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Don’t follow Minnesota’s failed dental therapist experiment

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Earlier this decade, Minnesota lawmakers were convinced they had the solution for rural and low-income people not obtaining oral health care. Create a new mid-level provider called a dental therapist, and all would be right in the world.

What has happened instead should be a cautionary tale for Arizona, where an East Coast foundation is peddling the same off-target solution. While the Pew Foundation and its allies declare Minnesota’s dental therapist experiment a spectacular fireworks show, it’s really nothing more than a few people standing around waving sparklers.

Robert Roda

Robert Roda

Since that vote seven years ago, the percentage of Minnesota’s Medicaid children receiving any dental service has stubbornly remained around 41 percent. Adding almost 80 dental therapists didn’t budge the rate at all. Nor did it reduce dental costs. And now the federal government has put the state on notice: It is at risk of having federal Medicaid money withheld.

In contrast, 49 percent of Arizona kids on AHCCCS had a dental visit last year, about the national average. That’s still not high enough, but increasing the rate comes from understanding why kids aren’t getting oral health care. It’s not because of a lack of providers. We need real solutions that address real issues.

Minnesota shows us why. After seven years of expecting dental therapists to fix the problem, Minnesota’s elected officials are scrambling to get more children into dental chairs. Nowhere to be found is any suggestion to add more dental therapists.

Instead, the governor asked for a substantial increase in Medicaid dental reimbursement rates, which are so low that dentists won’t sign up. Legislators, having been assured dental therapists were the panacea, saw no need to raise those rates.

They’re just now realizing this was never a workforce problem; Minnesota has plenty of dentists. The Legislature there wasted time and energy creating a new kind of professional, while ignoring the real barriers to access.

Just as in Minnesota, Arizona does not face a workforce shortage. Indeed, 90 percent of publicly insured children live within 15 minutes of a dentist who accepts AHCCCS patients.

Higher reimbursement rates would help attract more Arizona dentists, but the bigger challenge is that AHCCCS limits the number of dentists who can sign up. I personally know dentists who would accept AHCCCS patients but have been turned down by the state’s contracted insurance plans. Adding dental therapists doesn’t fix that bottleneck.

Allowing any willing dentist into the program would increase access for children. And there’s more we should be doing, like focusing on the real challenges that parents face in getting their kids to a dental office. We should continue to be creative in expanding preventive services to avoid tooth decay in the first place.  We can effectively do this with our existing dental team and the solutions dentists advocated and legislators approved.

Dental therapists are a distraction. They solve nothing. Legislative efforts to bring this position to Arizona divert attention from the real issues and real solutions. They set us up to be the next Minnesota, scrambling a few years from now after we learn that Pew’s hollow promises only delayed the day of reckoning.

Let’s not go there. Let’s work together on solutions that will really make a difference.

— Dr. Robert Roda, a Scottsdale endodontist, is president of the Arizona Dental Association.

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The views expressed in guest commentaries are those of the author and are not the views of the Arizona Capitol Times.

10 comments

  1. Another barrier is the SUBSTANTIAL legal risks faced by dentists who accept Medicaid. There are many cases of malicious prosecution of dentists, falsely accused of fraud. Even when acquitted, often taking YEARS, the dentist has lost everything… literally everything.

    Given the legal risks, I would not accept medicaid if they offered to pay me DOUBLE my regular fees. I’m not willing to gamble away my autonomy, security, and freedom. This risk is quite real. One need only to do a search for these cases.

  2. To build a workforce of that magnitude it takes more than seven years Dr. Roda. Dentists have had almost 20 years now (since stated in 2000 surgeon general report) to address oral healthcare access problems and little has changed. There is a huge need for dental care among both children and adults and the research IS there, you just have to look! Private practice is no longer enough. If the dental field wants more credibility among the medical field, it NEEDS to expand. That will help more people reach dental services. Get rid of the strict supervision levels on dental hygienists to get out there and do the work they do best as preventive oral health specialists and maybe you wont have to worry about dental therapists. Until then, this unfortunate war between dentists and dental hygienists will continue.

  3. There’s a war between hygienists and dentists??? LOL! I’ve been at this for 30 years, and I have not witnessed such a “war.” All is good on the home front here. 🙂

  4. If you get into the policy side of it, there’s a war. I never noticed it being in cushy private practices for the past 18 years until I started doing research and helping my association behind the scenes.

