The National Perspective: States Working on New Providers Shelly Gehshan, MPP Director, Pew Children s Dental Campaign Pew Center on the States sgehshan@pewtrusts.org What I ll Cover Cost of Delay report grades on 3 workforce measures Why current workforce is not sufficient Models being considered Change is coming! Key provisions in national reform legislation (see handout) 1 1
Produced with the support of the W.K.Kellogg Foundation and the DentaQuest Foundation 2 The 8 Benchmarks Can hygienists apply sealants in a school setting without a dentist s prior exam? Does the state reimburse medical providers for preventive services? Has the state authorized a new primary care dental provider? Are school sealant programs present in at least 25 percent of high-risk schools? Does the state provide fluoridated water to at least 75 percent of its population on community supplies? Does the state meet the national average for Medicaid utilization? Does the state meet the national average for Medicaid payment? Does the state submit data to the National Oral Health Surveillance System? 3 2
33 States and DC Received a C or Lower 4 Benchmark 2: Hygienists in Sealant Programs State allows hygienists to provide sealants without a prior dentist s exam, 2009 Number of states Yes 30 No 21 Systemic reviews by ADA and CDC have stated that visual assessment which hygienists are qualified to provide is adequate to determine the need for sealants Prior examination by a dentist is not necessary, and can limit the reach of school-based sealant programs Interpretations of laws on this vary update in 2011 will verify them 5 3
WA MT ND ME CA OR NV ID UT WY CO SD NE KS MN IA MO WI IL MI IN KY OH WV NY PA VA VT NH MA* CT RI NJ DE MD DC NC AZ NM OK AR TN SC MS AL GA TX LA AK FL* Direct Supervision Required (7) General Supervision in PH Setting; Dentist Exam Required (14) HI Dentist Exam Sometimes Required (8) General Supervision in PH Setting; Dentist Exam Not Required (22) *FL A change to not require a dentist s exam had been proposed, but not enacted, at the time Pew s report went to press. *MA Recent changes will allow hygienists in schools and other public health settings to place sealants without a dentist s prior exam, but those changes were not yet in effect at the time Pew s report went to press. Current system and workforce is not sufficient Financing for dental care is likely to grow and will spur demand An estimated 5.3 million more children will have dental insurance due to national health reform The needs are great Shortage and maldistribution of dentists Shortage is getting worse. Too few care for low income, rural patients Dental safety net only reaches 10% of the 83 million who lack access Growing recognition that new providers can competently and safely deliver high-quality care Few private practice dentists participate in Medicaid and CHIP programs Medicaid rate increases don t solve the problem 7 4
Children s Medical Care Coverage 60 50 47.1M 47.8M 40 # of children (in millions) 30 20 24.8M 27.7M Current After 2013 10 0 4.8M 6.5M Medicaid CHIP Private Uninsured* Type of Insurance 7.3M * Illegal immigrants and children from families with income <100% FPL are excluded from the mandate NOTE: In 2006, the number of children without dental insurance coverage was over 15.4 million, according to MEPS Statistical Brief #221 (September 2008) Data from: Kaiser Family Foundation, Statehealthfacts.org, Monthly Medicaid Enrollment for Children, June 2009 (2009) and Monthly CHIP Enrollment for Children, June 2008 (2009). U.S. Census health insurance coverage data 2008 (2009). Federal Interagency Forum on Child and Family Statistics, Health Insurance Coverage (2007), 8 Source: Health Resources and Services Administration, U.S. Department of Health and Human Services. Shortage Designation: HPSAs, MUAs & MUPs. Table 4. Health Professional Shortage Areas by State Detail for Dental Care Regardless of Metropolitan / Non- Metropolitan Status as of June 7, 2009. http://bhpr.hrsa.gov/shortage/ (accessed July 8, 2009) 9 5
Benchmark 7: New Primary Care Dental Providers State has authorized a new primary care dental provider, 2009 Number of States Yes 1 No 50 An increasing number of states are exploring new types of dental professionals to expand access and fill specific gaps. In 2009, Minnesota became the first state to authorize a new provider. And philanthropies including Pew are playing an active role in helping states examine their workforce options. 10 WA ME MT ND OR ID MN VT NH MA CA NV UT WY CO SD NE KS IA MO WI IL IN MI KY OH WV PA VA NY RI CT NJ DE MD DC NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI State has authorized new provider 11 6
WA ME MT ND OR ID MN VT NH MA CA NV UT WY CO SD NE KS IA MO WI IL IN MI KY OH WV PA VA NY RI CT NJ DE MD DC NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI State dental associations are discussing authorizing new mid-levels 12 Benchmark 6: Medicaid Payment to Medical Providers for Dental Services Medicaid pays medical staff for early preventative dental health care, 2009 Number of States Yes 35 No 16 Doctors, nurses, nurse practitioners and physician assistants are increasingly being recognized for their ability to see children, especially infants and toddlers, earlier and more frequently than dentists. 13 7
WA ME MT ND OR ID MN VT NH MA CA NV UT WY CO SD NE KS IA MO WI IL IN MI KY OH WV PA VA NY RI CT NJ DE MD DC NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI Reimburses medical providers Will begin reimbursing in 2010 Considering 14 New provider models in dentistry Community Dental Health Coordinator (CDHC) Dental therapist (DT, DHAT) Combined dental hygienist/therapist (DH/ DT) Minnesota dental therapist/advanced dental therapist (MN DT and ADT) Advanced dental hygiene practitioner (ADHP) 15 8
