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As a dentist and owner of a multi-site practice in Minnesota, I’m writing to respond to the letter from the president of the Arizona Dental Association, Dr. Robert Roda entitled, “Don’t follow Minnesota’s failed dental therapist experiment,” published on March 29. A number of his comments about the Minnesota experience with dental therapy are, at best, misleading. I’d like to set the record straight as a private practice dentist and an employer of dental therapists. For me, dental therapy has been an important tool to help expand care to more people, especially patients on Medicaid, and a way to grow my practice.
John T. Powers
Dr. Roda claims dental therapists “solve nothing.” Tell that to the patient in a community health center dental clinic who is able to get his tooth ache handled with a shorter wait time because the dental therapist was available to treat him weeks before a dentist could have seen him. Tell that to the mother in rural Minnesota who is able to get her children’s needs addressed regularly and avoid them developing decay or needing painful extractions. Tell the thousands of patients on Medicaid who are now receiving regular care that having a dental therapist treat them “solves nothing.”
Dr. Roda also naively notes that dental therapists have not led to lowered dental costs in Minnesota. We authorized dental therapists in Minnesota to address two major problems: too few dentists were accepting Medicaid patients and in most of our counties – many of them rural – we had a dentist shortage. Dental therapists have started to make an impact on both of these fronts. Because of dental therapists’ lower labor costs (about 30 – 50% the average hourly wage of dentists in my state), those of us in private practice who have hired them are finding it financially viable to serve more Medicaid patients – we are not taking such a hit on the state’s low Medicaid reimbursement rate. Federally qualified health centers using dental therapists are able to use the savings in staff salaries to provide more free and low-cost care to the uninsured. And a number of practices are deploying dental therapists to rural community locations because it’s more affordable than sending a dentist. In fact, dental therapists are being used to address what Dr. Roda called the “real challenges that parents face getting to the dental office.” Children’s Dental Services, the largest nonprofit dental operation serving children in my state, sends dental therapists to low-income schools to fill decayed teeth—at a substantially lower cost than what it would take to send a dentist.
In Minnesota the Medicaid agency decided to reimburse dental therapists at the same rate as dentists. In Arizona, the precedent is to reimburse midlevel providers at a lower rate. That would offer the state budget immediate savings. But let’s think in the long-term. Right now the most expensive member of the dental team is performing routine restorations that a qualified, lower-cost provider could perform. That’s highly inefficient and one factor in why dental costs are high. If dental therapists become a fixture in Arizona’s dental delivery system, the cost savings they would bring to dental practices would help keep dental costs from continuing to spiral up – as labor is the most expensive component of a dental practice, while also providing care to more lower-income people.
Apple Tree, another nonprofit provider, has a mobile team that provides on- site care at a veterans nursing home. Without Minnesota’s law they would have to hire a dentist to do the thousands of restorations now performed by a dental therapist, at an additional cost of $52,000 annually.
For all these reasons and more, dental therapy graduates are in great demand and dentists are hiring them as quickly as we can train them.
Arizona, like Minnesota, has a significant access problem. Solving it will take a multi-faceted approach. Making dental practices more cost-efficient and geographically flexible is part of the solution – an important part. Dental therapy can help get us there. Medical practices and their patients have benefitted from incorporating nurse practitioners and physician assistants for decades. Arizona’s dentists and patients deserve – and need – the same opportunity to benefit from midlevel providers that thousands of Minnesotans have had.
I would say to those Arizona dentists who believe it won’t help their practices – don’t hire them. But don’t deprive your colleagues—especially those working in safety net clinics and rural communities—of the opportunity to improve their practices and the health of their patients.
John T. Powers is a dentist who is licensed to practice in Minnesota.
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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.
Here in Arizona we have dental practitioner Paradise. There is no meaningful oversight of “professional practiced”. Dentists charge whatever they feel like. Ethics is a word from Swahili. This is MY experience with about 6 or 7 dentists. Sad but true. Even my Congressman is a dentist. Check the things he does for an idea of dentists in Az.
Dr Powers, among other things, you are helping perpetuate the myth that lower-cost providers = lower fees to patients. Most proponents of dental therapists cite their lower pay and call it lowering the cost of dentistry as a benefit when speaking about patients who avoid the dentist because of the fear of high fees. When patients hear that dental therapists are lower-cost labor they believe they are hearing “lower fees”, while business people hear “lower overhead”. We both know which one it is…and it is not lower fees for patients. Dental therapists do not equal lower fees to patients…so the private practice employment of dental therapists is for lower overhead which translates to higher profits. I’ll grant you that the Medicaid reimbursements require lower overhead to survive, but that is a different discussion.
Your examples based on Minnesota are irrelevant in Arizona, as the bill for dental therapists in Arizona has nothing in common with your dental therapist legislation. In Arizona, and most other states, they are going purely “free-market” and their bills create zero obligations to address any issues of Access to Care. We both know that about 2/3 of the DTs in MN are employees in private practice…and because there is a limited supply, every private practice employment of a dental therapist deprives a public health or non-profit setting from the benefits of a dental therapist. In addition, we both know that the obligation to address Access to Care issues by employed dental therapists in MN is only “more than 50% of their workload”. I cannot find a definition of “workload” in that legislation… Is it a count of patients? Procedures? Value of prodedures? Time spent? Number of appointments? I can imagine that the private practice employers have many opportunities to maximize practice profits by manipulation of that definition. And how lucky! There is no state oversight on that. Along the same lines, the reports on dental therapists are almost entirely about the 1/3 employed in public, community, and non-profit settings. What is the impact of the 2/3 employed in private practice? Does anybody know? And why are you the only dentist in MN promoting dental therapists? What do the others have to say? (I’ve read several that aren’t as entrepreneurial as you, and they find the Medicaid reimbursements are just too low to make it work, even with lower-cost dental therapists.)
