THERAPISTS & ADVOCACY

Presented ByCarter Brown, DMD, FAGD, FACD, FICD, FPFA

Vice President, Academy of General Dentistry

Why the Interest?

What the Policy Makers See82 million with limited care

The Governmental Efforts

& Safety Nets• Populations underutilizing available services• Up to a third of the population do not get care from the

Private Market• Depends on a set of uncoordinated programs and policies:– Systems: FQHCs, VA, HIS– Policies: Medicaid, CHIP– Other: Volunteer Pro Bono Care, Free Clinics, Dental Schools,

Corporate Medicaid practices, other community and public health programs

• Limited capacity and overall has not addressed the underutilization in substantive way

Policy Makers Are Lookingat the Wrong Things

They Don’t Understand, YouCan Never Get 100%

Source: National Healthcare Disparities Report 2005, Department of DHHS

DENTAL VISITS IN THE LAST YEAR

Source: IADR March 2007, Medical Expenditure Panel Survey

1996 MEPS Visit No visit Total

< FPL 4,320,000 9,210,000 13,530,000

100 < 200% 4,650,000 10,250,000 14,900,000

200 < 400% 12,750,000 10,530,000 23,280,000

400% + 10,170,000 5,540,000 15,710,000

Total 31,890,000 35,530,000 67,420,000

2004 MEPS

< FPL 4,410,000 7,910,000 12,320,000

100 < 200% 5,700,000 9,120,000 14,820,000

200 < 400% 11,860,000 10,990,000 22,850,000

400% + 13,620,000 6,140,000 19,760,000

Total 35,590,000 34,160,000 69,750,000

DHHS Responses:• OIG Report on EPSDT Dental Service Utilization (1996) –

< 1-in-5 getting any dental services• HCFA/HRSA Oral Health Initiative (1990s)• Surgeon General’s Conference, Workshop and Report on

Oral Health (1999–2000)• NGA Oral Health Policy Academies (2000–2001)

Congressional Responses:• GAO Reports, Midlevel trials proposed• Legislation• Hearings (Deamonte Driver)

WHO• Alaska ANTHC • Minnesota Legislature, University of Minnesota, Metropolitan

State Normandale• Renewed CMS attention/new administration• Prominent foundation involvement:– PEW– Kellogg• HRSA / CA Health Foundation-funded Institute of Medicine

(IOM) studies• Public Health Dentists, Small core group• ADEA, interest expressed in the model

Access No set definition, clouds the debate

• Access: AGD Making Dentistry Available

– Patient Education and Responsibility– Affordability – Sufficient Medicaid/insurance coverage to

make healthcare affordable for patient– Availability – Incentives/financial support to enable dentists

to serve in underserved/rural areas

History on Midlevels• In 1917, ‘Dental Dressers’ were established in

some counties in England:– The first dental therapists– American hygienist with the addition of ‘filling those

cavities without pulpal involvement’ and ‘the extraction of ‘temporary teeth in school clinics’

– Desperate shortage of school service dental officers– First World War– The Dental Act of 1956 there were enough dentists to

work in the service and the dresser’s duties were reduced to that of a hygienist

History on Midlevels• In 1920, New Zealand established a School Dental

Service:– Called Dental Nurses– Were the first contact point for rural patients with an onward

referral to a dentist if necessary

History on Midlevels• Back to the UK:– In 1950, there was once again a desperate

shortage of dentists in the school services– Following visits to New Zealand the Dentist Act of

1956 was changed to allow the training of Dental Auxiliaries – however, Dental Auxiliaries would be referred patients by the Dentist

History on Midlevels• In 2002, British Association of Dental Therapists caused

the Dental Act to be amended• Dental Therapists were allowed to work in general

practice and along with that the SOP finally changed and ‘extended duties’ were added

• In every country that has therapists, these associations become a political force and SOP continually expand

Added Procedures in England• Scaling and polishing

• Apply materials to teeth such as fluoride and fissure sealants• Take dental radiographs• Provide dental health education on a one to one basis or in a group situation• Routine restorations in both deciduous and permanent teeth, on adults and

children, from Class 1-V cavity preparations• Can use all materials except pre cast or pinned placements• Treats adults as well as children• Extract deciduous teeth under local infiltration analgesia• Pulp therapy treatment of deciduous teeth• Placement of pre formed crowns on deciduous teeth• Administration of Inferior Dental Nerve Block analgesia• Emergency temporary replacement of crowns and fillings• Take impressions• Treat patients under conscious sedation provided the dentist remains in the

surgery throughout the treatment

Where Are They?

