Access to Care

Phased Strategies for Reducing the Barriers to Dental Care

Research tells us that nearly 10 million Californians — including low-income children, the elderly and people with disabilities — face barriers to accessing the dental care they need. Barriers are multi-factorial, influenced by economics, culture, education and geography – a complex problem with no single solution.

The California Dental Association is proactively addressing the problem to improve access to care through nearly a decade of work and numerous evidence-based studies. Our report, Phased Strategies for Reducing the Barriers to Dental Care in California, outlines a 3-phase approach, each with multiple recommendations:

  1. Establish State Oral Health Leadership and Optimize Existing Resources (years 1-3)
  2. Focus on Prevention and Early Intervention for Children (years 3-5)
  3. Innovate the Dental Delivery System to Expand Capacity (years 4-7)

These strategies serve as a framework to guide CDA’s efforts to find solutions that ensure underserved Californians are able to access the oral health care services they need and deserve.

Access Activity Update

CDA's activities to advance the Access Plan objectives are reported quarterly to the Board of Trustees and can be accessed by clicking here or by scrolling down through the 3 Phases below. For additional information on CDA access advocacy, click here.

Phase 1: Establishing State Oral Health Leadership and Optimize Existing Resources
  1. State oral health infrastructure: Shortly after his arrival in California in 2015, our state dental director, Jay Kumar, DDS, MPH, led a large group of stakeholders in developing the California Oral Health Plan (COHP), a 10-year strategic roadmap that includes a two-year implementation plan to improve the oral health of all Californians. The plan, which aligns well with the objectives of CDA’s access report, Phased Strategies for Reducing the Barriers to Dental Care in California was publically launched at an event in Sacramento on June 19 -20, 2018.

    In 2017 and 2018, the oral health program, under Dr. Kumar’s leadership has:

    • Implemented a four - year Health Resources and Services Administration (HRSA) grant for Perinatal and Infant Oral Health Quality Improvement (PIOHQI) in Sonoma county
    • Supported continued community water fluoridation implementation in Santa Clara, which began in the eastern portion of San Jose in December 2016
    • Promoted data collection and reporting for the Kindergarten Oral Health Assessment (AB 1433)
    • Engaged with other chronic disease programs in the CDPH on a three-year project to reinvigorate the Rethink Your Drink campaign to contain and disseminate effective oral health messages
    • Contracted with UCSF to provide technical assistance to local health departments as they build dental public health infrastructure and programs
    • Initiated a health literacy project with UC Berkeley and ADA to develop a literacy toolkit for dentists
    • Developed tobacco cessation education for dentists in conjunction with CDA, offering these resources at CDA Presents, on cda.org, and in the Journal of the California Dental Association
    • Launched the oral health plan state-wide through two oral health summits, held in Sacramento in June and Los Angeles in August
    • Initiated 3rd grade surveillance state-wide
    • Entered into grant agreements with 59 local health jurisdictions to develop public health programs based on an assessment of needs.
  1. Expand capacity within dental public health & safety net expansion of dental services: These two objectives come together in CDA’s work on connecting and supporting clinics and dentists to establish contracting arrangements to provide dental care to clinic patients. Dentists and clinics continue to express interest in this model and several have begun contracted arrangements. As Medi-Cal expansion and the reinstatement of adult dental services has produced a large number of beneficiaries who now have coverage and need dental care, the pressure on the system to provide services has grown. CDA continues to be a resource to dentists and clinics interested in contracting arrangements.

    CDA staff is available to educate members about this new opportunity to provide dental services and is available to present to components on this, as well as other non-traditional practice models, such as the Virtual Dental Home and collaborating with RDHAPs.

  2. Volunteer provision of care coordination: As of April 2019, CDA has completed 15 CDA Cares events, the last event occurring in Solano, March 8-9. At that event, nearly 1200 volunteers supported the provision of $1.3 million worth of dental services to 1,491 people. This brings the total impact of CDA Cares to $ 23.65 million in services provided to 28,552 people, with the help of over 25,275 volunteers. The next event, scheduled for San Bernardino, September 27-28, 2019, had not occurred at the time of this report.

