This paper presents current research and data surrounding oral health services delivery in Los Angeles County and California, specifically with focuses on provider payment, workforce, improved access to care, and community education. The information was collected through conversations with dental providers and community clinics, oral health advocates, stakeholders, and research. A summary of current challenges and subsequent recommendations is listed below. The recommendations will inform the Community Clinic Association of Los Angeles County’s (CCALAC) dental and oral health policy and advocacy platform.

Provider Payment

A large portion of California’s oral health providers are unable to participate in the state’s Medi-Cal program due to insufficient reimbursement rates, arduous enrollment paperwork, and other barriers (Klein, 2017). The Little Hoover Commission released a report covering the Medicaid dental system in April of 2016. It discussed the lack of provider involvement in California’s Medicaid dental program, otherwise known as Denti-Cal and cited the fact that providers who participate in the program receive among the nation’s lowest reimbursement rates, while other states’ dentists who participate in their state Medicaid program receive reimbursements up to three times the amount Californian providers receive (Ibarra, 2016). As a result of the shortage of dentists willing to accept Denti-Cal patients, access to oral health services is limited for beneficiaries. The inclusion of specialty services in the dental reimbursement package would incentivize more providers to participate in Denti-Cal.

On November 8, 2016, California voters approved the California Healthcare, Research and Prevention Tobacco Tax Act (Prop 56) to increase the excise tax rate on cigarettes and tobacco products. For Fiscal Year 2016-2017, Governor Jerry Brown approved a budget that allocated $140 million of Prop 56 revenue for DHCS to provide “supplemental payments” for hundreds of dental procedures. The intent was to increase access to dental care for beneficiaries by offering supplemental payments to dental providers who bill under the Dental Fee-for-Services or the Dental Managed Care Plans.  Governor Brown continued to provide additional funding of $210 million from Prop 56 revenue for the Denti-Cal program in the FY 2018-2019 state budget. Even though Governor Brown has approved funding from Prop 56 revenue for the Denti-Cal program, Prop 56 does not specify a minimum percentage of funds to designate to dental (SB 856 Budget, 2018). Additionally, allocating Prop 56 funds to the program would require annual federal approval (SB 856 Budget, 2018). These parameters could negatively impact the sustainability of these supplemental payments. An increase in long-term provider payment plans will help incentivize more California oral health providers to participate in the Medi-Cal program and ultimately create more access points for Medi-Cal patients.

The Department of Health Care Services (DHCS) continuously releases updated versions of its provider handbook. The handbook addresses: billing information, forms, and other relevant provider materials are included in multiple sections of the handbook (‘Denti-Cal Provider Handbook,’ 2018). Continuous updates as required will help to streamline provider payments and ensure timely access for patients

Recommendations

1. Advocate higher, long-term and sustainable Denti-Cal reimbursement rates to incentivize dental providers, including specialists, with cultural and linguistic competency to participate in Denti-Cal, therefore expanding access to dental services for Medi-Cal patients.
2. Advocate for sustainable access to dental funds in the My Health LA[1] (MHLA) program, adequate funding for dental services in the MHLA program, and clear and timely communication from MHLA to providers of any changes to dental reimbursement codes.
3. Recommend DHCS to reduce administrative burden for Denti-Cal providers and streamline and simplify billing processes so that Medi-Cal patients can receive services in a timely manner.
4. Advocate more dental procedures be included for provider reimbursement.

Workforce

Health Professional Shortage Areas (HPSAs) are designated by the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers). In terms of dental professionals, the federal government defines HPSAs as an area with a population to provider ratio larger than 5,000 to 1 (Kaiser Family Foundation, 2017). As of 2017, California has 439 total dental care HPSA Designations (Kaiser Family Foundation, 2017). The shortage of oral health professionals participating in Denti-Cal is largely due to a lack of state incentive programs to compensate for low provider reimbursement rates.

