Dental therapist = dentist

[setdoc7]

Doubtful - #1 If you know of VT (and I have a 2nd home there in a fairly rural part of the state), once you get outside of Burlington (meaning about 98.5% of the state) it generally very rural with some occasional small towns and small "cities" that has an economy that is nowadays generally seasonal tourism based. These are the generally "underserved" areas that politicians intend (wish) that the mid levels will practice in. Unless someone likes living in a rural area, this will be a tough lifestyle sell for them

#2 - It's not like VT's mid level program will be turning out thousands of mid level providers a year. The numbers that I've heard floated around are somewhere around 15 - 20. It will take a long time to train and have a significant amount of mid levels potentially begin treating patients in VT, and that assumes that there will be continued interest by potential mid levels for years to come

#3 - As I have said over and over again - economically, a mid level CAN'T provide treatment any more cost effectively than a dentist can - the reimbursement fee schedule is the same, the materials costs are the same, etc. Especially with a medicaid based population, the fees that a dentist or a mid-level work off of are at best just covering our overhead, and often working at a loss. You will not see a mid-level providing cheaper care than a dentist can, unless of course the state or federal gov't chooses to subsidize a mid-level provider, at which point their decreasing the overall pool of medicaid dollars to go around by spending more of it on a smaller subset of people

#4 - the "access problem" very often isn't finding a dentist who will treat them, it's finding a dentist who will treat them for free..... Good luck with that

I agree with you. Further, the whole "access" argument is skewed. In a recent correspondence with HRSA, I asked how the Bronx, NY, the area where my residency program is, has been designated a federally qualified dental shortage area. Specifically I asked if the residency positions, which are filled avery year, are counted. The Bronx, NY, for those who do not know, has the most residency positions of any county in the country. The residency positions are mostly funded by GME money. HRSA answered that they are not counted. LOL. If these positions were included (almost 200 dental residents working full time) I wonder if this designation would change?

The argument that corporate dentistry will hire therapists is a good one. They can be paid less. This works. Where corporate dentistry works.

The dental public health residency at my institution continually argues that therapists will free up dentists to do more complex procedures. That assumes there is an increased volume of these complex procedures to do. Since most of the public health people I know work in ivory towers, I often feel they are out of touch with the private practice world, and spout reasoning which has no reflection on reality.

I feel the cost of running an office will be too great for individual therapists to shoulder, as the compliance and overhead are too great for their limited scope of practice. The only way they will infiltrate our domain is by working as a salaried employee for a group of dentists, or corporate. IMHO. With that said, I also believe they should be under direct supervision. As we know, "things happen" and without a licensed dentist on hand to take care of any misadventure, the patient will be at risk.

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[DoctaFauci]

I agree with you. Further, the whole "access" argument is skewed. In a recent correspondence with HRSA, I asked how the Bronx, NY, the area where my residency program is, has been designated a federally qualified dental shortage area. Specifically I asked if the residency positions, which are filled avery year, are counted. The Bronx, NY, for those who do not know, has the most residency positions of any county in the country. The residency positions are mostly funded by GME money. HRSA answered that they are not counted. LOL. If these positions were included (almost 200 dental residents working full time) I wonder if this designation would change?

The argument that corporate dentistry will hire therapists is a good one. They can be paid less. This works. Where corporate dentistry works.

The dental public health residency at my institution continually argues that therapists will free up dentists to do more complex procedures. That assumes there is an increased volume of these complex procedures to do. Since most of the public health people I know work in ivory towers, I often feel they are out of touch with the private practice world, and spout reasoning which has no reflection on reality.

I feel the cost of running an office will be too great for individual therapists to shoulder, as the compliance and overhead are too great for their limited scope of practice. The only way they will infiltrate our domain is by working as a salaried employee for a group of dentists, or corporate. IMHO. With that said, I also believe they should be under direct supervision. As we know, "things happen" and without a licensed dentist on hand to take care of any misadventure, the patient will be at risk.

