Healthy Choices

Sacramento region scrambles to confront new ‘dental care crisis’

The last in a long line of Northern California hospitals abruptly announced last week it will discontinue dental surgery programs, igniting a scramble by community health leaders to solve what they termed yet another “dental care crisis” in Sacramento County.

Sutter Medical Center is just the latest health system to shut down its dental surgery program over concern for the bottom line. Sutter’s decision leaves the region with no hospital willing to brave financial losses in order to serve such vulnerable patients as severely autistic adults who must undergo costly anesthesia to endure dental work.

“Though we’ve been the sole community provider for years, we can no longer afford to bear this cost alone,” said Sutter Medical Center CEO Carrie Owen Plietz, while pledging to work with community leaders to help find an alternative.

Sutter’s pullout heightens the challenge for Sacramento County’s health leaders, who are already trying to remedy the county’s record of poor performance in providing oral health care access to children. Only 30.6 percent of the more than 110,000 Sacramento low-income children with Medi-Cal – the state’s version of Medicaid – saw a dentist in 2010-11, the third-worst rate in California. Now, the same advisory committee working to improve those results must tackle this new, weighty setback in local access to dental care.

Sutter’s decision means that the vast majority of the region’s developmentally disabled children and adults, or those suffering seizures or tics, such as cerebral palsy or Parkinson’s disease patients, will no longer have a place to go regionally where a dentist can work with an anesthesiologist in a hospital setting to provide care.

Dr. James Stephens is president of the California Dental Association, which represents upwards of 25,000 members statewide. Noting that the problem goes beyond Sacramento County, Stephens issued a statement calling for “immediate action to help medically fragile and developmentally disabled children and adults continue to receive necessary dental care at hospital and surgery centers statewide.”

Stephens said that about 1,100 cases of “medically fragile children and adults” were treated last year at the Sutter facilities that will fully shut down July 31, honoring only appointments made before May 22. No new appointments are being accepted.

“This is clearly an access to care crisis for our state’s most vulnerable citizens,” Stephens said. He urged the state Department of Health Care Services to promptly identify a solution for patients.

Department spokesman Norman Williams said in a written statement that the state is working on filling the void. He said department staff have already met with Sutter officials and the head of WellSpace Health, a federally qualified community health center with clinics and dental services in Sacramento County. Jonathan Porteus, CEO of WellSpace, said it’s possible that some of the more functional patients may find care at the clinics.

Although Sutter’s decision to discontinue its program is based on Medi-Cal’s low reimbursment rate for dental surgery largely for the poor and disabled, everyone is affected. Laws prevent nonprofit hospitals from carving out just one population for denial of care, so Sutter must also turn away the business of anybody seeking dental surgery.

Anesthesia preferred

Long ago, some dentists used restraints to try to hold these patients still, an essential goal when sharp instruments and drills pose the threat of oral injury. For children, some would use what was called “pedi-wrap,” a wide band binding the child by the torso to the dental chair. These days, full anesthesia is the approved procedure for severely disabled patients, and some young children.

“The lack of understanding of what’s taking place is really frightening,” said Karen Farnsworth, executive director of California Programs for the Autistic. Farnsworth runs a residential program in Santa Rosa that houses several severely autistic clients.

Ten of the 12 men in Farnsworth’s program require anesthesia to undergo dental work, she said. But while they are put under, the men also receive additional medical care they also refuse were they awake, such as vaccines, flu shots, X-rays, tuberculosis tests, blood work and EKGs.

“People who have severe autism have a really hard time processing sensory input. They hear every single thing at the same level, with no ability to filter out sounds. A light touch can be excruciating,” Farnsworth said. “Not only autistic people, but some who are intellectually impaired also have heightened sensitivity. They couldn’t handle the vibration of dental instruments in their mouths. They become afraid for their lives. Their senses are much more heightened.”

Though Farnsworth’s facilities are in the Bay Area, she’s had to transport her clients far from home to Sutter facilities in Sacramento because nearby hospitals had already discontinued their dental surgery programs.

