Calif. Legislature grills DHCS director over audit report results

Representatives from the California Department of Health Care Services (DHCS) responded to grueling questions from the state Legislature last week about how the department plans to fix California's Medicaid dental program, Denti-Cal.

At a hearing on Tuesday, the Joint Legislative Audit Committee, the Senate and Assembly health committees, and stakeholders discussed how DHCS plans to implement the recommendations of a December 2014 state audit. The audit found that half of the 5.1 million children enrolled in Denti-Cal did not receive dental care in 2013 and that five California counties may not have access to any Denti-Cal providers.

Jennifer Kent, director of DHCS. Image courtesy of DHCS.

Despite being the DHCS director for only six weeks, Jennifer Kent faced the Legislature. She stressed that the department has heard their concerns and wants to increase transparency about the workings of the almost $1 billion program.

The department is embarking on a new 1115 Medicaid waiver to specifically target funding for new providers who agree to dedicate part of their practice to Medi-Cal patients and to existing providers who expand the number of Medi-Cal patients they see, Kent said. It is also looking into alternative care methods, such as a mobile dental van.

Kent was pressed about the department's stated timeline for implementing the audit's recommendations. Since the report was released last December, the department has only implemented one recommendation, according to Dale Carlson, the team leader at the California State Auditor's office for the audit under review.

Of the recommended changes, DHCS agreed with all except for one that asked the department to include a provider-to-beneficiary ratio as a performance measure to evaluate access and availability of dental services. Of the remaining 22 recommendations that DHCS agreed to, 15 will be implemented after July 2015, two by July 2016, and five currently do not have any implementation rates that are listed as pending or ongoing, according to Carlson's testimony.

Elaine Howle, California state auditor, disagreed with DHCS' proposed timeline, instead believing that at least two of the recommendations can be implemented sooner than July.

When specifically questioned if the recommendation to resume a regular reimbursement rates review could be expedited, Kent's response was that the department is already working as fast as it can, emphasizing that it is currently in the middle of a budget cycle.

"I think that the rate study is [expedited] to the extent that it could be expedited. I don't know if it could," she said. "I think it would be best-suited to float into next year's budget process."

In addition to questioning Kent about the department's timeline for re-establishing the rates survey, the committee also scrutinized DHCS' decision to not implement the recommended provider-to-beneficiary ratio as a performance measure. Kent defended the department's response, saying that DHCS agrees with the recommendation, but it does not know how to implement a proper ratio for fee-for-service Denti-Cal providers.

"There's a proxy ratio that we use in managed care. ... In fee-for-service, we're not quite sure what that ratio can or should be," she said.

However in DHCS' submitted response, the department said it did not agree with the recommendation to implement the ratio as a performance measure, because it is not part of the required reporting process. When questioned why her answer before the Legislature differed from her answer on paper, Kent said that the submitted response was the simplified version of her verbal answer.

The need for an accurate provider directory and provider-to-beneficiary ratio also were echoed throughout the rest of the hearing.

Stakeholder John Blake, DDS, executive director of the Children's Dental Health Clinic in Long Beach, CA, said that the department should focus on getting accurate data about providers who take Denti-Cal patients when asked what the DHCS should immediately target.

"First would probably be making sure they have an adequate assessment of the providers and how many [patients] they can treat," he said. "Right behind that would be [reimbursement] rates."

Similarly, Assembly Member Jim Wood, DDS (D-Healdsburg), said that having the data about providers is crucial to providing adequate care.

"Who knows what our provider network really is right now," he said. "We need better metrics. I think you'll find that the network is much smaller than what the books say."

Dr. Wood also said that, although he had not been practicing, he was still listed as a provider. Kent, who looked up Dr. Wood's file, said that he signed a paper years ago that he was not accepting new members but would like to be kept on file.

"It's sometimes hard to keep those up-to-date," she said. "It's an imperfect system at best."

Kent also said that she is open to talking with Delta Dental, the private company the state contracts with to provide services and who manages the provider directory, to see if it can follow up with providers on a more regular basis.

Although the legislators understood that Kent is new to the job, the message that immediate change is needed and that the previous actions of the department were not to be tolerated was not lost on Kent.

She understood and stressed that it would not happen again under her leadership. Her department is already working on implementing 11 mandated monitoring standards and implementing a dashboard similar to Medi-Cal.

"I know the reports weren't done, and that's not an excuse, and I'm not making excuses," Kent said. "So when I say we're going to put them on track ... we're going to do them because the law says that."