Public Hearing on Denti-Cal

March 19, 2018

Mr. Pedro Nava
Little Hoover Commission
925 L Street, Suite 805
Sacramento, CA 95814

Re: Public Hearing on Denti-Cal, March 22, 2018

Dear Chairman Nava,

Thank you for continuing to follow-up on the eye-opening Denti-Cal report issued in April 2016. It was an important start to ensuring equitable dental care access for low-income Californians. Given the agenda of the public hearing on March 22 is focused on a day in the life of the patient and provider, I want to share some of our experiences at the nonprofit Gary and Mary West Senior Dental Center (“Senior Dental Center”) located in downtown San Diego and provide recommendations to strengthen the Denti-Cal program.

As CEO and Dental Director of the Senior Dental Center, I have had the unique opportunity to help establish and study an integrated care model offering dental care combined with overall health and wellness services to address the needs of low-income seniors. Since opening nearly two years ago, we have treated over 700 low-income seniors, many with special needs.

At the Senior Dental Center, a significant portion of our patients are living with serious oral health issues, including pain, infection and malnutrition due to dental disease. Many have not seen a dentist in years; for others, it’s been decades due to the high costs associated with dental care. This is in spite of the fact that more than 85 percent of our patients are covered under the Denti-Cal program. Unfortunately, what we’re seeing at our Senior Dental Center is not unique: it is happening across the state.

Patients with Special Needs

Providing dental care to individuals with severe medical or mental health conditions can be particularly challenging for dental professionals and involve complicated treatment processes. Treating such persons often requires more time because usual methods of performing dental procedures are not feasible and/or extra time is required to appropriately manage a patient’s medical or mental health conditions.

We see such challenges on a daily basis at our Senior Dental Center. Many patients cannot tolerate being in a dental chair long enough to have necessary treatments completed and others require additional medical screening at every appointment before treatment can be undertaken.

An important step to ensuring access to critical dental services for these complex patients includes providing a means to compensate practices for taking on such complicated cases. SB 1464, legislation introduced by California State Senators Scott Wiener (D-San Francisco) and Richard Pan (D-Sacramento), aims to expand access for children and adults who have chronic medical, mental, behavioral, or developmental conditions and disabilities which complicate their dental care by ensuring providers have more adequate compensation to treat these patients. This legislation proposes to establish additional payments for providers that treat patients with special needs, reimbursing them for the extra time and resources spent on their care. It will begin to address the access deficiencies for some of Denti-Cal’s most vulnerable beneficiaries.

Adequate Payment and Coverage of Services

Additional actions are needed and possible to move Denti-Cal even further toward becoming a true dental care safety net for all program beneficiaries. I would encourage your attention to the following:

Allocation of Proposition 56 Funds
Continued commitment of Proposition 56 funds for increased Denti-Cal provider reimbursements to incentivize provider participation is essential. Many dental providers legitimately cite low reimbursement rates and high administrative burden as deterrents in participating in the Denti-Cal program. According to current data from DHCS, there are no Denti-Cal participating dentists in 13 of the state’s 58 counties, primarily in rural Northern California. In seven counties, there is only one participating dentist. In San Francisco, there are only 20 dentists and orthodontists to serve roughly 150,000 Medi-Cal enrollees.[i] Last year’s legislative allocation enabled the provision of supplementary payments that should result in some increases in dentists’ participation. Continuing allocation of Proposition 56 funding will be important to avoid any gains from being erased.

Preventive Services
Last year, basic preventive services were not eligible for these supplemental payments. That omission should be corrected. Preventive services are essential for good oral health care. Maintaining an individual’s own teeth is always superior to attempting to restore teeth and function after loss due to decay and disease. Preventive services are likely less expensive in the long term, as expensive restorations are avoided.

Supplementary payments for preventive services are also key to improving access for Denti-Cal patients. Preventive services represent a large share of the continuing care provided to a practice’s patients. The challenges that practices face due to low Denti-Cal payments are most severe for those dental practices serving larger numbers of Denti-Cal patients. Supplementary payments for preventive services will assist such practices in maintaining or increasing access for Denti-Cal patients.

Periodontal Services
Periodontal services should also be eligible for supplemental payments. The prevalence of gingivitis and other forms of gum disease increases significantly with age. Moreover, there is strong and growing evidence of the relationship between these conditions and medical problems, most notably diabetes and heart disease. Periodontal services are a prime example of how adequate oral healthcare can help to avoid future higher costs of medical care. Now that the full adult benefit has been restored, a review of coverage criteria details is critical to ensure that all persons benefitting from essential periodontal services have coverage. In addition, the processes for practices obtaining approval for services needs to be consistent, efficient and flexible enough to account for special circumstances.

Assisting High Volume Denti-Cal Practices
Denti-Cal’s low payment rates means that practices essentially must subsidize care for program beneficiaries with revenues earned from other patients. Such cross subsidization becomes impossible as the numbers of Denti-Cal patients a practice serves become large. Such practices could be aided, and Denti-Cal access enhanced, if these high-volume practices received some form of supplemental payment. Keeping these practices as very active participants in Denti-Cal would likely have the additional benefit of reducing transportation barriers as high volume Denti-Cal practices are more likely to be located in areas with greater concentrations of program beneficiaries.

I, and the other clinical professionals at the Senior Dental Center, look forward to further opportunities to positively contribute to this dialogue. Should you have any questions, or wish to discuss my comments further, please contact me at


Dr. Karen Becerra, DDS, MPH
CEO and Dental Director
Gary and Mary West Senior Dental Center


[i] R. Shinkman, “Now That They Have Dental Insurance, California’s Low-Income Adults Must Find a Dentist That Accepts It.” January 2018.