• Alaska• Australia• New Zealand• Canada• Great Britain• Various other smaller projects

Alaska DHATPer the DHAT Website

• DHAT:– 10 practicing DHATs trained in NZ– Since 2003, only one has stopped practice in AK– First training center in the US, partnership with UW

• MEDEX– 9 graduates, 13 in training– Predict: 32 DHATs in AK by 2012– PDHA -11 cert (22)– EFDHA -12 cert (23)– DHAH - 0 cert– Role models for younger

Alaska DHAT

• Alaska DHAT training program information:

– First year: 40 weeks– Second year: 39 weeks– Total: 79 weeks (3,160

hours)

• Curriculum breakdown, first year:

– Biological Science: 30%– Social Science: 10%– Pre-Clinic: 40% (623 hours)– Clinic: 20% (316 hours)

• Curriculum breakdown, second year:

– Biological Science: 15%– Social Science: 7%– Pre-Clinic: 0%– Clinic: 78% (1,215 hours)

• Curriculum breakdown, two years combined:

– Biological Science: 22.5%– Social Science: 8.5%– Pre-Clinic: 20% (632

hours)– Clinic: 49% (1,548 hours)

Alaska DHAT

• After graduation, 400 hours preceptorship

• Standards and procedures:–Standing orders–Renewal every two years

Australia

• Dental therapists have practiced in Victoria since 1975.• Since 2000, movement of dental therapists into new

work settings such as private, community, and hospital practices.

• Prior to 2000, dental therapists were limited to children attending school.

• Now provide up to eighteen years and, upon the prescription of a dentist, from nineteen to twenty-five years.

• In orthodontic practices, care prescribed by an orthodontist or dentist may now be provided by dental therapists to clients of all ages.

This Year, a New OversightGroup in Australia:

National Oral Health Alliance• Did not recommend enhanced Therapists, instead they

recommended what the AGD has been saying for 5 years, namely:

– Phasing in a dental residency (foundation) year over 5–10 years as policy, infrastructure, professional mentoring, and support develop (initially $20m pa for operations and $60m pa for infrastructure)

– Introducing regional, rural, and remote incentives to improve the distribution of the workforce (initially $10m pa)

New Zealand

• Now, dental therapists train for three years at university or a polytechnic and are registered with the Dental Council of New Zealand

• The majority of dental therapists are employed by District Health Boards in schools, though a small numbers work in private practice alongside a dentist

• While dental therapists work independently, they will have a professional link to a dentist and refer your child to a dentist when more specialized care is required

New Zealand• Treatments that can be carried out by a dental

therapist include:– Advice on oral health and cleaning practices for children and adults

– Cleaning the teeth

– Diagnosis of decay (cavities) in baby (deciduous) or permanent (adult) teeth – this may include using x-rays

– Restoration of decayed adult and baby teeth using fillings

– Extraction of baby teeth

– Preventive therapies to keep teeth healthy – for example using special sealants or topical fluoride

– Referrals to other oral health practitioners for assessment and treatment

– Keep records of dental treatment

New Zealand• Therapists don’t stay long, not cost effective• High career satisfaction but much less satisfied

with remuneration• Done in 10 years with dental therapy• Younger DTs were more interested in moving to

private practice• A mean of 6.5 years in career

Source: Ayers, K.M., et al. The working practices and career satisfaction of dental therapists in New Zealand. Comm Dent Heal 2007; 24:257-63.

New Zealand• The dental health of young children continues to be

among the worst in the developed world, figures reveal• Forty-four per cent of 5-year-olds have at least one

decayed, missing or filled tooth, a school dental services report has found

• The Government has spent $417 million on the problem since 2007 but the figures have shown little improvement

• In 2000, 48 per cent of 5-year-olds had cavities, and the figure has not dropped below 43 per cent since

• New Zealand rates are worse than the UK, US, and Australia

Source: Gillis, Abby. NZ children's dental health still among worst. New Zealand Herald, March 2011.

Canada

• Large country• Many rural, isolated populations• Transportation challenges• Dentists concentrated in population centers• Access to dental care limited

Canada• Fillings on primary and permanent teeth• Vital pulpotomies on primary teeth• Stainless steel crowns on primary teeth• Extractions of primary teeth (Prov & Fed)• Extractions of permanent teeth (Fed)• Sealants• Cleanings• Fluoride• Radiographs• Education

Canada

• Too many dental staff for the amount of dental work that needed to be done

• Large provincial deficit, conservative government• Government scrapped the program in 1987,

except for the northern program• Expanded dental hygiene schools

Dental Team Concept• Prevention, prevention, prevention!• Expanded Auxiliaries within the practice can play key

role in prevention• Establishment of Dental Home*• Dental benefits designs to support establishment of

dental home from childhood**• Cost savings for patients & carriers!

