Sign of the times: A dentists' office on a busy Sacramento street used to have a sign in the window: "Medi-Cal Patients Welcome."
The sign is gone now.
It came down even before budget-balancing cutbacks took effect last month. California dentists are increasingly questioning their involvement in Denti-Cal, the dental benefit program of Medi-Cal, California's Medicaid program.
"It's such a fragile network, and I don't think that's well understood," said Gayle Mathe, manager of policy development for the California Dental Association.
"The dentists who stay in it stay because they're dedicated," Mathe said. "They may be the last dentist in 50 miles still treating Medi-Cal patients and they can't bring themselves to stop, even though it would probably be a good business decision."
A 10% cutback in all Medi-Cal reimbursements approved by the Legislature earlier this year and upheld in court last week won't make things easier. But dentists say the amount of money they're paid is only part of the problem.
"There are all kinds of problems besides reimbursement," said Nagaraj Murthy, a dentist in Compton since 1979. "The way the program is administered is just not very good for dentists. If we could get some kind of stable funding system that doesn't get jerked around every time there's a tight budget, and if we could do something about the huge amount of bureaucratic red tape involved, dentists would be a lot more willing to accept reduced payments that amount to about 30% or 40% of the fee schedule," Murthy said.
"The politicians and lawmakers should be a little more compassionate to the network of providers who are still holding the bag," Murthy added.
'Lots of Improvements To Be Done'
Stan Rosenstein, chief deputy director of the California Department of Health Care Services and administrator of the Medi-Cal program, agrees that parts of the Denti-Cal program are less than ideal.
"There are lots of improvements to be done for Denti-Cal," Rosenstein said. "It's a complex program with a lot of variables to consider."
Dental advocates say the state should increase its support for Denti-Cal, not cut back. The California Dental Association is one of nine plaintiffs in a lawsuit challenging California lawmakers' decision to reduce Medi-Cal reimbursements by 10%.
"California has not made the commitment to oral health that it needs to make," Mathe said. "Our state Office of Oral Health has two people working in it. In New York, it's like 90 people. In California, the dental program accounts for about 2% of the Medi-Cal budget. The national average is about 5%," Mathe said.
Rosenstein urged caution when comparing California's dental program to other states' programs.
"California is one of only six states in the nation to offer dental coverage to adults," Rosenstein said. "And it has offered adults coverage every year since the inception of Medicaid in 1966."
Rosenstein said getting apples-to-apples comparisons with state programs as complicated as Denti-Cal is a difficult proposition. Each state handles its system differently.
Federal Medicaid laws do not mandate dental coverage for adults, although the laws do require states to cover children's dental services.
Problems Beyond Reimbursements
Dental advocates say that even if benefits are maintained for adults in California, low reimbursement rates, mountains of paperwork and long-term uncertainty discourage dentists from participating in Denti-Cal.
"The program has to have some kind of predictability and stability," Murthy said. "Dentists need to be assured that next year will be the same as this year. Every year we don't know if reimbursements are going to be cut or if the whole program is going to be eliminated.
"It has to come through the Legislature. Every year we go through this. I've been in the program since 1991, and it really has been every year -- 17 years. The state reminds us every year that adult coverage is an optional benefit. If you have that kind of attitude, what kind of stability is that?" Murthy asked.
Bureaucratic red tape also is a problem for many dentists.
"It's amazingly difficult to navigate the system," Mathe said. "The enrollment process, claims submissions and the back and forth between providers and the state needs streamlining," Mathe said.
"Enrollment for dentists should be simple and streamlined, an easy click-through process online," Mathe said. "Instead you have this huge packet of materials and cumbersome, slow communications. Sometimes it takes months of back and forth to get simple issues dealt with," Mathe said.
Rosenstein blames some of Denti-Cal's problems on lawsuits.
"We had a lawsuit that required us to have high reimbursement for dental procedures," Rosenstein said. "Although reimbursements went up considerably, the number of providers only went up a little.
"What that proved was that rates alone will not drive increased access to dental care," Rosenstein said.
Rosenstein said documentation requirements were reduced in response to lawsuits. As a result, "the dental program became a very high fraud area. We had common situations in which providers -- sometimes not even dentists -- would pay children and parents to come in for dental treatment. They'd provide a large number of unnecessary dental procedures -- pinprick fillings in kids' teeth -- and bill for them.
"We took aggressive action and, unfortunately because of fraud and abuse, we increased documentation standards," Rosenstein said.
Currently, about 4,000 of California's 34,000 active dentists provide 97% of all services to Denti-Cal beneficiaries, according to the Dental Health Foundation.
That number is dropping, but nobody is sure how fast.
"We're trying to figure out how to capture that information," Mathe said. "We're fairly certain that number is going down because anecdotally we hear about more dental offices leaving the Denti-Cal system than entering it."
Social workers and referral agencies say it's getting harder to find dentists who accept new Medi-Cal patients. Despite the federal mandate that children receive dental coverage, dental advocates say the scarcity of dentists in the program will have an effect on children's dental care.
"If dentists close to you aren't taking new patients, you're not going to drive 100 miles to get a checkup for you or your kids," Mathe said. "Dental disease is the most common chronic disease of children, and children become adults. We need to be smart about this," Mathe said.
"It's definitely worse in the rural parts of the state," Murthy said. "In urban areas if your dentist decides not to take Medi-Cal anymore, you can look around and probably find someone else relatively close by. But in the rural areas, it's a lot harder," Murthy said.