California Health Advocates is one of several organizations who submitted this letter opposing the State Plan Amendment (SPA) to reduce rates that Denti-Cal providers receive to provide gum treatment in nursing homes and also requiring x-rays be performed prior to rendering gum treatment services. We are concerned that this proposal would further limit the availability of critical gum treatment for older adults and people with disabilities – particularly in institutional settings. A recent report from the Center for Oral Health found that one-third of nursing facility residents are in need of immediate gum treatment. Without treatment, residents suffer pain, tooth loss, and increased risk for infection and hospitalization.
June 18, 2018
Department of Health Care Services
Medi-Cal Dental Division
Attn: Alani Jackson, Chief
1501 Capitol Avenue, MS 4900
Sacramento, California 95899
Re: SPA 18-0025, Proposed State Plan Amendment to Formalize Periodontal Maintenance Rate Adjustments and Prior Authorization for Dental Benefits
Submitted Electronically via: Publicinput@dhcs.ca.gov
Dear Ms. Jackson,
The undersigned write to provide comment on the Department of Health Care Services’ (DHCS) proposal to formalize periodontal rates and prior authorization requirements as laid out in Provider Bulletin, Volume 23, Number 12 posted in July 2016. For the reasons outlined below, we strongly oppose the proposed changes and urge the Department to establish utilization controls and rate reimbursement levels that provide for increased access to critically needed dental care rather than limit it. Even under the Department’s current system, institutionalized Californians are not getting the dental care they need. The proposed changes would further compound the inadequacies already in the Denti-Cal system.
Nursing Facility Residents Have Exceedingly High Periodontal Unmet Need
While most adult Medi-Cal beneficiaries lost access to periodontal treatment from 2009-2018, residents of institutions (nursing facility residents and residents of Intermediate Care facilities for the Developmentally Disabled) in theory maintained access to this benefit. Yet, a recent report from the Center for Oral Health published in April 2018 concluded that nearly one-third of residents of institutions need gum treatment immediately with 40% of residents having substantial debris or deposits covering more than two-thirds of their natural tooth services and almost one-third have significant inflammation in their gums.(1) Likewise, individuals with developmental disabilities have high unmet need with studies showing that nearly 80% of this population suffering from gum disease.(2) Most residents of institutions are Medi-Cal eligible. Yet, even without the new limitations set forth in the Department’s SPA, it is evident that they have not had meaningful access to dental treatment.
Lack of Access has led to Poorer Health & Increased Costs
Lack of periodontal treatment leads to infection of the gums, loss of teeth, and other significant health issues. Over one-third of nursing facility residents have no remaining natural teeth.3 This is an unacceptable and unsettling outcome when tooth loss is entirely preventable when people have access to treatment. Tooth loss in turn leads to poorer nutrition, weight loss, poorer quality of life, and exacerbates chronic conditions like diabetes. Untreated gum disease also leads to an increase in avoidable hospitalizations due to bacteria from the gums traveling into the lungs causing aspiration pneumonia. The harm to individuals and their overall health, combined with the resulting avoidably high medical costs, mandates that the Department adopt rates and policies that are evidence-based and increase access to quality periodontal treatment rather than continue to pursue the restrictions embodied in this SPA.
A Reduction in Rates Will Lead to Decreased Access
There are few dental providers who are both equipped and willing to serve residents in institutional settings. In order to grow the pool and ensure sufficient access to care, the rate they receive to provide periodontal maintenance must be adequate to cover the cost of providing these services. As demonstrated above, access to treatment is already inadequate. If the Department reduces the rate, fewer providers would serve this population, and access would be limited even further.
The Department has given no justification for the rate reduction other than cost savings. But these cost savings will come at the expense of access to treatment for a population that is already woefully underserved by the Denti-Cal program and will lead to increased health costs in the long term. The Department is required to pay providers rates that are “sufficient to enlist enough providers so that care and services are available under the plan…”(4) In fact, the Department has recognized that rates are currently inadequate through its proposal to pay providers supplemental payments for gum treatment through Proposition 56 funding.(5) It is incongruous to increase rates to address access while simultaneously offsetting that increase through a rate reduction.(6)
The X-Ray Pre-Authorization Requirement Also Limits Access to Treatment
We also oppose the requirement that providers in facilities submit radiographs to demonstrate medical necessity to perform scaling and root planing. Individuals in need of care in nursing facilities are often not capable of having x-rays performed for a number of reasons. Nursing facility residents frequently have medical and cognitive conditions that make it difficult or impossible to perform an x-ray. Furthermore, many facilities are not equipped to perform x-rays safely on site. While the Department allows for an exception process whereby x-rays can be avoided, this process entails additional administrative requirements (including the submission of photographs and levels of review) that unnecessarily impede and delay access to needed treatment.
To achieve the goal of only covering medically necessary services, we urge the Department to adopt reasonable utilization controls that will not result in further decreased access to dental services. For example, the Department should review submitted claims for scaling and root planing on a regular basis to identify whether providers are engaging in over utilization, and conduct audits in cases in which the Department suspects that services are being improperly rendered.
The proposals put forth by the Department undermine the Department’s ability to ensure enough providers participate in the Denti-Cal program to afford beneficiaries with access to needed treatment. The Department has acknowledged issues with the sufficiency of its rates and related impact on provider participation through the adoption of targeted rate increases for services. The Department has also been made aware of the inadequate access to treatment that nursing facility residents are now receiving and the resulting negative impact on their health under the current rate and pre-authorization requirements. Moving forward with these proposals will only further limit access to a critical benefit for an already underserved population.
Thank you for your consideration of these comments. For questions, please contact Amber Christ at email@example.com.
Justice in Aging
Aging Services Collaborative of Santa Clara County
Asian Americans Advancing Justice – Los Angeles
CA Office of the State Long-Term Care Ombudsman
California Health Advocates
California LTC Ombudsman Association (CLTCOA)
California Pan-Ethnic Health Network
Dientes Community Dental
Disability Action Center
Health Access California
Healthy Aging Association
IHSS Consumer Alliance
Legal Aid Society of San Mateo County
Life Skills Training & Educational Programs
LifeLong Medical Care
Maternal and Child Health Access
National Health Law Program (NHeLP)
Ombudsman Services of San Mateo County, Inc.
Partners In Care Foundation
Seniors Council/Area Agency on Aging of Santa Cruz & San Benito Counties
Silicon Valley Independent Living Center
The Arc of California
Walt Weckwerth, DDS
WISE & Healthy Aging
Acting Deputy Administrator and Director
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services
via email to Timothy.firstname.lastname@example.org
Regional Administrator (Acting)
Centers for Medicare & Medicaid Services, Region 9
via email to Catherine.email@example.com