*Advisory Committee on Training in Primary Care Medicine & Dentistry’s (ACTPCMD) 8th Congressional Report (2010) recommends expansion of dental home to medicine as key to prevention and cost-savings

**See the American Academy of Pediatric Dentistry’s (AAPD) Policy on Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs (2008)

Midlevel Providers• Examples: hygienists/dental assistants/expanded function dental

assistants (EFDA) within the dental team model, Dental Health Aide Therapist (DHAT)*(AK), Registered Dental Hygienist in Alternative Practice (RDHAP) (CA), Dental Therapist/Advanced Dental Therapist (MN), independent practice of hygienists (CO, ME), Advanced Dental Hygiene Practitioner (ADHP)(Not yet implemented), limited access permits (OR), public health hygiene endorsements (OR, ME), collaborative practice dental hygienists(NM), Level III Hygienist (KS).

• Concern: Independent practice w/o direct supervision of a dentist (a.k.a. “Alternative model of oral healthcare delivery”)

Midlevel ProvidersIn the Affordable Care Act:• SEC. 5304.  ALTERNATIVE  DENTAL  HEALTH  CARE

PROVIDERS  DEMONSTRATION PROJECT• Subpart X of  part D  of  title III  of  the   Public Health  Service

Act  (42  U.S.C.   256f  et   seq.)   is  amended  by  adding at  the   end  the  following:

– “SEC. 340G–1. DEMONSTRATION PROGRAM– “(a) IN  GENERAL.—”(1) AUTHORIZATION.—The

Secretary is authorized to award grants to 15 eligible entities to enable such  entities to establish a demonstration program to establish training programs to train, or to employ, alternative dental health care providers in order to increase access to dental health care services in rural and other underserved communities.

Midlevel Providers

In the Affordable Care Act:• “(2) DEFINITION.—The term ‘alternative dental

health care providers’ includes community dental health coordinators, advance practice dental hygienists, independent dental hygienists, supervised dental hygienists, primary care physicians, dental therapists, dental health aides, and any other health professional that the Secretary determines appropriate.

Alternative Models

• Advanced Dental Hygiene Practitioner (ADHP)• Community Dental Health Coordinator (CDHC)• Dental Therapist (DHAT and numerous variations)

ADHP

• Created by ADHA• Completion of hygiene program + 2 years of

Master’s study• Diagnose and treat, including restorations and

extractions• General or No Supervision• Pilot Study in CO indicated hygienists failed to

practice in underserved areas• Not implemented in any state

New Data, Implicationsof New Legislature

• Possible funding for the ALTERNATIVE DENTAL HEALTHCARE PROVIDERS  DEMONSTRATION PROJECT

• Expansion of National Health Service Corps to specifically include dental therapists

• Create demonstration programs for training and employment of alternative dental health care providers, including within the Departments of Defense and Veteran Affairs, Federal Bureau of Prisons and Indian Health Service

• Amend Medicaid reimbursement criteria to include services provided by alternative dental providers.

CDHC

• Created by ADA• 18 Months of training• Community, public health, and private practice

settings• Provides education/case worker services under

general supervision• Limited treatment with door open for modification

of SOP• New Mexico to implement

Dental Therapists

• Favored by Pew and W.K. Kellogg• Modeled after New Zealand, Great Britain, Canada• Two years or so of education• Diagnosis, restorations & extractions• General supervision • Implemented in AK (native) & MN• Benchmark for Proponents - Minnesota

Minnesota Model• Dental Therapist (DT):– Both indirect and general supervision– Only 26 to 28 months of training– 16 licensed so far

• Advanced Dental Therapist (ADT):– 2,000 hours– Prerequisite DT license– General Supervision

• Practice Settings:– Both DT and ADT are limited to primarily practicing (about 50%)

in settings that serve low-income, uninsured, and underserved patients or in a dental health professional shortage area.

