Improving Access to Dental Services for Individuals With Developmental Disabilities

Improving Access to Dental Services for Individuals With Developmental Disabilities MAC TAYLOR LEGISLATIVE ANALYST SEPTEMBER 27, 2018 analysis full gutter AN LAO REPORT LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Executive Summary Individuals with developmental disabilities face a number of behavioral, cognitive, and physical challenges that can adversely affect their health. Oral health is no exception. Individuals with developmental disabilities often need extra appointments or special accommodations that dentists may be unwilling or unable to provide. This report analyzes the extent to which dental services are available and sufficient for individuals with developmental disabilities. Finding that access challenges exist, we consider options and make recommendations for improving access. Regional Centers (RCs) Coordinate Services—Including Dental Care—for Individuals With Developmental Disabilities. State law directs the Department of Developmental Services (DDS) to provide individuals with qualifying developmental disabilities (called “consumers” in statute) with services to meet their needs in the least restrictive environment possible. Twenty-one independent nonprofit RCs coordinate services for consumers in the community. Consumers Largely Pay for Dental Services With State-Funded Dental Insurance. RCs may only pay for services directly if those services are not covered and funded by another public or private source, such as the state’s Medicaid program—Medi-Cal—or private insurance. Nearly eight in ten consumers are income-eligible for dental insurance through the state’s Medi-Cal dental program, Denti-Cal. Traditional Approach to Dental Care Not Designed With DDS Consumers in Mind. The vast majority of Denti-Cal providers work in private dental offices that are not typically set up to serve DDS consumers, especially consumers with severe behavioral or physical limitations. Some Denti-Cal providers, such as Registered Dental Hygienists in Alternative Practice (RDHAPs), are trained to serve homebound and/or medically compromised patients and serve consumers more frequently, but there are relatively few of them statewide. While there are other potentially promising alternative approaches to dental service delivery for consumers, such as Virtual Dental Homes (VDHs) or house-call dentistry, these are also relatively rare. Many Consumers Lack Routine Dental Care. According to Denti-Cal data, only about 22 percent of consumers enrolled in Denti-Cal received even one dental service in each of 2014, 2015, and 2016. Low Denti-Cal Provider Participation and Denti-Cal Payment Structure Limit Access for Consumers. Only 20 percent of the state’s dentists participate in Denti-Cal. The relatively low number of Denti-Cal providers means longer waits for appointments, farther distances to travel, and/or the decision to forgo dental care for consumers. Denti-Cal also limits benefits or sets low reimbursement rates that constrain access to certain dental services commonly needed by consumers, such as periodontal treatment for gum disease. In addition, under the current Denti-Cal payment structure, which pays dentists by the procedure, providers have an incentive to maximize the number of patients they see each day. This works against what is often the consumer requirement for additional appointments and time to receive dental services. Many consumers, for example, are unaccustomed to seeing the dentist and might require behavioral desensitization—methods that help put a patient at ease before a dental procedure. These methods often require additional time and visits. www.lao.ca.gov 1 analysis full gutter AN LAO REPORT RCs and DDS Have Taken Steps to Address Consumers’ Dental Needs, Yet Access Remains a Problem. Over the past couple of decades, DDS and RCs have taken steps to address the access problem. Currently, 17 of 21 RCs employ a dental coordinator whose responsibilities include expanding the network of dental providers willing to serve DDS consumers, helping providers with Denti-Cal administration, conducting consumer case reviews, helping individual consumers find providers, training consumers and residential care providers on oral hygiene, and coordinating desensitization. The RCs without a dental coordinator serve areas with some of the worst access to Denti-Cal providers. DDS has also targeted state funding provided for community resource development to projects proposed by RCs to expand access to dental care, such as development of clinic-based services that can accommodate DDS consumers. While these actions have helped to improve consumer access, consumer access remains a significant problem, as evidenced by Denti-Cal data. Recommendations We make several recommendations, based on our three key assessments, to improve consumers’ access to dental care: Assessment—Dental Coordination at RCs Effective, but Currently Insufficient in its Use Statewide: • Require the administration to submit a plan to the Legislature to increase the number of dental coordinators at RCs statewide. The administration should consider using DDS’ existing community resource development funds to fully or partially support the plan. Assessment—Denti-Cal Benefit and Rate Structure Limits DDS Consumers’ Access: • Authorize behavior management benefit for DDS consumers eligible for Denti-Cal. • Improve access to periodontal treatment for DDS consumers eligible for Denti-Cal: » Modify or eliminate the current treatment authorization request requirement for scaling and root planing benefit for DDS consumers. » Modify or eliminate the limit on periodontal maintenance for DDS consumers. » Restore the prior Denti-Cal rate for periodontal maintenance. Assessment—Too Few Dental Providers Willing and Able to Serve Consumers: • Consider authorizing a pilot program that would provide a supplemental payment to Denti-Cal providers who have undergone training to treat DDS consumers. • Expand RDHAPs’ scope of practice. • Consider requiring the administration to submit a plan targeting the use of DDS’ community resource development funds to develop additional dental resources. Potential components of the plan might include: » Increasing dental coordination at RCs, as noted above. » Increasing service provision at clinics, such as federally qualified health centers. » Increasing the number of VDHs. • Consider providing incentives for dentists to practice house-call dentistry. 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT INTRODUCTION Individuals with developmental disabilities face needs of those formerly institutionalized. The staff a number of behavioral, cognitive, and physical of the Regional Centers (RCs)—which oversee challenges that can adversely affect their health. the provision of services in the community—have Oral health is no exception. Many individuals indicated that dental services are a pressing need with developmental disabilities cannot personally among their consumers living in the community. maintain their own dental hygiene and suffer poor Research has highlighted disproportionately high oral health outcomes, such as decaying teeth rates of dental disease and tooth decay among and gum disease, as a result. Under state law, individuals with developmental disabilities and has individuals with qualifying developmental disabilities noted that these individuals are more likely than the can receive dental services paid for by the state, general population to lack access to regular dental but often they need extra appointments or special care across their lifespan. This report analyzes accommodations that dentists are unable or the extent to which dental services for individuals unwilling to provide. With the scheduled closure with developmental disabilities are available and of the state’s three remaining state-run institutions sufficient in their communities. Finding that access for individuals with developmental disabilities— challenges exist, we consider options for improving known as Developmental Centers (DCs)—and the access to dental services for this population. accompanying transition of DC residents into the (There are several acronyms used in this report. community, the Department of Developmental We provide a list of them, with definitions, as an Services (DDS) is funding the development of appendix to the report.) new community resources to address the service BACKGROUND Overview of Developmental Services lifelong developmental disability. The department administers both community-based services and Lanterman Developmental Disabilities state-run services. These are each described Services Act of 1969 (the “Lanterman Act”). below. Under the Lanterman Act, the state provides Community Services Program. In 2017-18, individuals who have developmental disabilities DDS served an estimated 320,000 individuals with with services and supports to meet their needs, developmental disabilities (“consumers” in statutory preferences, and goals in the least restrictive language) through its community services program. environment possible. These services and supports Twenty-one independent nonprofit RC agencies are overseen by DDS. The Lanterman Act defines coordinate services for consumers, which includes a developmental disability as a “substantial assessing eligibility and developing individual disability” that starts before the age of 18 and is program plans (IPPs). Consumers receiving expected to continue indefinitely. This definition community services can be divided into two broad includes cerebral palsy, epilepsy, autism, intellectual groups: disabilities, and other conditions closely related to intellectual disabilities that require similar treatment • Infants and Toddlers. For infants and (such as traumatic brain injury). Unlike most other toddlers under the age of three who exhibit public human services or health services programs, a developmental delay (it is often unclear at individuals receiving services through DDS need this age whether the delay reflects a lifelong not meet any income criteria. Rather, the main developmental disability), RCs coordinate qualification criterion is diagnosis of a substantial a more limited set of services (such as www.lao.ca.gov 3 analysis full gutter AN LAO REPORT early intervention services and speech, 2015; most of those residents now live in occupational, and physical therapies) through the community.) At the start of 2017-18, the Early Start program. RCs currently serve 534 residents lived at closure DCs and by the approximately 42,000 infants and toddlers in end of 2017-18, 240 consumers remained. the Early Start program. Once individuals move from DCs into the • “Active Status” Consumers. Active status community, they receive services as active consumers are ages three and older and have status consumers through the community been deemed eligible for lifelong services services program. under the Lanterman Act. DDS currently • Nonclosure Facilities. DDS will continue serves approximately 279,000 active status to operate a secure treatment program at consumers, with caseload increasing about Porterville DC, which serves individuals 4 percent annually in recent years. committed by a court because they are a safety risk to themselves or others and/or Because RCs do not necessarily coordinate have been deemed incompetent to stand trial dental care for infants and toddlers, this report for an alleged criminal offense. By statute, focuses on active status consumers (including Porterville DC’s secure treatment program DC residents moving into the community) and will can serve up to 211 people. DDS will also simply use the term consumers throughout to refer continue to run Canyon Springs Community to this group. Facility in Riverside County, which can house RCs coordinate residential, health, day program, up to 63 people at a time, many of whom employment, transportation, and respite services, have recently left Porterville DC’s secure among others, for consumers. As the mandated treatment program. payer of last resort, RCs only pay for services if they are not covered and paid for through another Characteristics That Can Affect the government program, such as Medi-Cal, or through Oral Health of Individuals With a third party, such as private health insurance. Developmental Disabilities RCs contract with tens of thousands of vendors around the state to purchase services and supports Individuals with developmental disabilities for consumers. DDS provides RCs with a budget may have one or more characteristics that for both their administrative operations and the complicate their oral health and make receiving purchase of services (POS) from vendors. dental treatments more difficult, especially under DCs Program. At the start of 2017-18, DDS traditional models of care. Below, we describe served about 800 individuals in three DCs, which some of these characteristics. Later in the report, are licensed and certified as general acute care we discuss how these characteristics complicate hospitals, and in one state-run community facility. oral health and dental care. These state-run facilities can be divided into two Cognitive Challenges. According to December broad groups: 2017 data collected by DDS, about six in ten consumers have an intellectual disability. Eight • Closure DCs. In 2015, the administration percent have an intellectual disability that is announced its plan—which the Legislature considered severe or profound (as opposed to approved—to close