Filling the dental divide

The proof is in the emergency rooms, they say: There’s a dental access problem, and it’s growing.

Pointing to the number of costly ER visits by people in dental distress, advocates and legislators in Washington say a new category of dental providers – able to perform more complicated procedures than hygienists but not the most difficult procedures done by dentists – would address the problem. “Midlevel” practitioners, they say, would be able to serve more people in need where they live, including in underserved areas, at a lower cost.

They face opposition from dentists who are skeptical of cost-savings claims and who say the access issue isn’t a workforce problem, but a paying-the-bills problem: Restore dental coverage for Washington adults on Medicaid, they say, and it would go away.

Washington is among nearly a dozen states that considered bills this year to license a new category of dental practitioners, sometimes called dental therapists. Midlevel dental providers have already gone to work in Minnesota and tribal areas of Alaska.

The efforts are backed by national organizations such as the W.K. Kellogg Foundation and the Pew Charitable Trusts and state organizations such as the Children’s Alliance, which has offices in Seattle and Spokane.

Although bills have been proposed in the House and the Senate, they’ve made it far in neither.

Still, “I don’t think this issue is going to go away,” said Sen. David Frockt, a Seattle Democrat who backed midlevel practitioner legislation in 2012 and 2013 and said he’ll continue to push it in 2014.

“The question is, why are so many people coming to emergency rooms with untreated problems?” Frockt said.

There are multiple answers, he said: a lack of affordable insurance, the lack of coverage for most low-income adults – and too few dentists willing to work in some areas, including some rural parts of the state but also some urban clinics.

That means the problem requires multiple solutions, Frockt said, including restoration of dental care under Medicaid but also a boost in the number of providers able to deliver treatment.

“Why shouldn’t we be able to do this in community clinics, where we know the chairs are there and we know there’s not enough capacity in terms of the dentists who are there?” Frockt said, stressing that he wants to work with dentists to find a solution.

Because it wouldn’t work, argued Dr. Chris Herzog, a pediatric dentist in Spokane who serves on the Washington State Dental Association’s board of directors. He’s testified in Olympia against midlevel practitioner bills for the past three years, since they were first introduced in the House by Rep. Eileen Cody, a West Seattle Democrat and chairwoman of the House Health Care Committee.

Dentists also have concerns about how the new providers would be supervised and trained, he said. A major point of contention: Whether midlevel practitioners would require on-site oversight by a dentist, compared with off-site oversight enabled by telemedicine, for example. Many dentists say off-site supervision would be too risky for patients, leaving them without someone trained to respond in a medical emergency.

But in the end, Herzog said, the question remains: Without publicly funded coverage for low-income adults, who’s going to pay for care, whether it’s from a dentist or a new type of provider?

At the start of 2011, the state stopped providing Medicaid coverage of all dental care for adults except for emergencies. It later restored preventive coverage for pregnant women, some elderly people and some people with developmental disabilities, but most low-income adults remain uninsured. As the Legislature continued its special session Friday, at least partial restoration of the benefits remained a possibility.

“You can create 40 different providers if you want, but if there’s no way for anyone to get paid to provide care for them, no one’s ever going to get taken care of,” Herzog said.

The state does provide dental coverage for children on Medicaid. And judging by care received by children in low-income families, dentists are well enough distributed throughout the state to serve patients – when there’s money to pay them, said Bracken Killpack, director of government affairs for the state dental association.

“If you look at kids, where there is consistent funding – and we have had a reliable safety net for kids – we do very well,” Killpack said. “In Washington state, we have the second-lowest levels of untreated decay in the country. Children that have dental cavities, they’re getting treated.”

But many adults are not. The Washington State Hospital Association reported in 2011 that in one recent 18-month period, dental problems accounted for more than 54,000 emergency room visits in the state, at an expense to taxpayers of more than $35 million. Dental emergencies are likely to be the result of not having regular dental care or dental insurance, the association said.

Eastern Washington University’s dental hygiene clinic at the Riverpoint campus serves about 7,000 low-income uninsured patients a year, said Rebecca Stolberg, chairwoman of the university’s dental hygiene program. The clinic’s fees run about 75 percent less than fees at a typical dentist office, she said.

Hygiene students clean patients’ teeth and take X-rays, Stolberg said. But for decay and loose teeth, they have to refer people to dental clinics, where they’re likely to encounter waiting lists, she said.

“We see the need every day,” Stolberg said. “We see up to 100 patients a day walk through that door, and they have so much work that needs to be done beyond what our dental hygiene students can do legally.”

EWU’s department has secured funding and state and university approval of a curriculum for a midlevel training program that would add a year of courses at EWU’s Riverpoint campus to its four-year hygienist program, reflecting the training model used in Minnesota, Stolberg said. She said she has “lists and lists” of students who want to apply, and it could accept eight to 10 students in its first year.

All the program needs, she said, is a state law allowing graduates to work.

They would be able to do everything a hygienist does – cleanings, X-rays, applying sealants, performing exams – plus perform “simple” extractions, prescribe pain medications and drill cavities. Midlevel students would also get “a lot more information about how to handle a medical emergency,” Stolberg said.

“The dentists feel we are infringing on their duties, and they don’t want us to work unsupervised,” she said. “Our challenge is to show them we are going to be competent and can work unsupervised, and that they’re still going to get all those people into their offices” for crowns, implants and other “big stuff.”

Stolberg said she agrees with dentists that state coverage of dental care for low-income adults is important. But she believes midlevel practitioners would be able to serve people in need at a lower cost than dentists, she said. The idea is not that midlevel providers would open their own businesses, but rather serve in subsidized clinics or as part of the staff in a private dentist office.

“What the research in Minnesota is showing, with these new midlevels, is that they work for less money than the dentist – their education is less expensive than dental school,” Stolberg said. “They want to serve just that midlevel need and get people out of pain and … triaged to the next step.”

Killpack, of the dental association, said he often hears advocates say midlevel providers would lower costs. “We just don’t see that,” he said.

Overhead costs related to care wouldn’t go down, he said, and he predicted patients would be charged the same for midlevel providers’ services as they’re charged by dentists.

Rep. Cody wasn’t so sure. Nurse practitioners and physician assistants receive lower reimbursement rates from insurers than doctors, she said.

“It should be the same thing as on the medical side,” Cody said. “Why do you need to charge as much if you haven’t had as much training and you’re only doing a limited scope of procedures?”

As opposition has mounted from organized dentistry, the issue has become contentious politically, said Tera Bianchi, manager of the Oral Health Access Project at the Children’s Alliance.

“Unfortunately they are successfully blocking what is an evidence-based, really important conversation,” she said.

Cody said dentists are putting up the same fight doctors fought before physician assistants started working in the 1960s: “I keep pointing out to them that we now are serving a huge amount of our rural areas with midlevel health care practitioners – PAs and nurse practitioners – and they’re diagnosing whether you’re having a heart attack. All we’re suggesting here is whether they can fill your cavity.”