DENTI-CAL TOWN HALL MEETING RESULTS

CALIFORNIA DENTAL ASSOCIATION AND CALIFORNIA DEPARTMENT OF HEALTH SERVICES, OFFICE OF MEDI-CAL DENTAL SERVICES DENTI-CAL TOWN HALL MEETING RESULTS Prepared by: Social Entrepreneurs, Inc. 6121 Lakeside Drive, Suite 160 Reno, Nevada 89511 775 324 4567 phone 775 324 4941 fax

DENTI-CAL TOWN HALL MEETING SCHEDULE Colton Fresno San Bernardino County Medical University of California Center - Fresno Society Conference Center June 29, 2001 June 22, 2001 Sacramento San Francisco California Dental Association University of the Pacific School of Dentistry July 12, 2001 July 13, 2001 San Diego Los Angeles San Diego Concourse UCLA Faculty Center July 20, 2001 July 27, 2001 This report was prepared by Social Entrepreneurs, Inc. under contract with the California Dental Association. We would like to thank the numerous people who provided information, attended Town Hall meetings, and made other important contributions to this report. Special gratitude is extended to David Pisani of the California Dental Association, and Robert Isman of the California Department of Health Services, Office of Medi-Cal Dental Services, without whom the Town Hall meetings and this report would not have been possible. ii

DENTI-CAL PROGRAM TOWN HALL MEETING RESULTS Table of Contents 1. Executive Summary...1 2. Town Hall Meeting Description...7 3. Town Hall Meeting Results...9 4. Next Steps...15 5. Conclusion...16 iii

DENTI-CAL PROGRAM TOWN HALL MEETING RESULTS 1. EXECUTIVE SUMMARY In April 2001, The California Dental Association (CDA) and the California Department of Health Services Office of Medi-Cal Dental Services (DHS) decided to convene six regional Town Hall meetings across California. The target audience for these meetings was key stakeholders of the Denti-Cal program. Key stakeholders identified for inclusion in the Town Hall meetings included current Denti-Cal providers, current Denti-Cal recipients, and individuals who previously fell into one of those two groups. In addition, other dental professionals, CDA component board members and executive directors, government officials, advocates, representatives from stakeholder groups and other public policy makers were also targeted for inclusion in the Town Hall meetings. Jointly, CDA and DHS issued an invitation to the Town Hall meetings for the purpose of soliciting input from the dental community, as well as other stakeholders, on ways in which the Denti-Cal program could be improved and made more user-friendly for both the provider and the beneficiary. It was explained to invitees that DHS was conducting a review of the Denti-Cal program. DHS noted that they strongly believed this was a valuable opportunity for the dental community and other stakeholders to play an active role in shaping policies that could improve the Denti-Cal program. The Town Hall meetings had three major objectives. They were intended to: 1. solicit feedback from key stakeholders, 2. communicate CDA's and DHS's desire and commitment to help facilitate improvements in the Denti-Cal program, and 3. obtain an understanding of how to better market the Denti-Cal program. In order to meet the first objective, namely to solicit feedback from key stakeholders, the Town Hall meetings were designed to: give stakeholders an opportunity to describe their experience with the Denti-Cal program, identify strengths of the program, identify areas to improve, and frame recommendations to make those improvements. To meet the second objective, each Town Hall meeting included representation from CDA and DHS. The CDA representative(s) used the Town Hall meetings to communicate its commitment to facilitating improvements in the Denti-Cal program. 1

