Teledentistry Could Boost Access to California's Poor Kids But Is Little Used. Why?

At a Head Start center in San Mateo County, preschoolers are receiving their first-ever dental exam, but there’s not a dentist in sight.

Instead, dental hygienists give each child a teeth cleaning, X-rays, and take pictures of their teeth. These images are transmitted via a Cloud-based server to Dr. Yogita Thakur, who reviews them from her office at Ravenswood Family Dentistry in East Palo Alto, 6 miles away.

“This is how we reach children in areas where dental care is usually limited,” Thakur said.

This process, called telehealth, allows dentists to diagnose, treat and educate patients remotely, rather than in person.  The primary aim is to bolster preventive care, but if the dentist sees that significant work is required, such as a root canal or crown, an in-person appointment can be scheduled.

The need for such innovation seems readily apparent.

“Most people in our society are not getting dental care,” said Dr. Paul Glassman, director of the Pacific Center for Special Care at the University of the Pacific School of Dentistry.

Despite dental problems being the No. 1 chronic disease that children face, a state audit of Medi-Cal’s dental program last year found that less than half of the 5.1 million children enrolled in the federal-state health plan for the poor were receiving care.

With the goal of changing that statistic, a law that went into effect this year requires Medi-Cal providers to be reimbursed for dental services provided through telehealth.

But as of July, only seven dentists in the state had billed the dental arm of Medi-Cal, called Denti-Cal, for teledentistry services.

A number of factors may be contributing to the law’s ineffectiveness, but few doubt that the key reason is Medi-Cal’s remarkably low reimbursement rates.

A report released by the Department of Health Care Services in July showed that Denti-Cal reimbursements are less than one-third of the national average paid by commercial insurance.

Some providers have stopped accepting new Denti-Cal patients altogether.

“Increasing reimbursement rates so they are sufficient to cover the cost of care is important to ensuring providers can participate in the Denti-Cal program, and that applies to whatever delivery model is used,” said Alicia Malaby, a spokeswoman for the California Dental Association (CDA).

In addition to the question of payment, providers may be wary of using teledentistry simply because “it’s a very different style of providing dental services,” Glassman said.

Some dentists worry that teledentistry will lead to increased competition for patients, but “it’s actually a way of expanding dental practice,” he said.

Glassman began developing a teledentistry model of care, called the Virtual Dental Home (VDH), 10 years ago.

“The idea was to figure out how to get to where the vulnerable populations are,” Glassman said.

A six-year pilot project demonstrated that virtual dental care could not only work, but reduce the cost of care as well.

“We’ve tested (the VDH model) in a number of different areas and populations. Head Start schools, Early Head Start, adults in residential care, low-income community centers, all the way up to nursing homes,” Glassman said.

These populations are some of the estimated 30 percent of Californians (about 11 million people) who face barriers to dental care.

One of the benefits of the VDH model is “its ability to facilitate patients’ access to the full dental team and comprehensive dental care,” Malaby said.

“I can sense the hesitancy because it’s so new,” Thakur said. “Providers think, ‘I did not really see and touch the patient, so how can I make a recommendation for their care?’ ”

Glassman understands the reluctance.

“I often joke when I’m speaking to dental hygienists, ‘How many of you remember the class you took on telehealth in dental school?’ ” Glassman said. “Because of course, there’s no such class.”

Providers need information and training to feel comfortable with teledentistry, said Carmela Castellano-Garcia, CEO of the California Primary Care Association (CPCA).

“Getting the word out on this is going to be top priority,” Castellano-Garcia said.

The CPCA is working with California’s new dental director, Dr. Jayanth Kumar, to provide new training programs.

Securing funding for teledentistry models is another challenge.

The CDA is co-sponsoring AB648, which would provide funding for implementing the Virtual Dental Home in new areas.

“It’s always a long process,” Castellano-Garcia said. “But ultimately, this is going to expand dental care in the state.”

At Ravenswood, the dental team wants to continue using the VDH model to reach low-income children as early as possible. About 80 percent of pediatric dental disease is found in low-income populations, Thakur said.

“The idea here is to prevent dental disease from ever happening.”

Hellesen writes for the California HealthCare Foundation Center for Health Reporting at the USC Annenberg School for Communication and Journalism.