Physicians Blog
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As I walked in the door yesterday my copy of ADA NEWS stared me in the face with the headline: Dental Therapy Programs: CODA agrees to establish accreditation standards.
I can’t say I am surprised. I presented the topic of mid-level providers in Dentistry in February of this year at a lunch and learn meeting. For a review of that presentation please visit my website (northsideoralsurgery.net) and scroll down the page to “Office Happenings and Sponsorship.” It is the third presentation hyperlink.
The ADA News article goes on to inform us the ADA has granted the Univ. of Minnesota the request to establish accreditation standards for Dental Therapy programs. The rest of the article explains the limitations of this step and the lengthy process of accreditation.
The article also informs us that Dr. Donald Joondeph, chair of the Commission on Dental Accreditation (CODA) is forming a task force to examine the issue of developing standards in dental therapy programs.
We all know the ADA is “on record as firmly opposing anyone other than dentist diagnosing oral disease of performing surgical/irreversible procedures.”
So, one may ask, if the ADA is firmly against dental therapist then why is CODA bothering to examine the accreditation process for the program in Minnesota? Why is a task force being formed to also consider the dental therapist model?
In my humble opinion as a dental specialist who was a Physician Assistant in anesthesia (thus a mid-level provider) before I attended Dental School these steps are being taken to push the issue of dental mid-level providers (DMLP) to the front of our profession. The act of evaluation for accreditation is simply the first step in the accreditation process. Once the Minnesota program is accredited, baring an unfavorable finding, dental therapy programs will have a green light to start turning out dental therapist who will be, for all practice purposes, practicing dentistry.
Mid Level Providers (MLP) are not new. Medicine has employed mid-level providers for over 40 years. These Certified Registered Nurse Practitioners, Physician’s Assistant, and Certified Registered Nurse Anesthetist perform a vital role in the healthcare industry. They permit the physician to delegate specific duties to those properly trained while they concentrate their time, knowledge, and skill on treating the more complex medical patients. They have evolved over the years in response to industry needs from existing paraprofessionals in the healthcare workforce. These MLPs work in conjunction with, not in place of, the physician to deliver care to those in need.
In dentistry, one may argue that MLPs already exist. Expanded duty dental assistants and dental hygienist work as part of a team with dentist to provide comprehensive oral healthcare. This model has been successful for many years.
The DMLP which will arise from these new programs is a dental mid-level provider is unlike the expanded dental assistant or hygienist.
My research in this area demonstrates there are currently four new types of dental mid-level providers emerging in the United States:
1. Dental Health Aide Therapist (DHAT): License provider with a bachelor’s degree who works with the dentist to provide basic dental services.
2. Advanced Dental Health Aide Therapist (ADHAT): DHAT with 2000 hours of preceptorship who has graduated from a master’s program for advanced dental therapy. They may practice without a dentist, but must obtain permission for care.
3. Community Dental Health Care Provider (CDHCP) : Less education versus the DHAT. They must work under dentist supervision and must work in underserved areas.
4. Advanced Dental Hygiene Practitioner (ADHP): Independently trained dental professional who can provide the services of a general dentist in an office without the supervision of a dentist.
As we can clearly see not all dental mid-level providers are created equal. ADHAT and ADHP are designed to function independent of a dentist to provide a wide range of oral healthcare in the form of diagnosis and treatment of individuals. This is clearly a break-point from the current team structure our expanded duty dental assistants and hygienist operate in. By functioning independently the ADHAT and ADHP create two tier system whereby some individuals receive their oral health care from doctors and some do not.
Why, you may ask, would the government create a new avenue of delivering dental care? The Government, and the foundations behind the formation of dental mid-level providers (i.e.: Pew Charitable Trust and The Kellogg Foundation), point to the decrease in number of general practice dentists in the face of an increasing in population which will occur in the next decade. This fact is further supported by the increase in the number of dental school graduates who become specialists. Today 16% of dentists are specialists. This should increase to 27% by 2020. Dental mid-level provider proponents point to the fact that fewer dentists are working full-time; thus, less hours of dental work are being done. All these factors lead to the logical conclusion there will be fewer general dentists in the future available to treat more patients. Thus, the supply dentists will become more selective and the cost of services will increase. Those with financial resources will receive dental care by dentist and those less fortunate will be forced to seek more affordable care.
Advocates of the DMLP believe the DMLP will step in and deliver care to those who cannot afford a dentist. These DMLP will fill the gap created by the lack of supply and affordability of the dentist to serve the increasing need for oral healthcare of patients will who are on government assistance or have poor insurance or simply cannot afford dental care.
Although, I cannot argue with the above noted logic of supply in demand, I can see there are three major flaws in the equation.
1. Money:
According to our government and others, the dental mid-level provider will be delivering care to the poor. The poor are typically resigned to some form of government financial assistance (Medicaid,Peach Care, etc.) or extremely poor insurance plans or cash. The reimbursement rates for such programs are typically below 50% of the usual and customary fees and sometime as low as 30%. Dentistry, whether delivered by dentist or dental mid-level provider, has certain fixed cost (rent, salary, supplies, materials, lab fees etc.) irrespective of who is delivering the care. If a typical dental office overhead of 60% and the mid-level provider receives less than 50% of the usual and customary fees, then where is the profit? No profit means the business cannot survive. If the government subsidizes the business then the funding of these clinics may be subjected to cutbacks and closures at the whim of the politicians. This will restrict access to care, thus not addressing the problem the DMLP was created to solve.
2. Improved access care?
Despite the plethora of medical mid-level providers there remains a significant shortage of primary care physicians in Georgia & the United States. The creation of an independent dental mid-level provider may generate increased access of care but not by generating more dentist; rather, the additional care with be delivered by non-dentist.
3. Location:
There may be more individuals delivering oral health care but where they deliver it will be dictated by supply and demand as well as the financial status of the community. A community or county that cannot support a full-time dentist due to its poor economy, sparse population, or lack of amenities, and good schools will not be able to support a dental mid-level provider either.
The University of Minnesota School of Dentistry in association with Metropolitan State University and Normandale Community College is currently the only DMLP program in the USA. Five other states (Kansas, New Mexico, Ohio, Vermont, and Washington) are seriously considering instituting a similar program. Dental mid-level providers are currently working at 53 countries around the globe.
The time for DMLP seems to have come. As dentist we need to be aware of the changes that may affect the way we practice our profession and provide for our families. As an Oral & Maxillofacial surgeon my practice may not be affected by the DMLP; but I do see the DMLP as changing the way in which my profession, Dentistry, is practiced by possibly altering the pier group in which I practice.
I urge each and every dentist in the USA to exercise their right to free speech and expression in relation to the DMLP. Organized Dentistry has a strong voice and it will be heard if we demand it.
Lee M. Whitesides DMD, MMSc
Lee M. Whitesides, DMD, MMSc.