the state’s remaining DCs moderate or mild). Former DC residents have even (which we refer to as “closure DCs”)—Sonoma higher rates of cognitive disability. According to a DC in Sonoma County by the end of 2018, May 2016 “Risk Management Report” prepared Fairview DC in Orange County by the end for DDS about individuals who moved from DCs of 2021, and the general treatment area of between 2010 and 2014, 70 percent have an Porterville DC in Tulare County by the end of intellectual disability that is severe (15 percent) or 2021. (At one time, the state operated seven profound (55 percent). DCs serving upwards of 13,000 consumers. It closed four DCs between 1996 and 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Behavioral Challenges. Some Figure 1 individuals with developmental Many Adults With Developmental Disabilities Have disabilities also have mental health Behavioral and/or Mental Health Challenges diagnoses, including 47 percent of former DC residents. According National Core Indicators, Adult Consumer Survey, California Statewide Report, 2014-15 to the 2014-15 National Core Indicators (NCI) Survey, 7 percent Additional Challenge Beyond Developmental Disabilitya Percent of California’s DDS consumers ages three through 18 have mental Behavioral challenges 29% illness or a psychiatric disorder. As Anxiety disorder 25 shown in Figure 1, the percentages Mood disorder 24 Psychotic disorder 9 are even higher for adults. These and other challenges for Take Medications individuals with developmental Take medications for mood, anxiety, or psychotic disorders, 35 or for other mental illness disabilities can result in the need Take medications for behavioral challenges 24 for supports in the activities of daily a Individuals may have more than one challenge or disorder. living. Nearly eight in ten children need extensive (30 percent) or which includes participation by the consumer, his some (48 percent) support to or her family (if applicable), his or her RC service manage and prevent self-injurious, disruptive, coordinator, and any other relevant individuals, and/or destructive behaviors. Figure 2 shows the such as RC clinical staff or service provider staff. percentages of adults in need of such supports. In addition to identifying the goals, objectives, and Other Physical and Communication preferences of the consumer, the IPP planning Challenges. One-quarter of adults with team identifies and documents the services and developmental disabilities cannot move without supports the consumer may need to live in the least aides, such as wheelchairs. Many consumers also restrictive and most integrated way possible. Such have difficulty communicating or require multilingual services and supports may include residential, service providers. For example, 30 percent of day program, employment, dental, medical, or adult consumers (and 18 percent of children) use therapeutic services, or respite for caregivers. gestures rather than spoken language, and for While the IPP is reviewed at least once every three nearly 20 percent of adult consumers and children, years, progress toward the goals and objectives in English is not their primary language. the IPP is tracked at least annually for consumers Identification and Coordination of who live with their families and at least quarterly Consumers’ Dental Service Needs for those who live outside the family home. These regular progress reports track dental and medical How Dental Needs Are Identified. Consumers’ appointments and current medications, although dental needs are identified through the IPP process, this information currently is not aggregated, which Figure 2 Behavioral Challenges Among Adults With Developmental Disabilities Result in Need for Supports National Core Indicators, Adult Consumer Survey, California Statewide Report, 2014-15 Require Supporta to Manage . . . Require Some Support Require Extensive Support Total Requiring Support Disruptive behaviors 29% 14% 43% Destructive behaviors 22 6 28 Self-injurious behaviors 17 3 20 a Individuals may require support for more than one reason. www.lao.ca.gov 5 analysis full gutter AN LAO REPORT limits the ability to understand outcomes across (RDHs), and one or more support staff including the DDS population. (See the nearby box for more (among others) registered dental assistants (RDAs). information about where DDS consumers live and This small office structure limits the number of how this location affects coordination of dental patients that dentists and their staff can treat. care.) Recent national data show that dentists treat an DDS also tracks consumer characteristics, average of 70 patients per week. Private dentist developmental information, and consumer offices also occupy relatively small office spaces quality-of-life measures through the Client with few chairs. Sole proprietorships nationwide, Development Evaluation Report (CDER). The CDER for example, each have an average of four chairs is completed once every one to three years and to serve their patients. As opposed to hospital includes several questions related to dental and operating rooms and oral surgery centers, the vast medical care. majority of private dental offices do not offer deep sedation or general anesthesia services. How Dental Services Are Coordinated. For the roughly 550 consumers who live at DCs as Hospital Operating Rooms and Oral Surgery of March 2018 (this number declines on a weekly Centers. For more intensive, restorative procedures basis as consumers move from DCs to the that require deep sedation and general anesthesia, community), dental services are provided onsite by patients can schedule appointments in hospital state-employed dental staff or contracted dental operating rooms and oral surgery centers. These providers. DCs are licensed as acute care hospitals facilities are equipped to provide a variety of and can administer general anesthesia onsite. For surgeries, and their personnel can often perform the roughly 279,000 consumers who live in the multiple dental procedures in one appointment. community (as of March 2018), dental services Hospitals and oral surgery centers, however, have are coordinated by family members and/or by RC limited capacity to provide dental procedures staff, which may include the consumer’s RC service relative to other surgical procedures. Limited coordinator or the RC dental coordinator, or both. capacity means long waiting lists—upwards of We conducted a survey of the 21 RCs to learn three years—for individuals with developmental more about their dental coordination efforts. We disabilities to receive dental services in these discuss the results of the survey as well as the role facilities. of the RC dental coordinator in more detail later in FQHCs and Other Safety Net Clinics. FQHCs this report. and other safety net clinics provide comprehensive primary care—often including dental services— Dental Service Settings for Individuals to medically underserved communities and With Developmental Disabilities populations. FQHCs are paid using a different payment model than other providers, one that Individuals with developmental disabilities receive incentivizes delivering services to more people. dental services in a variety of settings—including While this payment model may not incentivize private dentist offices, hospital operating rooms FQHCs to serve individuals with developmental and oral surgery centers, federally qualified health disabilities—as they often take longer to treat—two centers (FQHCs) and other safety net clinics, and in RCs are working with community health center their own homes. Where these individuals receive organizations to build FQHCs with the equipment services depends largely on where they live, their and personnel necessary to provide individuals with dental insurance (if they have insurance), their developmental disabilities with community-based familiarity and comfort with the dentist, and the services. acuity of their dental needs. Typically, however, At Home. Some individuals with developmental individuals with developmental disabilities receive disabilities, particularly those who need assistance dental services in private dentist offices. to move, receive dental services in their homes Private Dentist Offices. Private dentist offices from mobile dental providers. These providers, are typically sole proprietorships with a single such as Registered Dental Hygienists in Alternative dentist, one or more registered dental hygienists 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Practice (RDHAPs), typically set up a dental chair because of the additional cost of transportation to and other equipment in the consumer’s home and from a patient’s home, the difficulty in setting and perform dental procedures as they would in a up and taking down the equipment necessary private dentist office. There are few mobile dental to perform dental procedures, and the reduced providers who perform dental services in homes number of patients they are able to treat. Where Do Individuals With Developmental Disabilities Live? Where consumers of the Department of Developmental Services (DDS) live affects how they receive dental services and how their dental services are coordinated. The information below provides an overview of the various settings in which DDS consumers live and how dental services are coordinated in each setting. Regardless of setting, Regional Center (RC) staff may be involved in assisting consumers and their families or caregivers find dentists, make referrals, conduct patient screenings, or review patient case files. • Consumer’s Family Home. About three-quarters of DDS consumers live in the home of their parent or guardian. The parent or guardian is often involved in the coordination of dental services and in taking the consumer to appointments. • Independent Living Services (ILS) or Supported Living Services (SLS). Nearly 10 percent of DDS consumers live on their own, in a home or apartment they rent or own, and receive ILS or SLS. (ILS can also be provided to someone who lives in his or her family’s home.) ILS is for consumers who need training to learn functional skills to live on their own, whereas SLS is for consumers who need assistance with daily functions. SLS may include helping the consumer find an apartment, choosing a housemate, managing personal affairs, or tending to personal care. Because the acuity level varies widely among consumers receiving SLS, the method of coordinating and providing dental care also varies. • Community Care Facilities (CCFs). Nearly 10 percent of DDS consumers live in CCFs, which are licensed by the Department of Social Services and have varying degrees of care and supervision provided, depending on residents’ needs. Each CCF typically houses four to six DDS consumers. Dental services and associated transportation may be coordinated by RC staff or the consumer’s family member, residential caregiver, or day program service provider. • Intermediate Care Facilities for the Developmentally Disabled (ICF/DDs). About 3 percent of DDS consumers live in ICF/DDs, which are medical facilities licensed by the Department of Public Health (DPH). ICF/DDs provide varying degrees of nursing care and levels of staffing (and accommodate a varying number of residents) depending on their designation. Residents living in ICF/DDs tend to have more complex medical needs than do other DDS consumers (although these needs may be similarly complex to the needs of residents living in the most intensive CCFs). Some may be unable to travel easily to a dental office and may receive basic treatments at the ICF/DD. • Skilled Nursing Facility (SNFs). Less than 1 percent of DDS consumers (around 1,100 people at the end of December 2017) live in SNFs, which are licensed by DPH and provide 24-hour inpatient care. SNF residents have nursing and medical needs that may be similar to residents living in the more medically intensive ICF/DDs. SNF residents may receive some of their dental treatments at the SNF and travel to a dental office or surgical center for more intensive procedures. www.lao.ca.gov 7 analysis full gutter AN LAO REPORT Dental Service Delivery Approaches have about one or more years of experience. The license allows RDHAPs to practice in Currently, most DDS consumers receive community settings—such as schools, skilled dental services through the traditional delivery nursing facilities (SNFs), Intermediate Care approach—the same way most of the general Facilities for the Developmentally Disabled population receives its dental services. Below, we (ICF/DDs), patient homes, their own offices, briefly describe this approach and then several and in identified dental health professional alternatives that have been developed to treat shortage areas—without a dentist’s or patients (including many DDS consumers) for whom physician’s direct supervision. (A dental the traditional approach does not meet their needs. health professional shortage area is an area Traditional Service Delivery Approach. designated by the federal government as For most individuals, dental services start with not having enough dentists to adequately the patient making an appointment at a private serve the population.) They perform the same dentist office. The patient arrives at the office and services as RDHs (including prophylaxis, provides the administrative assistant (or similar scaling and root planing, periodontal staff member) with relevant information (including maintenance, application of sealants and insurance information) before