Oversight needed to improve Sacramento's dental plan
This story originally appeared in The Sacramento Bee.
Recent media coverage of Sacramento County's failed dental program for poor children has sparked intense outcry, with elected officials and children's advocates leveling some of their harshest criticism at dental plans.
Executives for one of those plans, Access Dental, offered their views of the controversy in an in-depth interview with the CHCF Center for Health Reporting.
Their plan participates in Sacramento County's unusual mandatory managed care program. The state pays Access Dental a monthly fee – currently about $11.50 – for each child on Medi-Cal assigned to the program under managed care.
The fee is paid regardless of whether the child actually sees a dentist.
In contrast, most other Medi-Cal dental programs in the state are "fee-for-service," with dentists paid for each visit they report.
The results under managed care have not been good, state data show.
Less than a third of Sacramento County children with Medi-Cal saw a dentist in fiscal 2010-11, compared with nearly half of children on Medi-Cal statewide. In some cases, as described in a CHCF Center for Health Reporting story published in February in The Bee, children had to wait months to be seen and treated for painful, rotted or broken teeth.
In Sacramento County, Access Dental provides coverage to 33,000 participants up to age 21, about a third of the total number of enrollees in the county. State data show that 33 percent of Access Dental's Sacramento County members saw a dentist in fiscal 2010-11.
Here are some highlights from the wide-ranging discussion with Access Dental Chief Executive Officer Reza Abbaszadeh, and James Gross, an attorney representing the plan.
On whether managed-care can work:
Abbaszadeh: Dental managed care can work. I believe the performance of these programs was weak. I admit that. To a large degree, at least in Sacramento, I can confidently say the great majority of these issues have been addressed. We are seeing that in our numbers in the past several months.
When it comes to government programs with very limited funding, a well-managed dental managed care program will give you the biggest bang for your buck.
On steps the plan is taking to improve access:
Abbaszadeh: We are coordinating multiple outreach efforts simultaneously to members. Many of these efforts are required by the state, including distributing letters to all of our members and following up with phone calls.
On why it has taken so long for dental plans and the state to respond:
Gross: Dental managed care is the red-headed stepchild of the Medi-Cal managed care program. We need a partner that works with us on a consistent basis. Maybe in that regard it feels like someone giving you a nudge when you need it.
When there have been problems, it has been difficult to get the Department (of Health Care Services) to respond to the plans. The plans should simply not be able to ignore it. They have a contracted responsibility, but they're not always clear about what the department wants them to do.
You can't expect plans to view this as only a moral responsibility. They are in business. The department has to have much greater involvement and has to have incentives and hammers.
On why state oversight is critical:
Abbaszadeh: Do we need regulators breathing down our neck? No, but the reality is you need to establish expectations. Will we reach utilization levels that we're seeing in the fee-for-service program? That now has become an expectation. But it's an expectation that has just been articulated in the past five months. … We are already seeing a significant increase in utilization. We would like to correct all of these things overnight, but the truth is, when you work with hundreds of dental offices, it is going to take time. We are visiting the offices, we're engaging them and finding out what is going on. I'm not suggesting it will take years to correct, but it will take months to correct.
On the state's recent interest in the dental issue:
Abbaszadeh: Even though when the article came out about the geographic managed care program in Sacramento we were on the receiving end of a lot of heat, this has been a very good thing for dental managed care.
Resources are being allocated at the state level. The situation has changed dramatically. We've been contracting in the Medi-Cal program for 18 years. I have never seen the state so engaged and focused on dental managed care. We are focused on the future, on improving performance. And what I am seeing on the other side, from the state, is a very different purchaser, a very engaged purchaser. They are articulating their demands, their goals. They are working with plans in doing outreach and discussing how the plans can improve outcomes. These are conversations we've never had.
On whether it's realistic to expect 100 percent utilization
Gross: In commercial, employer-sponsored health plans, the utilization for dental services is about 55 or 60 percent. You don't have nearly 100 percent. Clearly (Medi-Cal managed care utilization) is lower and should be higher. You have to have a much more intensive campaign with this population.
One thing we know is worse is the difficulty this population has in its mobility and employment problems and transportation. If you don't work with them on a consistent basis, not only to remind them of the importance of regular dental visits, but also to somehow make it easier for them to actually get their children to the dentist, then utilization levels will still be unacceptably low.
The department has not committed the resources over time to help do that.
Some plans haven't done much, either. That's just not going to work.
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