Representatives from the Denti-Cal program were also present at each Town Hall meeting. They also expressed their commitment to improving the Denti-Cal program as a result of the findings of the meetings. The third objective, to obtain a better understanding of how to market the Denti-Cal program, was achieved via the specific recommendations made by participants at each of the Town Hall meetings. In May 2001, CDA awarded a contract to Social Entrepreneurs, Inc. (SEI) to facilitate the Town Hall meetings and develop a report which summarized results from the meetings. SEI is a private consulting firm whose mission is "To measurably enhance the quality of life for individuals and communities by making significant improvements to the capabilities, efficiency, stability, and outcomes of human service organizations." Following the award of the contract, Kelly Crosbie from SEI met with David Pisani, CDA and Robert Isman, DHS, to frame the approach, agenda, and schedule for the six meetings. Town Hall meetings were scheduled to take place during June and July 2001 in Colton (San Bernardino County), Fresno, Sacramento, San Francisco, San Diego and Los Angeles. The six locales were selected as the locations that would provide the broadest geographic and demographic mix of urban and rural locales across California. Key stakeholders were invited to attend one of the meetings in a locale near them via a letter from CDA and DHS. A notice of the meetings and on line registration were also available on the CDA website. Local dental societies also publicized the Town Hall meetings. In addition, notices of the meetings were mailed to all of the large volume Denti-Cal providers in the State. Purpose of the Report The Town Hall meetings that took place during June and July 2001 were the result of an historic partnership between CDA and DHS. This partnership came about as both entities worked to identify and understand the issues or changes that could strengthen the Denti- Cal program. To that end, both CDA and DHS had multiple representatives present at all of the meetings. Their presence was intended to reinforce the desire for open, straightforward dialogue about the program. They were also there to listen and seek to understand the needs and vision of key stakeholders related to a Denti-Cal program which would truly serve California's most vulnerable populations with quality, accessible oral health care. The agenda for the meetings was developed as a result of several meetings between CDA, DHS and SEI. SEI sought to craft an agenda using a strengths-based approach to solicit the optimum amount of constructive feedback to achieve the goals of the Town Hall meetings. The goal was to engage key stakeholders in a respectful, yet directive fashion to ensure that all participants were encouraged and able to contribute to the meetings. 2

In addition, SEI agreed to document the results of each Town Hall meeting to ensure that key recommendations and findings were captured and retained for future use by the CDA and DHS. In addition to the meetings themselves, the major deliverable of this project is this report. The report is designed to outline key topics that arose at the Town Hall meetings, and any recommendations put forward to strengthen the Denti-Cal program. It is hoped that this report will be useful in tracking and measuring future progress as recommendations to strengthen the program are implemented. The full report and appendices will be available on the CDA website (www.cda.org) and the full report, including appendices, will be distributed to all participants listed in Appendix A. Data Collection Methods A three-tiered approach was used to obtain the information needed to understand how to strengthen the Denti-Cal program for both providers and recipients. 1. Member surveys. CDA members were asked to complete a survey that was contained in CDA Update, a newsletter published by CDA and distributed monthly to all its members. The survey posed a number of questions related to understanding of and attitudes about the Denti-Cal program. The surveys also sought to identify factors that might reduce the likelihood that a CDA member would participate as a Denti-Cal provider. As only a very small number of surveys were returned, the findings were used only as a general guide to the kinds of attitudes and perceptions that might be expected from the Town Hall meetings. 2. Town Hall meetings. Six Town Hall meetings were held in different locations across the State. Meetings were conducted in Colton (San Bernardino County), Fresno, Sacramento, San Francisco, San Diego and Los Angeles. The purpose of the meetings was to obtain direct, interactive opinions from key stakeholders on ways in which they thought the Denti-Cal program could be improved. 3. Written comments. Participants were able to submit recommendations or additional information to Kelly Crosbie via email or regular mail. In several instances, individuals and groups submitted written comments reflecting recommendations of individuals who were unable to attend the Town Hall meetings but wanted to publicly comment on an aspect of the Denti-Cal program. Those comments were incorporated into this report. There was considerable consistency of opinions among participants in the Town Hall meetings. 3