the appointment interim therapeutic restorations (ITRs), and the begins. One of the staff members takes the patient taking of impressions), but can perform them back to a dental chair, and an RDH thoroughly in nontraditional settings. RDHAPs can also cleans the patient’s teeth. Once the patient’s teeth determine which radiographs are needed by a are cleaned, the dentist performs a full examination supervising dentist to develop a subsequent of the teeth, gums, and mouth to check for signs treatment plan. of disease and decay. Should radiographs be For up to 18 months, an RDHAP may treat necessary, often an RDA or RDH will take the (but not diagnose) a patient who has not radiographs at some point during the visit. Once all been examined by a dentist or physician. of the dental procedures are completed, the patient After 18 months, the RDHAP must provide will be asked to go back to the administrative documentation that such an examination assistant to schedule a follow-up appointment. occurred and obtain a written prescription Most routine, preventive dental appointments (valid for up to two years) from the dentist to take approximately an hour, but appointments treat the patient. RDHAPs may independently can take longer depending on the nature of the submit insurance claims to receive payment procedures performed. (Please see the nearby box for their services. for a description of the common dental procedures Currently, 507 RDHAPs are licensed to discussed throughout this report.) practice in California and 191 are enrolled Alternative Service Delivery Approaches. as Medi-Cal dental program (“Denti-Cal”) The state has developed and/or piloted several providers. Most travel to provide dental alternative ways of delivering dental care to reach hygiene services—for example, to patients Californians (including DDS consumers) who in their homes and at SNFs and ICF/DDs. may have problems receiving dental services the A 2009 study of California RDHAPs estimated traditional way, whether due to location; income; that 30 percent of RDHAP patients had a or physical, cognitive, or mental health. Below, we developmental disability. In the same study, describe several of these: nearly half of RDHAPs reported having • RDHAPs. Statute authorized the RDHAP difficulty finding dentists to accept their licensure type in the late 1990s to serve referrals after the 18-month window. homebound and/or medically compromised • Virtual Dental Homes (VDHs). The VDH patients. RDHAPs are RDHs who also hold delivery approach delivers dental services a Bachelor of Science degree, complete a in community-based settings, rather than in certificate program, pass a written exam, and traditional dental offices, to serve patients 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT where they are—for example, in schools, partnering dentists through teledentistry Head Start programs, residential facilities, technology about the patient’s condition, or private homes. VDHs promote early course of treatment, and any necessary intervention and prevention services by RDHs referrals. Pilot projects between 2010 and under the general supervision of a licensed 2016 demonstrated that underserved and dentist (who need not be physically present). vulnerable populations could be successfully RDHs provide education, as well as preventive treated using the VDH delivery approach. and simple therapeutic services, and collect • Dentists Providing Services in Homes dental charts as well as dental and medical or Schools. Another alternative delivery histories of patients. RDHs then confer with approach—while not formalized as a Common Dental Procedures Discussed in This Report Below are descriptions of some of the most common dental procedures—preventive and restorative—addressed in this report. This list does not include dental examinations and dental radiographs (another word for x-rays), both of which are done for preventive and restorative purposes. Preventive Procedures. Preventive procedures are one-time or ongoing treatments that can prevent worse dental problems from developing: • Prophylaxis. Prophylaxis is another word for cleaning, the common procedure that most children and adults undergo once or twice each year to remove plaque and tartar from the crowns of the teeth. • Fluoride Treatments. Fluoride is a naturally occurring mineral that is applied directly to the teeth to prevent tooth decay and caries (another word for cavities). Fluoride, while present in many toothpastes and water supplies, can also be applied topically by any dental professional, including registered dental assistants. • Sealants. Sealants are thin protective coatings applied to the biting surface of molars to prevent decay and caries. Restorative Procedures. Restorative procedures attempt to fix a dental problem, “restoring” the tooth or gum to as healthy a state as possible: • Fillings. Dentists use fillings, which are made of an amalgam (mercury combined with a metal), composite resin, glass ionomer, or other material, in the caries of a tooth experiencing tooth decay. The filling also prevents the decay from worsening. • Scaling and Root Planing. Scaling and root planing are considered deep cleaning for the treatment of periodontitis (gum disease that causes inflammation and can lead to bone destruction). Scaling involves scraping plaque and calculus from the tooth surface and from under the gum line. Root planing involves scraping and smoothing the roots of the teeth. • Periodontal Maintenance. Periodontal maintenance is like prophylaxis for patients who have periodontitis and have first undergone scaling and root planing. Whereas prophylaxis treats the crowns of the teeth, periodontal maintenance also treats the roots and gums. • Interim Therapeutic Restoration (ITR). ITR involves placing a fluoride-releasing glass ionomer on a tooth to prevent further progression of a caries. ITR does not require the use of a local anesthetic (like filling a caries does) and is often used for hard-to-serve populations or as a stabilization method until additional restoration can be completed. www.lao.ca.gov 9 analysis full gutter AN LAO REPORT program—is for dentists themselves to in ten RC consumers are income-eligible for dental travel into the community to see patients in insurance through Denti-Cal. The Department of their homes, other residential facilities, or at Health Care Services (DHCS) generally determines schools. which dental benefits are covered by Denti-Cal, • DCs. As discussed earlier, DDS consumers what rates are set for each benefit, and how who still live at DCs receive their care, often Denti-Cal providers can bill for a particular including treatment performed under general service for a particular patient. DHCS also anesthesia, onsite from state-employed or determines which dental procedures require prior state-contracted dental providers. Although authorization, meaning a Denti-Cal provider must this approach has been convenient for DC document the medical necessity of the service residents, and ensured at least some degree (often with radiographs or photographs) and submit of dental care, the three remaining DCs will this documentation in the form of a Treatment be closed by 2021 (except for the secure Authorization Request (TAR) to Denti-Cal before treatment program at Porterville DC). performing the procedure. If DHCS denies the TAR and the RC determines that an appeal of the denial does not have merit, the RC can then decide Paying for Dental Services for whether or not to use its POS funds to pay for the Individuals With Developmental denied service. Disabilities Several recent legislative policy and budget RC Consumers Must Access Their Insurance. changes have affected the Denti-Cal program. Before an RC can use its POS funds to purchase Chapter 662 of 2014 (AB 1174, Bocanegra) allows dental services identified in a consumer’s IPP, dentists enrolled in Denti-Cal to bill for virtual state law requires RCs to exhaust benefits from all consultations provided through teledentistry. other available resources, including publicly funded This change means that Denti-Cal beneficiaries or private insurance programs. To demonstrate can receive dental services through VDHs. The that they have exhausted their benefits, RC 2017-18 budget increased Denti-Cal rates for consumers who are eligible for Denti-Cal or some certain services and fully restored adult dental other form of dental insurance (that is, through benefits that were cut during the recession. The Medicare, employer-sponsored insurance, or other 2018-19 budget both maintained the 2017-18 rate private insurance) must first attempt to receive increases and increased rates for additional dental dental services from a participating provider and services. It also added a provision allowing dentists be denied. For example, an insurer might deny to bill for additional time to treat patients with coverage because the service is not a covered special needs, but it is still unclear how DHCS benefit or the patient has already reached his or will implement this new provision. Finally, the her maximum annual number of allowed services 2018-19 budget increased the rates paid through or maximum annual dollar amount. Consumers Denti-Cal for general anesthesia and intravenous must then provide their RC with documentation of sedation in a dental setting to match the rates the service denial and receive a determination from paid through Medi-Cal for equivalent services in a their RC that an appeal of the service denial does medical setting. not have merit. RC POS. As the payer of last resort, RCs only Denti-Cal. Medi-Cal beneficiaries can receive pay for dental services with POS funds when all currently authorized dental services through insurance (Denti-Cal or some other form of dental Denti-Cal. A vast majority of Medi-Cal beneficiaries insurance) has denied coverage or falls short of receive dental services through the fee-for-service covering a needed treatment, a Denti-Cal provider (FFS) delivery system, although all beneficiaries cannot be found, or someone does not have dental in Sacramento County and some beneficiaries insurance but requires a treatment. An RC can in Los Angeles County receive dental services pay for the service with POS funds, but only up through a dental managed care plan. Nearly eight to the rate established by Denti-Cal for the same 10 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT procedure. If a needed service is not a Denti-Cal of $613. In addition, RCs spent some POS funding benefit or the situation is an emergency and the RC in a service category called “specialized therapeutic cannot find a provider willing to accept a Denti-Cal services” ($10 million in POS expenditures on about rate, in rare circumstances, the RC may negotiate a 3,500 consumers in 2016-17). These services rate with a dentist for treatment. could include special supports related to dental In 2016-17, RCs spent $3.7 million for the dental care, but because the expenditure data is not more services of 6,000 consumers (about 2.3 percent of specific, it is unclear what share of the expenditures consumers), for an average per-person expenditure is for this purpose. DDS CONSUMERS EXPERIENCE PROBLEMS WITH ORAL HEALTH AND ACCESS TO DENTAL CARE The oral health of individuals with developmental unable to use traditional dental chairs, or lack the disabilities is worse on average than the oral ability to hold his or her mouth open or control his health of the general population on several key or her movements. A consumer may also struggle factors. For example, they have higher rates and to describe symptoms or identify a problem. increased severity of periodontal disease, much . . . Leading to the Need for More Intensive higher rates of untreated caries, and more missing Dental Service Needs. For some DDS consumers, and decaying teeth. (One study in Massachusetts dental treatments require extra appointments or found that patients with developmental disabilities longer appointment times because the patient average 6.7 missing teeth, whereas the Centers needs extra time to alleviate anxiety or because for Disease Control and Prevention estimate the the dentist cannot work as quickly as he or general population averages 3.6 missing teeth.) she would with another patient. Patients with Compared to the general population, patients with developmental disabilities may need additional developmental disabilities are more likely to have supports at appointments, such as special missing teeth than to have teeth with fillings. This accommodations or behavior desensitization. A could be due, for example, to situations where their sizeable minority of DDS consumers require general decaying teeth are more likely to be extracted than anesthesia or intravenous sedation to undergo restored with fillings. Some oral health problems even routine dental treatments. General anesthesia stem directly from the particular disability itself. For often requires the use of an operating room in a example, mouth breathing among individuals with hospital or surgical center, yet the wait time for Down syndrome can lead to a dry mouth, which such facilities can be lengthy—sometimes as makes it more difficult to wash away bacteria and long as three years. All these factors can reduce can result in increased risk of gum disease. the amount of regular preventive care received. The Characteristics of a Developmental Resulting delays in access can worsen what might Disability Can Compound Oral Hygiene have been a small