1. Workforce Shortages/Dental Office Staffing
Even prior to the COVID-19 pandemic, dental practices in California were struggling with staff shortages, specifically a lack of dental assistants. First-year enrollment in dental assistant programs has declined 50% over the last 10 years. In recent months, the need to recruit dental staff has become even more prevalent as practices recover from the pandemic. Dental practices are stabilizing and have been able to rehire most team members, but staffing remains well below demand. Recent survey data shows that nearly 90% of practices have greater challenges in recruiting and hiring dental assistants than before the pandemic, and 44% of practices report that those challenges are limiting their ability to see more patients.
CDA is pursuing both immediate and long-term solutions through recruitment and training programs, state budget funding and legislation to improve dental career pipeline opportunities:
- The 2022-23 state budget recently approved by Gov. Gavin Newsom and the Legislature makes major investments in health care workforce development and provides great opportunities to address dental staffing needs. Expanding and diversifying the health care workforce was a top priority in this budget, with $1.7 billion invested in a variety of training initiatives along with a wide range of health care provider scholarship, loan and grant programs that many dentists and dental team members are eligible to apply for. CDA is particularly supportive of an additional $45 million to the High Road Training Partnership program, which will help its development and expansion into health and human services career assistance, and $175 million to a newly created Apprenticeship Innovation Program, which will provide funding to support apprenticeship course development, classroom instruction and other eligible activities with a focus on nontraditional apprenticeships including in health care. CDA has begun exploring work with the Newsom administration on opportunities to establish dental assisting apprenticeships. These investments build and expand upon existing funding for initiatives like CDA’s Smile Crew CA, designed to highlight careers in dental assisting and create a broad pool of qualified candidates.
- CDA sponsored AB 2276 by Assemblymember Wendy Carrillo (D-Los Angeles) to expand the scope of practice for dental assistants to include coronal polishing and placement of sealants under direct supervision if they have obtained the appropriate certifications. Currently, DAs can enroll and complete certification courses through the Dental Board of California to perform coronal polishing and apply sealants, but they cannot actually perform these tasks until they receive registered dental assistant licensure. Allowing DAs to perform duties to the limits of their certifications balances the needs of dental practices that are struggling to hire dental team members while also protecting patients by ensuring DAs are appropriately trained and supervised to perform these tasks. AB 2276 was held in the Assembly Appropriations Committee, but CDA has broadened its effort to pursue changes and modernization of the scope and licensure pathway for DAs in California.
2. Health Equity and Access Budget Proposals
Recognizing the state’s significant budget surplus, this year CDA requested one-time funding for two strategic investments in dental workforce and infrastructure to increase access to care for underserved, rural and vulnerable populations. We are very pleased that Gov. Newsom and the Legislature included both requests in the final 2022-23 budget:
- $50 million to build new and expand existing special needs dental clinics and outpatient surgery centers through a grant program operated by the California Health Facility Financing Authority. The funds can be allocated to pay for the construction, expansion or adaptation of dental surgical clinics or specialty dental clinics in California to increase access to oral health care for specialty populations. This expansion of settings will significantly expand access to dental care for individuals who are unable to undergo dental procedures in traditional dental offices due to special health care needs or the complexity of care needed. This is a historic investment for the special needs community and will have dramatic impact for decades to come.
- $10 million to fund the development of new and enhanced community-based clinical education rotations for dental students to improve the oral health of underserved groups in California. The Health Resources and Services Administration reported in 2021 a need for additional dental practitioners to meet the oral health needs of 2 million Californians living in dental health professional shortage areas (DHPSAs). The investment will be administered by a nonprofit foundation in collaboration with dental schools and will allow hundreds of dental students per year to serve in community settings in designated DHPSAs. This community-based education model is self-sustaining because the revenue generated by dental students providing treatment is sufficient to defray the cost after one year of implementation, so a one-time allocation can create sustained increases in access to care and permanent expansion of the dental workforce.
3. Medi-Cal Dental Program
More than half of children and a third of adults — over 14 million Californians — rely on the state’s Medi-Cal program for their medical and dental coverage. Historically, Medi-Cal patients have faced major barriers to care including long delays for appointments, difficulty finding specialists and traveling long distances to receive care. A primary reason has been a lack of providers who are able to participate in the program due to administrative and enrollment barriers as well as reimbursement rates that were among the lowest in the nation.
Making the Medi-Cal program functional has been a critical priority for CDA. Over the last five years, the Medi-Cal Dental Program has made tremendous progress that the state must continue to build upon. This is a result of (1) improved reimbursement rates following the passage of Proposition 56 (2016), a tobacco-tax increase co-sponsored by CDA; (2) enhanced federal funding through the Medicaid waiver process that is continuing through the CalAIM program; (3) restoration of adult dental benefits the state eliminated during the Great Recession; and (4) improvements to administrative and enrollment barriers for providers. These changes have increased dental-provider enrollment by 25% since 2017.
This year’s budget continues this progress, with Newsom and the legislature committing significant funding toward continued improvements in the Medi-Cal Dental Program. CDA successfully engaged in a number of Medi-Cal-related budget items this year including support for:
- Backfilling Proposition 56 tobacco tax declining revenues from the general fund to maintain Proposition 56 supplemental rates for dentists, which total $210 million this year. This backfill demonstrates a commitment to maintaining the program’s recent progress long-term and ensures the state can maintain these rate increases for Medi-Cal providers, which were made permanent in last year’s budget.
