One third of California residents and half of the state’s children qualify for Denti-Cal, the state’s Medi-Cal dental program. So leaders in counties like Santa Cruz, where 82 percent of the dentists don’t take Denti-Cal, are seeking new ways to serve this long-suffering low-income population.

“Most California dentists want nothing to do with Denti-Cal,” stated an April report by the Little Hoover Commission, an independent state oversight agency. It hammered Denti-Cal — calling it a broken system that has alienated its partners in the dental profession. Less than half of Denti-Cal beneficiaries use their benefits because they simply can’t find a dentist who will see them.

That has left counties, community clinics, nonprofits and private dentists to cobble together programs and safety nets for thousands of residents. Some of those are showing promise and some counties plan to expand them by applying for part of the $740 million state and federal agencies have allocated for the new Dental Transformation Initiative. It is meant to incentivize more dentists to offer preventative dental care to children.

While the California Dental Association, counties and private dentists say this is an encouraging step, there’s a long way to go to reviving the dysfunctional system, they say.

Dientes Community Dental Care, a community dental clinic receiving federal funding through Santa Cruz County, decided to commission its own report: Increasing Access to Dental Services for Children and Adults on the Central Coast, released in April. It showed that of the 80,000 people on Medi-Cal in Santa Cruz County, only 31 percent of them were able to see a dentist in 2014. Thirty-one percent of children under age 11 in the County have never seen a dentist and seniors on Medicare have no dental benefits except for extreme needs.

“Insurance does not equal access,” said Laura Marcus, Dientes’ executive director.

Despite its expansions, Dientes has to reject about 20 calls daily for dental service. Gaye Hancock was among them. She lost her job during the economic downturn and is working again but now has Denti-Cal. She started calling Dientes two years ago and finally resorted to getting her teeth cleaned at the Cabrillo College Dental Hygiene Clinic by student hygienists. They found cavities and bone loss which have forced Hancock to chew on just one side of her mouth since 2014.

“I’m 63, I’m just fighting to keep my teeth healthy,” she said.

As a result of the Santa Cruz report, the Santa Cruz County Oral Health Access Steering Committee emerged, including Santa Cruz and Monterey County government, education and dental industry representatives among others. They plan to present strategies in December 2016.

Denti-Cal Reimbursement

Denti-Cal reimbursement rates are among the lowest in the country and its arduous billing system has repelled most private dentists. According to a 2015 Department of Health Care Services report Denti-Cal pays only 31 percent of average national commercial rates for dental procedures.

John Blake, executive director of the nonprofit Children’s Dental Health Clinic in Long Beach, testified before the Little Hoover Commission that Denti-Cal has not had a provider fee increase since 2001.

“Dentists would rather provide care to the poor for free than hassle with the time and effort involved with trying to recoup 26 cents on the dollar in the Denti-Cal system,” he told the commission.

Eighty-five percent of the Children’s Clinic patients are on Denti-Cal but only half the budget is Denti-Cal reimbursements, county funds and patient payments. The rest has to be raised through foundation, corporate and individual donations and endowment and investment income.

Many private dentists would like to take Denti-Cal patients but say they simply can’t afford it. When new dentist Jonathan Lo purchased an existing practice in Los Angeles County in 2010, he didn’t have the financial resources to absorb the losses on every Denti-Cal patient he had. So he’s stopped taking new Denti-Cal patients and volunteers to do pro bono work at Blake’s children’s clinic.

Private dentists partnering with federally-funded clinics

One recommendation in the Santa Cruz report was for federally qualified health centers, which get paid much higher reimbursement rates for Denti-Cal-covered services, to contract with private dentists. This could help community clinics avoid expensive expansions and private dentists avoid hassling with Denti-Cal enrollment and reimbursement.

Ken Wallis, president of the California Dental Association, said the organization strongly supports this concept, approved by Congress in 2009.

Some community health centers are piloting this practice, said Ben Avey, a spokesman for the California Primary Care Association, representing California community clinics and health centers. But they aren’t yet comfortable talking about it.

Marcus of Dientes said there are many obstacles, such as determining who is responsible for the patient liability and how quality of care would be tracked in offsite dentist’s offices.

“There are a lot of regulations to be an FQHC, it’s not just like they will go ahead and get paid our rate, it’s a little more difficult,” said Randolph Cross, dental director for Salud Para La Gente in Watsonville, a federally qualified health clinic.

But Avey said his association predicts the practice will become more common and is providing information to clinics about how to contract with the private sector.

Blake has been trying for years to get federally qualified health clinics to partner with his clinic. When the federal government set up the guidelines for federally-funded medical clinics to do dental care, they weren’t required to do comprehensive care. So when patients need sedation, root canals or oral surgery, Blake gets the referral but not the compensation, he said.

And finding Denti-Cal dentists who do sedation on children is difficult. Children on Denti-Cal in Santa Cruz County have to travel to Monterey County, states the Santa Cruz report. Children in Amador County must travel multiple hours for sedation, said Nina Machado, Executive director of First 5 Amador.

Prevention

According to the Little Hoover Commission only 14 percent of Denti-Cal’s $1.3 billion budget is spent on prevention. The other 86 percent is spent on drilling, filling, capping and extracting.

“We can’t just provide more and more services,” said Marcus, “We need prevention.”

In Amador County, access to Denti-Cal providers is almost nonexistent, Machado said. So she and pediatrician David Stone secured a $3,000 grant from Sutter Medical Group – Philanthropy for fluoride and dental kits. A local dentist office trained medical staff for free to do oral exams and apply fluoride varnish, which can be billed through Medi-Cal. So far the project has more than tripled the number of children treated through previous programs, Machado said.

Amador is applying with Sacramento County for up to $16 million of Dental Transformation Initiative funding for teledentistry, expanding partnerships with pediatricians, and training local agencies to educate residents about their dental options. The counties estimate that dental vans could serve two thirds of students at school sites, said Debra Payne, public health program planner for Sacramento County.

The Little Hoover Commission report highlighted Amador’s approach and Alameda County’s Healthy Kids, Healthy Teeth Project, based on the statewide ABCD program in Washington, as programs that should be piloted in other counties. ABCD dentists get assistance and incentives of 60 percent more than the state’s standard Medicaid reimbursement. County health departments, foundations, dental societies and nonprofits help pay for that.

Alameda County uses general fund money to pay dentists $20 per visit twice a year for treating Denti-Cal patients aged 0 to 5 and providing preventative services and family oral health education. Dentists give the county appointment slots and county staff help make appointments in multiple languages.

“We have a three-fold increase in utilization of services for children who go through the program compared to general Denti-Cal patients in our county,” said Baharak Amanzadeh, Dental Health Administrator for the Alameda County Public Health Department. Alameda is also applying for Dental Transformation Initiative money.

While Wallis of the California Dental Association called the initiative an unprecedented investment in Denti-Cal, it remains to be seen how effective these pilot projects will be, he said.

The Association has been calling for a comprehensive transformation of Denti-Cal.

Blake projects that increasing the reimbursement rates even slightly and simplifying the claims process would prompt many dentists to devote 10 percent of their practices to Denti-Cal patients.

“Private dentists just want to pay their bills,” he said.