dental problem to start. Problems . . . The cognitive, behavioral, physical, Because many patients with developmental and/or communication challenges experienced by disabilities suffer distinct oral health problems, many individuals with developmental disabilities cannot easily comply with home care guidelines, affect their ability to practice good oral hygiene and and often lack adequate preventive care, they to receive dental treatment. At home, a consumer can end up requiring more extensive treatments may be physically unable to brush and floss his or (such as a higher than average number of fillings) her teeth, may struggle to comprehend self-care and/or intensive treatments (such as extractions instructions, or may resist allowing someone else or scaling and root planing) than they would to brush his or her teeth. At the dental office, a have otherwise. To avoid extensive treatment, consumer may struggle with severe anxiety, be dentists will sometimes resort to extracting all the www.lao.ca.gov 11 analysis full gutter AN LAO REPORT teeth and providing a full set of dentures. Some claims—actual data—it appears that survey data dentists, especially those who are less experienced vastly overstates the share of consumers receiving in working with patients with developmental dental care in a given year. (Even if we assume disabilities, will resort to using general anesthesia, that all DDS consumers who have private dental rather than providing behavioral supports. (Given insurance or no dental insurance received dental the lack of data available on this latter point, it is care and add that number of consumers to the unclear whether or not deep sedation is overused number of consumers who had a Denti-Cal claim, on patients with developmental disabilities.) it still means that about 40 percent—at most— received even one dental service in a year’s time.) Many Consumers Lack Accordingly, this finding suggests that CDER Routine Dental Care and NCI self-reported data may not be reliable gauges of whether dental care for consumers is To understand whether or not DDS consumers adequate. It also suggests more generally that this receive regular dental care, we turned to three available type of survey data may not be the best source sources of data—(1) information about utilization of information on which to base decisions about via Denti-Cal insurance claims for DDS consumers, dental programs or policies. (2) information reported by each consumer (and/or his or her family member or caregiver) via the CDER evaluation RCs Have Difficulty Finding survey, and (3) information reported by a sample of adult Dental Service Providers consumers (and/or their family members or caregivers) in the NCI survey. Finding Providers With Capacity to Treat Available Denti-Cal Claims Data Indicate Individuals With Developmental Disabilities Is That a Majority of DDS Consumers Fail to See Difficult. Dentists and dental hygienists receive a Dentist Each Year. As previously mentioned, limited training in school and through continuing nearly eight in ten DDS consumers are eligible for education courses on how to serve individuals Denti-Cal. According to Denti-Cal data, however, with developmental disabilities. For example, only about 22 percent of DDS consumers enrolled although the Commission on Dental Accreditation in Denti-Cal received a dental service in each requires that dental schools teach students how of 2014, 2015, and 2016. By contrast, about to assess patients with “special needs” (including 32 percent of Denti-Cal beneficiaries overall utilized developmental disabilities), recent survey data show dental services in each of those years, as shown in that the vast majority of respondents (associate Figure 3. Self-Reported Survey Data Figure 3 Appear to Vastly Overstate RC Consumers Receive Fewer Dental Services DDS Consumers’ Dental Care. in Denti-Cal Than Beneficiaries Overall The CDER and NCI surveys are based on data self-reported by Dental Service Utilizationa surveyed consumers. Recent RC Denti-Cal Difference responses reported in the CDER Calendar Year Consumers Beneficiariesb (Percentage Point) survey indicate that 77 percent 2014 23% 33% -10 of consumers saw a dentist in 2015 22 33 -11 the past 12 months. Results 2016 21 31 -10 from the 2014-15 NCI Survey Average 22% 32% -10 are similar—76 percent of adult a Dental service utilization calculated as the percentage of beneficiaries who receive any dental procedure during the calendar year. consumers reported seeing a b Excludes Medi-Cal beneficiaries enrolled in dental managed care plans due to data limitations. dentist in the prior year. Based on Available utilization data suggest no more than a 0.5 percentage point change in utilization if included. what we know about Denti-Cal RC = Regional Center. 12 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT deans, department chairs, and clinic directors) only about 9,000 dentists (20 percent) were believed students needed more time on this topic. Denti-Cal providers. Dentist participation in Optional advanced dental education programs, Denti-Cal also varies widely by county. In San such as general practice residencies, offer dentists Bernardino County, for example, nearly 30 percent additional clinical experience working with special of dentists were Denti-Cal providers in 2017. In needs patients, yet only 30 percent of graduates at least six other counties, by comparison, there enroll in one of these programs. Finally, although were no Denti-Cal providers in 2017. While the the Dental Board of California’s (DBC’s) regulations number of counties without Denti-Cal providers on continuing education suggest courses in dental does change each year, the low participation rate of service delivery that focus on “behavior guidance” the state’s dentists in the program does not. Fewer and patient management for individuals with special Denti-Cal providers generally means beneficiaries needs, these courses are not required and are not must wait longer for appointments, travel farther offered frequently. Research shows that providers distances to see a dentist, and/or decide to forgo who are not taught to assess the treatment needs dental care. of special needs patients, including individuals Problems With Low Denti-Cal Provider with developmental disabilities, often lack the Participation Exacerbated by Significant confidence to serve this population in the future, Increase in Number of Denti-Cal Recipients thereby limiting access to dental providers for this Since 2014. While dentist participation in Denti-Cal population. remains low, the number of Denti-Cal beneficiaries We conducted a survey of the 21 RCs to overall has increased significantly due to the learn more about their dental coordination efforts full implementation of the Patient Protection and included questions about the roles and and Affordable Care Act (ACA). Since 2014, an responsibilities of their dental coordinators (if additional four million Californians have become they have one), the types of dental providers their eligible for Denti-Cal, primarily as a result of the consumers see, and access challenges. In our state’s decision to expand Medi-Cal eligibility survey, nearly one-half of RCs reported that they to all individuals under age 65 with household are seldom or only sometimes able to coordinate incomes at or below 138 percent of the federal care for their consumers who are hardest to treat poverty level (commonly referred to as the ACA (and most said it is very difficult to book operating optional expansion). As a result, there was an rooms or surgical centers for consumers who need average of 1,500 or so beneficiaries for every one general anesthesia to undergo dental treatment). Denti-Cal provider statewide in 2017. As with They said that reimbursement rates and waiting dentist participation in Denti-Cal, however, the lists among those providers who accept Denti-Cal number of Denti-Cal beneficiaries per provider are primary hurdles to accessing care for the differs greatly by county, as shown in Figure 4 hardest to treat, but some also reported that (see next page). Even within a county, the number some dentists consider themselves ill-equipped to of Denti-Cal beneficiaries per provider can vary treat DDS consumers in their office. Even among greatly by county region, as shown in Figure 5 (see the dentists who do work with patients with page 15) for Los Angeles County. developmental disabilities, RCs report that some High beneficiary-provider ratios in many of prefer to see “high functioning” DDS consumers, California’s counties translates into high ratios in not having the expertise, willingness, or time (or not some RC catchment areas, as shown in Figure 6 having any mechanism to bill for extra time) to treat (see page 16). In fact, four RC catchment areas those with more complex needs. had a beneficiary-provider ratio at least twice the Access Is an Even Greater Challenge for Denti-Cal statewide average, one of which is in Denti-Cal Recipients Given Low Provider Los Angeles County, as shown in Figure 7 (see Participation. In 2017, out of the approximately page 17). 46,000 dentists licensed to practice in California, www.lao.ca.gov 13 analysis full gutter AN LAO REPORT Figure 4 Number of Denti-Cal Beneficiaries Per Participating Dentist Varies Greatly by Countya Fewer Beneficiaries Per Provider Suggests Better Access to Dental Services 1,500 or Fewer Beneficiaries Per Provider Between 1,500 and 3,000 Beneficiaries Per Provider More Than 3,000 Beneficiaries Per Provider No Providers b a The statewide average number of Denti-Cal beneficiaries per participating provider is approximately 1,500. b See Figure 5 for a detailed map of Los Angeles County. 14 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Figure 5 Number of Denti-Cal Beneficiaries Per Participating Dentist Can Vary Significantly Within a Countya By Los Angeles County Service Planning Areab Fewer Beneficiaries Per Provider Suggests Better Access to Dental Services 1,500 or Fewer Beneficiaries Per Provider Between 1,500 and 3,000 Beneficiaries Per Provider Antelope Valley More Than 3,000 Beneficiaries Per Provider San Fernando Valley San Gabriel Valley Metro LA West South East South Bay a The statewide average number of Denti-Cal beneficiaries per participating provider is approximately 1,500. b A Service Planning Area is a geographic region designated by the Los Angeles County Department of Public Health to help address the specific health needs of its residents. www.lao.ca.gov 15 analysis full gutter AN LAO REPORT Figure 6 Number of Denti-Cal Beneficiaries Per Participating Dentist Varies Greatly by RCa Fewer Beneficiaries Per Provider Suggests Better Access to Dental Services 1,500 or Fewer Beneficiaries Per Provider Far Northern Between 1,500 and 3,000 Beneficiaries Per Provider More Than 3,000 Beneficiaries Per Provider Redwood Coast Alta California North Bay Valley Mountain Golden Gate East Bay Central Valley Kern San Andreas Tri-Counties Inland Los Angeles County RCsb Orange County San Diego a The statewide average number of Denti-Cal beneficiaries per participating provider is approximately 1,500. b See Figure 7 for a detailed map of RCs in Los Angeles County. RCs = Regional Centers. 16 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Figure 7 All but One Los Angeles RC Catchment Area Has 1,500 or Fewer Denti-Cal Beneficiaries Per Participating Dentista Fewer Beneficiaries Per Provider Suggests Better Access to Dental Services 1,500 or Fewer Beneficiaries Per Provider More Than 3,000 Beneficiaries Per Provider North Los Angeles County San Gabriel/Pomona Frank D. Lanterman Westside South Central Los Angeles Eastern Los Angeles Harbor a The statewide average number of Denti-Cal beneficiaries per participating provider is approximately 1,500. RC = Regional Center. RC AND DDS HAVE TAKEN STEPS S TO ADDRESS CONSUMERS’ DENTAL NEEDS Recognizing that oral health and access to Use of Dental Coordinators dental care are problems for many individuals with Most RCs Have Hired Dental Coordinators. developmental disabilities, DDS and individual RCs In addition to having service coordinators who have taken certain steps over the past two decades work with consumers and their families to develop to address these issues. www.lao.ca.gov 17 analysis full gutter AN LAO REPORT and fulfill the overall objectives of a consumer’s coordinator. Most of the RC dental coordinators IPP, RCs also have clinical staff who handle issues have worked with their RC for at least five years related specifically to the medical and dental (the average length of employment is ten years) and care of the consumer population, including on an the primary responsibilities of the dental coordinator individual consumer basis. In our survey of the position appear similar across RCs. For example, 21 RCs, 17 reported that they also employ one 16 RCs report that expanding the network of dental or more dental coordinators. Fourteen RCs have providers willing to work with DDS consumers is one dental coordinator position and three RCs a core responsibility of their dental coordinator(s). have two positions (although at two of these three More than one-half of the RCs indicated that their RCs, the total number of hours worked between dental coordinators work with dental providers the two dental coordinators is still less than one on Denti-Cal-related issues. Figure 8 shows full-time position). Four RCs do not have a dental the various roles of a dental coordinator and the Figure 8 Roles of RC Dental Coordinators Number of RCs Reporting a Particular Role for Their Dental Coordinator a Expanding the Network of Dental Providers 16 Willing to Work With Consumers Coordinating Dental Care for Consumers 13 Making Patient Referrals 12 Retaining the Current Network of Dental Providers 12 Willing to Work With Consumers Working With Dental Providers on Denti-Cal-Related Issues 12 Conducting Case Reviews 11 Conducting Regional Center Staff Trainings 11 Conducting Residential Staff Trainings 11 Conducting Consumer Trainings 10 Conducting Patient Screenings 10 Coordinating General Anesthesia for Certain Consumers 9 Coordinating IV Sedation for Certain Consumers 7 Booking Time in Operating Rooms/Surgical Centers 2 for Consumers Who Need General Anesthesia a Seventeen of the state’s 21 RCs reported having a dental coordinator. RC = Regional Center. 