  3. Complete fluoridation in San Jose: In Santa Clara, the implementation of San Jose’s first fluoridation project began in December 2016 at the Santa Teresa Water Treatment Plant.  This landmark event results from the concerted efforts of many, including the Santa Clara Valley Water District (SCVWD), the Santa Clara County Dental Society, and CDAF.  Water fluoridation projects will continue, now under the leadership of the Santa Clara Department of Public Health, supported by Prop 56 funds distributed by the state oral health program.

  4. Expand capacity to provide children’s care, especially to young children: Significant resources have been directed to the Medi-Cal Dental Program through Prop. 56 funded supplemental payments and the Department of Health Care Services’ Dental Transformation Initiative (DTI).  The details of these two programs and CDA’s advocacy are described here and under Phase 2, Objective 2: Expand early prevention through reimbursement incentives.

    In January 2017, CDA released an online course for general dentists who wish to increase their knowledge and confidence to care for infants and young children. CDA is offering the course at no cost to members and non-members for a limited time and approximately 1400 people have completed the course. Known as TYKE (Treating Young Kids Every Day), the 2-hour course includes information and instruction on:

    • Knee-to-knee assessment
    • Caries risk assessment
    • Chronic disease management for caries
    • Motivational interviewing
    • Goal setting

    The Department of Health Care Services (DHCS) implemented Domain 2 of the DTI in January 2017 (see Phase 2, Objective 2 for details). This domain, which uses caries risk assessment (CRA) and a chronic disease management model of preventive services and minimally-invasive treatment approaches to reduce caries incidence and severity for children ages 0–5, requires participating dentists to receive a standardized CRA training to participate. CDA worked closely with DHCS and the state dental director to ensure TYKE satisfies Domain 2 training requirements. TYKE can be accessed here.

    Further, this year, CDA is sponsoring AB 154 (Pan), to require the Medi-Cal Dental Program to reimburse for dental caries treatment using Silver Diamine Fluoride (SDF). Though this treatment is being tested in the Domain 2 pilot, the benefits of SDF are well established for very young children, people with disabilities, and the frail elderly, who may not be able to tolerate definitive7y7 dental treatment. Last year, CDA sponsored the same policy via AB 1148, but it was vetoed by the governor, who directed that changes to Medi-Cal benefits, such as this, be handled in the budget process. This year we are working through both processes to achieve this benefit.

    Additionally, DHCS has 13 operational Local Dental Pilot Projects (LDPPs) in Domain 4 of the DTI.  These projects engage multiple local stakeholders to increase dental care to previously non-utilizing children, with the goal of reducing disease incidence and severity.  Many of these projects are implementing a series of initiatives to achieve this goal, including virtual dental homes, infant oral health referrals from pediatricians to dentists, care coordinators, and prevention programs in schools, Head Start and WIC programs, and more.

Phase 2: Focusing on Prevention and Early Intervention for Children
  1. Utilize proven technology: The Virtual Dental Home (VDH) model of dental care uses technology to connect allied dental team members located at community sites, such as Head Starts, schools, and long-term care facilities, with dentists in offices or clinics, to facilitate the provision of comprehensive dental care to children and adults who face barriers to accessing that care in traditional service locations.

    The newest development in the expansion of the VDH care model comes with the approval of the model as part of the DTI’s Domain 4 LDPPs in eight California counties. These projects are connecting dental offices and clinics to multiple community sites, significantly extending the reach of the dentist and dental team to children previously without care. This model is also expanding to other states, including Colorado, Hawaii and Oregon.

    For more information on the Virtual Dental Home, visit: cda.org/journal; and for the details of the authorizing legislation, including requirements for participating dentists and allied dental team members visit: leginfo.legislature.ca.gov.

