Report 2013-125 Summary - December 2014
California Department of Health Care Services:
Weaknesses in Its Medi-Cal Dental Program Limit Children's Access to Dental Care
Our audit of the California Medical Assistance Program (Medi-Cal) Dental Program, administered by the California Department of Health Care Services (Health Care Services), highlighted the following:
- Although the proportion of children who had at least one dental procedure performed during the year —utilization rate—increased each year from 2011 to 2013, Health Care Services has not established criteria for assessing utilization rates under the fee-for-service model.
- While overall California appears to have an adequate number of active providers to meet the dental needs of child beneficiaries, some counties lacked active providers for children in the program.
- California's reimbursement rates for the 10 dental procedures most frequently authorized for payment within the program in 2012 averaged $21.60—only 35 percent of the national average for these same procedures in 2011.
- We estimate that recent changes in federal and state laws could increase the number of individuals using dental services through Medi-Cal from 2.7 million to as many as 6.4 million.
- Health Care Services has not reviewed reimbursement rates annually as required and thus, may remain unaware of their impact on access to dental services.
- Health Care Services has not enforced certain contract provisions related to increasing utilization.
- Health Care Services' current data collection efforts lack the specificity required to fully meet federal and state reporting requirements.
RESULTS IN BRIEF
Through the California Medical Assistance Program (Medi-Cal), the State of California participates in the federal Medicaid program, which provides health care services to the aged, disabled, and indigent. The California Department of Health Care Services (Health Care Services) is the single state agency responsible for administering Medi-Cal. Unfortunately, Health Care Services' information shortcomings and ineffective actions are putting children enrolled in Medi-Cal—child beneficiaries—at higher risk of dental disease.1 Health Care Services is responsible for meeting the health care needs, including the dental needs, of enrolled individuals and families who rely on public assistance under Medi-Cal. According to the U.S. Department of Health and Human Services (HHS), tooth decay is almost entirely preventable through a combination of good oral health habits at home, a healthy diet, and early and regular use of preventive dental services. Tooth decay in children can cause significant pain and loss of school days, and it can lead to infections and even death.
Child beneficiaries in the Medi-Cal Dental Program (program) can receive services under two delivery models: fee-for-service and managed care. Although California's utilization rate for child beneficiaries—the proportion of children who had at least one dental procedure performed during the year—increased by as much as 1.2 percentage points each year from 2011 to 2013, its annual utilization rates are still lower than those of many other states. Despite this fact, Health Care Services has not established criteria for assessing utilization rates under the fee-for-service model. Data from HHS's Centers for Medicare and Medicaid Services (CMS) indicate that nearly 56 percent of the 5.1 million children enrolled in Medi-Cal in federal fiscal year 2013—October 1, 2012, through September 30, 2013—did not receive dental care through the program. The CMS data indicate that the national average utilization rate was 47.6 percent and ranged from a low of 23.7 percent in Ohio to a high of 63.4 percent in Texas for that same federal fiscal year. CMS's data also indicate that California's utilization rate of 43.9 percent was the 12th worst among the states that submitted data. Our review of Health Care Services' data for 2011 through 2013 found similar results. Studies we reviewed concerning utilization rates for Medicaid child beneficiaries suggested several reasons for low utilization rates, including an uneven distribution of dentists nationwide and a relatively small number of dentists who participate in Medicaid.
Health Care Services also has not formally established criteria for assessing provider participation under the fee-for-service model. Therefore, we used a ratio of one provider to every 2,000 child beneficiaries—or 1:2,000—for this audit as an indicator of geographic areas in which an insufficient number of dental service providers may exist. We chose this ratio primarily because state regulations require that all managed care enrollees have a residence or workplace within 30 minutes or 15 miles of a contracting or plan-operated primary care provider and that providers exist in such numbers and distribution so that all enrollees experience a ratio of at least one primary care provider (on a full-time equivalent basis) to every 2,000 enrollees. As of January 2014, California as a whole appeared to have an adequate number of active providers to meet the dental needs of child beneficiaries because its provider-to-beneficiary ratio for child beneficiaries did not exceed 1:2,000.2 However, some counties lacked active providers for children in the program. For example, Health Care Services data showed that five counties with roughly 2,000 child beneficiaries who received at least one dental procedure in 2013 may not have any active Medi-Cal dental providers. Because of data limitations, we were unable to identify the providers rendering dental services to these 2,000 child beneficiaries. Furthermore, Health Care Services' data show that in 2013 11 counties had no dental providers willing to accept new Medi-Cal patients and that 16 counties had provider-to-beneficiary ratios above 1:2,000, indicating there may be an insufficient number of dental providers willing to accept new Medi-Cal patients. Health Care Services has taken some actions to increase the fee-for-service delivery system's provider participation, such as simplifying the administrative process by implementing an automated provider enrollment system, but much remains to be done.
