When my wife and I lived in Breathett County, Ky., an often-unemployed neighbor in his thirties had two teeth. The rest had been pulled when he was an adolescent and young adult by his grandpa as they became decayed and painful. When we moved to rural Maine it took five years before I found a (new) dentist in our two-county area who would see me. These reflect a couple points. Many dentists won’t see poor people on Medicaid, and there is a shortage of dentists in most of America except the affluent urban areas. (We won’t mention that I’m too stubborn to take my health care money into the city.)
It has been hard to get dental care for rural and poor people for the 45 years I’ve been in health care, and I was an intern 45 years ago. Organized dentistry argues with some validity that Medicaid doesn’t pay enough. I’m sure it is true that in states paying as little as 30 percent of customary charges, reimbursements won’t even cover the costs of care. On the other hand, organized dentistry has the reputation of being a formidable political force. In my experience at medical schools in Washington and Kentucky, I saw that political campaigns were able to reduce dental school class sizes through the state legislatures. As part of my job, I lobbied in Alaska, Montana, Idaho and Kentucky, where I was not personally aware of organized efforts to increase state Medicaid dental reimbursement. I may have just been in those capitols at the wrong times.
Medicine has extended practice privileges to nurse practitioners and physician assistants very considerably. When my wife went to the emergency room three years ago with a brand new bend in her arm, the only evident physician involvement was to order films and call the orthopedic physician assistant. The PA anesthetized and reduced the significantly displaced fracture, casted it, checked it periodically and removed the cast two months later with a completely satisfactory outcome. Yet organized dentistry generally maintains that only a dentist can be taught to drill and fill a cavity. In recent years that position is being seriously questioned.
The first serious breach in this country came from southwestern Alaska. The Yukon Kuskokwim Health Corporation is a consumer-controlled entity providing comprehensive health services to 50 Native American communities scattered across a roadless area about the size of Oregon. As in most of village Alaska, medical services are provided by Community Health Aides working in modern clinics with a defined formulary and a communications link to a physician at the headquarters hospital. This highly developed medical system, operating outside state licensure (as a quasi-tribal facility), has evolved over the last 40 years and works quite well. About 10 years ago the decision was made to adapt the health aide model to dental services.
The Alaska Dental Health Aide Therapist model was born. The American Dental Association testified before Congress on the dangers of having unqualified personnel performing permanent surgical procedures (i.e., fillings and extractions), but failed to convince Congress to stop the program. The first classes of therapists were trained in New Zealand, where there was already a training program in place—there were none like it in the United States at the time. Current classes receive two years of intensive training at the University of Washington School of Public Health in Seattle alongside the MEDEX Physician Assistant students. They conduct itinerant practices in the villages or work in fixed clinics in regional centers. Very high levels of patient satisfaction have been documented.
Minnesota has new legislation recognizing its own “dental therapist.” Upon completion of a curriculum currently available at Metropolitan State University, and 2,000 hours of supervised practice, the practitioner may become an “advanced dental therapist,” authorized to provide most dental care including extractions of permanent teeth in specified circumstances, without a dentist on site.
Dentistry seems to be in the position of medicine in the 1950s regarding solo practice, physician assistants and nurse practitioners. There were a few nurse practitioners, mostly trained by the docs they worked with, and they practiced in only a few states, but the AMA desperately tried to keep them out. The poor are paying the price. The “only I can do what I do” defense isn’t going to work much longer. Expensive equipment being used by one dentist a few hours per month is hard to justify. The objectives must be to reduce costs and get care closer to where poor people are. That probably means the gradual demise of lots of solo cottage practices including some rural practices.
The W.K. Kellogg Foundation expects to invest $16 million in Kansas, New Mexico, Ohio, Vermont and Washington by 2014 in hopes that these states will adopt dental therapist programs. The Pew Center for the States has released a methodology titled It Takes a Team that permits a dentist to plug in variables to assess the addition of a dental therapist to his or her practice in the care of Medicaid patients. The results of the study generally show a positive outcome. The American Dental Association takes issue with the methodology.
What’s your state doing?
Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.
Back to: Spring 2011 Issue