  2. Expand early prevention through reimbursement incentives: CDA has been a consistent advocate with the legislature and DHCS on the importance of adequate reimbursement, a robust dental provider network, and incentives for caring for young children.

    In 2017-18, during Prop. 56 funding implementation, CDA worked with the State Legislature and the Governor to secure an unprecedented $140 million dollars in the 2017-18 budget to provide supplemental funding to Denti-Cal providers. After federal approval in late 2017, the Department of Health Care Services began issuing supplemental payments on hundreds of dental procedures, an increase of 40% from previous fees, which included retroactive payments back to July 1, 2017. Further, the Governor’s 2018-19 budget proposal allocated an additional $70 million ($210 million total) plus federal matching dollars towards increases in dental provider reimbursements.

    Additionally, the DTI, which was funded by the Center for Medicare and Medicaid Services (CMS), is bringing in an additional $750 million over 5 years (2015-2020), to increase the Denti-Cal network of dentists and the provision of dental services to children ages 0-20 through incentives in the following four domains:

    1. increase preventive services for children by offering financial incentives to providers who increase the number of children who receive dental care, measured on an annual basis;
    2. implement a caries risk assessment and disease management pilot program for children ages 0-5;
    3. support continuity of care through incentives to bring patients back for annual recalls; and
    4. grant funds to Local Dental Pilot Programs that address one or more of the three domains mentioned previously.

    This project is now a couple of years into implementation and DHCS reports the following progress:

    Domain 1:

    • The preventive dental service utilization rate for children ages 1–20 increased by 7.48 percentage points from Calendar Year (CY) 2014 to CY 2017.
    • The number of Medi-Cal dentists providing preventive dental services to at least ten children ages 1–20 increased by 7.17 percent from CY 2014 to CY 2017.
    • DHCS provided $46.5 million in incentive payments for Program Year (PY) 1 and $52.3 million for PY 2 to date (April 2019).

    Domain 2:

    • Children ages 0–6 who fall into the three CRA categories within the 11 pilot counties, had a significantly higher increase of preventive dental services compared to the control group.
    • In January 2019, DHCS expanded Domain 2 to an additional 18 counties, bringing the total pilot counties to 29.
    • As of April 2019, DHCS had issued $6 million over the first 2 program years (2017-18).
    • As of March 2019, 1,100 providers had opted in to participate in Domain 2.


    Domain 3:

    • From CY 2015 to CY 2017, across 17 pilot counties, the percentage of children ages 0-20 receiving two-year continuity of care increased by 2.60 percentage points and three-year continuity of care increased by 1.98 percentage points.
    • From CY 2014 to CY 2017 utilization of preventive dental services increased by 9.83 percent in Domain 3 counties, and 6.74 percent in non-Domain 3 counties (includes clinic (SNC) encounters).
    • In PYs 1 and 2, DHCS provided a total of $21.7 million in inventive payments.
    • In January 2019, DHCS expanded the pilot to 19 additional counties, bringing the total to 36 pilot counties.


    Domain 4:

    • 13 pilots have been funded, at a total of $150 million for the duration of the project. Funds from two LDPPs that were not completed are being reallocated to the 13 remaining projects.

    Details of the DTI are at: dhcs.ca.gov.
  1. Protecting community water fluoridation (CWF): One of the goals of the state oral health plan is to increase the number of Californians who have access to CWF.  Some of the $30 million allocated annually to the state oral health program has been set aside for local projects and CWF is identified as a qualifying project. Additionally, UCSF, which is contracted with the State Office of Oral Health to provide technical assistance to local health departments, is also providing assistance to communities interested in CWF. CDA remains an engaged leader in this work as well.
Phase 3: Delivery System Innovation
  1. Adult Dental Care: Access to dental care for elders has been, and continues to be a challenge in California and around the country.  The federal government, through its Medicaid and Medicare policy fails to provide support for dental services for those who cannot afford to pay for them directly.  The Medicaid program is a children’s program; adult benefits are optional, and Medicare covers only the dental services that are medically necessary for the treatment of other medical conditions – limiting dental treatment to instances where a kidney transplant patient, for example, needs to be free of dental infections prior to transplant surgery. Recognition that elders across the country frequently go without the dental care they need has led to significant advocacy to establish a Medicare dental benefit, a national conversation  in which CDA and ADA have been engaged.