One dentist who has experienced the wave of shutdowns is Dr. Rodney Bughao, who has made frequent use of the Sutter dental surgery facilities for more than 20 years. Some of his patients have been combative, he said. In 2013, he counted about 1,500 procedures he performed on developmentally disabled patients under anesthesia.

“Over the years, I’ve become the go-to person for this community,” Bughao said from his El Dorado Hills dental practice. “There’s really no other reason to dedicate your entire career to this field unless you have an affinity for these guys. You can’t just turn your back on people.”

Bughao’s narrative began 20-some years ago, in hospitals around Northern California and the Central Valley that shut down their money-losing dental surgery programs one after another, falling like a cascade of dominoes. At each location, administrators looking closely at the books eventually discovered Medi-Cal reimbursement for dental surgery simply didn’t pay, didn’t even cover the costs.

“It was sometimes said politely, and sometimes not so politely, when I was asked to go,” as hospitals rescinded access to their facilities starting in the 1990s, Bughao said. His professional journey started in San Luis Obispo County, took him to Stanislaus County, San Joaquin County, Yuba County, Sacramento County and two Bay Area counties. In all, he’s worked at 14 facilities that eventually cut dental surgery programs from their health care offerings.

“Same thing happened at each place,” Bughao said. “For budgetary reasons, I was asked to move.”

Rates are too low

No one involved in trying to find a solution to the access-to-care problem disagrees that Medi-Cal’s dental reimbursements are too low.

Dr. John Blake, of the Children’s Dental Health Clinic in Long Beach, follows the issue throughout California. He said a typical rate for the first 30 minutes of anesthesia is $275; subsequent 15-minute segments cost $100 each. Medi-Cal reimburses hospitals $42.14 for the first 30 minutes; and $21.07 for each 15 minutes thereafter.

Then, he said, you have to shave off an additional 10 percent of the payment for state budget cuts. “If I were a hospital accountant, I’d say get rid of the program,” Blake said wryly. “It’s woefully inadequate to even cover the cost of doing business.”

In Sacramento County, a small slice of the affected population, those enrolled in Kaiser Permanente and Molina’s Medi-Cal-based programs, remain unaffected, and can receive dental surgery services at either Kaiser facilities or the Greater Sacramento Surgery Center, a free-standing outpatient surgery center.

Dr. Steven Polansky, a manager for the Greater Sacramento Surgery Center, said his group is also trying to cut deals with Blue Cross and Health Net to allow the center to perform dental surgery for people enrolled in those managed care networks. The center has six operating rooms, 12 recovery rooms and is licensed by the State Department of Health Services.

Meanwhile, Sutter has not agreed to various requests from state and community leaders – including state Senate President Pro Tem Darrell Steinberg and Assemblyman Dr. Richard Pan, both D-Sacramento – to postpone its closure, at least until an alternative can be found.

Sutter officials, however, say they are participating in talks with the state, the county and others, about helping to find a solution for the special-needs population.

Dr. Terrence Jones is chair of the county’s Medi-Cal Dental Advisory Committee, formed by legislation in response to a 2012 Sacramento Bee article produced in conjunction with the Center for Health Reporting. The article, which exposed the lack of dental care for low-income children, spurred a sincere effort to expand those services, Jones said.

In a letter to Sutter chief Owen Plietz, Jones said the committee had just begun to make a difference. “However, given the fragile nature of these improvements, we fear Sutter’s decision to stop all hospital dental services, effective immediately, severely threatens this progress.”

Though all applaud Sutter for persisting as long as it did in providing oral health care to developmentally disabled patients, many voiced displeasure with the suddenness of Sutter’s announcement. Many said it came without fair warning to the community.

“I am extremely concerned that the sudden cessation of these services will result in a serious unavailability of dental services,” Steinberg said in his letter to Owen Plietz.

He has called a meeting for Monday for interested parties to work toward a solution to Sacramento County’s latest dental-care access crisis.

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