Updated November 5, 2014
CDA-Sponsored Legislation (AB 1962): Dental Plan Accountability.
CDA sponsored AB 1962 (Skinner) this year, legislation signed into law in September that will provide increased dental plan transparency and value for patients and employers. The bill creates standardized requirements for dental plans to annually disclose to state regulators how they spend patient premium dollars and puts the state on a path to adopt a minimum percentage of premium revenue that dental plans must spend directly on patient care. Under current law, all medical plans are required to spend at least 80% of patient premium revenue directly on patient care as opposed to overhead costs and profits, a standard known as a medical loss ratio (MLR). However, no such standard exists for dental plans. Due to the lack of this patient protection, some dental plans self-report spending as little as 38% of premium revenue on patient care. Because dental plans have self-reported this data without standardized reporting requirements or the details necessary to verify their actual spending ratios, there is a lack of reliable data for the state to develop an evidence-based MLR standard for dental plans. AB 1962 brings dental plan reporting requirements to the same level that currently exists for medical plans and declares the Legislature's intent to adopt a formal MLR standard for dental plans effective Jan. 1, 2018. The MLR standard for medical plans has saved patients an estimated $9 billion on premiums since taking effect in 2011. Dental patients deserve the same protections and value from their dental plans. The first reporting deadline for dental plans is September 30, 2015.
CDA and a broad coalition successfully defeated Proposition 46 in the November 4th statewide election, a ballot measure that would have more than quadrupled the cap on non-economic damages under the Medical Injury Compensation Reform Act (MICRA) from $250,000 to $1.1 million, plus annual inflation adjustments going forward. 68% of voters opposed Proposition 46, which also contained provisions regarding drug testing of physicians and placed infeasible requirements on the state's prescription drug database that proponents admitted were only included as "sweetener" provisions because they polled well. The main objective of Proposition 46 was to make it more lucrative for trial lawyers to file lawsuits against dentists, doctors, hospitals, community clinics and other health care providers. The measure would have tripled the legal fees lawyers could collect in these lawsuits and increased healthcare costs by billions of dollars annually, seriously threatening patient access to care. The No On 46 campaign was a multifaceted effort that included statewide TV and radio ads, extensive social media and press outreach, and a robust grassroots outreach program in which CDA members were active participants.
Medi-Cal/Denti-Cal Provider Reimbursement Rates.
Last year the state began implementing the 10% Medi-Cal/Denti-Cal provider reimbursement rate cut adopted in the 2011 budget, which had been delayed due to a legal challenge mounted by CDA and other health care organizations. CDA successfully prevented the implementation of the "clawback" of provider payments that would have been retroactively applied dating back to June 2011, ensuring dentists are not forced to return funds received over the previous two years. However, providers will still face the 10% rate cut going forward and California already had among the lowest provider reimbursement rates in the country prior to the cut. With the implementation of the Affordable Care Act and its expanded coverage for millions of children and adults, California cannot afford to lose any providers willing to serve these patients as they gain much-needed dental coverage. The 2014-15 state budget signed by the Governor in June did not include increases in reimbursement rates, but it does require the Department of Health Care Services (DHCS) to establish a list of performance measures to evaluate utilization, access, availability and effectiveness of the Denti-Cal program, which should help demonstrate the impact of low rates. CDA is also a convener of a working group that includes DHCS and other stakeholders to develop solutions to the growing crisis around Medi-Cal/Denti-Cal services provided under general anesthesia, which many facilities statewide have either reduced or discontinued due to inadequate reimbursement rates.
The 2013-14 state budget package included a partial restoration of Denti-Cal benefits for adults and more than 3 million Californians are expected to be eligible to receive care as a result. Basic preventive and restorative services, along with full dentures, were brought back beginning May 1, 2014. Senator Darrell Steinberg, who visited the "CDA Cares" program in Sacramento in August of 2012, made restoration of adult Denti-Cal benefits a top priority during budget negotiations with the Governor and legislative leaders. Steinberg stated it was the volunteer work of the CDA dentists he witnessed that inspired him to make the restoration of adult Denti-Cal benefits a top priority. However, coverage for other important services, such as partial dentures and periodontal care, still needs to be restored.
