Special hearing highlights deficiencies of Denti-Cal

CDA participated in a special hearing recently to review the deficiencies of the state's Denti-Cal program.

The Little Hoover Commission, an independent oversight committee that examines ways to improve government programs, held a meeting at the state Capitol to delve into the problems highlighted in a report that found that California's 2014 reimbursement rates for the 25 most common Medicaid dental services were well below those in the comparable states of New York, Texas and Florida.

Dentists across California have long dealt with this problem and other barriers in the Denti-Cal program firsthand as they attempt to provide care for underserved populations. John Blake, DDS, testified at the meeting on CDA's behalf. Blake has worked many years in private practice and for the last 10 years as the executive director and dental director of the Children's Dental Health Clinic, a 501 (c) (3) nonprofit comprehensive dental treatment center and teaching program. Earlier this year, Blake was forced to shut down a satellite clinic in Bellflower due to the extremely low reimbursement rates and complicated nature of the Denti-Cal program. The clinic served a small underserved community in Southern California and was open four days a week. Two days a month, the clinic brought in a dental anesthesiologist to treat young children with multiple caries under IV sedation.

Even though the county provided the clinic space for free, it still cost approximately $16,000 to run each month and it was losing $8,000 monthly due to Denti-Cal's low reimbursement rates and the burdensome paperwork processes required by the state, Blake said.

Blake went on to explain how dentists across the state want to treat the underserved patient population, but it has become increasingly difficult to treat those enrolled in Denti-Cal because of the administrative burdens. Private dentist offices have an even greater difficulty in balancing their patient mix due to the low rates.

"Most of my dental colleagues I speak with want to do the right thing and help struggling patients. Many volunteer at the well-organized CDA Cares dental treatment events held throughout the state. Many used to work in the Denti-Cal system but have dropped out. The biggest reason for leaving the system is poor reimbursement, right behind that is the administrative burden," Blake said.

Assemblymember Jim Wood, DDS, who requested the commission's report, also testified at the hearing. Prior to joining the Legislature, he practiced dentistry for 27 years and was a Denti-Cal provider. He estimates that in his early years of practice, 90 percent of his patients were in the Denti-Cal program. But it slowly became more difficult to participate as a provider in the network because reimbursement rates were roughly 35 percent of the cost of providing care at his practice.

"You cannot do that very long and have a viable practice," Wood said.

It is even more difficult for young dentists, limiting their ability to join the program early in their careers.

"Graduating classes just out of (dental) school now face debt that's in the hundreds of thousands, which leads to thousands in monthly payments. Do the math and realize what kind of income it takes to make those monthly payments and cover living expenses," Wood said.

The percentage of children not receiving care because of Denti-Cal is glaring. There are now more than 12 million Medi-Cal beneficiaries with dental benefits in California. As pointed out in the state auditor's report of December 2014, less than half of the children enrolled in the Denti-Cal program in 2013 were able to access basic dental care. Recent estimates from the Department of Health Care Services (DHCS) indicate that only one in four adults enrolled in the Denti-Cal program accessed any dental treatment during 2014 once adult benefits were partially restored.

CDA made the point that when there is a system of care that provides needed dental treatment to less than half of the children who are eligible for services and when studies show that the number of dental-related emergency room visits for adults continues to increase, it is clearly a serious problem that needs multiple strategies to address it.

CDA staff testified at the hearing and encouraged the commission to focus on a multi-faceted approach to addressing the deficiencies in the Denti-Cal program. These include targeted provider reimbursement increases coupled with programmatic improvements in treatment delivery; streamlining the time-consuming and overly burdensome provider enrollment process; and finally, simplifying the complicated administrative hurdles needed for reimbursement of covered services. Addressing all three of these issues would result in more dentists able to participate in the network, therefore improving access to care for beneficiaries.

CDA believes it is necessary to make substantive program improvements to ensure access to high-quality dental care for California's beneficiaries. Focused changes should improve access to prevention and basic dental care treatment services for at-risk children by implementing a proven program that targets care to that population and provides enhanced reimbursement rates for key services.

CDA referenced the Access to Baby and Child Dentistry (ABCD) program in the state of Washington and the Healthy Kids, Healthy Teeth program in Alameda County, where Medicaid works with community agencies, like Head Start and WIC, to refer children age 0 to 5 to dentists who are certified participants in the program and, therefore, receive an enhanced reimbursement rate for certain prevention and basic treatment services. Implemented statewide, local community health workers would be used to identify vulnerable children enrolled in the Medicaid program younger than 5 years old, and link to a network of dental providers who are uniquely trained to treat these younger and more difficult-to-treat beneficiaries.  

By augmenting current reimbursement rates for certain key services, which include cleanings, fluoride application and basic restorations, the state can begin to transform its program to one that improves access to important treatment, sets children up for a lifetime of better oral health and improves access to care by encouraging provider participation in the program. This program design has a proven record of increased access to care, improved oral health outcomes, recruitment of dentists to the program and reduced per capita costs to the state.  

CDA also testified about the impact provider rate increases have had in other states in recruiting new providers to the network and improving access to care. Other critical program improvements like the virtual dental home, care coordinators/community outreach workers, support for dental school clinics and other provider incentives were also discussed.   

Changes like these are needed so dentists like Blake won't be forced to close more clinics and so more patients can get the care they desperately need. In response to growing concerns about lack of access to care for Denti-Cal patients, the 2015-16 state budget reversed a 10 percent reimbursement rate cut that took effect in 2013. However, the audit report, which is required by the Legislature, and this Little Hoover Commission meeting, demonstrates much more work is still needed.

"I can't emphasize enough that many of my colleagues believe it is the right thing to do to treat the population, but are faced with the reality that it is not a financially viable option," Wood said.

The Little Hoover Commission will produce a report based on its examination, including this hearing, in the near future.

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A new review of the state’s Denti-Cal program provides further evidence that current rates are insufficient and that there has been a significant decline in participating providers since 2008. Just released by the state Department of Health Care Services, the report shows that while there has been a nearly 40 percent increase in enrolled children and 77 percent increase in enrolled adults, there has been a double-digit decrease in providers in that same timeframe.