Other States

• W. K. Kellogg targeting 5 states for dental therapist pilot programs: KS, NM, OH, VT, and WA

• Washington:– Eastern Washington Univ. – ADHP Masters Program– HB 1310 (Advanced Dental Therapist) Bill withdrawn

(2011)

• Kansas:– HB 2280 (Registered Dental Practitioner) defeated (2011)– Does now have new Level III Hygienist

Legend: Pending Enacted Failed

States with Mid-Level Provider Legislation

• Released by W.K. Kellogg Foundation, April 2010

• Claims that dental therapists can provide “technically competent, safe and effective” care

• Fails to measure true patient health outcomes

• More of position paper than a clinical research report (as noted by title, A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States)

Nash Review of 1,100 Reports

ADA Systematic Review

• Sought to find the science to back up claims

• 7,700 articles reviewed

• Only 18 possibly useable, of which 12 were high bias, 5 were medium bias, and only 1 was low bias

• Found no improvement in the oral health of the community by adding therapists

• Quality of data was poor and refutes the foundations claims of hundreds of articles

California Study

• SB694 – A bill to study use of midlevel providers in CA

• No dentist shortage in CA

• Bill died in appropriations

• The sponsor has called for a special session of the legislature to discuss the bill – will take place in Dec. ‘12

Jackson Brown Articles• The Economic Aspects of Unsupervised Private Hygiene Practice and

Its Impact on Access to Care (2005)

• www.ada.org/sections/professionalResources/pdfs/report_hygiene.pdf

• “Unsupervised private dental hygiene practice has not had a notable effect on access to care in Colorado”

• “They are located in areas served also by dental offices with traditional dental hygienists”

• “The economic viability of the unsupervised hygienist business model is questionable because their prophylaxis fees, on average, are not different from traditional dental practices, which have the advantage of providing a full range of practice services”

Study of Alternate Dental Providers, Five State

Comparison• Five states, three models, three payment systems

• Only in a couple of scenarios would using therapist be minimally economically sustainable – they would have to be heavily subsidized

• “The current public payor and indigent reimbursement levels is not economically feasible for providers with salaries at 50% of the Dentists”

• “The limitations to greater access to dental care is that existing fee schedules do not cover the cost of treating the patients”

• The addition of additional providers does nothing to address this issue

AAPD Answers Kellogg

• In addition to AGD and the ADA, the AAPD also responded to the Nash/Kellogg Report

• Key points of AAPD:– Report fails to account for variations between 54

countries– Based on opinions, not data– Fails to address economic viability – Technical competence ≠ long-term patient

outcomes

The Perth Meeting

• The Presidents of the American Dental Association, the British Dental Association, the Australian Dental Association, the Canadian Dental Association, and the New Zealand Dental Association had a discussion on the success or failure of the therapist programs

• In ALL of the countries utilizing therapists, there was no improvement in Access and NO cost savings

ADEA and Public Health

• They claim that this workforce issue is being driven by:

– Access to care – Oral health disparities– Some believe that the DT could be an answer to

these problems

Dental Extenders at CHC’s

• WSDA introduces legislation to introduce AFDAs (Advanced Function Dental Auxiliaries) for community health centers approved by the Dental Quality Assurance Commission (DQAC)

• Essentially, public health EFDA with added surgical privileges under direct supervision

Prevention-Focused Care

• A fully trained dentist and a full oral health team (dental team concept), CDA, EFDA, RDH

• The dentist utilizes the team to increase efficiency in order to treat more patients but without decreasing the level of care

• Just adding more hole fillers doesn’t increase the level of overall oral health

Prevention-Focused CareFrom: Vibeke BælumDate: October 23, 2012Subject: Re: Dental therapists in Denmark

No, fortunately, we don't have dental therapists here, just dentists and dental hygienists.

We don't need more professionals that are licensed to drill and fill. The high speed drill was never instrumental for oral disease control.

Best regards,Vibeke

Prevention-Focused Care

• “Oral Health Inequities will only be reduced through the implementation of effective and appropriate oral health promotion policy.”

– The State of Oral Health in Europe, Dr. Rena Patel, September 2012

• 40 years ago, Denmark embarked upon oral health improvement, and by the end of the 1990’s, they have 99% of the children with consistent preventative services and a high national level of Oral Health Literacy

Number of Dentists –NOT the Issue

• 1:2,000 • Health Resources and Services Administration (HRSA)

standard is 1:5,000 or lower in many locations• Advancements in technology and increases in the

education and number of auxiliaries within the dental team show that capacity is the key, not ratios!

Number of Active Private Practicing General

Practitioners, 1996–200911

9,49

3

120,

250

123,

197

123,

625

124,

151

126,

097

126,

546

129,

096

130,

335

130,

054

132,

118

133,

688

134,

492

136,

717

2,25

4

2,26

7

2,23

9

2,25

7

2,27

3

2,26

1

2,27

4

2,24

9

2,24

8

2,27

4

2,26

0

2,25

6

2,26

3

2,24

6

0

500

1,000

1,500

2,000

2,500

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,00019

96

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Po

pu

lati

on

to

GP

Rati

o

Nu

mb

er

of

GP

s

Number of GPs Population/GP

Source: Distribution of Dentists in the United States by Region and State, various years, 1996 to 2009; and U.S. Census Bureau.