There are three types of HPSA scores: geographic, population, and facility. Access to care can still be an issue in an area oversaturated with dentists. There are numerous metrics taken into account, hence why dental is rated on a 0-26 scale. FQHCs that accept Medicaid and operate on a sliding fee scale may achieve a facility HPSA designation in the middle of a large urban area, such as NYC, b/c populations exist that are still priced out of the market, despite a surplus of dentists.

In most current and evolving models, dental therapists must practice under the direct/indirect supervision of a dentist and are usually limited to seeing at least 50% Medicaid patients (thus freeing clinicians to see more complex procedures in practices that currently accept Medicaid patients). They're basically a public health hygienist with limited restorative provisions. Their principal utility is in FQHCs, Title 1 schools, and rural areas. There is little evidence to suggest that they encroach upon the financial markets of current dental practice. Any assertion to that claim is not evidence-based. I am not advocating for dental therapists; I would rather see schools augment admissions to recruit dentists from underserved areas and URMs. However, it would be prudent of organized dental to own this model and write the policy to ensure that therapists indefinitely practice under the license of a dentist, or let the politicians write the future of our profession.

 

[setdoc7]

There are three types of HPSA scores: geographic, population, and facility. Access to care can still be an issue in an area oversaturated with dentists. There are numerous metrics taken into account, hence why dental is rated on a 0-26 scale. FQHCs that accept Medicaid and operate on a sliding fee scale may achieve a facility HPSA designation in the middle of a large urban area, such as NYC, b/c populations exist that are still priced out of the market, despite a surplus of dentists.

In most current and evolving models, dental therapists must practice under the direct/indirect supervision of a dentist and are usually limited to seeing at least 50% Medicaid patients (thus freeing clinicians to see more complex procedures in practices that currently accept Medicaid patients). They're basically a public health hygienist with limited restorative provisions. Their principal utility is in FQHCs, Title 1 schools, and rural areas. There is little evidence to suggest that they encroach upon the financial markets of current dental practice. Any assertion to that claim is not evidence-based. I am not advocating for dental therapists; I would rather see schools augment admissions to recruit dentists from underserved areas and URMs. However, it would be prudent of organized dental to own this model and write the policy to ensure that therapists indefinitely practice under the license of a dentist, or let the politicians write the future of our profession.

The residents I have mentioned almost exclusively treat patients who have Medicaid, Medicaid Managed Care, or are uninsured and treated on a sliding fee scale. They are not counted by HRSA.
The majority of patients seen at my center who are covered by Medicaid recieve restorations and simple extractions. Medicaid does not cover many complex procedures for adults, other than removeable, and the guidelines for approval are strict. Once a removeable prosthesis is made, it is many years before it can be remade, even if it is clearly necessary. Why would a dentist in this type of environment want to give away the main procedure, operative.
I would rather see the D schools emulate the public health model started in AZ. Send the 3rd of 4th year D students out to underserved areas to provide care. They receive invaluable experience, and the public in underserved areas are treated.

 

[DoctaFauci]

The residents I have mentioned almost exclusively treat patients who have Medicaid, Medicaid Managed Care, or are uninsured and treated on a sliding fee scale. They are not counted by HRSA.
The majority of patients seen at my center who are covered by Medicaid recieve restorations and simple extractions. Medicaid does not cover many complex procedures for adults, other than removeable, and the guidelines for approval are strict. Once a removeable prosthesis is made, it is many years before it can be remade, even if it is clearly necessary. Why would a dentist in this type of environment want to give away the main procedure, operative.
I would rather see the D schools emulate the public health model started in AZ. Send the 3rd of 4th year D students out to underserved areas to provide care. They receive invaluable experience, and the public in underserved areas are treated.

Do all of those clinics have associations with a primary care medical provider and appropriate referral base? Do they treat the full scope of dental practice? There are multiple criteria HRSA utilizes to determine issues regarding access to care. Residents are not an ideal dental home due to inconsistency with provider turnover. They also practice under limited licenses in most cases, and probably aren't counted for that reason.