18 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT number of RCs that report each role is a primary RCs Increasingly Rely on RDHAPs to responsibility of their dental coordinator(s). Provide Dental Services to DDS Hiring Dental Coordinators Is Up to the Consumers Discretion of RCs. RCs’ budgets include funding for both POS as well as for RCs’ own operating As RCs have had difficulty finding dentists costs, such as hiring service coordinators. DDS who are able or willing to serve individuals with determines an RC’s total budget for operating costs developmental disabilities, RCs have increasingly using a formula, based primarily on the number of looked to RDHAPs to provide their consumers with consumers served by that RC. DDS requires and dental services. This trend among RCs is largely funds RCs to have certain positions, while other explained by RDHAPs being more likely to accept positions are not necessarily required—for example, Denti-Cal (discussed further below), and being certain specifically identified administrative more familiar with the dental service needs of RC positions—but are funded by DDS. Funding consumers because of their work with homebound amounts for RC positions are based on salary levels patients or patients residing in institutional settings in the formula set by DDS. The salaries used in the such as SNFs. formula to calculate an RC’s budget for operating RDHAPs Are Twice as Likely as Dentists to costs, however, have not been updated for many Accept Denti-Cal. In 2015, Denti-Cal allowed years. If an RC identifies a priority that is neither RDHAPs to enroll in the Denti-Cal program as required nor funded by the formula, such as dental providers who could perform a range of services coordination, it consequently must choose to forgo without the direct supervision of a dentist. (While other positions or reduce other salaries in order to RDHAPs still need a dentist to diagnose the patient pay for dental coordination. It might be increasingly and prescribe treatment, RDHAPs can provide difficult for RCs to shuffle their budgets in this specified services and bill Denti-Cal on their own.) manner, however, as salary levels in the formula By 2017, about 40 percent of the state’s 507 become increasingly outdated. Currently, to recruit RDHAPs had enrolled in Denti-Cal, a participation and retain service coordinators, for example, nearly rate twice that of dentists. One primary reason all RCs already pay higher salaries than what the RDHAPs are more willing than dentists to accept formula provides. Denti-Cal is that they are better able to operate Many RCs Report Hiring RDHAPs as Dental within the program’s reimbursement rates—rates Coordinators. Our survey of RCs found that out of that are the same for dentists and RDHAPs for the 20 dental coordinators currently employed, half the same service. Whereas dentists cite these are RDHAPs. (Of the remainder, two are dentists, reimbursement rates as too low and thus one of three are RDAs, three are RDHs, one is a registered the primary reasons they do not participate in nurse, and one has a Bachelor of Science degree Denti-Cal, RDHAPs have been largely able and and many years working in a dental office.) RCs willing to work within the current rate structure. report hiring RDHAPs as dental coordinators for at As we discuss later, however, recent changes least two reasons—RDHAPs are familiar with the to administrative requirements for the services dental service needs of RC consumers because RDHAPs can provide, as well as reductions in the of serving patients with similar needs in residential reimbursement rates for some of those services, settings or institutional settings such as SNFs, might reduce their participation in the program and RDHAPs are often familiar with administrative going forward. processes in Denti-Cal. As dental coordinators, RDHAPs can help RC consumers eligible for Denti-Cal access their insurance and can recruit additional providers for Denti-Cal within an RC’s catchment area. www.lao.ca.gov 19 analysis full gutter AN LAO REPORT DDS Has Awarded Community needs of the many DDS consumers who never Placement Plan Funding to Develop lived in DCs. Dental Resources Allowing DC Staff to Serve Former About two decades ago, the Legislature and Residents Until Closure Governor approved a special annual appropriation DDS recently authorized the medical and dental for DDS for community placement plan (CPP) staff at closure DCs to provide services to former activities. DDS uses CPP funding to pay for DC residents (who now live in the community) the transitional costs associated with moving onsite at the DCs until they are closed. While this is consumers from DCs into the community. It allows only a temporary solution to the problem of access DDS to fund the development of new housing and to dental care (and medical care) among former nonresidential programs in the community to meet DC residents, it may provide needed services in the needs of former DC residents, who tend to the short term (particularly for those who require have more complex medical and behavioral needs general anesthesia). Thus far, however, it is unclear than the average DDS consumer already living in how well this option has been promoted and the community. relatively few former DC residents have utilized (or After conducting comprehensive individual plan to utilize) these services. In addition, DDS has assessments of DC residents, RCs submit chosen to limit this service only to those consumers proposals to DDS for the development of new or who formerly lived at a DC. expanded residential and nonresidential services and supports. Through the annual CPP, DDS Training and Education of Consumers, funds many of these proposals. The state budget Caregivers, and RC Service currently allocates about $50 million of base Coordinators funding annually for CPP. In recent years, CPP funding has been used for six dental projects in Most of the RCs that have a dental coordinator response to the needs of consumers moving out of reported in our survey that a key responsibility of Sonoma DC, including development or expansion their dental coordinators is educating consumers, of clinic-based services, dental provider training, caregivers, and RC service coordinators about mobile dental services, and development of the importance of good oral health in consumers’ specialty dental services. overall health. Consumers and their caregivers are also trained on consumer dental self-care Use of CPP Funds Will Be Expanded. techniques. One RC told us that it even tries to Chapter 18 of 2017 (AB 107, Committee on educate the caregivers about their own oral health Budget) authorized DDS to expand the use of because caregivers who take good care of their CPP funds to develop services and supports for own oral health tend to prioritize the oral health of individuals already living in the community (who consumers. A challenge noted by several RCs is never lived in a DC). The “community resource the turnover among residential care staff and how development plan” funds will present another often they have to train new staff on oral health opportunity to respond to some of the dental (and other issues) as a result. ANALYSIS OF CAUSES OF THE ACCESS PROBLEM In spite of efforts to improve access as just disabilities. In this section, we first delve into the discussed, the data show that access remains causes of the access problem, and then make a problem for individuals with developmental recommendations on how to improve access. 20 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Traditional Dental Care Delivery often have difficulty performing one or more of Approach Does Not Currently Meet these tasks. the Needs of Many Individuals With Many Consumers Need Desensitization. In many cases, consumers are not used to seeing Developmental Disabilities the dentist and need behavioral desensitization. A private dentist office or FQHC typically serves (See the nearby box for a description of behavioral patients who are familiar with dental services and desensitization.) Desensitization might mean the the environment in which they are provided, are individual needs to schedule several separate able to physically navigate the facility, and can appointments or request additional appointment speak to their dentist or hygienist about their oral time. How consumers receive these services, if at health. Individuals with developmental disabilities all, varies widely. What Is Behavioral Desensitization? While desensitization can refer to the medications or numbing agents taken or applied before a dental procedure, behavioral desensitization is a term used to describe methods for helping to put a patient at ease before a dental procedure. Certain dental procedures run the risk of harming either the patient or dentist if the patient is scared (for example, a patient could bite the dentist’s hand or a dental drill injuring the patient or dentist). Behavioral desensitization can play an important role in helping patients overcome these fears. As used in this report, behavioral desensitization, or just “desensitization,” could include practice visits to a dental office or meeting the dental provider before the actual appointment takes place. It could also include mimicking the types of procedures and techniques that will take place at an appointment, such as having the patient recline in a dental chair and opening his or her mouth and having someone position a dental mirror in the patient’s mouth. In a survey we conducted of Regional Centers (RCs) and in other interviews that we conducted with providers and RC staff, several noted that many consumers lack the dental care they need because too few providers are willing to conduct desensitization (at least in part because “behavior management” is not a billable procedure through Denti-Cal). Some RCs end up using their purchase of services funding to pay for such behavior management through a “specialized therapeutic services” code. Several RCs indicated that their dental coordinator manages and coordinates desensitization for consumers who need it. To provide some examples of what RCs attempt to do, South Central Los Angeles RC noted in an open-ended survey question that its dental coordinator intentionally conducts dental screenings in a comfortable and nonthreatening environment to put patients at ease. Another RC—San Gabriel/Pomona RC—developed a Dental Desensitization Clinic Program over the past two years. The program provides an initial consultation with a dentist (including a dental intake interview and behavior assessment) and practice dental sessions in a mock dental room at the RC. The mock dental room is set up to model a dentist’s office, with a dental chair and instruments. RC staff base the consumer’s number of mock sessions, and goals of the sessions, on the particular needs of that consumer. The mock sessions may include a board-certified behavior analyst or an autism coordinator. A dentist then conducts a dental exam and assessment and makes treatment referrals to providers, as needed. The referrals are intended to help the consumer find a dental home. Thus far, five consumers have “graduated” from the program (another 15 are currently participating). These five consumers no longer need to undergo dental treatment under general anesthesia as they did in the past. www.lao.ca.gov 21 analysis full gutter AN LAO REPORT Appointments Often Take Longer. As diagnosis, and/or require supports for behavioral discussed previously, the oral health of RC challenges. These are likely the consumers who consumers is, on average, worse than the general require additional time or special supports to population. Worse oral health means dentists undergo a dental appointment and benefit from and hygienists perform more intensive services the services provided by dental coordinators. Yet, on consumers, which require more appointment these benefits are not readily available to some time. Providers might also need to help consumers consumers in the DDS system because their RC work through challenges associated with their has not hired a dental coordinator. In addition, the developmental disability. Dentists and hygienists RCs without a dental coordinator are in some of the traditionally are paid based on the number of catchment areas with the worst access to Denti-Cal procedures they perform, so any additional time providers. they need to perform a procedure reduces the time There Are Too Few Dental Coordinators for they have to treat other patients. This disincentive the Number of Consumers. The four RCs without likely reduces the number of dental services a dental coordinator serve