State Senate head's proposal: Give dental choice to poor kids

This story originally appeared in The Sacramento Bee.

Seeking to break managed care’s monopoly on dental care for Sacramento County’s poor children, state Senate leader Darrell Steinberg plans to introduce legislation to allow more choice in who kids can see, his aide told the Sacramento County Board of Supervisors Tuesday.

More than 110,000 Sacramento County children on Medi-Cal participate in a mandatory managed care model for dental care, the only one of its kind in the state.

But that model also has one of the worst records of care: In fiscal year 2010-2011, 30.6 percent of Sacramento County children with Medi-Cal saw a dentist, compared with nearly half of the children on Medi-Cal statewide.

The Sacramento Democrat’s bill, which he plans to introduce next week, would make managed care voluntary and give Sacramento children the option of receiving care under a “fee-for-service” model, which pays dentists for each visit they report, said Steinberg’s health consultant Diane Van Maren. The measure also would include beefed-up consumer protections, she said.

If approved, it would take effect July 1, she said.

“There is an immediate need for change here in Sacramento,” Van Maren told the supervisors. “Managed care alone clearly is not working.”

A CHCF Center for Health Reporting story, published Feb. 12 in The Sacramento Bee, described shortcomings in the managed care model, and gave examples of children who have waited months or years to receive treatment for painful, rotted or broken teeth.

Under that model, the state contracts directly with private dental plans, paying them a monthly fee – about $12 – for each Sacramento County Medi-Cal child assigned to them. The fee does not depend on whether the child actually sees a dentist. Under fee-for-service, dentists don’t contract with a dental plan, but bill Medi-Cal for services provided.

Critics of Sacramento County’s program say the managed care model discourages dentists from seeing patients because they get paid either way.

A growing chorus of critics has called on the state to abandon the mandatory managed care model, which began as a pilot program nearly two decades ago, and give Sacramento County residents the fee-for-service option, at least temporarily.

But state Department of Health Care Services (DHCS) Director Toby Douglas, in previous correspondence with Steinberg, has 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 may have to alter agreements with the federal government, which provides some Medi-Cal funding.

Instead, Douglas has proposed changes to the existing model, such as resolving complaints from patients more quickly and getting tougher on dental plans that fail children, either by withholding payments to the plans or terminating their contracts.

“We do believe that the improvements that we’re pursuing in our managed-care contracts would be the quickest way to positively impact dental care for children in Sacramento County,” said DHCS spokesman Norman Williams.

But at least two Sacramento County supervisors questioned the concept of sticking with mandatory managed care.

Board chair Don Nottoli, who remembers the early promises made when mandatory managed care went into effect, said the program has resulted in “abysmal rates.”

“If it can’t work or doesn’t work, then it needs to be fixed or do something else,” Nottoli said. “It couldn’t be any worse than what we have here.”

Supervisor Phil Serna, who chairs First 5 Sacramento, added a sense of urgency to the discussion, calling on county staff to update him every few weeks on the issue.

“Over the course of 18 years, you kind of ask yourself, ‘Why is this taking this long to address?’” he said.

Near the end of the hearing, Toni Moore, executive director of First 5 Sacramento, called on the supervisors to take a stand on the issue, even though the state has authority over the program.

“We need stronger county leadership around this because, quite frankly, it hasn’t been there,” she said.

Serna responded immediately: “In response, Toni, to your recommendation that the county own this, I’m owning this,” he said.

The three other supervisors – Roberta MacGlashan, Susan Peters and Jimmie Yee – remained silent during the discussion and had not returned previous calls for comment.

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