Studies indicate that one of the primary reasons for low dental provider participation is low reimbursement rates. California's dental reimbursement rates are relatively low compared to national and regional averages and to the reimbursement rates of other states. For example, California's reimbursement rates for the 10 dental procedures most frequently authorized for payment within the program in 2012 averaged $21.60, which was only 35 percent of the national average of $61.96 for those same 10 procedures in 2011. California has not raised its dental reimbursement rates since fiscal year 2000-01, and it implemented in September 2013 a 10 percent state-mandated payment reduction for most dental service providers.
Although the statewide active provider-to-beneficiary ratio of 1:807 in 2013 appears sufficient to provide reasonable access to dental services for child beneficiaries, recent changes in federal and state laws that increase the number of children and adults who can receive additional covered dental services make us question whether California will have enough available dental providers to meet the needs of Medi-Cal beneficiaries. For example, federal and state law expanded Medi-Cal's eligibility income limits and restored limited dental services for adult beneficiaries. We estimate that these changes in federal and state laws could increase the number of individuals using dental services through Medi-Cal from 2.7 million to as many as 6.4 million.
Health Care Services also has not complied with state law requiring it to review reimbursement rates annually. The purpose of this review is to ensure the reasonable access to dental services by Medi-Cal beneficiaries. Health Care Services stated that it did not perform these reviews because of its workload and the State's fiscal climate. However, Health Care Services did not notify the Legislature that it would not be conducting these reviews. Although Health Care Services is working toward a plan to incorporate annual rate reviews into its workload, it did not provide us with an estimated date of completion. If Health Care Services does not perform annual reimbursement rate reviews, it remains unaware of the impact of its reimbursement rates, and it cannot reasonably justify requesting from the Legislature changes to the reimbursement rates to ensure reasonable access to dental services by Medi-Cal beneficiaries.
In addition, Health Care Services has not complied with its plan for monitoring access to services. In its monitoring plan, Health Care Services stated that it would report yearly on its comparison of the results from a specific dental utilization metric with results from three national and statewide surveys. However, we evaluated a draft copy of the dental portion of Health Care Services' access monitoring report, and the draft does not compare the results from Health Care Services' utilization metric with the three surveys in its plan. According to the chief of the provider and beneficiary services section, Health Care Services' Medi-Cal Dental Services Division (division) did not include the comparisons because it thought another division was responsible for completing the dental metrics in the monitoring plan. He further stated that the division would be revising the dental section of the report to include the comparisons proposed in the monitoring plan. Because Health Care Services has not compared its child beneficiaries' utilization data for Medi-Cal dental services to the results of the three surveys, it lacks information necessary to determine whether California's utilization rates are low.
Health Care Services' actions related to improving beneficiary utilization and provider participation have been ineffective. Our analysis of beneficiary utilization rates and provider-to-beneficiary ratios indicates that these activities have not resulted in meaningful improvements. For example, beneficiary utilization rates statewide increased by only 1.2 percentage points from 2011 to 2012 and by 1 percentage point from 2012 to 2013. Health Care Services is also not enforcing its key contract provisions related to improving beneficiary utilization rates and provider participation. Health Care Services has contracted with Delta Dental of California (Delta Dental) since 2004, at a maximum amount payable of up to $8.6 billion, to help administer the program. According to that contract, Delta Dental is responsible for performing several beneficiary and provider outreach activities. Even though Health Care Services believes that Delta Dental has fully complied with these provisions, we remain convinced that Delta Dental has not performed contract-required outreach for improving dental access in underserved areas. For instance, Delta Dental has not contracted with entities to provide additional dental services through fixed facilities or mobile clinics. By not ensuring the performance of contract provisions aimed at increasing beneficiary utilization and provider participation in underserved areas, Health Care Services increases the risk that dental disease and tooth decay will affect children in those areas.
