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CHICAGO — An emerging trend among states is to provide dental access to under-served residents, especially children. According to the 2011 50-state report card from the Pew Center for the States, “More than 16 million children still lack access to basic dental care despite efforts by states to improve their dental health policies.”
Since 2005, Alaska has had midlevel dental practitioners called dental health aide therapists (DHATs). Additionally, Minnesota has midlevel practitioners called dental therapist (DTs).
The University of Minnesota has recently added another new midlevel dental practitioner program in which graduates become advanced dental hygiene practitioners (ADHPs). Meanwhile, non-dentist practitioners are filling cavities, pulling teeth and performing root canals.
California, Connecticut, Kansas, Maine, New Hampshire, Oregon and Washington have all jumped on the bandwagon. These states are considering or are in the process with proposed legislation to create these new midlevel practitioners.
The American Dental Association has opposed the new trend that is being aided and promoted by the W.K. Kellogg Foundation and the Josiah Macy Jr.Foundation.
Given the current budgetary constraints at every level of government, and the already insufficient financing for dental care in most states, midlevel providers do not appear to be viable.
–ADA
The ADA told the Los Angeles Times that a series of studies supporting the establishment of these programs are merely "advocacy documents."
In response, the ADA recently commissioned six studies to document the economic sustainability, viability and issues of improved access of these non-dentist programs. The ADA studies were released on July 25.
The studies were performed by ECG Management Consultants. They produced reports for five of the states — Connecticut, Kansas, Maine, New Hampshire and Washington — and a five-state summary report.
Data were obtained from the ADA, each state’s dental association, dental education programs, community dental health centers and online sources. EGC also interviewed dental association leaders, dentists in public practice clinics and clinic administrators and representatives of dentist and dental provider education institutions, particularly in regard to tuition and program finances.
ECG modeled the training costs and length of training for each of the proposed new categories of midlevel practitioners. It also examined operating costs, probable salaries, academic debt of students and projected earnings and revenues.
These studies included possible payment scenarios including public, private and sliding scale fee systems. The reports contain a number of tables and figures comparing each scenario and offer a road map for legislators and health care organizations to consider before implementing these programs.
The studies said that perhaps the best possibility was to integrate midlevel providers into existing clinics to lower equipment costs, financing and rent. However, the overall results still did not change, and in some of the scenarios the tuition and training burden was not justified for students to enroll, according to the studies. The studies said that the programs would likely need a public subsidy to be successful.
Unsubsidized tuition was based on the actual cost of the Alaskan DHAT program and cost approximately $51,000 yearly, and considered a class size of 30. It was projected that training would cost a similar amount for any of the proposed programs. The studies said that the Alaskan model is quite lean and the costs could easily escalate when applied to other state’s unique situations.
"This is a first step, and not the last word. Certainly, lawmakers and public health authorities should consider the factors examined … before rushing to create dental providers that may be unable to fulfill their intended purpose of reducing health disparities."
ECG checked 45 different scenarios or payment models. Of these, it considered only five viable with positive net revenues. Four of the models were positive for the DHAT model; one involved the dental therapist model. Forty of the scenarios showed net losses ranging from $1,000 to $176,000.
“Given the current budgetary constraints at every level of government, and the already insufficient financing for dental care in most states, midlevel providers do not appear to be viable” the ADA wrote in a press release.
ADA President William R. Calnon said, “It is critical to understand that oral health disparities are a complex set of problems requiring an integrated set of solutions. Medicaid relief, community water fluoridation, oral health education and helping people overcome cultural, geographic and language barriers are critical components of this.”
The ADA said that non-dentists should not perform irreversible surgical procedures and that the midlevel practitioners programs are “the wrong way to go.”
The ADA said “the research is not all encompassing, but to our knowledge, no one has considered … the question (economic viability) comprehensively." According to the press release, the ADA encourages stakeholders to “avoid wasting constrained resources on programs that ultimately are not sustainable.”
Calnon said, “This is a first step, and not the last word. Certainly, lawmakers and public health authorities should consider the factors examined … before rushing to create dental providers that may be unable to fulfill their intended purpose of reducing health disparities”
See PBS video about dental therapists in Alaska.
Mel Borup Chandler lives in California. He writes about science-related topics, technological breakthroughs and medicine. His email address is mbccomentator@roadrunner.com.