Lastly, as with almost all other proponents of dental therapists, you bragged about the dental therapist achievements in the non-profit sector… not about the achievements in the private sector. That is a recurring and telling sign that “free-market” and private sector employment of dental therapists is NOT how a state should address Access to Care issues. I cannot speak for Dr Roda, but I will say that dental therapy legislation as proposed in Arizona will approximately “solve nothing”.
Spence,
There is no way in one article all elements of what is WORKING in dental therapy could be addressed. Nor is it reasonable to expect all proponents of the dental therapy model to jump in and defend the poor accusations of every half cocked word of opposition. Perhaps there are more therapist working in private practice rather than non profit offices but you have failed to address where these private practice a located. Private practices located in “critical access” locations are capable of providing significant amounts of care to medicare patients. These offices in critical access location the therapists are seeing upwards of %90 medicare patients. You stated that the lower labor fees only provide increased profits to the practice and is not passed on to the patient. This is true but was never designed to be cost savings to the patient but rather a way to make seeing medicare financially sustainable. So to insinuate practices are only hiring therapist to line their own pocket is once again is a half truth. In fact the only parties asking for more money in this situation is the ADA dental therapy opponents, stating “it is not an access issue it is a financial one.” In my experience it is the Doctors that have the the most compassion for their community and only sustainability financial concerns are the Dr.’s that are hiring therapists. Every thing I have read from the opponents of Dental Therapists is half truths, not well thought out and borderline slanderous. These opponents have zero personal experience in the functionality of a therapist and the benefits of the therapist to the community. I have seen first hand it is an ACCESS issue, patients tell me daily how thankful they are accept their insurance as they have gone years with out care. Yes perhaps there is care available but not without a significant distance to travel. If you buy something from Amazon would you read reviews from people who have never used the product? Show me someone who has actually worked with a therapist who has anything negative to say about their work, or functionality within a practice, someone who has looked at the books and found negative impact on the practice… Sorry it is just not going to happen, the Dr. I work for has been pleased to the extent of a two op add on and having two therapists on staff. And yes this Dr. has benefited financially because with therapist on staff seeing medicaid patients at the current reimbursement is financially sustainable.
I wish you made sense, but you only make half sense. Where do you get the data about the use of DTs in private practices? This is one of my major points: We don’t know the data. MN forgot to address it. I already agree that in practices whose mission is to address Access issues, that DTs do good things. But then again, dentists in those practices do good things and are a lot more versatile. That private practices hiring DTs are located in “critical access” areas and these practices are capable of doing good things is not information. That DTs are seeing up to 90% Medicaid (you said Medicare, but you must have meant Medicaid.) is a made up number. You might know your experience, but what about all the other offices and other DTs? You aren’t allowed to say what is going on in MN without knowing what is going on. The most entrepreneurial of dentists (and corporate and venture capitalist-owned practices are certainly at the top of that list) are not taken into account by your singular experience. I am not negating your experience, I am pointing out the 2/3 of MN’s DTs are unaccounted for as far as their impact on Access to Care. The state report focused on 15 sites, mostly the community clinics and FQHCs and some large private practices. I am not insinuating I know what is going on in MN, just that the most profit-oriented practices are likely to want cheap labor to maximize profits because that is what they do. It is not conducive to good dentistry, nor conducive to actually taking care of people, and if a rule about DTs taking care of Medicaid pts can be skirted, that is where I’d expect it to happen.
You said, “…never designed to be cost savings to the patient but rather a way to make seeing medicare financially sustainable.” is just wrong. You are obviously not familiar with the claims made in the press by proponents of DTs and what legislators are told. I am familiar with it and that is another of my major points: There are claims made that just are not true. This is one of them and your view agrees with mine: Nobody should be expecting that non-Medicaid patients will be charged lower fees. Yet the claim is made routinely. I have a problem with that lie.
I don’t expect anyone who has worked with DTs or who has been a pt of a DT has anything bad to say. So don’t go there with me. I am speaking about the public claims made and the legislative efforts and the statewide happenings. I am speaking about the use of DTs in other countries and what has worked and what has not. I am speaking about MN having a very imperfect legislation that has a diminished impact on Access because, among other things, the experience of other countries was not taken into account. I don’t question what you do, but you are not well versed in the broader subject outside of your office.
The most important point is that MN’s weak legislation at least tried to address Access to Care. It was not done as well as it could have been done, but my message to Arizona is to ignore any positive things about DTs in MN…because the legislation for AZ does not address Access to Care. It only addresses DTs, with no legislative directive to address Access to Care issues.
I just saw that the AZ bill for DTs has been amended to be directed toward Access to Care. I am happy to see that. Whether the state needs DTs to address Access to Care remains to be seen…but at least the legislation is now showing specific intentions in that direction.
Kind of ironic that Arizona has recently authorized dental therapy. Dr. Roda must feel pretty dumb now…
Graham,
#1- No reason for Dr Rhoda to feel dumb. He made some excellent points.
#2- The situation changed radically when the proponents of dental therapists capitulated to the logic of how and where DTs should be employed and supervised. The initial language of the DT Bill lacked any and all semblance of actually addressing the Access to Care issues of the populace… IMHO, it had no redeeming value. Well, the DT proponents decided to amend their core demands that wanted the marketplace to determine how, when, where the DTs would be employed. The final language of the Bill targeted their employment to settings whose mission is Access to Care, thus ensuring that DTs would very likely benefit the populace they are intended to help. Huge difference, IMHO. The end result of the amendments to the bill left little to argue about. None of that was in place when Dr Rhoda wrote his article.