nearly 50,000 active provided to DDS consumers. consumers. All four reported they would like to While Some Consumers Are Homebound, hire one, but cite funding constraints as preventing Dentists Making House Calls Are Rare. them from doing so. Access to dental care has Consumers with serious physical limitations require become a top priority at one of these four RCs. a significant amount of coordination to get to Even for the 17 RCs that report having and from a facility, and to navigate it once there. either one or two dental coordinators (at eight Therefore, caregivers and RCs often contract with RCs, the dental coordinator works part-time), the limited number of mobile providers in their the number of potential consumers served by community. While the vast majority of consumers each coordinator varies widely across RCs. For rely on Denti-Cal for insurance coverage, example, across RCs, a single dental coordinator, current Denti-Cal rates make it less likely that who may only be working part-time, serves an participating dentists would adopt a house-call average of nearly 14,000 consumers, ranging model of business. Making house calls would from as few as 1,700 consumers to as many as not only reduce the number of patients a dentist 30,000 consumers. The amount of time a dental could see but also would require more travel, coordinator could potentially spend on each upfront investment in mobile equipment, setup consumer’s case (this could include participating of instruments and equipment at each site, and in the consumer’s IPP meeting, reviewing his or accommodation of each particular patient’s living her treatment plan, conducting a dental screening, space. While seven RCs reported in our survey or finding a provider) similarly varies widely across that they work with at least one dentist who makes RCs, as shown in Figure 9. For example, across house calls, such dentists are rare. RCs, a single dental coordinator could spend, on average, seven minutes on each consumer’s case Current Dental Coordination per year, generally ranging from three minutes to Resources Are Inadequate 16 minutes. RCs report many benefits from having a dental While not all consumers need the services of the coordinator, including increasing access to dental dental coordinator (for instance, a consumer with care (often by expanding or sustaining the number only a mild intellectual disability may be capable of dental providers); conducting dental screenings; of sitting through a regular dental appointment making patient referrals; and educating RC staff, coordinated by his or her family), the dental families, service providers, and consumers on the coordinator-to-consumer ratio and the average importance of good oral hygiene and how to help amount of time per consumer are helpful gauges consumers get the care they need. In addition, in understanding the extent, adequacy of, and as noted earlier, many consumers have a severe/ variation in dental coordination resources available profound intellectual disability, have a mental health across RCs. Taking into account the share of 22 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT consumers that does not receive regular dental relatively worse access to dental providers, as care, the benefits RCs report as a result of having a discussed below. dental coordinator, and the minimal amount of time RCs Without Dental Coordinators in Areas that a dental coordinator could potentially spend With Relatively Worse Access. The catchment on each consumer’s case, we find that the number areas of the RCs that do not have a dental of dental coordinators is currently inadequate. This coordinator also happen to be among those with finding is bolstered by the fact that the RCs without the worst access to dentists that accept Denti-Cal. any dental coordinators also serve the areas with Three of those four RCs are also among those with Figure 9 Number of Annual Minutes Dental Coordinators Potentially Have Available Per Consumer, by RC Golden Gate RC 15.8 Most time Frank D. Lanterman RC potentially available: 15.8 minutes per Eastern Los Angeles RC consumer per year San Gabriel/Pomona RC Tri-Counties RC Westside RC San Andreas RC RC of Orange County Central Valley RC RC of the East Bay South Central Los Angeles RC North Los Angeles County RC Harbor RC Inland RC San Diego RC 5 10 15 20 Notes: Alta RC, Valley Mountain RC, Kern RC, and Far Northern RC do not have dental coordinators. The minutes available per consumer per year at Redwood Coast RC (90 minutes) make it an outlier and are not displayed here. The time potentially available per consumer per year cannot be calculated for North Bay RC. RC = Regional Center. www.lao.ca.gov 23 analysis full gutter AN LAO REPORT the worst access to RDHAPs that Figure 10 accept Denti-Cal. Figure 10 ranks RC Rankings on Access to Dental Providers RC catchment areas from best to worst in terms of consumer access RCs Without a Dental Coordinator Rank Near the Bottom in Access to (1) dentists accepting Denti-Cal Rankingsa on Access to . . . and (2) RC dental coordinators. Denti-Cal RC Dental In our survey, all of the RCs Dentistsb Coordinator with dental coordinators reported RC of Orange County 1 14 that expanding and maintaining Westside RC 2 2 the network of dental providers is Frank D. Lanterman RC 3 6 one of the top responsibilities of San Gabriel/Pomona RC 4 9 the dental coordinator position. North Los Angeles County RC 5 8 Harbor RC 6 11 Consumers served by the RCs Eastern Los Angeles RC 7 7 without dental coordinators are not Golden Gate RC 8 4 only in the areas with the worst San Andreas RC 9 13 access to providers, but are at RC of the East Bay 10 15 a distinct disadvantage because San Diego RC 11 16 there is not a dental coordinator Tri-Counties RC 12 10 working to improve access. Inland RC 13 17 North Bay RC 14 3 In Practice, Dental Alta California RCc 15 — Coordinators—Who Have a Limited Amount of Time Per Valley Mountain RCc 16 — Consumer—Have to Prioritize Central Valley RC 17 5 Administrative Tasks. Dental Kern RCc 18 — coordinators provide a wide range South Central Los Angeles RC 19 12 of important services at the RCs. Far Northern RCc 20 — However, some of these services Redwood Coast RC 21 1d are potentially more valuable a 1 = best ranking and 21 = worst ranking. b than others when it comes to Dentists accepting Denti-Cal. c Shaded rows indicate RCs without a dental coordinator. improving consumer outcomes. d Redwood Coast RC necessarily has the best dental coordinator-to-consumer-ratio because consumer population is More than half of RCs reported the smallest in the system at 3,500. It currently has two dental coordinators. RC = Regional Center. that helping dental providers navigate Denti-Cal-related issues Structure of Denti-Cal Benefits and is a responsibility of their dental Rates Limits Consumers’ Access to coordinator and five of these indicated it was a top-three priority. This function undoubtedly Dental Services increases the likelihood that a provider will work, RC consumers who are eligible for Denti-Cal or continue to work, with a consumer whose (the vast majority of RC consumers) have lower insurance is through Denti-Cal. (For example, utilization of dental services in the program than we know that some dentists will accept RC POS Denti-Cal beneficiaries overall. In addition, the payments, which are based on Denti-Cal rates, yet structure of Denti-Cal benefits and rates also limits will not accept Denti-Cal directly, implying that the the access of RC consumers to dental services, as rate alone is not the problem.) Yet, this primarily discussed below. administrative task may not take full advantage Denti-Cal Generally Does Not Pay for of a dental coordinator’s skills and education Additional Appointments or Time for Patients in a way that could benefit consumers’ health to Receive Dental Services. Denti-Cal typically outcomes, such as developing and coordinating a reimburses providers based on the number and desensitization program. 24 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT types of dental procedures performed, with who cannot move without assistance—require administrative requirements on certain services a significant amount of coordination to travel to prevent improper billing or overutilization. to a private dental office or FQHC. In addition, Additional appointments or appointment time— providers often have difficulty obtaining absent a dental procedure—have traditionally radiographs or photographs from individuals not been billable. (In 2018-19, some tobacco tax with developmental disabilities because of the revenues under Proposition 56 will be used to fund behavioral, cognitive, and physical challenges supplemental payments to Denti-Cal providers associated with their developmental disability. for the additional time they might need to treat The number of appointments for a provider to individuals with developmental disabilities. How perform these procedures and the difficulty these payments—which are one time for now— obtaining radiographs or photographs from will be implemented, however, is uncertain at the patient both serve as barriers to these this time.) Desensitization, which often requires individuals accessing treatment for their gum scheduling additional appointments or appointment disease. time, is also not billable in Denti-Cal. The inability • Two-Year Limit on Periodontal of Denti-Cal providers to bill for these services Maintenance. The second limitation is contributes to the low dental service utilization providers can only perform periodontal rates of consumers. It also reduces the incentives maintenance for two years, after which for certain providers, such as mobile dentists patients are required to undergo another and dental clinics, to start practices that require scaling and root planing prior to being eligible additional appointment time. for more periodontal maintenance. Some Limitations on Periodontal Procedures Prevent individuals with developmental disabilities Adequate Treatment of Periodontal Disease. have chronic gum disease that requires After scaling and root planing, providers typically periodontal maintenance for longer than perform periodontal maintenance on patients once two years after a scaling and root planing. every three months until patients’ gums improve. Scaling and root planing also require In Denti-Cal, providers generally can perform prior authorization, whereas periodontal scaling and root planing once every two years, maintenance does not. If consumers’ gum and periodontal maintenance once every three disease does not sufficiently improve over months after a scaling and root planing. (Prior to two years, and if they are not authorized for this year, periodontal maintenance was limited only another scaling and root planing, their oral to those Denti-Cal beneficiaries living in ICF/DDs health will deteriorate and more intensive and SNFs.) There are, however, two limitations restorative services will likely be necessary. set by Denti-Cal on scaling and root planing and periodontal maintenance that disproportionately limit Many Consumers Have Difficulty consumers’ access to these services: Obtaining General Anesthesia and • Prior Authorization Requirement on Scaling Intravenous (IV) Sedation Services in and Root Planing. The first limitation is Denti-Cal providers must submit TARs with radiographs Some DDS and RC staff estimate that between (or, permitted recently, photographs) prior to one-fifth and one-third of RC consumers require performing this procedure. These requests general anesthesia or IV sedation to undergo often require providers to schedule two dental treatment. Although IV sedation and appointments: one appointment to obtain general anesthesia are covered benefits in the radiographs and/or photographs (and other Medi-Cal system, a limited number of Denti-Cal information) in support of the request, providers offer these services in their offices and, and another appointment to perform of those who do, many are unable or unwilling the procedure. Many individuals with to serve consumers. Alternatively, consumers developmental disabilities—particularly those www.lao.ca.gov 25 analysis full gutter AN LAO REPORT can schedule appointments in hospital operating compounds oral health problems and necessitates rooms or outpatient dental surgery centers that later more expensive and time-intensive restorative offer general anesthesia or IV sedation and accept services such as teeth extraction and dentures. In Denti-Cal patients. There are a limited number of addition to a lack of facilities and providers who these facilities statewide and, especially in hospital offer these services, the treatment authorization operating rooms, other surgical procedures are process through Denti-Cal FFS and Medi-Cal prioritized over dental services. Consumer difficulty managed care is also redundant and burdensome obtaining these services not only contributes to for both the providers and the consumer and his or their low utilization rates in Denti-Cal, but also her caregiver. RECOMMENDATIONS TO IMPROVE CONSUMERS’ ACCESS TO DENTAL SERVICES Based on our findings and assessment, (CRDP) funds, to at least partially support the we provide several recommendations for the plan. (We discuss more fully the potential to target Legislature to consider. Figure 11 provides a CPP/CRDP funding to improve consumer access to summary of these recommendations. dental services in a later recommendation.) Cost to Transition to One Full-Time Dental