In an ideal world, Jennifer Kent would like to have added 1,000 new dentists across California willing to accept enrollees in Denti-Cal, the state’s low-income dental program, over the past year.
Kent, director of the California Department of Health Care Services, the agency that manages the program, has had to settle for a much more modest number. According to Kent, 73 new dentists were enticed to join Denti-Cal in 2017.
“It’s not moving as fast as we would like,” she said.
During the lean budget years of the economic recession, the state cut Denti-Cal benefits and only covered services for children. Full benefits were restored to adults last year, along with mandates to the local health plans that they provide transportation and interpretation services for dental appointments.
But Denti-Cal has been creaking under various financial and logistical burdens. While more than half of the state’s doctors treat patients in Medi-Cal, the state’s low-income health program, little more than 15 percent of dentists treat Denti-Cal enrollees.
Meanwhile, the pool of dentists participating in Denti-Cal shrunk 8 percent between 2013 and 2017, while the number of people enrolled grew about 40 percent during that same period of time, largely due to Affordable Care Act reforms. Medi-Cal and Denti-Cal now cover nearly one in three Californians.
According to Kent, dentists have been unhappy with the payments they receive from Denti-Cal, which are less than half of what private insurance or well-to-do patients pay. Dentists also don’t like the paperwork they are required to complete to enroll in the program and the fact that around 40 percent of patients enrolled in Denti-Cal managed care plans do not show up for appointments.
Patient advocates say those aren’t the only program woes. “The challenge is not just the number of providers, but how they are geographically distributed,” said Kiran Savage-Sangwan, health integration policy director for the California Pan Ethnic Health Network. She noted that rural areas of the state are underserved by dentists, and that there are also a dearth of bilingual providers to treat patients who don’t speak English.
‘A Big Check’ for Dentists
The Health Care Services department has been responding to many of these grievances. Enrollment red tape has been cut, and dentists wanting to enroll in Denti-Cal can usually do so in little more than three weeks, according to Kent.
Moreover, the agency has been pumping large sums into the Denti-Cal program. It injected $140 million in supplemental funding from the Proposition 56 tobacco tax funds for the 2017-18 fiscal year, which was used to increase the rates paid providers. For fiscal 2018-19, that supplemental funding was increased to $210 million, a 50 percent bump, with more payments earmarked to encourage preventative care. That money also draws federal Medicaid matching dollars, for a total of $600 million in total supplemental funding, according to data from the California Dental Association.
Of the Prop. 56 funds, $30 million is being earmarked to repay debt that dentists have incurred for their education. According to Kent, that money will be likely be targeted at dentists practicing for less than five years. Although the details of the debt relief program are still being worked out with the Office of Statewide Health Planning and Development, Kent said it would be used to encourage dentists willing to take on a large proportion of Denti-Cal enrollees. Debt retirement payments to a single dentist could be as high as $250,000 to $300,000, she added.
Kent observed that many newly minted dentists have taken on so much student debt that most are being compelled to work for large practices immediately after graduating from dental school, even if they otherwise might be willing to work for a safety-net provider or even open their own practice. Student loans are also discouraging them from considering putting up a shingle in a rural part of the state.
“If someone said, ‘I’m willing to relocate to Alturas or Quincy, or the back side of Mono Lake,’ I think we would certainly be willing to consider that (application),” she said.
Although the California Dental Association has over the years criticized Denti-Cal rates, the state’s primary dental lobby is warm to this proposal. “CDA is enthusiastic about the program’s potential to attract dentists to underserved areas of the state and the program’s potential to support care for California’s neediest population,” it said in a statement issued in late June, just before the new fiscal year began.
Kent noted that the first applications and payments will likely be awarded in the beginning half of 2019. She hopes 100 dentists will be willing to enter the program and expects that word-of-mouth about the sums of money being paid out could encourage applications.
“Providers talk to each other, and if one is getting a big check, they start talking about it,” she said. “That is usually how provider participation changes in the Medi-Cal world.”
Tackling the No-Show Problem
DHCS is still mulling a comprehensive solution to reduce the number of no-show patients, which is often exacerbated by issues such as inflexible work hours for patients or their parents, child-care issues or lack of transportation. Although Medi-Cal is required to provide transportation to appointments if patients need it, this assistance can range from free bus passes to reimbursement for ridesharing services such as Uber or Lyft, depending on the local health plan.
The Fresno County Department of Public Health, which serves one of the lowest-income regions in the Central Valley, granted $4 million over five years to two area non-profits, Reading and Beyond and the Fresno Economic Opportunities Commission, to try and place Denti-Cal enrollees into a regular dental home where they will be treated every six months. The hope is that this will increase patient uptake by local providers and cut no-shows, which were around 30 percent last year.
“We’re very frustrated about that,” said David Luchini, the Fresno department’s assistant director. Nearly half of Denti-Cal enrollees in the county have some form of tooth decay that needs to be treated, he added.
According to James Richardson, Reading and Beyond’s dental project coordinator, the biggest barrier to getting patients to show up for appointments is intimidation. “They may see a sign in English that the dentist accepts Denti-Cal, but they’re unsure they speak their language,” he said. That worry can be compounded during an initial visit when paperwork has to be filled out.
The pilot, which began just about a year ago, serves about 6,000 families, including 9,000 children, who are referred to about 150 Denti-Cal providers. Twenty-six outreach workers will go to the office with the Denti-Cal enrollee to smooth over the treatment process. The workers are fluent in Hmong, Spanish and English, according to Richardson. Reading and Beyond and the Economic Opportunities Commission also work with the two Medi-Cal health plans in the county, CalViva Health and Anthem Blue Cross of California, to arrange patient transportation to appointments.
Denti-Cal enrollees are called three times in the week before an appointment as a reminder. If the enrollee can’t be reached the day before the appointment, it will be canceled and outreach will be made to the patient and family to reschedule.
According to Fresno County data, of the 3,000 appointments arranged through the pilot since last summer, fewer than 200 have resulted in no-shows, a rate of less than 7 percent.
“It’s been very successful,” Richardson said.