  5. CBRDH, I’d like to know how and why you and others believe “Dentists have had almost 20 years now (since stated in 2000 surgeon general report) to address oral healthcare access problems and little has changed.” The dental societies in all states do what they can. All of them organize and perform charitable services and dental giveaway days, eg Give Kids a Smile and Missions of Mercy…and pretty much all of us have a heart and give our patients a break when they need it. BUT you are confused if you think the dentists of our country are obliged to definitely solve public health issues by virtue of our license to practice.
    Public health problems are dealt with as a matter of public policies, programs, and funds, not “dentists” policies, programs or funds. We constantly propose legislation to address the issues, but there is nothing the government does that isn’t slow and costly.
    Would you appreciate it if the general public thought you and your dental hygiene organizations were responsible for all the people with bad breath, stained teeth, and gingivitis from their dental plaque? Wouldn’t you say something like, “At least make an appointment and sit in the chair?”
    Also, keep in mind that every country on the planet has similar issues of provider shortage areas, socioeconomic disparities of dental health, difficulty recruiting and retaining providers to participate in public health ‘insurance’ (Medicaid), people neglecting themselves and mis-using the hospital ER…including countries that have had dental therapists almost 100 years.
    I’d love for you to paint a picture of hygienists getting “out there and do the work they do best as preventive oral health specialists”. Will the hygienists buy dental equipment and employ assistants and travel to where the Medicaid patients live in provider shortage areas? Will they move there to fill the vacuum of dental health providers?
    Is there a country or state with general supervision (or total independence) that has the hygienists taking the lead in breaking down the barriers of Access to Care on their own as independent business people eager to fulfill this mission to serve the underserved and the vulnerable populations? How does it work there?

  6. The Future Realized

    The reality is that the Dentist’s themselves may not be to blame on an individual basis, but they hide behind the organizations they subscribe to. Mass dental society puts a ton of money and effort to stomp out any advancement in the dental hygiene profession.

    Why not just allow the profession to advance? Hygienists could create so many different opportunities for themselves and the underserved if they lifted all the unnecessary restrictions in legislation.
    The most ridiculous and obvious of all the restrictions… who pays us and how. Why should that matter.? Lift the restrictions and see what we might be able to do with the freedom to serve.

    I have personally seen so much unconscionable malpractice in one day working under dentists. Hygienist are not empowered to say or do anything about it. Somehow we are the threat to the public? I don’t buy that and neither should anybody else.

    Hygienist’s are not a threat to the dentist, the dental profession, or the public. We are an underutilized asset with exponential potential to help advance the entire profession. We could be the source of integrating oral health with all healthcare systems in very creative ways. The narrow minded views voiced before it has ever been implemented is ignorance in action. Advancement of any healthcare system needs to be fostered and encouraged not met with adversity and unwarranted staunch criticism.

    I dare any of these nay sayers to have an open mind and an open heart and see what might be possible if they met the hygienists with encouragement and helped navigate to broaden the dental health profession. I dare them to put their own dis-beliefs to the test. Challenge yourself to help with a solution. Expand your vision. See if we really can make a difference for EVERYONE!

  7. At least we can agree that there is a need. The dental associations and societies sure have a funny way of showing they are “doing all they can” when they cannot even compromise in expanding the dental workforce. Dental hygienists are also an integral part to those charity programs you mentiones but they are a temporary solution. A dental therapist is not the only answer for a multifaceted problem like this, but it can certainly help. If both dentists and dental hygienists could work more as a team we would probably have a similar workforce as the medical field. Maybe then the government would provide more funding and policies to help these efforts. Dental therapists will achieve the same level of education as a nurse practitioner or physician assistant. The same battles took place there and these midlevel professions are a huge asset to the field. Tell me why again the dental association/societies are so stubborn in giving this a try?

  8. And as far as dentists having obligations in advocating and serving the public health, is there not something in the dentist’s preamble that promotes that? Having a self governing association/societies that you are paying as members to is a big part of that effort. Many dentists just choose to sit on the sidelines instead of getting involved. Public health efforts are not just “dealt with as a matter of public policies, programs, and funds” Public health efforts are achieved best when professionals (including dentists), organizations and the people collaborate and fight for change. This disconnect is one of the reasons why public health efforts are slow to occur. Dentists have an integral role in public health whether they want to be a part of it or not.

  9. Dr Roda,
    I think you distilled the issues very well… and your suggestions make good sense.

    (PS I left you a message on FB about this…please read and reply.)

  10. The Future Realized

    It is unfortunate but a Dentist’s negative opinion on this matter without proposing solutions is extremely transparent. Does it seem more plausible that the reason Dental Associations spend obscene amounts of money on resisting the ADHA’s efforts is because they are so concerned about public safety and public health or that they are afraid the hygienist advancement will somehow affect their bottom line.

    All one needs to do is read the legislation to see right thru the phony bologne reasons they give as to why these efforts are a “distraction” or “cheap labor”.

    After years of trying to liberate the profession from the obvious Anti-trust violations within State regulatory agencies, they finally bend by allowing the “public health dental hygienist”. Only if that professional works specifically for essentially Medicaid paying patients and or for free are they “legally allowed” to provide care independently. Just curious why the care from that same professional is not allowed to be compensated freely. Or why the care is restricted to specifically only allowing care on the patients who usually have the most involved dental health conditions, yet they claim we can not serve independently because we are a “threat” to the public. We can provide for the most difficult patients independently for free or Medicaid, but we are a danger to the rest of the public?

    We are not suggesting we want to open up our own dental practices. I believe the Dentist’s have cornered that market. That is where the insecurity of the dentists gets ridiculous. The point is we can serve in so many other ways given the opportunity. There are a lot of areas that do not even cross the mind of the Dentists. Allow us the chance to be the innovators in this area. You may be pleasantly surprised at the referrals sent your way.

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