A state audit report in December 2014 chronicled the California Department of Health Care Services’ years of dental neglect of California’s low-income and disabled residents, including more than 5 million children. “Health Care Services’ information shortcomings and ineffective actions are putting children enrolled in Medi-Cal – child beneficiaries – at higher risk of dental disease,” the report said.

More than 12.5 million low-income and disabled Californians receive health coverage from Medi-Cal. The program has a $94 billion budget; $1.3 billion of which goes to Denti-Cal.

Lack of Denti-Cal Providers

The biggest problem for Denti-Cal patients, particularly those in rural areas, is lack of access to a dentist. Fifty-five percent of California counties may have “an insufficient number of dental providers willing to accept new Medi-Cal patients,” the audit said. That includes five counties, which may not have any Denti-Cal providers, and 11 other counties that have Denti-Cal providers but they are not accepting new Denti-Cal patients.

The reason is that dentists lose money treating Denti-Cal patients. California’s reimbursement rates for 10 common dental procedures averaged $21.60 in 2012, according to the audit. That’s only 35 percent of the national average of $61.96 in 2011. California has not raised its dental reimbursement rates since 2000.

The result has been a depressed level of dental care for low-income California residents compared to the rest of the nation. Only 44 percent of the 5.1 million children enrolled in Denti-Cal received dental care through the program in 2012-13, the audit said. The national average utilization rate was 47.6 percent of patients, ranging from a low of 23.7 percent in Ohio to a high of 63.4 percent in Texas.

Little Hoover Commission examines program

Denti-Cal’s problems were the focus of a Sept. 24 hearing by the state watchdog agency the Little Hoover Commission. The commission took up the issue at the request of Sen. Richard Pan, D-Sacramento, who is a pediatrician, and Assemblyman Jim Wood, D-North Coast, who is a retired dentist. “Millions of low-income Californians on Denti-Cal are suffering because the promise of dental coverage by the state is not being fulfilled by Denti-Cal,” they said in an April 6 letter to the Commission.

Pan kicked off the four-hour hearing noting that one third of Californians are covered by Medi-Cal, and pointing out that tooth decay is preventable with regular dental care. “Unfortunately, every indication is that the Denti-Cal program has been neglected for decades – it is broken,” said Pan.

He’s made phone calls on behalf of Medi-Cal patients having trouble finding a dentist. “I shared their frustration when I … couldn’t reach a dentist to get them dental care,” he said.

The problem has been going on for years. In 2008 only one-fifth of the children in Sacramento County’s Denti-Cal program actually received dental care, Pan said. “It was clear that DHCS did not seem to exercise very much oversight or knew what was happening – or not happening actually – to our children in that time.”

DHCS has not, as required by law, annually reviewed its reimbursement rates “to ensure the reasonable access to dental services by Medi-Cal beneficiaries,” the audit said. The department also has not complied with its pledge to annually compare Denti-Cal’s performance with results from national and statewide surveys. Denti-Cal “thought another division was responsible for completing the dental metrics in the monitoring plan,” the audit said.

Blame placed on low reimbursement rates

Pan, along with several other industry experts testifying at the hearing, said that reimbursement rates need to be increased to make it worthwhile for dentists to take on the extra work. Reimbursement is so low that some dentists find it is less burdensome to directly provide charity care to poor patients rather than going through Denti-Cal and dealing with its paperwork and other bureaucratic hurdles.

“When you have payment rates that do not adequately cover practice expenses, there’s pressure on providers then to make that up – if they are going to be viable – to perform high volumes and particularly more highly paid services and procedures,” Pan said. “The department then responds, when they see this higher volume, to create even more barriers to payment, which drives out more providers. And basically who are you left with? People who have figured out how to work the system to do high volumes just to keep the practice viable.”

Similar testimony was provided by numerous dental professionals. All of which put the woman representing the Denti-Cal program – Rene Mollow, DHCS deputy director of Health Care Benefits and Eligibility – on the hotseat.

“I first do want to acknowledge the challenges that we’ve had in the program and to represent the commitment … in working through and making sure we do improve the management and administration of the program,” said Mollow. “I think, based upon responses that we have made to the state auditor, we have demonstrated our commitment to making the improvements.”

She said there’s been a lot of discussion on reimbursement rates. She also acknowledged that the problems are more extensive, including cumbersome paperwork requirements. For example, the Denti-Cal application for dentists is 40 pages long. Denti-Cal preauthorization, based on documentation including x-rays, is often required before some procedures are allowed to be performed. Several professionals also complained about the ratcheting up of anesthesiology regulations.

