This article originally appeared in The Sacramento Bee.
Almost two decades ago, the state made Sacramento County the testing ground for a new model of delivering dental care to poor children. Officials envisioned a managed care system that would control costs and improve children's ability to see a dentist.
Today that model persists – but state data show that the county has consistently produced one of California's worst records for care.
Critics – including local dentists, county officials, school nurses and family members – contend that Sacramento's special model of care forces many children to wait months or even years before receiving needed treatment, even if they have broken or rotting teeth, or are in so much pain that they can't chew.
Among the examples they cite is 6-year-old Christina Romero, who was told by her dental office that she would have to wait more than a month for treatment, even though she had a fever and a toothache so severe it was causing her to miss school, her mother and school officials said.
They point to 18-year-old Stephanie Erickson, who endured a painful broken tooth for years while her mother says she begged dental offices to perform an extraction.
And they talk about 4-year-old Julian Flores, who for two years regularly cried in pain while eating before his mother says she was finally able to receive the authorization necessary to get root canals on all 20 of his baby teeth.
In each case, the state was paying dental plans a monthly fee to treat the children.
In fiscal year 2010-11, only 30.6 percent of more than 110,000 Sacramento children with Medi-Cal – the government insurance program for the poor – saw a dentist, according to state data. By comparison, nearly half of their Medi-Cal peers statewide visited a dental office. That year, the county ranked third worst in terms of the percentage of kids who got care in the state – above only rural Alpine and Trinity counties. During the three previous years, it was the state's lowest performing children's dental system, state numbers show.
"If there's anybody here who thinks this is working, that's not where I am," said Dr. Jim Musser, a pediatric dentist who eventually operated on Julian Flores. "This really needs to change. I'm in the trenches. I see it on a daily basis."
Musser specializes in treating children who require general anesthesia because of severe decay. He takes referrals from the local Medi-Cal system but is also one of its more vocal critics. He said many Sacramento children with Medi-Cal coverage wait months before they can get a referral to see him, then weeks more for the approvals he needs to be permitted to treat them.
That elapsed time, he said, sometimes means the difference between saving a child's tooth or losing it.
Plans are paid monthly fee
Musser is part of a coalition of dentists and county leaders who blame many of Sacramento's access problems on the "geographic managed care" program that the state imposed upon the county 18 years ago. Under that model, which is unique in California, the state pays private dental plans in Sacramento County a monthly fee – currently about $12 – for each Medi-Cal child assigned to them. The amount paid is the same whether or not the child sees a dentist.
Sacramento is the only county in the state where this program is mandatory; in other counties, dentists bill the state for each Medi-Cal visit in what is known as a "fee-for-service" model.
The state first initiated geographic managed care as a two-year pilot program in Sacramento in 1994. State officials at the time said they intended to expand the model to the rest of the state.
The benefits were supposed to be twofold: The state would save money by controlling costs, which were increasing under "fee-for-service." And, by being guaranteed a provider, poor children would have better access to care.
The pilot program never did expand, but it never ended, either. Today, the state contracts with five dental plans in Sacramento County. Last year, it paid them a total of nearly $20 million.
In exchange, the dental plans assume the risk and responsibility for caring for children on Medi-Cal. They agree to either provide treatment in their own offices, or subcontract the care out to local dentists for a portion of the fee they receive from the state.
The plans are obligated to provide 24-hour emergency care for children with severe dental problems, to schedule all other appointments within a month, to see at least 38 percent of enrolled patients each year and to report that data to the state.
In 2008, after reducing payments to providers by 10 percent, the state in exchange did away with a financial penalty for not achieving this minimum rate. The provider cuts were soon reversed, but the penalty was not reinstated.
Representatives from the managed care plans blame Sacramento's poor numbers at least partly on problems with the state's data. Unlike fee-for-service dentists – who get paid for each visit they report – they say dentists who work with the geographic managed care have little incentive to report their visits since they get paid regardless.
Added to that, they argue that "fee-for-service" dentists have an incentive to "overtreat," since they get paid more for providing more care, whether or not it's necessary.
"In our model they don't have to do that," said Dr. Amir Neshat, CEO of Liberty Dental, which insured 12,500 Sacramento children through the program last year. "They try to keep people well."
Neshat and other plan representatives suggest that geographic managed care works better than the traditional fee-for-service model in many ways. They say it allows for more accountability and better oversight, since managed care plans are required to report information to the state and address complaints.
