Dental Care Hardships for State’s Poor Told : Medicine: Some Medi-Cal patients cannot find treatment in 14 counties, report says. Many dentists complain of fees that do not cover costs of providing care.

Poor patients whose dental care is paid for by the Medi-Cal program cannot find dentists to treat them in 14 California counties and must wait 40% longer for an appointment in the remaining 44 counties than privately insured patients, according to a report released today.

These and other findings show that California is violating minimum federal standards governing medical assistance programs, the report concludes.

A study that led to the report was commissioned last fall by the state Assembly’s Special Committee on Medi-Cal Oversight and funded by the California Policy Seminar of the University of California. The purpose was to investigate complaints about inadequate access to dental care for an estimated 3 million Californians who depend on Medi-Cal to pay their medical and dental bills.

The report echoes claims by Medi-Cal recipients in a class-action lawsuit filed in December, 1987, in U.S. District Court in Sacramento against state Health Services Department Director Kenneth Kizer and other top health care officials.

The suit alleges that Medi-Cal pays obstetricians and dentists so little that the poor in many parts of the state effectively were excluded from maternity and dental care. The maternity portion of the lawsuit was settled last November, but the dispute over access to dental care remains before the court.

Robert D. Newman, staff attorney with the Western Center on Law and Poverty in Los Angeles, one of several legal aid organizations representing the plaintiffs, said the California Policy Seminar report would be introduced as evidence. “It basically corroborates what we already have put into evidence,” Newman said.

Federal standards for medical assistance programs are set by the Health Care Financing Administration, which provides roughly half the money for these state-administered programs. Its standards require that at least two-thirds of a state’s health care providers participate in the program, encouraged by fees that ensure the poor the same access to the same quality of care as people with private insurance.

Officials at HCFA familiar with the California program could not be reached for comment.

The authors of the California Policy Seminar Report--researchers at UCLA’s Schools of Dentistry and Public Health--found that only 16% of California’s 18,000 dentists will accept new Medi-Cal patients. Most who do not told researchers they were discouraged by fees that do not come close to covering their expenses for providing care.

The study was done by researchers, posing as Medi-Cal recipients, who called 611 dentists, requesting appointments for themselves and a 7-year-old child. The method was chosen to approximate the situation a Medi-Cal patient would encounter. Ninety-six percent of the dentists in this sample were willing to be interviewed in greater detail about their views of the Medi-Cal program, according to Dr. Peter C. Damiano, a visiting assistant professor at UCLA’s dentistry school and the report’s lead author.

Dr. Stanley R. Nuzum, dental consultant to Medi-Cal, acknowledged that fee levels are extremely low, but said dentists are not the only ones suffering.

“Throughout the medical program we are only paying 35% to 40% of what’s being billed,” he said. “It is up to the governor and the Legislature to appropriate enough money to pay more, and he (Gov. George Deukmejian) is not even providing the money to pay for any services this month.”

Nuzum was referring to a legislative impasse on a special appropriation to cover Medi-Cal bills for June. The program ran out of money in May, one month before the end of the 1989-90 budget year.

Researchers found the lack of dental care most acute in rural counties. They could find no dentist willing to accept Medi-Cal dependent adults or children as patients in Alpine, Amador, Calaveras, Colusa, Del Norte, Inyo, Lake, Mariposa, Modoc, Mono, Plumas, San Benito, Sierra or Tuolumne counties. Newman, the lawyer in the Medi-Cal suit, said patients have testified they must drive three hours to find a dentist willing to treat them.

California’s list of covered dental services is generous compared to some states’ medical assistance programs. Many offer no dental coverage at all, Damiano said. But the promise of coverage in California is a hollow one for many who cannot find a dentist willing to provide the service for what Medi-Cal pays.

An initial office visit, for example, is reimbursed by Medi-Cal at $9, compared to $18 to $50 paid by private insurers or health maintenance organizations, the researchers found. For root canal surgery on a molar, Medi-Cal pays $175, according to the report. Private insurers pay between $290 and $500, depending on the insurance plan.

Not only are fees inadequate. Regulations, including some requiring written authorization from Medi-Cal for certain treatments, were so cumbersome that they impinge on the quality of patient care, dentists told the researchers.

Dr. Calman Kurtzman, a Santa Monica dentist, is one of those who dropped out of the program after participating for more than 20 years.

“It finally got to the point where there was so much paper work and the fees were so low and there was so much you couldn’t do without written authorization that it made more sense to just do it for free than deal with the hassle of Medi-Cal,” he said.

Kurtzman was critical of what he considers a bias in Medi-Cal’s coverage that encourages dentists to pull patients’ diseased teeth rather than try to save them. He cited the program’s limit of one teeth cleaning per year as inadequate for patients whose teeth are threatened by gum disease.

(The researchers recommend, among other improvements to the program, that twice-yearly teeth cleaning be covered by Medi-Cal).

Another dentist, also in Santa Monica, has stuck with the program, but quietly. He asked that his name not be used for fear of being inundated with patients.

“I came out of a public health background and I feel that people are entitled to care, so that’s why I do it--although the reimbursement is terrible, it’s junk,” the dentist said. He considers that portion of his practice “charity work,” and said he is still able to make a comfortable living because Medi-Cal recipients are only 15% of his patients.

Dr. Dale F. Redig, executive director of the California Dental Assn., said his group concurs with the findings, and has made similar representations to state health officials “hundreds of times.”

The report is to be distributed to about 1,000 health officials and state policy makers, including state legislators, according to Estelle Jelinek of the California Policy Seminar, an organization co-sponsored by the University of California system and the Legislature to fund research into issues of relevance to public policy.

Assemblyman Burt Margolin, (D-Los Angeles), chairman of the Medi-Cal oversight committee which commissioned the report, could not be reached for comment.