As mentioned above, the Governor’s 2018-2019 state budget includes funding for the Prop 56 program. A major addition to the Denti-Cal program is a one-time allocation of $30M for new dentists who need assistance in paying off school loans (CDA, 2018). A portion of Prop 56 funds are allocated to loan repayment programs for both physicians and dental professionals. Of the $220M allocated for loan-repayments, $30M will be dispersed among recent dental graduates, while recent physician graduates have been allocated $190M (State of California, 2018). The program is conditional, requiring dentists to enroll in the Denti-Cal program and see Denti-Cal patients in their community (CDA, 2018).

California may soon look to other states such as New York for non-physician incentive programs. New York’s Primary Care Service Corps dedicates funding for non-physician personnel such as dentists and dental hygienists (Rural Health Information Hub, 2018). The funding serves as a loan-repayment method and is reserved for those agreeing to work in state-recognized underserved areas.

Recommendations

1. Advocate long-term workforce programs (loan repayments, dental residency programs, rotation programs, etc.) that encourage various levels of dental professionals who have cultural and linguistic competency to provide care for all Californians.
2. Recommend DHCS provide a regular report that contains data on the recruitment of Denti-Cal providers of all levels and data on Denti-Cal providers who exit the program.

Improved Access to Care

Timely access to care is a common deterrent to Denti-Cal patients. Lists of covered services and available providers are murky. Different dental payment plans require different pathways when it comes to seeking care. Some patient populations receive more coverage and attention than others. Misinformation or a lack thereof creates a lack of incentive for those who wish to utilize dental services.

While full dental coverage has been restored, it is still difficult for Denti-Cal patients to find providers within an accessible distance, or even at all. Due to low reimbursement rates, dentists either cannot afford to continue participating in the program or do not bother to enroll in the first place (Klein, 2017).

Dental Plans: California’s 58 counties utilize either dental fee-for-service (DFFS) or dental managed care (DMC) plans. In 1995, DMC was implemented in Sacramento and Los Angeles Counties (‘Denti-Cal Managed Care,’ 2018). DMC enrollment is mandatory in Sacramento County, while Los Angeles County dental patients must choose to participate in a DMC plan (‘Denti-Cal Managed Care,’ 2018). Sacramento County operates on a Geographic Managed Care (GMC) plan that links patients with providers based on zip codes (‘Denti-Cal Managed Care,’ 2018). Los Angeles partners with Prepaid Health Plans (PHP) for their managed care patient population: Access Dental, Health Net Dental, and LIBERTY Dental (‘Denti-Cal Managed Care,’ 2018). All three plans are available in both Sacramento and Los Angeles County. Patients enrolled in DMC are assigned to a provider, creating a gatekeeper and a dental home. DMC benefits are also covered under FFS plans. Patients enrolled in FFS may contact and enroll with any provider in the Denti-Cal network (‘Denti-Cal Managed Care,’ 2018). As stated, FFS benefits are the same as DMC benefits.

In 2014, DHCS reported 46.1% of individuals in both Sacramento and Los Angeles Counties under FFS utilized dental services. Among individuals enrolled in DMC insurance plans, 41.7% individuals under 21 utilized dental services in Sacramento County, compared to 40.9% individuals younger than 21 in Los Angeles County (DHCS, 2014). For general Denti-Cal individuals over the age of 21, 45% utilized dental services (DHCS, 2014). It is possible the higher utilization rates among FFS patients is due in part to the lack of “gatekeeper” one must go through in order to obtain a referral, such as under DMC.

The DHCS reported in 2017 an overall 11% decrease in utilization among individuals in Sacramento County ages 0-20 from FY 2014-2015 (41.3%) to FY 2015-2016 (37.3%). A 10% overall decrease in utilization was reported for individuals in Los Angeles County ages 0-20 from FY 2014-2015 (42.1%) to FY 2015-2016 (39.4%) (DHCS, 2016). Reasons for decreases in utilization across counties were not listed.

Aside from determining whether a patient has dental benefits, it is difficult for patients to locate a dentist that is currently accepting Denti-Cal patients. Only 15.4% of dentists in California accept Denti-Cal (Shinkman, 2018). There are several counties that do not have dentists who accept Denti-Cal, or who have dentists at all (Shinkman, 2018). For example, in San Francisco, there are only 20 dentists to serve about 150,000 Denti-Call beneficiaries (Shinkman, 2018).