ISSUE: DENTAL COORDINATION Coordinator at Each RC. We estimate the PROVEN EFFECTIVE, BUT annual cost to fund a dedicated position at each RC at about $2 million. This would cover CURRENTLY INSUFFICIENT IN ITS the current cost of dental coordination and the USE STATEWIDE cost for RCs to collectively hire ten additional positions—one at each of the four RCs that do Require Administration to Submit not currently have a dental coordinator and the Plan to Increase the Number of Dental equivalent of six positions to bring current part-time dental coordinator positions up to full-time. We Coordinators Statewide recommend the Legislature direct the administration Dental coordinators play an important role in to include its estimated costs in its plan. maintaining and improving the oral health of DDS Targeting Additional Dental Coordination consumers. RCs recognize this benefit and 17 Resources to RCs With Special Circumstances. have made it a priority to fund these positions The administration’s plan should consider whether within their operating budgets. We recommend additional dental coordination resources—beyond the Legislature direct the administration to submit one full-time position—are needed at some of a plan, in conjunction with the 2019-20 budget the RCs that have particularly large caseloads, process, to bring each of the 21 RCs up to the lack good access to dental providers, or have equivalent of having at least one full-time dental another specific need (such as a large number of coordinator and potentially target additional consumers with complex medical or behavioral resources to particularly high needs areas. The challenges). The plan should consider allocating plan should consider the possibility of requiring and resources that would allow RCs to hire largely funding a dedicated position at each RC within the administrative positions that could assist dental RC contracts and establishing uniform expectations providers with Denti-Cal-related administrative and/or performance outcomes for this position. issues. This would free up dental coordinators—all The plan also should consider the potential to of whom are professionals in the dental field— use existing resources, such as targeted use of to focus on more substantive ways to improve CPP/Community Resource Development Plan consumers’ oral health. 26 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT ISSUE: DENTI-CAL BENEFIT disabilities, which could increase their utilization of dental services. Desensitization might also AND RATE STRUCTURE LIMIT reduce the number of consumers who need IV CONSUMERS’ ACCESS sedation or general anesthesia, potentially reducing state costs for these procedures. Other states, Authorize Behavior Management for including New Mexico and New York, currently DDS Consumers Eligible for Denti-Cal offer behavior management as a benefit to certain individuals with behavioral needs in their state We recommend the Legislature authorize Medicaid dental programs. Both offer supplemental behavior management as a benefit for DDS payments in acknowledgment of the additional consumers who are eligible for Denti-Cal. This new knowledge and time necessary to treat patients benefit would incentivize some providers to attempt with behavioral needs. In New Mexico, specific desensitization of their patients with developmental continuing education and clinical hour requirements Figure 11 Summary of Recommendations Issue Recommendation(s) Dental Coordination Effective, but Currently Insufficient in its Use Statewide Dental coordinators play an important role in increasing • Require administration to submit plan to increase access to dental care among DDS consumers, but four number of dental coordinators statewide, considering RCs do not have one and many other RCs have only potential to use existing resources to at least partially part-time dental coordinators. support the plan. Denti-Cal Benefit and Rate Structure Limit Consumers’ Access Structure of Denti-Cal benefits and rates limits consumers’ • Authorize behavior management for DDS consumers access to dental services, especially given consumers’ eligible for Denti-Cal. unique needs. DDS consumers who are eligible for • Improve access to periodontal treatment for DDS Denti-Cal use fewer dental services than Denti-Cal consumers eligible for Denti-Cal: beneficiaries overall. – Modify or eliminate current TAR requirement for scaling and root planing benefit for DDS consumers. – Modify or eliminate limit on periodontal maintenance benefit for DDS consumers. – Restore the prior Denti-Cal rate for periodontal maintenance. Too Few Dental Providers Willing and Able to Serve Consumers Finding dental service providers to treat DDS consumers • Consider authorizing a pilot program to educate and pay is difficult. Many dental providers are unable or unwilling a financial incentive to dental service providers to serve to serve consumers. Traditional delivery service DDS consumers. approaches for dental services do not currently meet the • Expand RDHAPs’ scope of practice. needs of many consumers. • Consider requiring administration to submit plan targeting the use of CPP/CRDP funds to develop additional dental resources. Potential components of the plan might include: – Increasing dental coordination at RCs. – Increasing service provision at FQHCs. – Increasing the number of VDHs. • Consider providing incentives for dentists to practice house-call dentistry. DDS = Department of Developmental Services; RC = Regional Center; TAR = Treatment Authorization Request; RDHAP = Registered Dental Hygienist in Alternative Practice; CPP = Community Placement Plan; CRDP = Community Resource Development Plan; FQHC = Federally Qualified Health Center; and VDH = Virtual Dental Home. www.lao.ca.gov 27 analysis full gutter AN LAO REPORT must be met to receive the supplemental payment. to modify the TAR requirement for scaling Though we have not included similar requirements and root planing so that a TAR no longer in our recommendation, we do include them in requires radiographs or photographs for DDS a proposed pilot program we describe below. consumers, or to exempt consumers from We estimate that the total cost of this benefit for the TAR requirement altogether. Based on an DDS consumers—absent any potential savings in anticipated increase in utilization among DDS the long run—would be between $10 million and consumers up to the utilization rate among $30 million annually (depending on the amount Denti-Cal beneficiaries generally, we estimate of the procedure rate), at least one-half of which the total annual cost of this change at would be covered by the federal government. approximately $4 million (at least half of which (At the time this report went to print, DHCS would be covered by the federal government). authorized behavior management as a benefit for • Modify or Eliminate Limit on Periodontal special needs patients—including individuals with Maintenance Benefit for DDS Consumers. a developmental condition—funded only through Denti-Cal providers can only perform June 30, 2019 using tobacco tax revenues under periodontal maintenance for two years, Proposition 56. Though a good first step, we after which patients are required to undergo continue to recommend the Legislature authorize another scaling and root planing prior to being behavior management as an ongoing benefit for eligible for additional periodontal maintenance. DDS consumers eligible for Denti-Cal.) Some individuals with developmental disabilities have chronic gum disease that Improve Access to Periodontal essentially requires ongoing periodontal Treatment for DDS Consumers maintenance. To address this issue, one Eligible for Denti-Cal option for the Legislature would be to direct DHCS to modify the limit on periodontal There are a number of administrative barriers in maintenance—for example, to require a dental the Denti-Cal program that make it more difficult for exam after two years as opposed to another providers to treat DDS consumers’ gum disease. scaling and root planing—or to exempt We recommend the Legislature address this issue. consumers from the limit altogether. Based on Below, we provide a number of options that would an anticipated increase in utilization among change current Denti-Cal benefits and rates to DDS consumers up to the utilization among help consumers access periodontal treatment. If Denti-Cal beneficiaries generally, we estimate adopted, these changes would result in a lower the total annual cost of this change at incidence of gum disease among consumers, which approximately $5 million (at least half of which would lessen their need for more costly restorative would be covered by the federal government). dental procedures and improve their oral health. • Restore the Prior Denti-Cal Rate for • Modify or Eliminate Current TAR Periodontal Maintenance. In 2016, DHCS Requirement for Scaling and Root Planing cut the Denti-Cal rate for periodontal Benefit for DDS Consumers. To provide maintenance from $130 to $55 for all patients with scaling and root planing, providers. Periodontal maintenance is a key Denti-Cal providers must submit TARs with procedure for many DDS consumers, and one clear radiographs or photographs to the that RDHAPs often perform. Restoring the program for approval. For DDS consumers, Denti-Cal rate for periodontal maintenance providers are often unable to submit adequate could also help stem the potential loss of radiographs or photographs because of RDHAP providers in the Denti-Cal system physical or behavioral challenges associated (as a result of the rate cut) and provide with consumers’ developmental disabilities. an incentive for more RDHs to consider To address this issue, one option for the becoming RDHAPs. To address this issue, one Legislature would be to direct DHCS either option for the Legislature would be to direct 28 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT DHCS to restore the Denti-Cal rate back to increased the number of Denti-Cal providers that $130. We estimate the total annual cost of are willing and able to serve consumers statewide. restoring the rate at about $20 million (at least Expand RDHAPs’ Scope of Practice half of which would be covered by the federal government). The estimate assumes utilization Currently, most RCs report that they have among DDS consumers increases up to the consumers who receive dental services from utilization among Denti-Cal beneficiaries RDHAPs. Given the valuable role that RDHAPs generally. can play in increasing access to dental care for consumers (particularly among those who are homebound or have anxiety about going to the ISSUE: TOO FEW DENTAL dentist), we recommend the Legislature direct PROVIDERS WILLING AND ABLE DHCS to (1) work with relevant stakeholders TO SERVE CONSUMERS to discuss ways to expand RDHAPs’ scope of practice and (2) come back to the Legislature with Consider Authorizing a Pilot Program a statutory proposal for legislative consideration. Below are some examples of ways to expand the to Educate and Pay a Financial scope of RDHAPs’ practice that could increase Incentive to Dental Service Providers consumers’ access to care: to Serve DDS Consumers • Authorize additional allowable billable We recommend the Legislature consider procedures by RDHAPs, such as behavior authorizing a pilot program to educate and management and administration of the lowest train Denti-Cal providers on how to serve DDS level of sedation. consumers. In return, these providers would then • Extend the amount of time an RDHAP may be eligible for a supplemental payment once they treat a patient without the oversight of a begin providing dental services to DDS consumers. dentist. The stakeholder group could discuss To qualify for this supplemental payment, providers ways in which this could improve health would need to complete a number of continuing outcomes without increasing safety risks. education hours and perform a number of clinic • Allow an RDHAP to act as the patient’s hours working with consumers. This pilot program primary point of contact for dental care. The would be similar to a longstanding program in stakeholder group could assess the instances New Mexico that allows dentists in the state’s in which the RDHAP should refer a patient to Medicaid dental program to access supplemental a dentist. payments for services provided to individuals with developmental disabilities. The Legislature could Consider Requiring Administration to direct the DBC and the Dental Hygiene Committee of California to determine the specific number Submit Plan Targeting Use of of continuing education hours and clinical hours CPP/CRDP Funds to Develop required to qualify for the payment, and direct Additional Dental Resources DHCS to set the amount of the payment. This pilot program would complement a supplemental Currently, DDS receives funding through payment approved in the 2018-19 budget package the annual state budget process to develop for Denti-Cal providers who already treat individuals community-based resources for consumers with “special health care needs” (which could transitioning from DCs (through CPP funding) include individuals with developmental disabilities) and will soon begin utilizing some of this funding but often need additional time to provide dental for development of community-based resources services. By providing both training and financial for consumers who were already living in the incentives to serve DDS consumers, the pilot community through the CRDP. Traditionally, this program could