Community Dental Health Coordinator (CDHC) 12 month didactic, 6 month internship Certified, not licensed Pilot projects operating in CA, OK, PA Scope: patient navigation, health literacy, some preventive services Like a social worker with a few dental skills Pros: May facilitate dentist participation in Medicaid Cons: Few reimbursable services make sustainability difficult 16 Dental Therapist (DT, DHAT model) Based on New Zealand model in use since 1920s Operating in tribal areas of Alaska since 2003 Remote supervision by dentists 2-year degree, through University of Washington Some countries moving to a modular 3-year dental therapy-dental hygiene program (oral health therapist) Close to nurse practitioner primary care Pros: Proven model: many studies supporting safety, quality, effectiveness Cons: Alaska lawsuit has polarized opinions somewhat 17 9
Minnesota Dental Therapist (MN DT) 4-year bachelor s degree First class now being trained at UMN Dental School Authorized to work with underserved populations Basic DT would operate in dental clinics under limited general supervision of dentist, and indirect supervision for restorative care Pros: First new primary care dental provider to be authorized by a state Cons; Similar scope to international DT, but twice the training, reducing cost effectiveness 18 Minnesota Advanced Dental Therapist (MN ADT) 2-year master s degree, and 2,000 hours of work as basic DT First class now being trained at MNScU; Board of Dentistry determining accreditation of this program Authorized to work with underserved populations, provide nonsurgical extraction of loose permanent teeth ADT could operate without a dentist in more settings than basic DT (e.g., nursing homes), under collaborative practice agreements Pros: Able to be deployed in more settings Cons; Very high level of education for few added services, reducing cost effectiveness 19 10
Advanced Dental Hygiene Practitioner (ADHP) Currently a proposed model; ADHA has finalized curriculum 2-year Masters program for bachelor s level hygienists Close to nurse practitioner Pros Pool of RDHs ready to train Could be supported by reimbursable services Cons: Very high level of education for few added services, reducing cost effectiveness Evokes long-standing turf battles between dentists and hygienists 20 Dental Hygienist /Dental Therapist Three-year modular approach (1 yr basic sciences, 1 yr hygiene, 1 yr dental therapy) Used in Great Britain, New Zealand, Australia Could be easily deployed; several states considering this Pros Pool of 2-year RDHs ready to train Could be supported by reimbursable services Cons Evokes long-standing turf battles between dentists and hygienists May trigger same objections as dental therapists 21 11
Three main variables for new provider models Scope of practice Education levels Supervision 22 But there are more considerations to keep in mind How will the new provider fit into existing systems of medical and dental care? Dental clinics, CHCs, hospitals, nursing homes? Where will new providers locate? Will the model address maldistribution? Who is the new provider intended to serve? Low-income, children, elderly, rural? 23 12
Scope: Restorative Capacity of Providers Procedures CDHC proposed EFDA ADHP proposed DHAT (AK model) MN DT Atraumatic Restorative Technique (ART) X X X Placement of temporary restorations X X X X X Simple restorations X X X X Prefabricated crowns X X X Simple extractions X X X Lab processed crowns Pulpotomy X X X Pulp capping X X X X Source: NASHP, Clinical Capacity of Current and Proposed Providers, Table developed by NASHP, February 2008; updated March, 2010 with MN DT model (Minnesota Statutes 2009, 150A.105, subdivision 4) 25 13
Categories of Intraoral Procedures ordered from most to least restric4ve Advanced Restora4ve Care Diagnosis & Treatment Planning Basic Restora4ve Care Preven4ve: Scaling and Root Planing Preven4ve: Coronal Polishing Provider Type Den4st Den%st x x x x x Combina4on Dental Therapists/Dental Hygienists Advanced Dental Hygiene Prac%%oner x x x x Dental Hygienist Therapist, Interna%onal x x x Dental Therapists Dental Therapist, Interna%onal varies x x Alaska Dental Health Aide Therapist limited x x Minnesota Advanced Dental Therapist limited x x Minnesota Basic Dental Therapist x x Dental Hygienists Dental Hygienist x x Expanded Func%on Dental Hygienist varies x x Dental Assistant Expanded Func%on Dental Assistant varies x Dental Assistant varies Oral Preven%ve Assistant limited x Community Dental Health Coordinator Community Dental Health Coordinator x B. Edelstein, Training New Dental Health Providers in the U.S., W.K. Kellogg Foundation (2009), 12. 26 Education: Length of Training (Post High School): US and International Dental Providers Source: B. Edelstein, Training New Dental Health Providers in the U.S., W.K. Kellogg Foundation (2009), 29. 27 14
Proposed Supervision Levels CDHC: General/indirect DT, DHAT: General, under standing orders of a dentist (use teledentistry for remote areas) DH/DT: General, under standing orders MN DT: Indirect, general for some services MN ADT: General, through collaborative practice agreements ADHP: General, collaborative practice NOTE: depends on state law and regulation, will vary 28 Pew Guidelines on what models we support (see www.pewcenteronthestates/dental) Based on evidence, international and domestic Model addresses a states needs Scope of practice should fit gaps in the system Education should be adequate and cost-effective (not excessive for scope of practice) Least restrictive level of supervision to ensure safety AND expand access 29 15
Pew workforce studies on the way Economics of private practice a model to estimate potential impact of new providers on productivity, costs, income of private practices (Scott Inc.) How will collaborative practice work? reimbursement for consultations, oversight technologies, malpractice (UCSF, Mertz, Dower) Economics of safety net clinics will examine impact of new providers on productivity, costs, income with public funds (Bailit, Beazoglou) 30 Pew Children s Dental Campaign Mission: To promote policies that will help millions of children maintain healthy teeth, and come to school ready to learn. www.pewcenteronthestates.org/dental 31 16
Shelly Gehshan, MPP sgehshan@pewtrusts.org www.pewcenteronthestates.org/dental 202-552-2075 17