But Mollow sought to put a positive spin on the situation.

“We pride ourselves on ensuring program integrity while also ensuring access to services and maintain the viability of the program given the expenditures of the program and the population that we do serve,” she said. “We do recognize the challenges with the administrative processing in terms of claims and provider enrollment. We are looking at ways to do some streamlining.”

Pressure for specific solutions

Commissioner David Beier asked Mollow about the audit. “Did you view that as a three-alarm or four-alarm fire that required an urgent response?” he said.

Mollow responded, “Yes, the audit raised concerns. But the findings of the audit were things we were already working on. So these were things based upon the administrative simplification, issues with provider enrollment, all of the things people were raising to us as concerns.”

Beier wanted to hear more specifics about corrective measures. “In your testimony there’s a lot of ‘looking ats’ and ‘considering,’” he said. “What are the major changes that have been implemented in almost a year since the audit?”

Mollow responded, “We’ve looked at improving upon our contract oversight and management of the fiscal intermediary. We have required the provision of the beneficiary and provider outreach plans. We are now working with stakeholder review of those plans. We are working with stakeholders on beneficiary and provider performance metrics. We have a very robust process in place.”

Influx of new patients

Also robust is the number of new patients coming into the Medi-Cal program due to changes in federal and state laws that expand coverage. An additional 2.7 million Denti-Cal patients – perhaps as many as 6.4 million – are expected to be added in the coming years. “[That] make[s] us question whether California will have enough available dental providers to meet the needs of Medi-Cal beneficiaries,” the audit said.

Sen. Anthony Cannella, R-Ceres, who is also a Little Hoover commissioner, was unconvinced by Mollow’s assurances that the department is on top of the problems.

“I just think that it doesn’t seem like we are taking this as serious as we should when we have people with real needs,” he said. “And these have real consequences. Children that have problems with their teeth, it’s a stigma that they carry for the rest of their lives. So we are creating more and more problems that I think can be solved pretty easily.”

Commission Chairman Pedro Nava quizzed Mollow about why her department hasn’t fixed the problems or sought help from the Legislature. Mollow responded that changes must first go through the regulatory process. That didn’t satisfy Nava.

“As a former legislator, this is where I would say to the department, ‘Where the hell you been?’” he said. “In a nice way. The push to make the change should come from the department. Because the last thing you want is an uneducated legislator deciding they want to fix it. Because then there’s unintended consequences that the Little Hoover Commission has to come back in and look at five years later.

“One of the things that ought to happen when you leave here is to meet and talk about your legislative package and come up with a bipartisan legislative proposal. Without some movement on the legislative front, you don’t want us coming back and asking, ‘How come you ain’t done it yet?’”

The commission plans to release a report to the Legislature on the Denti-Cal problems and recommendations for solutions.

Nearly one in six California school districts has dropped out of a federal outreach program for low-income student health that brings millions in unfettered dollars into schools, citing bungled state management and years-long delays in receiving funds … . The exodus is part of the continuing fallout from a 2012 federal investigation that found California had “serious deficiencies” in its oversight and management of the School-Based Medi-Cal Administrative Activities program. The program reimburses schools for a portion of the cost of referring students to Medi-Cal, California’s name for the federal Medicaid low-income health insurance program.

 

After the 2012 investigation, federal officials temporarily froze payments to school districts effective July 1, 2012, recalculated previously paid claims submitted in 2011-12, introduced a formula for interim payments and devised a new method of calculating claims moving forward.

 

As a result, some districts are still waiting to be reimbursed for 2009 expenses, while others have been told to return money from previous reimbursements that are now under review.

Lax oversight, poor Internet security and more

It’s the sixth highly critical audit of state government since June. That’s an unusual concentration of negative reports based on a review of the auditor’s archive of reports and a Nexis search of recent years of Sacramento coverage. Many audits in past years offered mixed reviews of government agencies, such as this October 2012 assessment of how public universities report crime. This summer, audits appeared much more likely to be harsh.

Last month, Howle issued a report about wrongdoing revealed by state whistle-blowers. This is from the San Francisco Chronicle:

An engineer for the California Department of Transportation was busy working on his golf swing when he was supposed to be at work, according to an audit released this week detailing bad behavior by state employees and public agencies. … [The} report found 10 substantiated allegations from whistle-blowers with more than $4.2 million in wasted money, improper payments and misuse of work time by public employees.

