Pressure to boost Medi-Cal dental reimbursements

Jim Wood tells a story about teeth that makes him smile.

Wood — a dentist and a state assemblyman from Sonoma County — remembers the time a patient of his who was an elementary school teacher told him about a student suffering from serious dental problems. The little girl’s family was poor and they lived in a rural area. They couldn’t find a dentist to treat her.

A state audit of dental services under the Medi-Cal program last year found that more than half the low-income kids enrolled in Medi-Cal in 2013 did not receive dental care through the program that year.

The family lived too far for them to travel to Wood’s office in Cloverdale. But Wood was able to find a dentist closer to their home to treat the girl.

“It completely changed her from someone who was withdrawn and quiet and under-performing to a child who was outgoing, active and performing at grade level,” Wood says.

That’s where this good-news story goes bad. There are many more children like that girl – potentially millions — who aren’t able to get the care they need and have no one to intervene on their behalf.

A state audit of dental services under the Medi-Cal program last year found that more than half the low-income kids enrolled in Medi-Cal in 2013 did not receive dental care through the program that year. There’s no way to know how many of those kids needed cavities filled. But if they are not even getting a check-up or having their teeth cleaned on a regular basis, chances are their teeth are not as healthy as they should be.

One big reason more kids aren’t going to the dentist is that, in many areas, there are not enough dentists to go around. There were about 5 million California kids on Medi-Cal when those numbers were gathered. Thanks to the federal Affordable Care Act, another million children are now eligible.

“When you are being reimbursed 35 cents or 40 cents on the dollar, it does not take a financial genius to figure out that you can’t do that very long and remain viable,” he said.

The state Department of Health Services, which runs the program, has not followed state laws requiring it to determine if Medi-Cal has enough dentists to serve all the children who need care. The department has not even set a standard for how many dentists are necessary to treat kids who are not in managed care health plans.

For managed care, the state requires the plans to contract with at least one dentist for every 2,000 kids. Using that standard, the auditor said it appears that there are enough dentists in the program statewide, but not in every county. In some counties, in fact, there are no dentists at all treating Medi-Cal patients. Elsewhere, dentists are not accepting new patients.

The auditor concluded that the shortage of dentists is likely tied to California’s low reimbursement rates. The state pays an average of less than $22 for the ten dental procedures most frequently authorized for payment – a figure that is just 35 percent of the national average. The state has not raised its rates for 15 years, and in 2013 California cut those rates by 10 percent.

Wood shut down his practice before entering the Legislature. But he says many of his colleagues in the profession can no longer afford to participate in the program, especially given the high overhead costs they have to maintain equipment and staff.

“When you are being reimbursed 35 cents or 40 cents on the dollar, it does not take a financial genius to figure out that you can’t do that very long and remain viable,” he said.

Gov. Jerry Brown has resisted raising Medi-Cal rates, arguing that regional shortages of doctors and dentists have more complex origins than simply a payment system that falls short. Even with the multi-billion-dollar surplus he announced last month, Brown held firm, declining to increase rates in his revised budget.

But that might soon change. Proposals in the Legislature to restore the 10 percent cut are winning wide support. And here’s a change: this is one area of social spending where Democrats and Republicans agree. Many of the most conservative Republicans are from rural areas – and that’s where the shortage is greatest.

With bipartisan backing in the Legislature, it seems likely that Brown will compromise on this issue as the final budget moves toward passage later this month.

And that would give California kids something to smile about.
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Ed’s Note:  Daniel Weintraub is editor of the California Health Report, where this story first appeared. Email him at daniel.weintraub@gmail.com