- $31.7 million to backfill a federal funding shortfall in the Dental Transformation Initiative. This means that dentists who provided services under DTI domains 1 and 3 in 2021 will receive the full incentive payments they were expecting for services already rendered. This is an important aspect in preserving the trust between providers and the Medi-Cal program.
- Expansion of the lab-processed crown benefit to cover all posterior lab-processed crowns for adults. Previously, only stainless crowns were covered by Medi-Cal, which has been a long-standing gap in Medi-Cal dental coverage. CDA is concerned with the low reimbursement rate and will continue to seek an increase in the rate to ensure this important coverage expansion is meaningful, functional and a real benefit for Medi-Cal members.
- Permanent extension and funding of the CalHealthCares Student Loan Repayment Program. This technical change and ongoing funding will allow the program to continue expanding access to care statewide by supporting new dentists serving the Medi-Cal population.
More details on how the 2022-23 state budget will impact dentistry can be found here.
4. AB 35: Medical Injury Compensation Reform Act (MICRA) – Support
California’s health care community, including CDA and The Dentists Insurance Company (TDIC), has reached an agreement that will extend the long-term predictability and sustainability of MICRA, the state’s medical professional liability law. This agreement settles a decades-long divide on the issue and has resulted in the withdrawal of a November 2022 ballot measure that would have dismantled the MICRA law.
The agreement keeps in place MICRA’s essential cost-control guardrails while protecting the rights of injured patients. The MICRA coalition and the ballot measure sponsors jointly supported AB 35 (Reyes) to codify the agreement, and the sponsors have removed the measure from the ballot.
AB 35 includes several provisions that will update MICRA while continuing its medical liability protections. The most central provision changes the cap on noneconomic damages from the current $250,000 to:
- Cases not involving a patient death: $350,000 starting Jan. 1, 2023, with an incremental increase over the next 10 years to $750,000.
- Cases involving a patient death: $500,000 starting Jan. 1, 2023, with an incremental increase over the next 10 years to $1 million.
- After 10 years, an annual 2% adjustment would apply to the limits.
- These new limits will only apply to cases filed Jan. 1, 2023, or later; they will not apply retroactively.
More details can be found here.
5. AB 1982: Protection of Patient Choice in Teledentistry – CDA Sponsor
The use of telehealth has significantly increased since the onset of the COVID-19 pandemic. While telehealth has proven to be an effective model of delivering care, third-party corporate telehealth providers operate in a completely virtual environment and generally have no relationship or interaction with a patient’s in-network provider. Last year, Newsom signed AB 457 (Santiago), which requires health plans and insurers to comply with specified notice and consent requirements if the plan or insurer offers a service via a third-party corporate telehealth provider. However, dental benefit plans were exempt from the requirements of AB 457 despite also steering patients to use third-party corporate telehealth providers. Telehealth is a useful tool in dentistry to triage patients experiencing pain or discomfort, but almost no dental care can be provided remotely. These triage appointments can unknowingly impact a patient’s visit-frequency limitations and annual maximums before the patient even sees a dentist in person for necessary treatment. This year, CDA is sponsoring AB 1982 by Assemblymember Miguel Santiago (D-Los Angeles), which will ensure patients also have the ability to make an informed decision about how to access their dental care, as they do for their medical care, by removing the dental exclusion from statute and direct dental benefit plans to provide a disclosure of the impact of third-party telehealth visits on a patient’s benefit limitations. This bill will ensure patients receive quality telehealth services, protect the patient-provider relationship and provide better integration of care. AB 1982 passed out of the Assembly with bipartisan support and is now in the Senate.
6. Dental Plan Accountability & Transparency
Over the past several years, CDA has worked to improve the transparency and value of dental benefit plans, hold dental plans accountable for how they spend premium dollars and level the playing field for dentists and consumers. Furthermore, the COVID-19 pandemic highlighted the ability of medical and dental plans to make record profits during a public health emergency by collecting the same amount in premiums while paying fewer claims, as patients were receiving care less often. Since the onset of the pandemic, costs of personal protective equipment have skyrocketed and been incredibly unpredictable, issues exacerbated by product scarcity, supply chain disruptions and price gouging. Many providers are still paying in the range of $10 to $25 per patient for medically necessary PPE, adding up to thousands of dollars of extra costs every month. Dental plans did not share in the burden of these costs in any substantial way, worsening the longer-term trend in which payments from plans remain stagnant while the cost of providing care continues to rise. CDA has advocated for a number of bills signed into law in recent years that strengthen transparency and accountability of dental plans.
7. Direct-to-Consumer Orthodontic Consumer Protections
Providing dental care that involves the movement of teeth without a proper evaluation, including X-rays, can lead to serious patient harm, such as loose or cracked teeth, bleeding tongue and gums, gum recession or a misaligned bite. With the emergence of direct-to-consumer business models offering various dental services that are ordered without an in-person clinical examination, it is imperative that dental treatment continues to meet a uniform standard of care regardless of whether a dentist provides treatment through telehealth or in person. CDA continues to advocate for consumer protections that ensure that DTC orthodontic business models have the same level of dentist oversight and patient safety as the virtual dental home model and in-person dental care. CDA will continue to work with the appropriate enforcement entities, including the dental board, to push for increased patient safety while pursuing improved statutory and regulatory enforcement.
Updated July 2022