Medi-Cal 2020 Waiver: The Medi-Cal 2020 Waiver is “a five-year renewal of California’s Section 1115 Medicaid Waiver” (California Association of Public Hospitals and Health Systems, 2018). This waiver advocates for preventive efforts surrounding health by allocating $740 million in financial incentives for California dentists to join the Denti-Cal program (CDA, 2016).  The Medi-Cal 2020 Waiver is innovative in that it addresses California’s Denti-Cal program, which has lacked advertising and funding in the past. The CDA (2016) noted that “this is the first time the state’s neglected and underfunded dental program, Denti-Cal, has received this kind of attention and substantial investment.” (CDA, 2016).

One portion of the Medi-Cal 2020 Waiver is the Dental Transformation Initiative (DTI) Program, which seeks to expand access and address the needs of children on Medi-Cal. The DTI has four domains: (1) “increase statewide proportion of children ages 1 through 20 enrolled in Medi-Cal who receive a preventive dental service by 10 percentage points over a five-year period” (2) “diagnose early childhood caries by utilizing Caries Risk Assessments (CRA) to treat it as a chronic disease and to introduce a model that proactively prevents and mitigates oral disease;” (3) “increase continuity of care for beneficiaries ages 20 and under for 2, 3, 4, 5, and 6 continuous periods;” and (4) “address one or more of the three domains through alternative programs, potentially using strategies focused on rural areas, including local case management initiatives and partnerships” (‘Dental Transformation Initiative,’ 2018). The fourth domain is currently being piloted in select California counties, including Los Angeles County.

Both UCLA and USC are currently participating in the DTI program. UCLA has partnered with several programs throughout their piloted program to expand preventive dental care to 500,000 children across Los Angeles County who are enrolled in Medi-Cal (Aldrich, 2017). USC, in partnership with Cal State University, launched a pilot program to provide dental treatment and education to Medi-Cal enrolled children throughout LA County (Hobbs, 2017).

Oral Health Delivery through Community Clinics: Throughout the state of California, 487 health centers offer dental services on site (OSHPD, 2016, email communication). Of those 487 health center sites, 115 are in Los Angeles County (OSHPD, 2016). Given the number of dental sites in Los Angeles County and the under-utilization of services by Medi-Cal and MHLA patients, systematic barriers to care must be addressed.

The My Health LA (MHLA) dental budget allocation has been $5M each year since the program came into effect, even though the number of clinic sites offering dental has been steadily increasing each year (MHLA, 2018). MHLA is a free healthcare program for Los Angeles County residents who cannot afford health insurance otherwise or are unable to access it. Many individuals on MHLA are unable to enroll in Medi-Cal and it is crucial that all Angelinos have access to healthcare services. Currently, there are 52 clinics with dental on site accepting MHLA. Dental expenses for FY 2017-2018 exceeded the allocated $5M. As part of the MHLA grant agreement, the county uses unspent MHLA and county agency dollars to cover the difference. Additionally, leftover provider funds are expected to cover “payments made to [Community Partners] for pharmacy through the Pharmacy Phase II program” (MHLA, 2017).

Teledentistry: A more innovative form of outreach when it comes to accessing oral health services is teledentistry. One California program, the Pacific Center for Specialty Care, received a $400,000 grant to expand their teledentistry services. “In a six-year pilot program, the Pacific Center has implemented the Virtual Dental Home system in 50 California Head Start preschools, elementary schools, community centers, residential care facilities for people with disabilities, senior centers, and nursing homes” (DentistryIQ Editors, 2017). Access to facilities that allow patients to see dental professionals, in person or via video calls, creates more immediate utilization of services and saves time and money that would be spent trying to visit a dentist.