Dental Director/State Oral Health Plan.
CDA's access to care plan prioritizes above all else the need for a comprehensive state oral health program led by a state dental director. Since the development of that plan over two years ago, CDA actively engaged the Governor's administration about the importance of hiring a licensed dentist with strong experience in state oral health programs to organize and execute essential dental public health functions; someone who has experience in leveraging state resources, securing federal funding and improving the delivery of dental disease prevention to vulnerable Californians. These advocacy efforts were successful and the Governor's 2014-15 budget revisions released in April called for ongoing funding for a state dental director and an epidemiologist in the Department of Public Health to establish a state oral health program. The dental director will be specifically charged with developing a burden of disease report, leading the collaborative process to create a state oral health plan and managing the ongoing implementation of that plan. The dental director's role will also include establishing prevention and oral health literacy projects, and working to secure funding for prevention-focused oral health and essential disease prevention services, particularly for children. The funding was incorporated into the 2014-15 state budget that took effect July 1 and the state is currently accepting applications for the positions, which should be filled by the end of the year.
Dental Hygiene Committee Sunset Review.
Established by legislation in 2008, the Dental Hygiene Committee of California (DHCC) went through its first legislative sunset review process this year and the DHCC, along with the California Dental Hygienists Association, recommended a series of substantial policy changes that CDA opposes. The changes included: reducing oversight of certain dental hygienist duties by moving local anesthesia, nitrous oxide, and soft tissue curettage from direct to general supervision duties; deleting the requirement that registered dental hygienists in alternative practice (RDHAPs) obtain a dentist's prescription in order to continue providing services to new patients after 18 months; formally removing the committee from the Dental Board's jurisdiction and changing the committee to a Board; and eliminating the requirement that any recommendations by the DHCC for scope of practice changes be submitted to the Dental Board. CDA advocated against these proposals early in the sunset review process and the Legislature rejected these changes, extending the DHCC for another four years without any expansion of the committee's authority or the hygiene profession's scope of practice as proposed by the DHCC and the California Dental Hygienists Association.
Health Care Reform.
California has moved rapidly towards full implementation of the Affordable Care Act (ACA) and 2014 marks the first year that most Americans needed to obtain health insurance coverage or pay a penalty. Pediatric dental services are one of the Essential Health Benefits that are offered in the Exchange, and CDA worked to ensure families could purchase those benefits from stand-alone dental plans, which results in more choice for families. In 2015, stand-alone dental plans will also be offering adult benefits through family plans. Additionally, in 2015 health plans will be offering pediatric dental benefits as well. CDA continues to advocate with the California Health Benefit Exchange Board and the Legislature to ensure that the Exchange is a competitive marketplace for dental benefits, that consumers are provided a transparent set of options and that they can maintain a relationship with their current dentist when purchasing dental coverage for their families.
Virtual Dental Home (AB 1174).
AB 1174 (Bocanegra), signed into law in September, establishes primary elements of the "Virtual Dental Home" Health Workforce Pilot Project into law. Specifically, AB 1174 allows certain expanded duties (determining radiograph needs and placing protective restorations, known as interim therapeutic restorations, under the diagnosis and direction of a dentist) for registered dental hygienists, registered dental hygienists in alternative practice and registered dental assistants in extended functions in a Virtual Dental Home setting (community clinics, nursing homes, preschools, etc.) using telehealth technology. Such functions have been tested over the past several years as a part of the pilot project, which will now continue as a permanent program. CDA supports AB 1174 as a cost-effective way to reduce barriers to oral health care and worked continuously with the author and other stakeholders to ensure that the bill included important provisions relating to treatment settings, supervision and education.