Summary of Findings A summary of some of the key findings on issues related to the Denti-Cal program, including its strengths, areas to improve, and recommendations are included in this section. In addition, next steps are included. Detailed results and common themes that emerged across multiple Town Hall meetings are found in Section 3 of this report. To effectively change the Denti-Cal program, participants were first asked to share their vision of what a functional, user-friendly, effective Denti-Cal program would look like. This vision was intended to drive all of the recommendations and leverage the strengths of the existing program. The vision of participants was that all Californians would be educated and have an understanding that dental care is a part of primary health care, through an integrated primary and oral health care system that focuses on education and prevention as well as treatment. Services would be available starting at an early age and both beneficiaries and providers would have incentives for participating in/providing preventive services. Each beneficiary s best interest regarding their oral health would be considered when making oral health determinations, so that all medically necessary services would be covered and provided. To accomplish the provision of appropriate care, decisions and corresponding policies and procedures would be based upon scientific, evidence-based research and best practices. Each stakeholder in the system would understand their responsibility and there would be a relationship between the beneficiary, the provider and the payor that defined and balanced both the rights and responsibilities of each stakeholder. The strengths participants saw in the program include: the social conscience of dentists, their perseverance and passion to provide needed services; the history of the program, and the number of beneficiaries who have received and continue to receive services; the fact the Denti-Cal program serves the neediest, most vulnerable population in California and is perceived as a good, generous program; the increased fees and access to preventive care, e.g., sealants, covering 2 prophys per year, and raising fees for porcelain crowns were also perceived to be strengths of the program. 4

A summary of some of the areas that Denti-Cal could benefit from changing fell into five key areas: 1) providers, 2) fees, 3) the paperwork, authorization and appeals process, 4) the appropriateness and type of services covered by the program, and 5) communication. Specifically, the lack of providers, particularly anesthesiologists and other specialists and difficulty getting access to legitimate, accurate referral lists was perceived as a major area to improve. This is compounded by the low reimbursement rates or lack of reimbursement, particularly to hospitals, anesthesiologists, for behavior management and for those who work with special populations, as it hinders efforts to recruit more providers. The amount and type of paperwork required is perceived as burdensome, complicated and long and as often resulting in a denial of care. The fourth issue identified included the rules, regulations, paperwork and forms currently in use in the system. In addition, some policies are perceived as inadvertently pushing practitioners toward medically inappropriate or unnecessary procedures in order to provide needed care, such as pulling teeth to get partial dentures. Many participants noted that providers and beneficiaries lack necessary information about the program and its processes. Effective communication related to issues such as eligibility, service providers, reimbursement policies and procedures, and protocols for obtaining real time answers to questions regarding a beneficiary's care, particularly in an emergency, is critical. Of the many recommendations that were made at the six Town Hall meetings, the following were common to most or all of the meetings: 1. Create a permanent advisory group to meet on a regular basis and plan, implement and evaluate the changes made to the Denti-Cal program and provide ongoing input to the program from providers, beneficiaries and other stakeholders. 2. Promote oral health as part of primary health by developing an interdisciplinary approach to beneficiary treatment. 3. Develop a health education component regarding oral health that will engage, involve, and educate health care partners and beneficiaries in the importance of oral health. 4. Define and evaluate the Denti-Cal Program's vision, mission and priorities. 5. Enhance provider participation in the Denti-Cal program. 5

6. Simplify the Denti-Cal program rules, regulations, authorizations, forms and processes. 7. Assist in developing a balanced relationship between providers, beneficiaries and the payor. 8. Use evidence-based research, best practices, and medical necessity as the basis for authorizing and providing care. 9. Evaluate current procedures and reimbursement rates and revise to more appropriately cover the cost of services rendered. 10. Enhance communication processes to increase all stakeholders' access to important information including provider lists and eligibility and reimbursement information. (Suggested mechanisms included putting program information on a web site, creating a listserv for Denti-Cal providers, and allowing email communications with Delta dental consultants.) Specific rationale related to each of these recommendations is provided in Section 3 of this report Note: Several other recommendations were identified in multiple meetings and should also be considered in the development of a specific action plan. Some of those recommendations included providing and reimbursing case management, addressing special needs populations via behavior management fees and increased rates, and better integration of systems serving the same population including Medi-Cal, Denti-Cal and Healthy Families. All of the participant recommendations can be found in Appendix B. Conclusion The overarching conclusion is that the Denti-Cal program is a necessary and beneficial program that can be measurably improved in a number of ways. It would benefit most from defining its mission and vision and in setting priorities for those it can serve. Town Hall meeting participants understand that improvements to the Denti-Cal program in and of themselves will not achieve their vision for California's oral health. Rather Denti-Cal is one of a number of programs and activities endeavoring to meet a larger oral health need. That need is for oral health to be seen as part of primary health and that oral health and primary health services will be integrated to ensure a continuum of care. A list of the five recommended, actionable next steps can be found in Section 4 of this report. 6