A dentist or clinic in that environment also wouldn't have need for a dental therapist, b/c they are strictly treating that patient population. The argument for therapists concerns areas where there is a dentist shortage or in mixed income practices that may see a small proportion of Medicaid patients for a therapist to see that population while the dentist treats more lucrative, fee-for-service procedures. The therapist is essentially salaried like an expanded function hygienist but brings in more revenue. It also depends on the state, as Medicaid varies drastically by state concerning reimbursement. It is simply not worth a dentists time to see Medicaid patients in a state like FL b/c reimbursement is so low.

AZ is a fine model; GA and ECU in the south do this as well. However, many states do not have the infrastructure (FQHCs, clinics) to support students, and many dental schools claim to run too large a deficit to not have students producing in the main clinic (even though we know undergrads produce paltry numbers).

 

[tc434]

This is a way out there idea and not about dental therapists as mid-level providers, but what if all dentists had to do 1 year of service after graduation to provide service to underserved populations? How many more people would have access to care? They would be licensed dentists working (for peanuts) in (federal/state government) clinics in underserved areas around the country. Students loans would not accrue interest during that year. I know the idea of being required to do something is a big deal breaker but there are how many thousands of dental students that graduate each year?

 

[Cold Front]

This is a way out there idea and not about dental therapists as mid-level providers, but what if all dentists had to do 1 year of service after graduation to provide service to underserved populations? How many more people would have access to care? They would be licensed dentists working (for peanuts) in (federal/state government) clinics in underserved areas around the country. Students loans would not accrue interest during that year. I know the idea of being required to do something is a big deal breaker but there are how many thousands of dental students that graduate each year?

That would be a novel idea. However, who would have the authority to manage and run such program? Surely state level dental boards would be the best option, but since all states wouldn't unanimously agree on the idea, you would see a large number of graduating dentists avoiding to go to a state that has the 1-year mandatory dental shortage area practice program. So you really didn't solve the problem, you actually made it worse by alienating dentists and eventually creating more shortage areas at those states. The NHSC is already there to help shortage area, along with many loan forgiveness programs at state level, so this isn't about expanding those programs, although they are growing due to the higher student loans, but they won't solve the big picture.

DrJeff said it best, this is not about access, it's about people wanting free dental service. 3 states were brave enough to increase their Medicaid fees from 35% to 70% to what private insurances would normally pay, and suddenly dentists were roaming all over those states by accepting Medicaid plans. Texas, Connecticut and Maryland are number 1 targets for corporate dental offices like Kools Smiles, who specialize in kids Medicaid dentistry, and just in it for the greed, but also help with access issues. I didn't look up, but I bet those 3 states have the lowest shortage areas than any other state.

Again, unfortunately, better access = free care for patients = better reimbursement rate for dentists. All those 3 factors must co-exist to solve the shortage problems. Dental therapists idea by the state governments is just flipping the middle finger at dentists who refuse to get reimbursed less, and it's not the solution the public or the profession needs.

 

[DoctaFauci]

This is a way out there idea and not about dental therapists as mid-level providers, but what if all dentists had to do 1 year of service after graduation to provide service to underserved populations? How many more people would have access to care? They would be licensed dentists working (for peanuts) in (federal/state government) clinics in underserved areas around the country. Students loans would not accrue interest during that year. I know the idea of being required to do something is a big deal breaker but there are how many thousands of dental students that graduate each year?

There is abundant research on this. http://www.ncbi.nlm.nih.gov/pubmed/16803811

Long story short, it isn't enough and private practice dentists have to begin seeing indigent populations.

 

[setdoc7]

There is abundant research on this. http://www.ncbi.nlm.nih.gov/pubmed/16803811

Long story short, it isn't enough and private practice dentists have to begin seeing indigent populations.

