State health chief vows changes to Sacramento County dental program

This story originally appeared in The Sacramento Bee.

The state's Medi-Cal chief, under pressure to improve dental care for Sacramento's poor children, pledged this week to implement changes so kids won't have to wait months to receive treatment for painful, rotted or broken teeth.

In response to concerns raised by Senate President Pro Tem Darrell Steinberg, D-Sacramento, Toby Douglas outlined the steps that the state Department of Health Care Services will take to ensure that the more than 110,000 Sacramento County children with Medi-Cal get "high quality and timely" dental care.

He promised quicker resolution to complaints from patients and said the department will get tougher on dental plans that fail children, either by withholding payments or terminating their contracts.

"We are currently reevaluating all existing dental plan contracts ... and developing stronger language to give DHCS the ability to withhold payments if the plan's performance negatively impacts beneficiary access or quality of care," he wrote in a letter Tuesday to Steinberg.

Douglas' letter came after Steinberg wrote him last week calling for a review of the "geographic managed care" dental program that is unique to Sacramento County but has a dismal record.

Steinberg's letter, in turn, was spurred by a CHCF Center for Health Reporting story, published in The Bee, that described the shortcomings of the managed care program.

In fiscal year 2010-2011, 30.6 percent of Sacramento County children with Medi-Cal saw a dentist, compared with nearly half of children on Medi-Cal statewide. During three of the past four years, Sacramento had the state's lowest performing children's dental system, state data show.

Under the Sacramento County model, the state pays private dental plans a monthly fee - currently about $12 - for each Medi-Cal child assigned to them. The fee does not depend on 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 county Medi-Cal dental programs in the state are "fee-for-service," with dentists being paid for each visit they report.

In his letter, Douglas said it would be "most expedient and effective" to keep Sacramento kids in the managed care program rather than shifting them into fee-for-service, in part because the state would have to alter agreements with the federal government, which provides some Medi-Cal funding.

So, to improve the existing program, his department is reviewing existing contracts and preparing to beef up new contracts, which take effect between July 1 and Jan. 1, he said.

The contracts will contain performance measures that will allow DHCS to "terminate plans for poor performance or failing to meet responsibilities," he wrote.

He also said the department has improved its response to patient complaints and will send letters to all Sacramento Medi-Cal dental care recipients with information on how to access care and resolve concerns. The complaints are normally handled within 24 hours, he said.

Steinberg and critics of the dental program welcomed the letter with caution, saying they want to see the changes in action, especially better enforcement of contract provisions.

"We need more specifics on how the DHCS is proposing to improve its contracting process and more directly hold accountable those providers who are not performing," said Steinberg spokesman Mark Hedlund. "We can't allow bureaucratic problems to get in the way of providing this critical care."

Cathy Levering, executive director of the Sacramento District Dental Society, echoed Hedlund's concerns about accountability.

"In the current contract, there are consequences for underperforming," she said. "I suppose my question is why has it not been enforced already and what language would make it more 'enforceable'?"

Debra Payne, health and dental program planner at First 5 Sacramento, added that Douglas' letter didn't address other important issues. In 2010, First 5 published a report critical of the dental program and has been working with DHCS to improve care.

For one, Payne said, the plans are paid to see children from birth to age 3, yet most don't.

She also wonders why Sacramento children on Medi-Cal must remain part of a mandatory managed care plan. "Why couldn't it be made voluntary?" much as it is in Los Angeles County, she asked.

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