2. TOWN HALL MEETING DESCRIPTION This section provides an overview of the agenda developed and used to facilitate activities within each of the Town Hall meetings. It also gives a brief description of the philosophical approach used to craft the agenda that resulted in the structure of the meetings. Agenda SEI s approach to the Town Hall meetings was to build an agenda that framed key questions that needed to be answered within the context of the meetings. These questions were developed in conjunction with CDA and DHS. The next step was to structure the group activities to gain answers to those questions. It was important that the agenda reflect an understanding that different stakeholders may have conflicting answers to the same question. In fact, the agenda was designed to allow various groups or stakeholders to identify and address inherent "disconnects" in perspectives based upon their own experiences. The agenda which resulted from the planning efforts was as follows: 1. Welcome and Introductions (Who is in the room and why?) 2. Purpose and Intended Outcomes of the Town Hall Meetings (What are we here for, what do we hope to accomplish?) 3. Strengths of the Denti-Cal Program (What is working well?) 4. Areas to Improve (What can work better?) 5. Visioning Activity (If your provision/reception of Denti-Cal services were a completely positive experience, what would it be like?) 6. Next Steps (What needs to happen before that vision can become reality?) This agenda was used for each of the six Town Hall meetings. Philosophical Approach The facilitation approach used for the Town Hall meetings was derived from "solutionbased therapy," a model developed by Scott Miller, Ph.D. The model is research-based and was developed following extensive work with highly vulnerable populations. The core philosophical tenet of the model is to validate the knowledge of key stakeholders 7

regarding what changes would improve their circumstances about a given problem or issue. In that way it is solution-based as opposed to problem-based. The model was designed to listen, affirm and validate participants' reality regarding a topic, while gaining valuable insight into their vision for improving their circumstances. (Handbook of Solution Focused Brief Therapy: Foundations, Applications, and Research with Mark Hubble, Jossey-Bass, 1996.) This approach was particularly attractive for use in the Town Hall meetings, as all planners agreed that asking key stakeholders how to improve the Denti-Cal program was the primary reason for holding the meetings. It was believed that this approach would underscore that the meetings were not just "business as usual." Operationally, the approach was designed to honor the experience of stakeholders, structure participation to ensure that the meeting goals were met, actively listen and restate findings to test for understanding, and respectfully solicit and coordinate participation so that each participant had an opportunity to share their experiences and expertise. Within the agenda, various activities occurred that reinforced this philosophical approach. In the Welcome/Introductions/Purpose of Meeting, Robert Isman, DHS, gave participants the history of what had brought them to the point leading up to the Town Hall meetings. He emphasized the never before nature of the collaboration between CDA and DHS. David Pisani, CDA, supported this and encouraged participants to share openly the factors they believed could help improve the Denti-Cal program. It was reinforced by all presenters that the meetings were seen as an opportunity to find ways to make the program friendlier to both the provider and service recipient community. Kelly Crosbie shared the Intended Outcomes of Town Hall Meetings, noting that the meetings were designed to include working with both providers and recipients of the oral health community to strengthen the program. It was also noted that six Town Hall meetings were being held in diverse geographic locales so as to expand the audience beyond one group and to include as many key stakeholders as possible. This helped provide a more complete, rounded understanding of the issues surrounding the Denti-Cal program. Participants were oriented to the solution-focused approach and asked to participate in multiple manners--both by telling policy makers what doesn't work and how to fix it, but also by identifying aspects of the program that are working well, to prevent inadvertent changes to components that are working well. The meetings began with a brainstorming by participants of the Denti-Cal Program Strengths/Areas to Improve. This included Ms. Crosbie's facilitation of a situational analysis of the Denti-Cal program from a variety of perspectives, including both service provider and recipient. Once completed, participants engaged in a Visioning Activity. This activity was used to help the group envision the attributes of a functional, effective, user-friendly Denti-Cal program. Participants were asked to describe what the optimal system should look like. 8

