Will Poor Kids in Sacramento County Ever Get Dental Care?

Remedial placeholder-trailer legislation proposed and passed at the Capitol
by Michael Monasky

The California Assembly Budget Committee 1 held a variety of hearings on Monday on a $6 billion budget for Medi-Cal proposed by the Department of Health Care Services (DHCS).

Director Toby Douglas told committee chair Holly Mitchell, (D) South Los Angeles, that low utilization rates and poor access to dental resources plague the Geographic-Managed Care (GMC) DentiCal program in Sacramento County. Douglas promised that health care plans are making outbound calls to inform parents about dental resources for their kids. He encouraged dental plans to pay incentives to dental care providers who increase utilization. Monitoring the number of children's dental appointments on a monthly basis is one form of quality control proposed by the director.

The Department of Managed Health Care (DMHC) oversees private and commercial health care plans. A spokesman said he is working with Douglas to cover complaints focused on the mandatory dental plan in Sacramento County. A medical survey is under way, which requires a complete review of health plan activities just short of the subpoena process. There are due process requirements which must be met by the state in supervising health plans in this way. A 60-75 day time frame still remains for provider dentists to enroll in fee-for-service programs. Douglas also discussed so-called “pay for performance” standards.

DHCS Director Douglas declared that only time will tell if mandatory GMC DentiCal should be continued in Sacramento County, and that the department is not pursuing a fee-for-service alternative since there is no fee-for-service provider network available. Mitchell asked Douglas for a time frame for solving this persistent problem. Douglas said that immediate, monthly measurements were under way. He said that the patient target population was infancy to five years of age, and that DHCS is working to clear up dental provider confusion over covered benefits. Health plans are offering bonus payments to dental care providers who improve delivery of services to poor children.

Shannon Grove, (R) Bakersfield, asked Douglas why it took a recent investigative report by the Sacramento Bee to expose problems with DentiCal; why didn't DHCS make these revelations? Douglas responded that continuing contract talks between the state and the health plans were addressing issues of access to dental care resources. Richard Pan, (D) Sacramento, expressed multiple frustrations: that the program is still a pilot after 18 years of abject failure; that kids on MediCal cannot get dental care; and that quality control should be exercised by the state over the program. Dentists give care for free because it is cheaper than processing the paperwork for GMC DentiCal in Sacramento County; “we cannot let this continue,” Pan said.

Douglas persisted in his support of the existing dental plans: “we believe the health care plans can increase utilization” by parents and kids. Roger Dickinson, (D) Sacramento, called the process an “unpleasant experience.” As chair of Sacramento County's First Five Commission, he asserted that access to dental care is a continuing, long-term problem. Grove weighed in again: how could Douglas be certain that incentives to providers would increase access to care when the incentive amount is unknown? A DMHC spokesman testified that complaints about access to dental care have not reached his department. The Legislative Analyst's Office (LAO) favors the voluntary GMC DentiCal option for Sacramento County, and noted that DMHC is mandated to report health plan quality issues to the legislature.

Don McClurg, MD, is the chair of the DentiCal subcommittee of the Sacramento County Public Health Advisory Board. He said that that the complaint process is confusing to parents with multiple phone numbers. He said about 18-24 months of data would be required to show trends of improvements in access to dental care, and that sick kids with acute dental problems don't have that kind of time. Terry Jones, a local dentist with the First Five Commission, declared that there has been “18 years of dental neglect.” Jones noted that there is a cost for fee-for-service, but an even greater human cost when dental needs remain unmet. First Five staffer Debra Payne countered DHCS Director Douglas' statement that there are no fee-for-service resources available in Sacramento County. She said that there are five Federally Qualified Health Centers with dental clinics in operation today ready to deliver alternative, fee-for-service dental care.

Budget Committee chair Mitchell saw “consistent themes” in public testimony, including longstanding and emotional issues related to denial of dental care. Dickinson repeated a common frustration-that getting data from GMC health plans and the state departments that regulate them was an “enormous difficulty.” While asking a final question about the federal Affordable Care Act and its effects upon dental health for children and adults, Mitchell closed the hearing saying that dental coverage “has basically gone away.” Meanwhile, the Assembly Budget Committee approved the placeholder-trailer language from Senator Steinberg's office. Further legislative negotiations will be held to help develop that language.