Reporter follows hygienists' battle to treat vulnerable patients Date: 03/29/18
Ana B. Ibarra
By Mary Otto
Sacramento-based California Healthline reporter Ana B. Ibarra has been following a battle being waged by independent practice dental hygienists who contend that actions by the state of California are forcing them to give up their most vulnerable patients, poor and frail people covered by Denti-Cal, the state’s Medicaid dental program.
In one story late last year, Ibarra captured the scene at a Rancho Cucamonga residential care facility where a visiting dental hygienist Gita Aminloo was caring for one of those patients, Devon Rising, who is blind and disabled. After California cut Denti-Cal reimbursement rates and set new authorization requirements for such visits, Aminloo and other hygienists sued, warning that the changes were making it very difficult to continue to provide needed care.
The state defended the measures as necessary to control costs and prevent unnecessary care. Then, in a March 2 story, Ibarra provided readers with an update on the story. In a ruling, Los Angeles Superior Court Judge Mary Strobel found that the state had failed to obtain permission from the federal government before it cut its rate for a special cleaning by 58 percent and created a new preauthorization process for the hygienists’ visits, Ibarra wrote.
In this Q and A, Ibarra offers insights into her coverage of this unfolding story and what it reveals about the complexities and challenges of obtaining and providing dental care to disabled patients under one state’s Medicaid system. And she provides some words of wisdom to fellow journalists who might want to explore this topic in their own states.
Q: There is a real shortage of oral health care for Americans with disabilities. It can be very hard to find a dentist who treats patients with special needs. That story you wrote late last year opens with a scene featuring dental hygienist Gita Aminloo singing as she worked with her patient, Devon Rising, at his residential care facility. Can you tell us a little more about the techniques these dental hygienists use to bring care to patients with special needs?
A: During my visit to Gita’s appointments at a residential care facility in Southern California, where she brought her own tools and set up shop in the dining room, she saw four patients — all had severe disabilities, but of different types. Some were in wheelchairs while others could sit on a regular kitchen chair as she inspected and cleaned their teeth. Gita required the help of her assistant to keep some of the patients from swinging their heads. They sang nursery rhymes to patients as a way to soothe them. If they weren’t singing, they were speaking to the patient, reaffirming everything would be OK. Occasionally, one would hold on to a patient’s hand, again as a way to calm them and keep them from screaming or moving. They had to be careful as well as quick to not aggravate patients.
Q: The independent practice dental hygienists in your story travel from place to place to bring care to their patients. This model is not used in every state. Do the dental hygienists work with dentists? Do they run their practices all by themselves?
A: While they run their own practice and can do their own work unsupervised, these hygienists aren’t allowed to diagnose patients, so they work in partnership with dentists. In Gita’s case, she says there is one dentist in the area she works in who will see disabled patients. The dentist will take care of the patient’s more intrusive dental work and then refer them to Gita who can follow up with the needed cleanings every three months, as long as both providers get permission from Denti-Cal to do so.
Q: The dental hygienists in your stories have claimed the state’s decisions to reduce their reimbursement rates and to set new reauthorization requirements have made it very difficult for them to continue to provide care for these vulnerable patients. The state has defended its actions, arguing that the steps were taken in order to reduce unnecessary care and bring costs into line. You recently wrote that a Los Angeles County Superior Court judge weighed in on the fight. How did the judge come down on the hygienists’ suit?
A: The lawsuit was based on this idea that the state’s Department of Health Care Services is required to get permission from the federal government before changing the rates for Medicaid providers. The judge said it was not clear why the department didn’t do this and sided with the hygienists.
Q: The dental hygienists you spoke with after the court ruling still sounded discouraged. Why?
A: They say that as long as the Department of Health Care Services, which oversees the Denti-Cal program, appeals and keeps the case in courts, nothing will change soon. They fear this will drag on for months if not years.
Q: Can you tell us a little more about how this is impacting the dental hygienists and their disabled patients?
A: For one, the new X-ray policy makes it very difficult for them to treat their patients, the hygienists say. Their patients have involuntary head movements, they fuss and can’t follow instructions, so getting them to stay still for a decent image of their mouths is almost impossible, they say. Those who have managed to get X-rays of some of their patients say their treatment requests are denied, and without this permission they can’t see patients. Because these dental patients tend to have poor oral hygiene, routine care is essential. When treatment is delayed or dropped, that’s when oral infections happen. As for the hygienists, if their rates are lowered and they lose patients, that means reduced income.
Q: Have state officials had anything more to say about this? Do you plan to continue to follow this story?
A: From the beginning of my reporting, the state has held that the policy changes were made to meet the standard of care in the industry – dentists, for example, are already required to submit X-rays. And yes, I do plan to continue to follow this issue.
Q: Do you have any advice for reporters interested in delving into the challenges of getting dental care to disabled people in their own states?
A: I think writing about dental care for vulnerable populations is so important. Dental care can be complicated to cover because rules vary so much by state, sometimes even by county, and certainly by type of patient. In California, there is a push to improve Medicaid’s dental program, but this will take time and in the meanwhile some folks including vulnerable populations may be going without the much needed care. I would advise that reporters familiarize themselves with how dental services fare in their states for the general population even before setting focus on the disabled. Unfortunately, people with disabilities have to take slightly different routes or jump additional hoops when it comes to accessing dental services, so you want to start by understanding how the system works for the general population.