Pediatric dental services are included in the essential health
benefits standard of the Affordable Care Act. This means the ACA
requires individual and small-group plans sold in the exchanges and
outside the exchanges to offer pediatric dental services, as of January
of 2014 – just less than a year from now. And dental services
already are part of the benefit package for children who are enrolled in
Demand for pediatric dental services is about to increase. But no one knows by how much.
One thing we do know is that the Centers for Disease Control estimate
over two thirds of Americans age 16 to 19 have decay in their permanent
teeth. The CDC also estimates one quarter of children start school with
tooth decay. How many of these people will step forward for dental
care is unclear. But the school aged population may be screened more
consistently for dental problems now that dental problems have been
identified as a marker for lost school days and because of increased
pediatric dental insurance coverage.
Our Medicaid eligible population is about to boom. Just to give you
some sense of scale, you should know that California estimates a further
900,000 pediatric Medicaid enrollees will soon join Medi-Cal,
California's version of Medicaid.
Another thing we do know is that about half of all currently Medicaid
eligible children have not seen a dentist within the past year. Whether
bringing their parents into Medicaid eligibility as part of what is
sometimes called a "culture of coverage" will increase pediatric dental
demand in the population of Medicaid enrollees is also unclear. This is
especially tricky to forecast since Medicaid dental coverage for adults
— an optional program — is increasingly rare.
One final thing we do know is that some subset of Medicaid enrollees
who have tried to access pediatric dental services but failed, did so
because of an inability to find a dental provider who would accept
Medicaid reimbursement. This number is hard to quantify but is most
often extrapolated from looking at the percentage of licensed practicing
dentists in a given service area who accept Medicaid reimbursement.
HHS estimates that twenty percent of the nation's 179,000 practicing
dentists accept Medicaid and notes that the licensed dentist pool has
not kept up with population growth. Interestingly, the labor supply of
other oral health proffessionals (dental hygenists, etc.) has kept up
with population growth while dentistry has gone grey.
Medicaid dental reimbursements are low. Though they vary from state
to state, they can be as low as 25% of market rates. The National
Academy for Health Policy did an interesting study in 2008 comparing
Medicaid dental reimbursement rates and the effects of targeted
reimbursement increases as well as reduced administrative paperwork.
Sure enough, raising the reimbursement rate and lowering the
administrative burden increased the number of Medicaid participating
Rate thresholds matter, it turns out, but only if a state has the
funds to raise Medicaid pediatric dental rate thresholds. Some of those
who do not have begun to talk about using dental therapists for some
aspects of oral care. Known as "mid-level providers" for the place they
take between dental hygenists and general dentists, dental therapists
are an interesting group. Dental therapists typically have two to three
years of training beyond high school.
Minnesota is the first state to have established a licensing system
for dental therapists and advanced dental therapists. Dental
therapists, under either general or indirect supervision, may perform
many of the services we now associate with dentistry: charting,
cleaning, even some work on cavities and more advanced services.
Minnesota's Board of Dentistry appears to have made at least a
temporary peace with what I call dentistry's scope of practice wars —
the rules and regulations regarding supervisory ratios, services that
may be offered by dental therapists, and the education and training of
Minnesota's licensing scheme is new. Since 2011, there have been only
a small numbers of graduates. But we do have substantial experience in
using dental therapists with under-served rural populations in Alaska.
Alaska's Dental Therapist Health Aides ("DHAT") experiment has been
moving forward since 2005 under the auspices of the Alaskan Native
Tribal Health Consortium. The first DHAT trainee cohort was trained in
New Zealand but DHAT's dental therapists are no longer trained overseas,
though it is private foundation money that has done much to launch and
extend this experiment.
The results for consumers are good, even very good. Care is available
in remote or hard to reach places and is provided in a community
context. Quality measures have been quite high.
Now, remote Alaskan locations are one thing and rural underserved
populations in Minnesota are another, but I am pretty certain the dental
therapist scope of practice wars have only just begun. Organized
dentistry is concerned about quality standards, educational standards,
and the liability concerns of dental therapist supervisors. Organized
dentistry is also worried about oral health care provider competition.
I will watch this story unfold. California's Children's
Partnership's recent call for the licensing of dental therapists — in a
state with some of the most restrictive scope of practice rules in the
United States — should be worth following.
I tell my students that, in health care, innovation often starts in
the arena of government funded health insurance and spreads to the
world of commercial insurance only later. If Medicaid leads the way in
championing the use of dental therapists as lower cost providers to
fulfill its promise of pediatric dental services, I assure you
commercial insurance providers both inside and outside of the exchanges
will take note.
So, whoever you are, just open your mouth wide and say "dental therapist."
X posted at http://prawfsblawg.blogs.com/