Each group was asked to make specific recommendations to incrementally or completely change the Denti-Cal program. Recommendations were framed operationally whenever possible. Finally, the participants identified Next Steps/Priorities. Where possible, actions were prioritized with groups establishing the top five next steps that would need to occur to strengthen the Denti-Cal program. 3. TOWN HALL MEETING RESULTS This section contains a compilation of the general findings and a summary of common themes that emerged from the Town Hall meetings. The results are organized as follows: General Findings Vision for the Denti-Cal Program Strengths Areas to Improve Recommendations General Findings Over 250 individuals participated in the six Town Hall meetings throughout California. Participation ranged from 27 to a high of 60 individuals, representing a myriad of perspectives. For the most part, participants were very passionate and engaged by the process and had hope that change could and would occur as a result of their participation. The makeup of the groups varied from meeting to meeting. However, participants at each meeting included Denti-Cal providers, dental auxiliaries, clinics, CDA members and in several cases, recipients. Client advocates were present at four of the six meetings. Consumers identified themselves at three of the six meetings. Hospitals and teaching universities were present at two of the six meetings. Representatives of special populations were present at each of the six meetings, in support of a variety of special needs. As noted in Section 1, CDA and DHS representatives were present at each of the meetings. While differences exist across geographic areas and between urban and rural communities, this seemed to have little impact on the overall findings or themes that emerged related to the Denti-Cal program. The overarching conclusion is that the Denti-Cal program is a necessary and beneficial program that can be measurably improved in a number of ways. It would benefit most from defining its mission and vision and in setting priorities for those it can serve. This is 9

in part because participants understand that improvements to the Denti-Cal program in and of themselves will not achieve their vision for California's oral health. Rather, Denti- Cal is one of a number of programs and activities that are working to meet a larger oral health need, namely, that oral health will be seen as part of primary health and that oral health and primary health services will be integrated to ensure a continuum of care. That being said, participants exhibited agreement about both the strengths and the areas of the program that can be improved. They also had considerable agreement about recommendations and the next steps to take in improving Denti-Cal. A summary of the general findings by category can be found below and is followed by a summary of common themes across participant groups for each of the questions posed to the groups. VISION Each of the six Town Hall meetings included a visioning exercise to articulate the attributes of an effective, user friendly system. The individual results by geographic site are found in Appendix B. Several points were common across each Town Hall meeting. The compilation of those common points can be used to articulate the overarching vision. This vision, shared by many participants, is a system where: The community is educated and has an understanding that dental care is a part of primary health care. Therefore, primary and oral health care services would be integrated. This system would focus on education and prevention as well as treatment so that oral health services would be accessed at an early age and both providers and beneficiaries would have incentives for participating in/providing preventive services. The end result would be a community, including health care providers and beneficiaries, who value oral health. Building on this holistic approach, the system would foster interdisciplinary care and would utilize case management services as appropriate to coordinate and integrate appropriate care with an understanding that special populations have unique needs. Appropriate care would be that which considered each beneficiary's best interest regarding their oral health, so that all medically necessary services are covered and provided. To accomplish the provision of appropriate care, decisions and corresponding policies and procedures would be based upon evidence-based scientific research and best practices. 10

Each stakeholder in the system would understand their responsibility and there would be a relationship between the beneficiary, the provider and the payor that defined and balanced both the rights and responsibilities of each stakeholder. Rather than placing the entire responsibility on Denti-Cal to achieve this vision, Denti-Cal would clearly articulate its mission and then set priorities to achieve its mission. Once established, those priorities would be communicated to all key stakeholders with a clear understanding of Denti-Cal's role and the gap between that role and the ultimate vision. This gap would then be addressed through other advocacy and public policy efforts. Once Denti-Cal's priorities were established, the program would be adjusted to account for the difficulty in providing dental services in general and with special needs populations in particular. Adjustments would include reimbursing procedures and providers, including specialties and anesthesiologists, at an appropriate level. Finally, Denti-Cal beneficiaries would have access to and receive care just like any other individual with oral health needs. This would include an awareness of eligibility, an understanding of how to access care, and sufficient providers to offer the care needed. STRENGTHS To build toward this vision, the participants were asked to identify strengths that can be found within or that are part of the Denti-Cal program. These strengths should be leveraged while working toward the shared vision. The full text is found in Appendix B. However, the common strengths of the Denti-Cal program noted by participants are: The social conscience of dentists, their perseverance and passion to provide needed services. The history of the program, its growth and the number of beneficiaries who have received and continue to receive services. Denti-Cal has improved the services available for children and has blocked a potential barrier by not requiring pre-authorization for them. In addition, programs such as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, which requires the provision of all medically necessary services for children under age 21, are seen as a strength. The Denti-Cal program serves the neediest, most vulnerable population in California and is perceived as a good, generous program. 11