CAPACITY,Survey March 2011

CAPACITY,Survey March 2011

• Of the 589 members who were seeing fewer patients than two years ago, 47.5 percent indicated that they are seeing between 11 and 25 percent fewer patients; 36.3 percent are seeing 10 percent or less fewer patients; and 10.9 percent indicated that they are seeing between 26 and 50 percent less patients

• Of the 328 members who were seeing more patients than two years ago, 45 percent indicated that they are seeing between 11 and 25 percent more patients; 27.7 percent are seeing 10 percent or less more patients; and 13.4 percent indicated that they are seeing between 26 and 50 percent less patients

• The Dental Economics Advisory Group states that, with the new dental schools coming on line and the anticipated workforce and technology enhancements, the supply of dentists is not likely to be a problem

• “Capacity Utilization” problem: In Economics this means, “Don’t create more until you use what you already have”

• PEW's “shortage of dentists” based their assumption on the numbers who are willing to treat low-market or non-market patients

• PEW refuses to understand that, “regardless of how many DHATs they produce, they still can't address the dental needs of the underserved dealing with social and cultural issues, transportation and health literacy.” Dr. Ron Tankersley, ADA Past President

• The Foundations and others don't seem to want to work on the major aspects of the issue

• In a report to the National Oral Health Conference, a state with 62% dentist involvement in Medicaid in a 5-year CDC assessment done by DOH using ASTDD standards on 5,732 children in 73 schools in 2008 showed:

In the Untreated Caries Summary:

• The children in the Medicaid group showed “NO DIFFERENCE” than any other category

• Their data was the same as insured patients

In the Treatment Urgency Summary:

• The children in the Medicaid group showed “NO DIFFERENCE” than any other category

• Their data was the same as insured patients

• Some claim that Medicaid reimbursements don’t affect participation, but a statewide school nurse survey showed the opposite trend

• Increases in Medicaid rates had a direct correlation to the numbers of dentists

• However, Parent Involvement and Transportation were the biggest barriers, not dentists’ involvement

Fiscal Pressure onMedicaid Programs

• “CMS sees Medicaid costs outpace projections.”

• “Medicaid spending will increase 7.9% per year over the next 10 years. That compares to a growth rate of 4.8% in the general economy.”

• “We must act quickly to keep state Medicaid programs fiscally sound.”

Source: CMS and HHS

• “20 states cut Medicaid payment rates last year. At least 16 governors have proposed rate reductions this year.”

Source: Kaiser Family Foundation

• Oral health is affected by more factors than access to dental care

• Because so many factors at the individual, environmental, and delivery system levels affect oral health, interpreting the findings from international studies is difficult

Source: Community Dentistry and Oral Epidemiology, 2006

• “Direct public expenditures constitute only 6% of total spending for dental care in the US, just three-eighths of the proportion in Australia, and almost all of it is limited to the care of children

• New Zealand’s program in the schools has been in place a long time and, thus, it may be surprising to learn that Baltimore adolescents had (among all countries in ICS I and ICS II) the lowest number of DMF teeth and the second- or third-lowest number of decayed teeth”

Source: Chen MS, Andersen RM, Barmes DE, Leclercq MH, Lyttle CS. Comparing oral health systems: a second international collaborative study.

• “Financial barriers to access are significant in explaining how much desired dental care is actually received in the US”

• Workforce is but a very small part of oral health improvement

Source: Mueller CD, Schur CL, Paramore LC. Access to Dental Care in the United States.

• “The New Zealand oral health therapist program is touted as the model for this country’s foray into a mid-level provider. In 2004, the DHBNZ (Ministry of Health) declared the School Dental Service to be “in strategic crisis” and that inequities continue to exist, notably with low income, minorities, and rural populations. They further concluded that facilities were run down, not suited to modern practice and non-compliant with health and safety standards.”

Source: Dr. Crall, AAPD presentation.

• The AAPD suggests the burden of proof from studying such models is to first show they actually work, versus trying to implement nationwide programs based on “what harm can they do? / something is better than nothing”

• “Something” that drains away resources and provides less comprehensive care for children could in fact be worse than doing nothing”

Source: Dr. Crall, AAPD presentation.

New Strategy

• The goal is Improved Oral Health– Access is only a small part of Oral Health– Workforce is only a small part of Access

• The REAL BARRIERS are Oral Health Literacy, Economic, Transportation, Cultural, and Social Issues

• Don’t fight over what will not help Oral Health anyway

Get InvolvedUS Representative Jeff Duncan

THANK YOU!