I do not think forcing the private practice dentist to treat "indigent" patients is the answer. The cost is prohibitive and goes against the free enterprise model. No other health care industry does this. The school model would work better, in my opinion, if those who were in control of the schools (administration) would jump into the 21st century. Mobile dental units are a moderate investment that can be used to transport care into areas where brick and mortar clinics would be too expensive. Many of the D schools do not have enough chair space as it is, and these mobile centers would free up the school clinics. Students do not need to miss any lectures, as they could be streamed to them. Treatments in these units would go directly to the school as reimbursement, so no loss of revenue. No salaries for the students another advantage.
Dental schools running at a loss or at low remuneration is on administration, and they should find ways to cut costs in order to streamline the overhead which they are aware of. Revenue shortfall in D school has generally meant increasing tuition. I believe that cost cutting can be done by trimming faculty, restructuring use of existing facilities, and sharing expenses with other schools within the university. Unfortunately, there are too any kingdoms within universities and not enough cooperation. This goes for the structure of D school as well. Just my opinion.

 

[DoctaFauci]

"I do not think forcing the private practice dentist to treat "indigent" patients is the answer. The cost is prohibitive and goes against the free enterprise model."

Dentistry is principally a profession, not a for-profit enterprise. We have a responsibility to society to reduce oral health disparities and increase access to care. Less than 30% of dentists treat Medicaid in any capacity nationwide. That is not acceptable. Other sectors of healthcare have been profiting off Medicaid/Medicare for some time, and it is the lack of advocacy from the dental profession over time which has led to poor schedule reimbursement for Medicaid in dentistry.

" The school model would work better"

As the above study, and many more, demonstrate, the capacity of 60 schools and even increased PGY-1 models does not even make a significant dent in reducing access to care. Well over 100 million people in this country do not visit a dentist annually, and the majority of that have not seen a dentist in several years. Mobile dentistry is good for preventive dentistry, not so much for creating dental homes.

"Dental schools running at a loss or at low remuneration is on administration"

I don't think you begin to grasp how expensive it is to run a dental school. Even an efficient private practice with experienced dentists runs at 70% overhead. Dental schools don't come close to being efficient, even if they are well administered. There's a reason several notable schools closed: Northwestern, Georgetown, Emory, etc.

 

[DrJeff]

Dentistry is principally a profession, not a for-profit enterprise. We have a responsibility to society to reduce oral health disparities and increase access to care. Less than 30% of dentists treat Medicaid in any capacity nationwide. That is not acceptable. Other sectors of healthcare have been profiting off Medicaid/Medicare for some time, and it is the lack of advocacy from the dental profession over time which has led to poor schedule reimbursement for Medicaid in dentistry.

Do we as dentists also have an "obligation" to loose money, since after all most of us are business owners and EMPLOYERS who have multiple people essentially depending on us to help provide their livelihood via employment. When medicaid is reimbursing one far less than what our overhead is for that procedure, you can't see too many people on medicaid and still remain in business. In my own practice, for adult medicaid patients, my reimbursement is between 20-25% of my usual fee depending on the specific procedure, and while my accountant keeps telling my partner and I that we run a fairly efficient office, our overhead is well over double that. There is absolutely nothing wrong with making a profit in the profession of dentistry, we have all taken a great deal of time and expense to acquire the skill set that we have and as such deserve to be compensated for that.

As the above study, and many more, demonstrate, the capacity of 60 schools and even increased PGY-1 models does not even make a significant dent in reducing access to care. Well over 100 million people in this country do not visit a dentist annually, and the majority of that have not seen a dentist in several years. Mobile dentistry is good for preventive dentistry, not so much for creating dental homes.

You're making the assumption that all of those that currently aren't seeking dental care for a host of reasons, actually want to seek dental care. That is the difference between "access" to care and "utilization" of care. The reality is that there are some people who no matter what system you try and implement to deliver care, just won't want care. How much extra expense, expense that can take away from care for others should we put forth to try and achieve the unrealistic goal of 100% utilization given the finite pool of resources there is? I don't know what that answer is, and I'm sure that it will vary from person to person

 

[CanaDMD]

Do we as dentists also have an "obligation" to loose money, since after all most of us are business owners and EMPLOYERS who have multiple people essentially depending on us to help provide their livelihood via employment. When medicaid is reimbursing one far less than what our overhead is for that procedure, you can't see too many people on medicaid and still remain in business. In my own practice, for adult medicaid patients, my reimbursement is between 20-25% of my usual fee depending on the specific procedure, and while my accountant keeps telling my partner and I that we run a fairly efficient office, our overhead is well over double that. There is absolutely nothing wrong with making a profit in the profession of dentistry, we have all taken a great deal of time and expense to acquire the skill set that we have and as such deserve to be compensated for that.





