By Lynn Graebner
California Health Report
Low income children in Santa Cruz County already have a tough time getting in to see a dentist. As the state prepares to start transitioning 6,791 Santa Cruz County children covered under the state’s Healthy Families Program to Medi-Cal in 2013, dental options for those kids could get even slimmer.
In June Governor Jerry Brown signed a state budget eliminating the Healthy Families Program. That requires that 875,000 children be transitioned in 2013 from their Healthy Families plans to Medi-Cal. For dental service those kids will now be covered by Medi-Cal’s Denti-Cal program.
Some dental providers predict that historically poor performance by Denti-Cal and the fact that California has one of the lowest Medicaid reimbursement rates for providers in the nation, will result in less access to dentists for low and middle income children because many dentists won’t take Denti-Cal.
Pediatric dentist Marc Grossman, one of the founders of Dientes Community Dental Care, a Santa Cruz safety net clinic, now has a private practice with his partner James M. Smith in Freedom, next to Watsonville. They were taking Denti-Cal patients but stopped because the system was difficult to work with and the low reimbursement rates of 20 percent to 30 percent of their fees, Grossman said.
“It had gotten to the point where you were forced to use different materials and treat people differently than I wanted to treat people,” Smith said.
They still take children covered by the Healthy Families Program even though the reimbursement rate is only 40 percent to 50 percent of their normal fees because the
program is managed so much better than Denti-Cal and is easier to work with, Grossman said.
He is disheartened that he’ll have to say goodbye to many of his Healthy Families patients who he’s watched grow up because he can’t afford the reimbursements or the headaches that come with Denti-Cal. In that system, everything is based on fraud prevention, he said.
“They required us to take photos of an 11-month-old to prove there was decay. Why would I fake that?” he said.
The California Department of Healthcare Services said it is reaching out to Healthy Families providers, newly-licensed dentists and current Medi-Cal dental providers to ensure that the 875,000 kids entering Denti-Cal will get service.
An analysis of that outreach effort will be released to the public, but the department is not sure when that will be, wrote Norman Williams, Deputy Director of the Office of Public Affairs at the California Department of Healthcare Services in an e-mail response to questions.
The department stated that 82 percent of Healthy Families providers already accept Medi-Cal patients and that this transition simplifies coverage options and reduces costs for children at certain income levels. It is also estimated to save the state $13 million in 2012-2013, $58 million in 2013-2014 and $71 million annually after that, Williams responded.
Despite the state’s claims that most Healthy Families providers will also accept Medi-Cal, there simply aren’t enough providers, especially specialists, in Santa Cruz County taking Denti-Cal to serve the need, providers say.
Only two federally qualified health centers, also known as safety net clinics, Western Dental Services Inc. and a few private practitioners in Santa Cruz County, take Denti-Cal patients. And currently thousands of low-income children in the county with public health insurance are not accessing dental care, said Laura Marcus, Executive Director of Dientes Community Dental Care in Santa Cruz.
“No matter how big we grow no matter how many chairs we add we’re not catching up,” she said. “For sure there will be longer waiting lists,” she said.
Dientes is a federally qualified health center and gets compensated by Medicaid at a higher rate than private dentists taking Denti-Cal patients. It offers full service dentistry to low income, no income and both publically insured and uninsured individuals and sees about 3,500 children a year.
Maria-Elena Mexicano’s three children are Dientes patients. She originally applied for Denti-Cal coverage for them but when she didn’t like the way she was treated by staff at the Medi-Cal human resources offices in Salinas, she looked into other plans and found Healthy Families. Because Dientes also takes Denti-Cal, her family won’t have to switch providers.
Unfortunately Mexicano can’t get dental coverage for herself. The federal government considers most adult dental services optional and in 2009 the California Legislature cut adult dental services under Denti-Cal as a result of the budget crisis.
Even when Mexicano had coverage under Denti-Cal she was only using it for emergencies because she didn’t know she was eligible for cleanings and other preventative services.
“That’s the big failure with Medi-Cal, they don’t communicate effectively with beneficiaries,” Marcus said.
Another program for low and middle income kids in the county is the Healthy Kids Program. It takes families who wouldn’t have previously qualified for Denti-Cal because their income is too high. Healthy Kids beneficiaries have incomes below 300 percent of the federal poverty level, $69,000 for a family of four.
The Central California Alliance for Health, a locally operated public health plan administers Healthy Kids which is funded by the county as well as hospitals, nonprofits and foundations. But its capacity is limited. Currently 1,246 children in the county are enrolled in that program and 430 are on a waiting list, said Maria Love, an administrative analyst for the Santa Cruz County Health Services Agency.
Like Marcus, she says even with Healthy Families there were already thousands of children in the county not receiving dental services.
“The dental part [of the Healthy Families transition to Medi-Cal] will be one of the biggest challenges for sure,” she said.
Typically the Healthy Families Program provides a higher rate of compensation to dentists than Denti-Cal. Medi-Cal is matched 50-50 with federal funds while federal funds provide two thirds of the funding for the Healthy Families Program, Williams stated.
Anthony Wright, Executive Director for Health Access California, a nonprofit consumer advocacy coalition in Sacramento, said his organization doesn’t think Medicaid is an awful program. He said there’s clear evidence that a majority of people with Medicaid coverage are satisfied and appreciative of it.
But in the scenario with Healthy Families, the fact that beneficiaries will be moved from a dental program with a higher reimbursement rate to a program with a lower one will have a significant affect, he said.
“At the end of the day it’s a cut and will inevitably have an impact on the access,” he said.
“The rates paid in the Denti-Cal program are well below the cost of providing care, this has a tremendous impact on the number of dentists that can participate in the program,” stated the California Dental Association in an e-mail response to questions.
“Many of our members have expressed frustration with the Denti-Cal program, including exceptionally low rates, the cumbersome process needed to become an approved Denti-Cal provider and the challenges in ensuring a pediatric specialist can see children when needed,” the Association reported.
In terms of Medicaid reimbursement levels to providers, California is almost at the bottom, ranking 46th in the country, Williams wrote.
“Fees have just gotten so ridiculously low it’s easier for me to convince dentists to take patients paying nothing than to do Medi-Cal,” said Hugo Ferlito, Associate Chief Operating Officer of Salud Para La Gente, a Watsonville-based federally qualified health center. It’s a nonprofit safety net clinic like Dientes that cares for patients regardless of their ability to pay.
Salud operates three physical clinics as well as 14 school-based clinics and is in the process of opening clinics at Cabrillo and Live Oak Elementary Schools and in Seaside.
Last year Salud had an operating budget of $13 million and did an additional $4 million in uncompensated care, Ferlito said.
“If someone is in pain, we take care of them,” he said. So Salud employs a full-time grant writer, gets money from the cities of Watsonville and Santa Cruz and Santa Cruz County. “It’s just a scramble,” he said.
“Many of our members provide a great amount of work pro bono rather than trying to maneuver through the financial and administrative barriers to providing Denti-Cal services, the California Dental Association stated. But that’s not a workable replacement for a functional statewide dental system.
“California must develop a true dental system of care that meets the needs of its citizens,”
the association contends.