    Though California’s Dental Medi-Cal program has included adult dental benefits for most of its 50-plus years of existence, in 2009, the California legislature eliminated nonemergency adult dental services, retaining only the option to be relieved from pain and infection through tooth extraction. In 2014, adult services were partially restored, allowing for fillings, but not periodontal care, partials, or posterior endodontics or crowns. CDA, along with other advocates, worked with legislators to bring back the full set of adult dental benefits in 2017- 2018 budget, effective January 2018.

    This was very positive news for California’s most vulnerable seniors, followed by better news with budget allocations in 2017 that provided supplemental payments on many basic dental services but did not include increases on prevention or periodontal care. The 2018-19 budget proposal improved on the 2017 supplements and includes reimbursement increases on services not previously included, such as supplemental payments for adult exams and periodontal services. Also effective July 2018 was the addition of a code for behavior management (D9920) which allows, for the first time in Denti-Cal, a provider to receive reimbursement for extra time that is required when treating many patients with special healthcare needs. This can include, for example, extra time required to accommodate physical or behavioral needs of patients with Alzheimer’s disease.

    While there are many challenges for low-income and frail elders to access to dental care, these developments, along with expansion of delivery systems such as the Virtual Dental Home, move us in the right direction, increasing the availability and sustainability for the provision of dental care.

In the News
Students advocate for dentistry, oral health at the state Capitol

04/30/2019
Grassroots Advocacy Days are in full swing as student representatives from California’s six dental schools met with their local legislators and legislative staff to discuss critical issues affecting dentistry. CDA coordinates these small-group advocacy days each year at the state Capitol in Sacramento. The goal is to help members learn about the legislative process and to allow participants to have in-depth, interactive discussions with lawmakers about dentistry and oral health.

 

State program expands provider incentives to new counties

02/14/2019
Dentists in 26 counties have a new opportunity to participate in the Dental Transformation Initiative to help improve dental health for low-income children enrolled in the Medi-Cal Program while receiving enhanced reimbursement by meeting specific incentive metrics. As part of California's 1115 waiver, the DTI focuses on high-value care, improved access to dental care, and the use of performance measures to improve the program through four “domains.”

 

Appreciative patients share stories of pain relieved, smiles restored

02/01/2019
In just over a month, CDA Cares volunteers will deliver no-cost dental services to an estimated 1,950 individuals who experience barriers to care. Over two days, March 8-9, at the Solano County Fairgrounds in Vallejo, Calif., dentists, hygienists, lab technicians, dental assistants and other professionals will volunteer their services and time, providing cleanings, extractions, root canals, dentures, triage and oral health education. The Foundation still seeks volunteers in all clinical areas, especially oral surgeons, lab techs and nurses and physicians for medical triage.

 

Give Kids a Smile 2019 kicks off Feb. 1

01/25/2019
Local dental societies are teaming up with the ADA once again for the annual Give Kids a Smile program, a volunteer initiative to provide dental screenings, treatment and education at no charge to underserved children. Give Kids a Smile kicks off the first Friday in February to coincide with National Children’s Dental Health Month. This year, the date is Feb. 1; however, GKAS programs can take place throughout the year.

 

Medi-Cal Dental Program improvements aim to recruit, retain providers

01/24/2019
Through the improved Medi-Cal Dental Program, more than 13 million individuals are eligible for dental benefits, and a streamlined application and significant rate increases are prompting more dentists to join the program as providers. The changes follow years of action to improve the program, including CDA’s efforts to educate the public and policymakers about the importance of good oral health care. Jennifer Kent, director of the California Department of Health Care Services, in this Q&A discusses the program’s recent changes and what dentists can expect as providers.

 

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