be evaluated to determine if it funding has been allocated for one-time uses. www.lao.ca.gov 29 analysis full gutter AN LAO REPORT Beyond setting some very general overall goals up a dental desensitization clinic and mock and limitations—primarily related to DC closures— dental room modeled after the program at statute has generally remained silent on how DDS San Gabriel/Pomona RC. (As that program should allocate these resources. DDS typically is in its nascent stages and will undergo an sets overarching guidelines, but waits for RCs evaluation, it may be prudent to wait for the to submit proposals and requests for funding to final results of the evaluation before requiring develop or expand projects, such as new models anything specific across RCs.) of homes or new day programs. While there are • Increasing Service Provision at FQHCs. benefits to the current allocation process, namely There are currently 176 FQHCs and 24 FQHC that the allocation is focused on locally driven “look-alikes” in California (with about 1,500 preferences of RCs that have good knowledge of delivery sites). (FQHC look-alikes follow local needs, it lacks assurances that funding is federal guidelines, but do not receive federal necessarily allocated to statewide priorities (beyond FQHC grant funding.) At least 169 of these development of community-based housing for health center organizations provided at least former DC residents). some dental services in 2016. For 15 FQHCs Our office has noted in previous analyses that (or look-alikes), dental services made up at the DDS system currently lacks a robust method least 50 percent of the services they provided for measuring and understanding consumers’ in 2016. In our survey, about half of RCs needs on a statewide basis. We raised this issue reported that their consumers use the dental in particular as the Legislature was considering services at FQHCs or other community clinics. whether to allow DDS to expand the use of CPP CPP/CRDP funding could be targeted toward funds to overall community resource development enhancement of dental services—including given the significant amount of funding provided to office modifications and provider training—for DDS for this purpose each year (about $50 million individuals with special needs at existing or General Fund). Given our identification and new FQHCs. By funding these enhancements, quantification of the dental access problem among the administration could guarantee—via the DDS consumers, as well as of potential solutions contract with the FQHC—provision of dental to improve access, the Legislature might consider services for DDS consumers. requiring DDS to target a portion of CPP/CRDP • Increasing the Number of VDHs. VDHs are spending in ongoing ways (as opposed to the a particularly good model for individuals who traditional focus on one-time uses) that help are homebound, hard to serve, or otherwise address the dental access problem. Should the afraid of going to a traditional dental office. Legislature choose this path, we recommend it This makes VDHs a good model for DDS direct the administration to submit a plan, as part consumers, and several RCs reported that of the 2019-20 budget process, proposing ways their consumers use dental services via VDHs. to effectively target CPP/CRDP funds to achieve This model could potentially reduce the need a legislative objective of improving dental access for general anesthesia among DDS consumers among DDS consumers. Potential components of as well if they become comfortable receiving the plan might include: services in their home from their RDH. CPP/ CRDP funding could be targeted to increase • Increasing Dental Coordination at RCs. As the number of VDH services for individuals discussed previously, CPP/CRDP funds could with developmental disabilities. Although be used to fund dental coordinator positions developing VDH infrastructure would require at RCs. To maximize the impact of dental targeted investment of CPP/CRDP funding, coordination on consumers with behavioral VDHs should be mostly sustainable once challenges or anxiety, CPP/CRDP funds established because they can bill insurance might be targeted to require RCs to each set for services rendered. 30 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT Consider Providing Incentives for gas, mobile equipment, and lost billing potential Dentists to Practice House-Call (since the provider could not see as many patients). Dentistry The total cost would depend on how many providers are willing to conduct house calls or Currently, there are very few incentives for a develop a mobile practice as well as on how dentist to make house calls to homebound DDS many homebound patients they are able to see. patients. Nevertheless, the willingness of a provider The General Fund cost would likely be in the low to make a house call could mean the difference millions of dollars, at most. Determining the most between dental care and no dental care for a effective, yet reasonable, incentive amount may homebound patient. Furthermore, our RC survey require outreach to providers. As an example, if the indicates that in at least seven RCs, a dentist(s) incentive were set at $150 (which is currently what makes home visits. For the provider who is willing one RC pays a dentist to serve its consumers in or interested in working with the homebound their residences) and RCs were able to coordinate DDS population as part of his or her practice, the about 25,000 visits annually (that is roughly one Legislature could consider appropriating funds visit per year for close to half of the 55,000 DDS through the DDS RC POS budget to provide the consumers who cannot walk, for example), the total dentist an incentive payment. The provider would General Fund cost would reach close to $4 million. still receive relevant insurance reimbursement There could potentially be offsetting savings in the (either through Denti-Cal or private insurance). The state’s Medi-Cal program if house calls reduced the incentive would help offset other costs—travel time, need for general anesthesia or the need for more intensive treatments. CONCLUSION Individuals with developmental disabilities have recommendations to increase the number of dental distinctive dental service needs primarily because of providers willing to serve this population—both in the behavioral, cognitive, and physical challenges traditional dental settings and through alternative associated with their disabilities that often result care approaches—and to improve the effectiveness in poor oral health. We find that dental services of the services they receive. Though the state are unavailable or insufficient for many of these would incur short-term costs based on our individuals in their communities. The Lanterman recommendations, we anticipate that these costs Act requires the state to provide individuals with will decrease over time as fewer costly restorative developmental disabilities with services and procedures are performed and the oral health of supports that help them live healthy, independent many individuals with developmental disabilities lives. This report is intended to help the state better improves. achieve that goal in terms of health by offering www.lao.ca.gov 31 analysis full gutter AN LAO REPORT 32 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT APPENDIX: LIST OF ACRONYMS USED IN THIS REPORT ACA—Patient Protection and Affordable Care state’s Medicaid program, and the state’s Medi-Cal Act. Federal health care reform law enacted in dental program, Denti-Cal. 2010. DMC—Dental Managed Care. One of two CCF—Community Care Facility. Facility dental delivery systems offered by DHCS to licensed by the Department of Social Services enrollees in Denti-Cal. Under DMC, Denti-Cal pays that provides 24-hour nonmedical residential a managed care plan a set monthly rate for each care to children or adults, including those with enrollee to cover care provided by a network of developmental disabilities. dental providers. DMC operates in two counties— CDER—Client Development Evaluation Los Angeles and Sacramento. Report. Diagnostic and evaluation survey tool DPH—Department of Public Health. The used to collect information about individuals with department responsible for a range of public developmental disabilities served by DDS (called health-related activities, including licensure of “consumers” in statute). Every consumer’s CDER is certain facilities that house some DDS consumers. updated at least once every three years. FFS—Fee-for-Service. One of two dental CPP—Community Placement Plan. DDS’ delivery systems offered by DHCS to Denti-Cal annual plan—based on information and requests enrollees. Under FFS, the state pays dental provided by RCs—for developing and funding providers for each dental treatment provided. Most community-based resources for consumers moving Denti-Cal coverage is provided through FFS. out of DCs. FQHC—Federally Qualified Health Center. CRDP—Community Resource Development Community-based clinic that receives federal Plan. DDS’ annual plan that expands the use of funding to provide health care, sometimes including CPP funding to the development of resources for dental care, in a designated underserved area. The consumers already living in the community. state generally pays each FQHC a specific amount DBC—Dental Board of California. The state for each Medi-Cal patient visit, regardless of the government board responsible for licensing services provided. dental providers and enforcing dental laws and ICF/DD—Intermediate Care Facility for the regulations. Developmentally Disabled. Health facility licensed DC—Developmental Center. DDS-operated by DPH that provides 24-hour care to individuals institution for individuals with developmental with developmental disabilities. disabilities that is licensed as a general acute care ILS—Independent Living Services. hospital. Except for the secure treatment program Services provided to DDS consumers who live at Porterville DC, DDS is in the process of closing independently, in their own home, or with family the three remaining DCs. members. ILS provides consumers with training in DDS—Department of Developmental the functional skills needed to live on their own. Services. The department that provides services IPP—Individual Program Plan. Plan that and supports for individuals with developmental identifies the services and supports a consumer disabilities. needs to live in the least restrictive environment DHCS—Department of Health Care Services. possible. The IPP is developed through a process The department that provides qualifying low-income that includes the consumer, his or her family, RC Californians with access to health care, including staff, and other relevant participants, such as medical, dental, mental health, substance abuse, service providers. and long-term care. It administers Medi-Cal, the www.lao.ca.gov 33 analysis full gutter AN LAO REPORT ITR—Interim Therapeutic Restoration. Process RDHAP—Registered Dental Hygienist in of temporarily sealing a cavity to prevent further Alternative Practice. An RDH who has additional tooth decay. education and experience and may provide IV—Intravenous (as in IV Sedation). IV some preventive services independently in sedation involves administering sedatives directly community-based settings. into a patient’s bloodstream via an injection in the SLS—Supported Living Services. Services vein. The sedatives block pain and typically cause provided to DDS consumers who live independently the patient to fall asleep. in their own home, but need varying levels of NCI—National Core Indicators. Survey assistance with daily functions. conducted in numerous states, including California, SNF—Skilled Nursing Facility. Health facility to assess the outcomes of services provided to licensed by DPH that provides 24-hour inpatient consumers. It is conducted among a representative care to residents. sample of consumers. TAR—Treatment Authorization Request. POS—Purchase of Service. When RCs pay for Request for approval submitted by Denti-Cal consumers’ services and supports. providers to DHCS for certain procedures before RC—Regional Center. Independent nonprofit reimbursement is authorized. agency that receives state funding to coordinate VDH—Virtual Dental Home. Dental system in services and supports for DDS consumers. There which services are delivered in community-based are 21 RCs in California. settings, rather than in traditional dental offices, RDA—Registered Dental Assistant. Licensed to serve patients where they live or go to school. dental professional who works alongside a dentist RDHs typically provide the services (which are providing care to patients and assisting with preventive or simple therapeutic treatments) and preparation of dental tools and materials. consult with supervising dentists remotely. RDH—Registered Dental Hygienist. Dental professional who has graduated from an accredited program and met other requirements and is licensed to provide preventive care to patients, such as teeth cleaning, under the direct or general supervision of a dentist. 34 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT www.lao.ca.gov 35 analysis full gutter AN LAO REPORT 36 LEGISLATIVE ANALYST’S OFFICE analysis full gutter AN LAO REPORT www.lao.ca.gov 37 analysis full gutter AN LAO REPORT LAO PUBLICATIONS This report was prepared by Sonja Petek and Brian Metzker, and reviewed by Mark C. Newton. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 38 LEGISLATIVE ANALYST’S OFFICE