Some efforts to communicate with key stakeholders have proven effective, including the Denti-Cal seminars and the Denti-Cal Bulletins. Increased access to preventive care, e.g., sealants, covering 2 prophys per year, and raising fees for porcelain crowns. AREAS TO IMPROVE The participants in each of the six Town Hall meetings were strongly in agreement on many of the areas that can be improved. Detailed areas to improve can be found in Appendix B. A number of very specific areas that could be improved were identified in each of the meetings. Common themes across participant groups fell into five key areas: 1) providers, 2) fees, 3) the paperwork, authorization and appeals process, 4) the appropriateness and type of services covered by the program, and 5) communication. To elaborate: A lack of providers, particularly anesthesiologists and other specialists and difficulty getting access to legitimate, accurate referral lists is a major area to improve. The low reimbursement rate or lack of reimbursement, particularly to hospitals, anesthesiologists, for behavior management and in working with special populations is seen as a major barrier and hinders efforts to recruit more providers. This is exacerbated by the amount and type of paperwork required. Specifically, participants noted that the process for pre-authorization needs to be revised. The paperwork is burdensome and often results in a denial of care. In addition, when approved, the authorization process is complicated and long, often taking 4 to 5 weeks. Finally, the appeal process appears to result in almost an automatic denial. These elements, when added up, result in disincentives for participating in the Denti-Cal Program. The fourth issue where great potential exists for improvement is in the area of services and procedures that are or are not covered, and the corresponding policies and procedures that define coverage. Systems changes that can facilitate authorization and reimbursement of emergency treatment would improve the system. In addition, some policies are perceived as inadvertently pushing practitioners toward medically inappropriate or unnecessary procedures in order to provide needed care, such as pulling teeth to get partial dentures, or discouraging providing quadrant care versus full mouth care when necessary. The fifth issue is one of communication. Many participants noted that providers and beneficiaries lack necessary information about the program and its processes. Mechanisms and tools could be improved to ensure effective communication. 12

Communication is critical related to issues such as eligibility, service providers, reimbursement policies and procedures, and protocols for getting real time answers to questions regarding a beneficiary's care, particularly in an emergency. RECOMMENDATIONS There were a number of specific recommendations made from each Town Hall meeting. It is critical that CDA and Denti-Cal review and respond to all of the recommendations. In some cases it may be necessary to clarify an existing policy or procedure. In others, it would be beneficial to develop a plan to implement the recommendation. Recommendations that were identified at multiple meetings are summarized below: 1. Create a permanent advisory group that will meet regularly to plan, implement and evaluate the changes made to the Denti-Cal Program and provide ongoing input to the program from providers, beneficiaries, and other stakeholders. Five of the six groups suggested that a stakeholder group be convened to work with CDA and Denti-Cal on an action plan. If some such advisory group is convened, they can be used to prioritize and further develop the action steps necessary to implement specific recommendations. A list of participants who volunteered to assist in developing next steps can be found at the end of each Town Hall meeting summary in Appendix B. 2. Promote oral health as part of primary health by developing an interdisciplinary approach to beneficiary treatment. Specifically, it was recommended that DHS and CDA look at ways to incorporate recommendations from the Surgeon General s Report on Oral Health. This could include setting up a case management system to enhance the linkage between primary and oral health systems. 3. Develop a health education component regarding oral health that will engage, involve, and educate health care partners and beneficiaries in the importance of oral health. This could include a public awareness/media campaign regarding oral health with key stakeholders such as medical, oral health, and community mental health providers. The intended outcome of the campaign should be to engage both the public and the private sector in promoting positive education and prevention efforts of the importance of oral health as part of primary health. Specific tools recommended included billboard, radio, website and printed materials including a comprehensive directory of services. 4. Define and evaluate the Denti-Cal program's vision, mission and priorities. It was recommended that Denti-Cal determine how far they are going to take the Denti-Cal program and once that vision is established, set priorities and fund services and recipients based upon those stated priorities. 5. Enhance provider participation in the Denti-Cal program. As one participant stated it, an overarching goal is to reach a time where all oral health providers would want to be Denti-Cal providers. A specific recommendation was to increase the number of 13