Recommendations

1. Recommend DHCS research and report the utilization rates of patients disaggregated by age, county, and race/ethnic groups in Dental Managed Care versus fee-for-service Medi-Cal patients.
2. Recommend increased funding from the federal and state government to enable clinics to open dental sites and address current physical space constraints, specifically through Health Resources and Services Administration (HRSA) New Access Point grants. New dental spaces will create access for patients and job opportunities for oral health professionals.
3. Advocate California to fund more innovative pilot programs that expand access points for Medi-Cal patients (i.e. Dental Transformation Initiative (DTI) community pilot programs and teledentistry pilots), with the intent to continue long-term funding opportunities.
4. Recommend DHCS develop a clear process and train its representatives at the call centers on how to accept and provide interpreters for LEP Medi-Cal patients and their providers.

Community Education

Many Medi-Cal and MHLA patients do not know they have dental service coverage. A lack of knowledge leads to lower utilization rates. Dr. Maritza Cabezas, DDS, MPH is Dental Director of the Los Angeles County Department of Public Health’s Oral Health Program. Her presentation at CCALAC’s Policy Café (2018) highlighted the current underutilization of dental services among Medi-Cal recipients in Los Angeles County. Her data from the Care Harbor study showed 81% of 810 respondents needed dental care in the past year but did not receive it. Furthermore, 77% of respondents who had Medi-Cal needed dental care but did not receive it.

Additionally, an overwhelming number of respondents with Medi-Cal (63%) reported they did not have dental insurance. Those respondents waited in line for hours at Care Harbor, just to access dental services, when they had dental coverage all along under Medi-Cal. This may be due to confusion over what is covered under Medi-Cal insurance; dental care is included. Dr. Cabezas’ analysis and discussion also highlighted the enormity of dental deserts in which most survey respondents live. Dental deserts are areas with a high population density, areas of low income, and areas that have no or insufficient dental services.

After examining Medi-Cal consumer-facing materials – such as the website, patient ID cards, and more – it is apparent that information surrounding dental benefits is not uniform. While the Medi-Cal website confirms that dental services are covered under Medi-Cal for both children and adults, the patient ID card does not. It is not a given that all patients will read the patient handbook, front-to-back, and memorize which services are covered under Medi-Cal.

Even more confusing is MHLA’s description of dental coverage. Consumer-facing materials do not explicitly address dental coverage for its beneficiaries. In doing a deep search on the MHLA website, one can access the patient handbook which explains dental services may be covered by some medical homes. A list of medical homes offering dental services is not provided, leaving the patient to contact a MHLA representative, or to ask a MHLA doctor.

Additionally, it is important that the information presented to patients is at a reading level the majority can comprehend. The 2018-2028 State Oral Health Plan (California Department of Public Health, 2018) defines health literacy as follows:

“the ability to read, understand, and act on health information; oral health is defined as the degree to which individuals have the capacity to obtain, process and understand basic oral health information and services needed to make appropriate oral health decisions.”

Health literacy is critical when it comes to motivating individuals to act, seeking oral health services as well as seeking preventive oral health services. Scholarly articles recommend patient materials contain language t at the sixth-grade level or lower to reach a larger patient population (Safeer & Keenan, 2005). Additionally, materials must be in languages patients speak, and providers must act in culturally appropriate manners to make patients feel welcomed, respected, and comfortable.

Recommendations

1. Advocate California provide funding to community-based organizations to conduct culturally and linguistically competent outreach on dental coverage and oral health education for all Californians.
2. Broaden Medi-Cal patients’ knowledge of access to dental services by fixing a dental-related image on the front of Medi-Cal Benefits Identification Cards.
3. Recommend MHLA include how MHLA enrollees may access dental services, on consumer-facing material. In addition, the MHLA Program should make easily and publicly available a list of medical homes that offer dental services to MHLA patients.
4. Recommend a health literacy standard to be used in all consumer-facing materials. The reading level should be at a sixth-grade level to match the reading level associated with Medi-Cal materials. Consumer-facing materials should also be translated into all threshold languages and undergo a community review process to ensure cultural and linguistic appropriateness.

[1] My Health LA (MHLA) is a no-cost health care program for people who live in Los Angeles County. MHLA is free to individuals and families who do not have and cannot get health insurance, such as Full-Scope Medi-Cal.

Download the full report and references here.