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Wednesday, January 23, 2013

Just Open Your Mouth Wide and Say: "Dental Therapist"

Pediatric dental services are included in the essential health benefits standard of the Affordable Care Act. This means the ACA requires  individual and small-group plans sold in the exchanges and outside the exchanges to offer pediatric dental services, as of January of 2014  -- just less than a year from now.   And dental services already are part of the benefit package for children who are enrolled in Medicaid. 

Demand for pediatric dental services is about to increase.  But no one knows by how much.

One thing we do know is that the Centers for Disease Control estimate over two thirds of Americans age 16 to 19 have decay in their permanent teeth. The CDC also estimates one quarter of children start school with tooth decay.  How many of these people will step forward for dental care is unclear. But the school aged population may be screened more consistently for dental problems now that dental problems have been identified as a marker for lost school days and because of increased pediatric dental insurance coverage.

Our Medicaid eligible population is about to boom. Just to give you some sense of scale, you should know that California estimates a further 900,000 pediatric Medicaid enrollees will soon join Medi-Cal, California's version of Medicaid.

Another thing we do know is that about half of all currently Medicaid eligible children have not seen a dentist within the past year. Whether bringing their parents into Medicaid eligibility as part of what is sometimes called a "culture of coverage" will increase pediatric dental demand in the population of Medicaid enrollees is also unclear. This is especially tricky to forecast since Medicaid dental coverage for adults -- an optional program -- is increasingly rare.

One final thing we do know is that some subset of Medicaid enrollees who have tried to access pediatric dental services but failed, did so because of an inability to find a dental provider who would accept Medicaid reimbursement.   This number is hard to quantify but is most often extrapolated from looking at the percentage of licensed practicing dentists in a given service area who accept Medicaid reimbursement.  HHS estimates that twenty percent of the nation's 179,000 practicing dentists accept Medicaid and notes that the licensed dentist pool has not kept up with population growth.  Interestingly, the labor supply of other oral health professionals (dental hygienists, etc.) has kept up with population growth while dentistry has gone grey.

Medicaid dental reimbursements are low. Though they vary from state to state, they can be as low as 25% of market rates.  The National Academy for Health Policy did an interesting study in 2008 comparing Medicaid dental reimbursement rates and the effects of targeted reimbursement increases as well as reduced administrative paperwork. Sure enough, raising the reimbursement rate and lowering the administrative burden increased the number of Medicaid participating dentists dramatically.

Rate thresholds matter, it turns out, but only if a state has the funds to raise Medicaid pediatric dental rate thresholds. Some of those who do not have begun to talk about using dental therapists for some aspects of oral care.  Known as "mid-level providers" for the place they take between dental hygienists and general dentists, dental therapists  are an interesting group. Dental therapists typically have two to three years of training beyond high school. 

Minnesota is the first state to have established a licensing system for dental therapists and advanced dental therapists.  Dental therapists, under either general or indirect supervision, may perform many of the services we now associate with dentistry: charting, cleaning, even some work on cavities and more advanced services.  Minnesota's Board of Dentistry appears to have made at least a temporary peace with what I call dentistry's scope of practice wars -- the rules and regulations regarding supervisory ratios, services that may be offered by dental therapists, and the education and training of dental therapists.

Minnesota's licensing scheme is new. Since 2011, there have been only a  small numbers of graduates. But we do have substantial experience in using dental therapists with under-served rural populations in Alaska. Alaska's Dental Therapist Health Aides ("DHAT") experiment has been moving forward since 2005 under the auspices of the Alaskan Native Tribal Health Consortium. The first DHAT trainee cohort was trained in New Zealand but DHAT's dental therapists are no longer trained overseas, though it is private foundation money that has done much to launch  and extend this experiment.

The results for consumers are good, even very good. Care is available in remote or hard to reach places and is provided in a community context. Quality measures have been quite high.

Now, remote Alaskan locations  are one thing and rural underserved populations in Minnesota are another, but I am pretty certain the dental therapist  scope of practice wars have only just begun. Organized dentistry is concerned about quality standards, educational standards, and the  liability concerns of dental therapist supervisors. Organized dentistry is also worried about oral health care provider competition.

I will watch this story unfold.  California's Children's Partnership's  recent call for the licensing of dental therapists -- in a state with some of the most restrictive scope of practice rules in the United States -- should be worth following.

I tell my students that,  in health care,  innovation often starts in the arena of government funded health insurance and spreads to the world of commercial insurance only later. If Medicaid leads the way in championing  the use of dental therapists as lower cost providers to fulfill its promise of pediatric dental services, I assure you commercial insurance providers both inside and outside of the exchanges will take note.

So, whoever you are,  just open your mouth wide and say "dental therapist."  




Posted by Ann Marie Marciarille on January 23, 2013 at 05:17 PM | Permalink


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Its sad that so many children have tooth infection/decay. Dental visits should begin from childhood.

Posted by: Alice | Jun 3, 2013 8:17:31 AM

That's: 20% of kids scrambling for 4% of dentist patient slots...

Posted by: anon | Jan 23, 2013 9:10:36 PM

Scope of practice is certainly ripe for review but the sources of the law are different in different states (statute, regulation, case law) -- so different that it really ought to be called the scope of practice doctrine.

The federal government can occasionally be observed, through its reimbursement power for federally funded health insurance, attempting to incentivize generous scope of practice interpretation. The best example of this might be the ongoing battles over the Medicare state opt-in to the exemption allowing certified nurse anesthetists to work independently.

As for Massachusetts, I ask your patience. A future post will take a look at the primary care provider shortage. In the meantime, Massachusetts has a ferocious battle of its own raging over -- you guessed it -- dental therapists.

Posted by: Ann Marie Marciarille | Jan 23, 2013 9:10:15 PM

So Medicaid patients are or will be 20% of the population, and 20% of dentists reserve an average of 20% of their slots for Medicaid patients...

That means that 20% of kids will be scrambling for 20% of dentist patient slots...

In the immortal words of Brody in "Jaws": "You're gonna need a bigger boat" (of dental therapists, that is)...

Posted by: anon | Jan 23, 2013 9:10:06 PM

Good point. The data is sparse but the CDC estimates Medicaid participating dentists reserve, on average, 15-20% of their patient panel for Medicaid enrollees. The payor mix numbers tell us what you may have suspected: Medicaid pediatric dental eligibility is a license to hunt, nothing more.

Posted by: Ann Marie Marciarille | Jan 23, 2013 8:41:35 PM

Presumably the Medicaid-accepting dentists do not have caseloads made up of 100% Medicaid patients. Is there any information on how many slots for Medicaid patients there are at the offices of the 36000 dentists who do accept Medicaid?

Posted by: anon | Jan 23, 2013 6:55:34 PM

It seems likely that the Affordable Care Act will be a success only if scope-of-practice regulations are heavily revised to allow much more of the practice of medicine to be done by people who do not have M.D. degrees. Massachusetts has been leading the rest of the country for about five years in this. What has happened to scope-of-practice regulations in Massachusetts that has kept the implementation of RomneyCare to lead to an explosion of medical costs, as demand from the newly-insured surges with limited supply?

Posted by: anon | Jan 23, 2013 6:19:35 PM

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