While Neshat agrees that certain plans may be underperforming, he cautions against generalizing those problems to the system as a whole.
"Let's figure out who is getting the right care and who is not, as opposed to putting out a blanket statement that this program is a failure," he said.
Stuart Gray, chief operating officer of the benefits division of Western Dental, which insured 43,000 children in Sacramento last year, said children in managed care are guaranteed a provider, something the state cannot promise under the fee-for-service model. Many dentists elect not to participate in Medi-Cal due to burdensome paperwork, payment delays and low reimbursement rates.
"If you need a root canal and you're a child in L.A. County or Orange County or San Diego County, you're going to have quite a challenge finding a dentist that will perform that procedure on a Medi-Cal patient," he said.
'Kids aren't being seen'
But for critics, the state has forced Sacramento County to be a guinea pig for a failed experiment for far too long.
Dr. Glennah Trochet, who spent 12 years as the county's public health officer before retiring last September, said complaints about geographic managed care have persisted since the program began in 1994.
"The concern was there wasn't adequate access for anybody on Medi-Cal," she said. "The impression was that it got worse when (managed care) came in."
Almost a decade after the pilot program began, in 2003, the local Community Services Planning Council published a study raising concerns about dental care for poor children in the county. In 2010, Sacramento First 5, a county commission that promotes early childhood development, published a critical report titled "Sacramento Children Deserve Better."
Following that report, a group of concerned dentists, county employees and other local leaders began meeting regularly with state officials and some health plan representatives to figure out how to improve dental care for the county's children.
They acknowledge another defense raised by the plans – that blame for the low rates of service in some cases rests with parents who, for a variety of reasons, fail to bring their children to a dentist regularly. But critics note that poor families from Fresno and San Diego confront similar issues, and those counties' numbers are better than Sacramento's.
Instead, they attribute the difference to a lack of state oversight combined with guaranteed monthly payments to the plans, which they say create a built-in disincentive for managed care dentists to treat Sacramento's children.
"Kids aren't being seen," said Cathy Levering, executive director of the Sacramento District Dental Society, a professional group that represents 1,545 dentists in the Sacramento region.
Levering said that, because of low reimbursement rates, mountains of paperwork and other bureaucratic headaches, many Sacramento dentists won't participate in Medi-Cal at all. She said many are also turned off by a geographic managed care system they consider "broken."
"Care is almost easier to provide free than to go through this rat race," she said.
Levering said she began hearing criticisms of geographic managed care when she joined the dental society a decade ago. As her office fielded increasingly frequent complaints from school nurses and parents in recent years, she began speaking out about the issue.
She said she is particularly concerned about the large number of offices that refuse to see very young children. According to one survey she conducted, 44 percent of dental offices that participate in geographic managed care wouldn't see a child until age 3 – despite the fact that the state pays them to see children from infancy.
'Going around in circles'
Parents often face significant obstacles when they try to submit complaints, Levering said.
She received a call about Julian Flores last fall, and helped get his mother in touch with Dr. Musser, who operated on the boy in December.
Julian, who has autism, developed decay as a toddler. His mother, Cheri, said she made his first appointment when he was about 1 1/2 at a Western Dental office off Elkhorn Boulevard. They sat in the waiting room for hours, she said, only to be told that Julian couldn't be seen.
She rescheduled twice more, she says, and the office failed to see Julian either time. Finally, she switched to a new health plan.
By that time, many of Julian's teeth were decayed and infected. He regularly cried when he ate. Under the new plan, Health Net, Julian saw a dentist. But, due to his autism, he needed a referral to a specialist who could operate on him. The process that eventually landed him in Musser's office took more than a year, in part because referrals given by the plan expired before the next available appointment, his mother said.
"The only thing I knew to do was to listen to what these people told me to do, and then it just had me going around in circles," Cheri Flores said.
Gray, of Western Dental, said the plan would investigate Flores' complaints. He said that although Julian was previously insured by Western, a scan of the company's databases showed no record of him ever having been to an office.
"We certainly want to learn what happened with regard to Julian and take whatever steps we can to correct anything that went wrong," he said in an email.
Sean O'Brien, director of dental operations for Health Net, which insured 9,300 children in Sacramento last year, said cases like Julian's often drag on unnecessarily because the plan doesn't hear about them from parents or advocates.