Dental Licensure Fees.
Last fall the Dental Board of California adopted regulations that raised the initial licensure and biennial renewal fees for dentists from $365 to $450 effective July 1, 2014, which was the maximum allowable under state law. These fees have not been increased since 1998, and the increase was proposed primarily as a result of increased enforcement expenses mandated (but not funded) by the Department of Consumer Affairs for all state licensing boards. CDA provided written comments on these regulations, acknowledging the length of time that these fees had remained the same, but emphasizing CDA's expectation that the board's level of customer service and responsiveness must be demonstrably improved as a result of any increase. CDA also urged the board to provide greater clarity on its fiscal condition and to consider making smaller, more incremental changes in the future. Because the board's budget forecasts indicated a continued deficit condition even with the July 1 increase, the board sponsored SB 1416 (Block) this year, which was signed into law in June and enacts an additional increase to $525 in 2015. The board maintained that without these increases key board functions such as licensure renewals and enforcement processes would have been affected, jeopardizing adequate oversight of the profession and patient safety. Even with the increase to $525 through SB 1416, the issue remains as to what the cap should be going forward to allow the board to raise fees incrementally through the regulatory process in the future, which will be considered next year when the board goes through the legislative sunset review process. The board has said it wants to pursue a cap of $700, based on an analysis of fees necessary to sustain board operations over the next 10 years. CDA is advocating that a comprehensive analysis of the board's structure and finances must occur prior to any additional fee or cap increases for the board. CDA will also continue to advocate that fees rise only as high as necessary, that the revenue generated is spent prudently and that customer service is considered an essential and important board function.
Proposition 65 Reform.
Approved by voter initiative in 1986, Prop. 65 requires businesses with 10 or more employees to provide "clear and reasonable warning" if a product or business location may expose employees or customers to a chemical known to the state to cause cancer or reproductive toxicity. Last year, Governor Brown announced an effort to develop reforms to "strengthen and restore the intent of Proposition 65". The Brown Administration held formal negotiating sessions with an invitation-only group of stakeholder organizations in an attempt to reach agreement on a reform package that would improve Prop. 65's warning notice and litigation provisions. CDA was the only health care organization invited to participate in these meetings, actively negotiating with the Governor's office, the Legislature, and a variety of business, legal, and consumer stakeholders. Ultimately, the administration was unable to reach consensus and dropped the legislative effort for 2013. However, agency-level regulatory efforts are continuing this year. CDA has submitted comments to the Office of Environmental Health Hazard Assessment (OEHHA), which is overseeing the regulatory process, expressing our primary concern that any reforms to Prop. 65 do not create new threats or re-open the existing restorative materials warning notice that has protected dentists from litigation for the past 10 years. CDA is also working to ensure that any Prop. 65 reforms do not unduly restrict legitimate health care treatment discussions between providers and patients.
Sugar-Sweetened Beverage Labeling (SB 1000).
CDA supports SB 1000 (Monning), a bill that would require all sugary drink bottles, cans, vending machines, dispensers, and restaurants to display a warning that "drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay." The acidity, carbonation, and sugars in these drinks creates a high risk of demineralization of dental enamel and makes consumption of these beverages one of the most significant contributors to dental decay in children. The bill is an attempt to promote informed purchasing decisions by highlighting the scientifically proven health risks of sugary beverage consumption. Despite the support of dozens of healthcare and education organizations, SB 1000 failed to advance in the Assembly and will not move forward this year.
Kindergarten Oral Health Assessment.
CDA remains committed to the Kindergarten Oral Health Assessment program created in 2006 through AB 1433 (Emmerson). The program requires students to have an oral health assessment during their first year of school. As a part of the Governor's school funding reform efforts, jurisdiction of the program, along with all other state mandates, was shifted to the local level. CDA is working to ensure that this program is maintained and that the governing statute for the program is protected.