You're making the assumption that all of those that currently aren't seeking dental care for a host of reasons, actually want to seek dental care. That is the difference between "access" to care and "utilization" of care. The reality is that there are some people who no matter what system you try and implement to deliver care, just won't want care. How much extra expense, expense that can take away from care for others should we put forth to try and achieve the unrealistic goal of 100% utilization given the finite pool of resources there is? I don't know what that answer is, and I'm sure that it will vary from person to person

Saying it's making a profit plays right into DMD_2016's post. But nevertheless, great post.

DMD_2016 : do you believe dentists should have a salary? Or should they work for their entire careers without taking home a penny? The "for profit" business in dentistry is essentially paying the dentist the salary he's earned. The percentage of profit in dental clinics doesn't count a dentists' fair salary. Count that in and not much is left.

 

[CarpenterDntist]

Great news: the Dental Hygiene Practitioner amendment just failed in Massachusetts-it was rejected by the Conference Committee and not included in the state budget released last night. The proposal is killed for this legislative session. The state dental society put out an aggressive ad and communications campaign and it worked. Hopefully now they can work with the state government to come up with a real solution to the access to care problem.

 

[setdoc7]

Dentistry is principally a profession, not a for-profit enterprise. We have a responsibility to society to reduce oral health disparities and increase access to care. Less than 30% of dentists treat Medicaid in any capacity nationwide. That is not acceptable. Other sectors of healthcare have been profiting off Medicaid/Medicare for some time, and it is the lack of advocacy from the dental profession over time which has led to poor schedule reimbursement for Medicaid in dentistry.



As the above study, and many more, demonstrate, the capacity of 60 schools and even increased PGY-1 models does not even make a significant dent in reducing access to care. Well over 100 million people in this country do not visit a dentist annually, and the majority of that have not seen a dentist in several years. Mobile dentistry is good for preventive dentistry, not so much for creating dental homes.



I don't think you begin to grasp how expensive it is to run a dental school. Even an efficient private practice with experienced dentists runs at 70% overhead. Dental schools don't come close to being efficient, even if they are well administered. There's a reason several notable schools closed: Northwestern, Georgetown, Emory, etc.

What exactly do you know about the finances of any dental school? And the 70% overhead is something you read, it is not written in stone. And what century are you living in? NW, Georgetown, and Emory closed is the 80's. Far more schools with far more seats have opened within the last 10 years. And until my practice gets not for profit status, dentistry is a business, a big business. If you doubt that, ask Dentsply, Nobel, J&J, Henry Schein, Astra Zeneca, and a long list of other companies.
Dental home is a public health term that appears interesting on paper, but the financial burden is clearly too great for any new grads to shoulder in a dental shortage area where there is not enough remuneration other than Medicaid. The start up alone is overwhelming. The therapist model only works when there is direct dentist supervision. The underserved population you describe does not need a simple buccal pit or occlusal restoration. They need full mouth oral rehab, beyond their scope.
And other sectors of healthcare "profiting" from Medicaid? Several years ago in a cost cutting plan, NY summarily cut its Medicaid reimbursement by 20%. What business can survive that type of across the board loss? Access to care means an entire restructuring of the way we train our doctors and deliver care, from the bottom up. Until then, every new venture will be just a band-aid.

 

[Cold Front]

Great news: the Dental Hygiene Practitioner amendment just failed in Massachusetts-it was rejected by the Conference Committee and not included in the state budget released last night. The proposal is killed for this legislative session. The state dental society put out an aggressive ad and communications campaign and it worked. Hopefully now they can work with the state government to come up with a real solution to the access to care problem.

That's interesting. MA is the first state that I'm aware of that denied the DT bill so far.

Michigan is the latest state that throws it's hat in the ring: http://www.mlive.com/opinion/index.ssf/2016/06/commentary_allowing_dental_the.html