 

The Caltrans engineer was found to have played golf on 55 workdays in a 19-month period while his time card listed him as working. State auditors faulted the engineer’s supervisor for failing to manage the employee or ensure his time sheets were accurate from August 2012 to March 2014.

 

The employee said he played golf as much as possible — for an estimated 4½ hours a day — during hours the auditor found he was supposed to be working.

 

The audit also found a month in May 2014 in which no one could account for how much work the engineer had done, if any, because there was a miscommunication about who was supposed to oversee the employee.

Also in August, Howle faulted state bureaucrats for being indifferent about Internet security. This is from AP:

Many state agencies are not complying with the state’s information technology standards, leaving them vulnerable to a major security breach of sensitive data such as Social Security numbers, health information or tax returns, the state auditor reported Tuesday.

 

“Our review found that many state entities have weaknesses in their controls over information security. These weaknesses leave some of the state’s sensitive data vulnerable to unauthorized use, disclosure, or disruption,” Auditor Elaine Howle wrote in the report. She notes that the state is a prime target for information security breaches as government agencies keep extensive amounts of confidential data. Many agencies also have not sufficiently planned for interruptions or disasters, she found.

State not tracking mentally ill gun owners

In July, Howle knocked Attorney General Kamala Harris and the state Department of Justice. This is from the Sacramento Bee:

Nearly two years after that the state Department of Justice and courts failed to identify thousands of mentally ill gun owners who are prohibited from having guns, the state auditor said Thursday that the department has failed to resolve its backlog of such cases.

 

State Auditor Elaine Howle wrote that the department’s “delays in fully implementing certain recommendations result in continued risk to public safety.”

 

Lawmakers in 2013 approved legislation appropriating $24 million to the Department of Justice to address a backlog of cases of prohibited people having guns. But the state auditor said the department had failed to fully implement seven of eight recommendations made in 2013 to improve department procedures.

 

For example, the department has not taken sufficient steps to ensure courts and mental health facilities are reporting mentally ill people for review, the audit said, and it continues to redirect staff to work on other priorities.

 

As of April, the audit said, the department had a review backlog of more than 257,000 people who are potentially prohibited from having guns.

In June, Howle ripped the State Bar of California. This is from AP:

The nation’s largest state bar failed to consistently protect the public from bad lawyers by settling hundreds of complaints, many without adequate discipline for botched cases or ethical violations, according to a scathing audit released Thursday that also found the organization has spent money with little financial accountability. …

 

As the state bar scurried to settle more than 5,100 backlogged complaints in 2010 and 2011, the severity of discipline imposed against attorneys decreased, according to the State Auditor’s report.

 

In 2012, the California Supreme Court rejected settlements reached with 27 attorneys because of insufficient discipline; 21 of those attorneys later got harsher punishments, including five who were disbarred, the audit said. Additionally, 131 attorneys whose complaints were settled in 2010 and 2011 later were disciplined after new complaints were filed, including 28 disbarments.

 

To reduce its backlog, the state bar allowed some attorneys whom it otherwise might have disciplined more severely – or even disbarred – to continue practicing law, placing the public at risk,” State Auditor Elaine Howle wrote to the governor and legislative leaders Thursday.

Call Medi-Cal, never get through

Also in June, Howle was sharply critical of the state Medi-Cal program. This is from AP:

Thousands of calls to California’s Medi-Cal complaint lines don’t get through, and thousands more that manage to ring the call center go unanswered, according to a new state audit.

 

For the year that ended in January 2015, the phone system to the Medi-Cal ombudsman’s office rejected up to 45,000 calls in a month, State Auditor Elaine Howle said in her report. Of the calls that did get through, only one-third and one-half were handled by ombudsman’s staff each month.

 

(B)etween February 2014 and January 2015, an average of 12,500 additional calls went unanswered,” the audit states. A department official blamed the unrelenting backlog and unanswered calls on inadequate staffing and “hardware limitations” that cause the call database to crash.

It is difficult to know what to make, if anything, of this rash of harsh audits. But former state Sen. Mark Wyland, R-Solana Beach, complained for years about a state government culture that he felt tolerated mistakes and poor performance. Perhaps the relative budget austerity of 2007-2013 led to even lower standards at some agencies.