"The minute we learn about it, we fix it in 24 hours," he said.
Diane Durst, who earns hourly wages from BevMo, said she called Access Dental on Fair Oaks Boulevard in September, after her son, Chris, then 16, bit into lasagna and felt a stinging pain radiate across his jaw. Soon, he started waking up at night crying.
Durst said the office told her they didn't have an opening until nearly three months later. She said she called three days in a row and then periodically after that, but couldn't get him an emergency appointment.
After a few weeks in pain, Chris Durst tagged along with his girlfriend during a visit to her dentist. He asked Dr. Cynthia Stuart if she would look at his tooth. Stuart – who is critical of the managed care Medi-Cal system and does not participate – saw a dying nerve and the beginnings of an abscess. She prescribed antibiotics, and called Chris' dental office.
"He has an abscessed tooth," Stuart says she told them. "He needs to be seen in a timely manner."
Durst was given a basic cleaning several weeks later by a dentist from Access Dental, but surgery was not scheduled until January, his mother said. In the meantime, he popped Motrin several times a day.
Dr. Reza Abbaszadeh, CEO of Access Dental, which insured 24,800 children in Sacramento through Medi-Cal last year, was not familiar with Durst's case. But he said the description of Durst's experience concerns him.
"If they have expressed that 'my kid is in pain,' to wait for a long period of time is unacceptable," he said.
Abbaszadeh said most of the complaints he hears about are at least partly rooted in confusion. He believes plans could do a better job making sure parents and advocates know whom to contact should they run into problems.
Looking for solutions
The state and some of the plans have demonstrated willingness in recent months to make changes.
Jon Chin, acting chief of the Medi-Cal Dental Services Division of the California Department of Health Care Services, said the state is in the process of requesting applications for the next round of contracts, which in Sacramento will take effect Jan. 1, 2013.
While Chin declined to provide specifics, he said in a written statement that the department "recognizes the importance of strengthening the accountability of the contracted plans that serve our beneficiaries." He said the final contract will include tougher performance benchmarks and financial penalties for plans that do not achieve them.
Other states have dramatically improved their dental managed care programs by strengthening contracts to ensure that plans meet reporting and performance standards, said Burt Edelstein, professor of dentistry and health policy and management at Columbia University.
Edelstein says states can also offer bonuses to those plans that improve the rates of children receiving care, or provide extra funding to ensure necessary treatments get covered.
"Depending on its motive," he said, managed care "can dramatically impede access or it can dramatically enhance access."
But improving the contract language won't help without better monitoring by the state, said Debra Payne, a health and dental program planner for First 5 Sacramento who has led the county's effort to reform children's dental services.
"If it's written in the contract, but it's not enforced, it really means nothing," she said.
Sacramento may find the seeds of a solution emerging within its own borders.
In 2009, First 5 Sacramento gave $2.5 million to the Effort, a local social services agency, to build four children's dental clinics. In the past 14 months, those clinics have treated more than 2,000 children, almost all of them on Medi-Cal.
The clinics subcontract with the managed care plans, receiving $3.43 a month per patient. They make up some of the difference with federal funds they receive for being a health center that serves the poor.
Tanya Burgos, manager of the clinics in North Highlands and Oak Park, said most of their young patients have had trouble getting care through the plans.
For Alisa Erickson, finding the Effort ended a years-long ordeal seeking care for her 18-year-old daughter, Stephanie. After Stephanie started having dental pain more than three years ago, her mother said, dental offices under two different plans told her, erroneously, that root canals and crowns were not covered benefits under Medi-Cal.
Erickson, who had lost her job, agreed to pay a non-Medi-Cal dentist $1,000 to do her daughter's root canal. She was unable to afford a crown, however, and Stephanie's tooth eventually broke.
Stephanie's Elk Grove dental office, run by SmileCare, wouldn't provide a referral for a specialist to extract the tooth, her mother said.
"It's been nothing but a nightmare," she said.
SmileCare, which covered 5,300 children in Sacramento last year, did not return repeated calls for comment.
This past October, Erickson heard about the Effort's clinics. When she brought Stephanie in, office staff told her root canals and crowns were covered benefits, and wrote a referral to an outside specialist.
Sitting at the Effort that day, tears welled up in Erickson's eyes. "Finally," she thought, "finally she's being taken care of."
Soon after, Stephanie's broken tooth was pulled.