be helpful for policymakers going forward. But the bottom line, from his perspective, is that it’s unlikely Question 2 will have a major impact on consumer costs.

That may end up being the case, at least as far as patients are concerned. But the impact on the industry could be significant.

Just consider how much money the American Dental Association says it is contributing to making Question 2 successful, and how much Delta Dental has spent to get in the way.