Senate panel backs change in kids' dental coverage

This story originally appeared in The Sacramento Bee.

The Legislature took its first formal step Thursday to free Sacramento County's poor children from the confines of mandatory managed dental care.

A Senate committee unanimously approved a proposal by Senate President Pro Tem Darrell Steinberg, D-Sacramento, to give Sacramento County children on Medi-Cal a choice for their dental coverage.

The legislation also would establish stricter standards for dental plans and tougher enforcement by state agencies.

Steinberg said the legislation is necessary because Sacramento County's mandatory managed care dental program, the only one of its kind in the state, has left some children waiting months for treatment for painful, rotted or broken teeth.

A CHCF Center for Health Reporting story published last month in The Sacramento Bee sparked Steinberg to seek the changes.

"In Sacramento County, there ought to be a choice between voluntary enrollment in managed care vs. the mandatory requirement," Steinberg told a hearing of the Senate budget subcommittee on health and human services. "There have been unacceptable gaps in service, children waiting months to get help for any basic dental condition."

In fiscal year 2010-2011, about 31 percent of Sacramento County children with Medi-Cal saw a dentist, compared with nearly half of children on Medi-Cal statewide.

Under Sacramento County's model, the state pays private dental plans a monthly fee – currently about $11.50 – for each Medi-Cal child assigned to them. The fee is paid regardless of whether the child actually sees a dentist.

Critics of the program say the model encourages dentists to avoid seeing patients because they get paid either way. In contrast, most other counties operate on a fee-for-service model, with dentists being paid for each visit they report.

Steinberg's bill, to be refined in the coming months, would give local Medi-Cal recipients the choice between managed care and fee-for-service. Only Los Angeles County operates this way.

If approved by the Legislature and signed by the governor, the legislation would go into effect July 1, although the change likely would require federal approval.

Steinberg also has noted that Toby Douglas, the director of the state Department of Health Care Services, has the authority to implement a fee-for-service system himself if he concludes managed care is not adequate.

But Douglas has not been receptive to fee-for-service in Sacramento County. He told the committee that his department has been working closely with Steinberg, dental advocates and the dental plans to improve care for Sacramento children now, and to beef up new contracts that will take effect on Jan 1.

"I'm 100 percent focused on making sure that managed care works now and we have a system that's accountable and we have the oversight, the monitoring and the right requirements on our plans," he said.

Steinberg left open the possibility that immediate improvements to the Sacramento model could influence his demands for fee-for-service. "There is a chance now for the plans themselves over the next two-plus months to dramatically improve their performance," he said. "Get to the statewide average. If you do that, it could be a different conversation and a different debate."

But Terrence Jones, a dentist and a past president of the Sacramento District Dental Society, told lawmakers he's skeptical that any improvements to managed care will last.

"After 18 years, not one plan has been terminated for failure to reach the minimum utilization standards," he said. "Plans were given a free ride regardless of performance."

James Gross, an attorney representing Access Dental, a plan that participates in Sacramento's managed care program, told the committee that the plans have had difficulties working with the state department in the past.

"A number of the plans have themselves been frustrated with a lack of communication and a lack of coordination with the department," he said.

He added that recent discussions with the department have been fruitful, and that Access Dental may support a voluntary fee-for-service model, depending on the specifics.

Sen. Bill Emmerson, R-Hemet, practiced as an orthodontist for more than 25 years. He offered strong support for Steinberg’s legislation, but said he would like the language refined.

“It’s been difficult for me to watch … oral health programs for children being decimated year after year in the state,” he said. “Even now we’re looking at ways to reduce cost while potentially sacrificing quality care.”

Sen. Elaine Alquist, D-Santa Clara, also raised doubt about the administration’s proposals to expand managed care elsewhere in the state given Sacramento’s experience.

“The department’s failure to ensure that our children here in Sacramento actually receive much-needed dental services under managed care does not give me any confidence in the administration’s other proposals to expand managed care,” she said.

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