Further, Health Care Services' current data collection efforts lack the specificity required to fully meet federal and state reporting requirements. For example, federal law requires Health Care Services to report annually the number of children receiving specific types of dental services, but Health Care Services does not collect all of the data in sufficient detail to report accurately the number of children who have received these dental services. In addition, recently enacted state law requires Health Care Services to report on dental health access, dental care availability, and the effectiveness of preventive care and treatment. We believe that one critical measure of access and availability is each county's provider-to-beneficiary ratio. Health Care Services does not currently track this type of information; thus it cannot effectively measure either children's access to or the availability of dental services in each county, nor can it accurately predict whether sufficient numbers of providers are available to meet the increasing needs of the program. In addition, because of limitations in the data related to dental providers that Health Care Services collects, it cannot accurately calculate this ratio by county. Finally, Health Care Services and its fiscal intermediaries authorized reimbursements of more than $70,000 for dental services purportedly provided to deceased beneficiaries because it had not updated its beneficiary eligibility system with death information.
To ensure that child beneficiaries throughout California can reasonably access dental services under Medi-Cal and to increase beneficiary utilization and provider participation, Health Care Services should take the following steps for the fee-for-service delivery system by May 2015:
- Establish criteria for assessing beneficiary utilization of dental services.
- Establish criteria for assessing provider participation in the program.
- Develop procedures to identify periodically any counties or other geographic areas where beneficiary utilization and provider participation fail to meet applicable criteria.
- Immediately take actions to resolve any declining trends identified during its monitoring efforts.
To ensure that the influx of beneficiaries resulting from recent changes to federal and state law is able to access Medi-Cal's dental services, Health Care Services should do the following:
- Continuously monitor beneficiary utilization, the number of beneficiaries having difficulty accessing appointments with providers, and the number of providers enrolling in and leaving the program.
- Immediately take actions to resolve any declining trends identified during its monitoring efforts.
To make certain that Medi-Cal beneficiaries have reasonable access to dental services, Health Care Services should immediately resume performing its annual reimbursement rate reviews, as state law requires.
To ensure that child beneficiaries' access to Medi-Cal dental services is comparable to the general population's access to service in the same geographic areas, Health Care Services should immediately adhere to its monitoring plan and compare its results measuring the percentage of child beneficiaries who had at least one dental visit in the past 12 months with the results from the three surveys conducted by other entities, as its state plan requires.
To improve utilization rates and provider participation under the fee-for-service delivery system, Health Care Services should immediately take these actions to make certain that Delta Dental performs the following contract-required outreach activities:
- Direct Delta Dental to submit annually a plan that describes how it will remedy the dental access problems in underserved areas within California.
- Direct Delta Dental to contract with one or more entities to provide additional dental services in either fixed facilities or mobile entities in underserved areas, as its contract requires.
To meet the requirements of the new state law, Health Care Services should establish the provider-to-beneficiary ratio in each county as one of the performance measures designed to evaluate access and availability of dental services and require that the provider field in its data systems is populated in all circumstances.
To ensure that it reports an accurate number of children who received specific types of dental services, Health Care Services should continue working on a solution to capture the details necessary to identify specific dental services rendered.
To make certain that Health Care Services and its fiscal intermediaries reimburse providers for services rendered to eligible beneficiaries only, Health Care Services should do the following:
- Obtain the U.S. Social Security Administration's Death Master File and update its beneficiary eligibility system with death information monthly.
- Coordinate with the appropriate fiscal intermediaries to recover any inappropriate payments made for services purportedly rendered to deceased beneficiaries.
Health Care Services agrees with all but one of our recommendations. Regarding the recommendation that it establish the provider-to-beneficiary ratio statewide and by county as performance measures, Health Care Services states that it does not agree because these measures are not part of the reporting required by state law.
1 We refer to people enrolled in Medi-Cal as beneficiaries. Individuals under age 21 enrolled in Medi-Cal are child beneficiaries.
2 To be counted as an active provider for the purposes of this audit, a provider must have rendered at least one program dental procedure to at least one child beneficiary in the past year.