providers by providing loan repayment programs for new graduates or incentives such as loan forgiveness for Denti-Cal service provision. Note: In addition to this strategy, it was recommended that a number of other recommendations might also indirectly contribute to enhanced participation in the Denti- Cal Program. These are outlined as recommendations 6 through 10 below. 6. Simplify the Denti-Cal program rules, regulations, authorizations, forms and processes. An overhaul of the pre-authorization, processing and appeals process is recommended to ensure that it is user-friendly, coherent and consistent throughout California. Eliminating red tape where possible, and ensuring that Denti-Cal gives clear and consistent information about issues such as the basis for denial of a reimbursement claim is recommended. 7. Assist in developing a balanced relationship between providers, beneficiaries and the payor. Responsibilities should be defined related to communicating a beneficiary's eligibility and need for care. A clear and concise process must be available to providers and beneficiaries when attempting to obtain information regarding benefits, procedures covered and the overall importance of oral health. Providers should be able to work with Denti-Cal to design processes to hold beneficiaries accountable for their care including the possibility of co-payments or billing for no-show appointments. 8. Use evidence-based scientific research, best practices and medical necessity as the basis for authorizing and providing care. Evaluate and redesign current covered procedures so that evidence-based scientific research and best practices are utilized in the treatment of beneficiaries. For example, it was repeatedly recommended that medical necessity sometimes requires the ability to do more than one procedure per day which would ease a beneficiary's suffering and allow the practitioner to be as efficient as possible. It was also recommended that best practices would include beneficiary appropriate interventions or treatments for beneficiaries with special needs, such as the developmentally disabled and elderly. 9. Evaluate current procedures and reimbursement rates and revise to more appropriately cover the cost for services rendered. It was recommended that an analysis be conducted of current and industry standard reimbursement rates and that the fee schedule be improved for a number of procedures including: specialists, behavior modification particularly for special needs populations, anesthesiologist fees, hospital fees, lab costs, and other fees. 10. Enhance communication processes to increase all stakeholders' access to important information. It is recommended that information including provider lists and eligibility and reimbursement information be made available to all key stakeholders via a number of means including a web site, creating a listserv for Denti-Cal providers, and allowing email communications with Delta dental consultants. 14

4. NEXT STEPS Each of the Town Hall meetings ended in an exercise to frame the next steps that would need to occur to strengthen the Denti-Cal program. This involved consolidating the results of the visioning activities, the areas to improve and the recommendations to determine which concrete action steps should be included as next steps. Where possible, actions were prioritized. Participants were encouraged to solidify recommendations into no more than five action steps so as not to diffuse the efforts of the group. The next steps developed at each Town Hall meeting can be found in Appendix B. In reviewing the next steps suggested by the groups, several issues needed to be considered. First, some recommendations were directly within the scope and control of the Denti-Cal program, whereas other recommendations, such as the public engagement campaign, require partnerships and collaborations with other entities in order to be successful. There was almost universal agreement to convene a stakeholder group to work on many of the recommendations made by the different groups. It is important that resources be used in the most efficient, effective manner, so as to ensure that an end product is actionable and implementable. That being the case, use of multiple work groups involving stakeholders appears throughout the next steps. In considering the next steps that should be pursued first, it was important that the historic nature of the collaboration between CDA and Denti-Cal be leveraged by identifying opportunities for the two entities to work together on next steps, as appropriate. Additionally, some of the recommendations require sequencing, in that certain activities must occur before it makes sense to embark on others. Therefore, foundational recommendations, such as defining Denti-Cal's mission and setting priorities, must take place before Denti-Cal can commit to a public engagement campaign that would ideally be in alignment with those priorities. In consideration of those factors, based upon the recommendations found in Section 3, and incorporating the next steps developed out of the work of each Town Hall meeting, the five most commonly proposed next steps articulated at multiple meeting sites are listed below. However, please note that for the recommendations found in Section 3 to be implemented, more steps will be necessary. Thus, this is simply the starting point for the changes that the participants believe need to take place. The first five next steps are: 15

1. Denti-Cal program leadership and staff will evaluate the Denti-Cal mission and vision and establish priorities. Included in this process will be a consideration of special needs populations. Denti-Cal will then fund based on their mission and priorities with an eye for interdisciplinary care, if that is determined to be part of their mission. 2. CDA and Denti-Cal program shall allocate resources and convene a work group including but not limited to those from among the stakeholder volunteers listed in this report with an interest and expertise in reviewing and revising existing/available procedures to be considered for inclusion (coverage) or not, using the recommendations and areas to improve found at the end of this report. 3. CDA and Denti-Cal will review recommendations, evaluate and identify which recommendations could be implemented via the use of technology and the Internet. This may include mechanisms to communicate with stakeholders, list providers, manage beneficiary benefits (referrals, eligibility, etc.) and communicate changes and progress on issues in this report 4. Once steps 1 through 3 are completed, Denti-Cal will allocate resources and convene a work group, to include, but not limited to representatives from among stakeholder volunteers with an interest and expertise in evaluating, revising and improving the paperwork systems, with the goal of improving the preauthorization system, streamlining forms and reducing red tape. All recommendations or outputs from this workgroup must consider, and where necessary, incorporate the results of steps 1-3. 5. Once steps 1 through 3 are completed, CDA and Denti-Cal program will allocate resources and convene a work group to include, but not be limited to representatives from the stakeholder volunteers list, soliciting those participants with an interest and expertise in evaluating and promoting rate increases based on costs (chair time multiplied per procedure) to closer to UCR. This work group will review the recommendations and areas to improve found in Appendix B and consider lab costs, anesthesia for disabled/young kids, behavior management, premedication in office, as well as the potential for fee increases for exams, x-rays, extractions, and fillings to address costs that have risen since 1992. 5. CONCLUSION Throughout June and July 2001, CDA and DHS engaged in an historic partnership by conducting six Town Hall meetings throughout California for the purpose of soliciting input from the dental community, as well as other stakeholders on ways in which the Denti-Cal program could be improved and made more user-friendly for both the provider and the beneficiary. All parties involved strongly believed this was a valuable 16

opportunity for the dental community and other stakeholders to play an active role in shaping policies that could improve the Denti-Cal program. The Town Hall meetings had three major objectives. They were intended to: 1. solicit feedback from key stakeholders, 2. communicate CDA's and DHS's desire and commitment to help facilitate improvements in the Denti-Cal program, and 3. obtain an understanding of how to better market the Denti-Cal program. Over 250 individuals participated in the six Town Hall meetings throughout California. Participation ranged from 27 to a high of 60 individuals, representing a myriad of perspectives. For the most part, participants were very passionate and engaged by the process and had hope that change could and would occur as a result of their participation. Participants at each meeting included Denti-Cal providers, dental auxiliaries, clinics, CDA members and in several cases, recipients. Client advocates were present at four of the six meetings. Consumers identified themselves at three of the six meetings. Hospitals and teaching universities were present at two of the six meetings. Representatives of special populations were present at each of the six meetings, in support of a variety of special needs. While differences exist across geographic areas and between urban and rural communities, this seemed to have little impact on the overall findings or themes that emerged related to the Denti-Cal program. The overarching conclusion is that the Denti-Cal program is a necessary and beneficial program that can be measurably improved in a number of ways. It would benefit most from defining its mission and vision and in setting priorities for those it can serve. Common themes across participant groups related to improving the Denti-Cal program fell into five key areas: 1) providers, 2) fees, 3) the paperwork, authorization and appeals process, 4) the appropriateness and type of services covered by the program, and 5) communication. Specific recommendations were offered by participants related to each of these themes. In addition, many participants committed to ongoing involvement to help bring about some of the changes they recommended. Their involvement, coupled with the commitment of CDA and DHS, offers a real opportunity to improve not only the Denti- Cal program, but the oral health of many Californians, a vision articulated throughout the Town Hall meetings. 17