Dental Therapy: A Joker in the Stacked Deck of Access to Care

There exists no universal definition for the term “access to care.”^1,2 Meanings are all over the map. Different advocacy groups, all with differing agendas, all weigh in with their unique specifics.   

Is access to care a euphemism meaning universal dental care for the Medicaid population, or all citizens, inclusive of “dental deserts” in remote rural demographics or hardscrabble inner cities? Further, what standard of care is defined by access to care? Is access to care cryptic promotion for a dual standard of healthcare services, or a stepping stone for a diminished universal government single-payer program, of Medicaid for all? 

Lacking accepted defining criteria for exactly what constitutes access to care, the deck is stacked. Any organization is free to invent its rules for play within our nation’s healthcare delivery. Groups and agendas are diverse and often highly contrasting. Players at the table include government agencies, corporate dentistry, organized dentistry at any and all levels, the W.K. Kellogg Foundation, and Pew Charitable Trusts, as well as the dental education-industrial complex. 

Each of these disparate entities often seeks different outcomes, as well as operates off different and conflicting sets of “facts.” Some work from principles of free market economics and optimal consumer choice. Others prefer top-down big-government solutions from “enlightened” (elitist?) policymakers. Some groups compromise and attempt to find middle ground with others. Others hold fast to their “all in” principles in this high stakes game of Texas Hold’em.

Government

The US Department of Health and Human Services offers the following:³

Access to healthcare means having “the timely use of personal health services to achieve the best health outcomes” (IOM, 1993). Attaining good access to care requires three discrete steps: 

• Gaining entry into the healthcare system.
• Getting access to sites of care where patients can receive needed services.
• Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.

Healthcare access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate healthcare, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they can gain access to healthcare.
• Utilization measures of the ultimate outcome of good access to care (ie, the successful receipt of needed services).

These stated objectives and measurements by the federal government seem vague and conflicted, and they often contrast with their actions and reality. How often do we witness “best health outcomes” under dental Medicaid? Is a dental Medicaid beneficiary card truly a viable and worthwhile “entry into the healthcare system”? Do patients “access sites of care where they (patients) can receive needed services,” or do they access sites of care designed to maximize production dollars for business owners, irrespective of patient needs? Is it reasonable and rational for dental Medicaid beneficiaries to trust their provider under the current program? Is the fee schedule and list of provided services under a state’s dental Medicaid program (or insurance program) in compliance with standard of care, which disincentivises fraud and abuses? Without a frequent and comprehensive auditing system in place, who defines “needed services” and if objectives were met? 

Corporate Dentistry

The Association of Dental Support Organizations (ADSO), the largest lobbyist group for corporate dentistry, informs in its vision statement: “The ADSO member organizations support a practice environment where dentists have the ability to choose the administrative services which best allows them to focus on patients, expand access to quality care [bold lettering added] and improve the oral health of their communities.”⁴ Wording isn’t simply “access to care,” but “access to quality care.” This distinction of access to quality care may be important, in that most members of the ADSO have little or no participation in dental Medicaid.

Employers within the DSO industry continually run employment recruitment ads online, in dental journals, and at dental conventions. Numbers of DSO recruiters are very evident on dental school campuses. This all speaks to an industry demand for employee providers, as big business dentistry supplants small business dentistry. It also may indicate a rapid continual employee turnover, which requires perpetual replacement. Undoubtedly, dental therapists would be a welcome addition within the DSO industry. 

State Dental Associations

The Wisconsin Dental Association (WDA) makes the case that access to care is problematic due to gross underfunding.⁵ Reimbursement rates are approximately 30 to 35 cents on the dollar for dentist providers. Assuming an average 70% overhead expense for operation of a dental office, clinics would lose substantial income in electing to treat dental Medicaid patients.

This is predicated upon patients served to appropriate standards of care. Obviously, increasing the number of dentists in the industry or even delegation of care to lower paid dental therapists couldn’t make up for such a severe financial discrepancy in the private sector. The dental Medicaid program as currently operated in many states is too broken for simple fixes of expanding the number of providers.

“The government has decided providing health care (including dental) to low-income individuals is a worthy goal, but has chosen to pay those who provide that care at a rate substantially below what it costs to deliver those services,”⁶ the WDA states on its website.  

“Instead of paying providers up front for the costs of these services, the government depends on providers to either absorb the losses (this becomes increasingly difficult as rates go lower) or to do its job of ‘taxing’ individuals to cover the costs by cost-shifting losses on to private-sector patients and/or their dental benefits plans,” the WDA continues.

“The dental community believes the system would be more transparent and provide better access to dental care for those enrolled in government programs if the government would stand by its original promise and properly fund the health care programs policy-makers have established,” the WDA says.

“It should not be the job of health care providers to implement a hidden tax to fulfill promises made by the government or society as a whole. Providing quality care to MA (Medicaid Assistance) patients is dentists’ responsibility; finding an appropriate mechanism to pay for those services is the government’s/society’s responsibility,” concludes the WDA.  

Other state dental associations such as the California Dental Association and the ADA address access to care primarily via promoting prevention and education.^7,8 Our current model of neverending clinical operative intervention with the dental underserved population seems economically unsustainable. Prevention and education must be paramount.

The ADA has issued an online report that demonstrates the overwhelming majority of Medicaid eligible children reside within 15 minutes of a Medicaid credentialed dental provider.⁹ Readers may simply click on the image of any of the 50 states to view particular details. The ADA demonstrates there is little if any dental workforce shortage for the existing demand.

The 2012 position paper of the American Academy of Pediatric Dentistry (AADD) refuted outcomes proffered in support of dental therapists by the Kellogg Foundation and Pew.¹⁰ The AAPD contended that the dental therapist model “is an economically unviable option for the private sector oral health care in the U.S.”

Further, the AAPD said, “There is no evidence to suggest that dental therapists deliver any expertise comparable to a dentist in the fields of diagnosis, pathology, trauma care, pharmacology, behavioral guidance, treatment plan development, and care of special needs patients.” 

Finally, the AAPD said that it “strongly believes there should not be a two-tiered standard of care, with our nation’s most vulnerable children receiving services by providers with less education and experience, especially when evidence-based research to support the safety, efficiency, effectiveness, and sustainability of such delivery models is not available.”

The Academy of General Dentistry (AGD) issued a white paper as early as 2008 with its perspectives on increasing access to care,¹¹ which was followed by an additional 2015 white paper “Barriers and Solutions to Accessing Care.”¹²

The AGD stressed that “Legislatures (falsely) equate access with insurance coverage, and with having enough doctors and hospitals within the areas in which populations live. However, having insurance or having health care providers located within the immediate vicinity does not guarantee that people who need services will get them.”

The AGD’s positions also stressed that patients’ best interests were served with licensed doctor supervision.

“Removing the oversight of the dentist removes the one professional who has the overall knowledge and training to coordinate all aspects of treatment that patients might need,” the AGD said.

The AGD placed a focus on the critical nature of nutritional and oral health education, with various fluoridation programs. Its targets were patient populations, educators of children, other healthcare providers, public media, parents, and daycare providers. The critical value of a dental home, also a focus of the AAPD, for each patient was emphasized.

The AGD made the point that a strong prevention program like Denmark’s is vastly superior to national programs like those in New Zealand or the United States. Denmark made drastic reductions in dental caries rates, while New Zealand and the United States are on the treadmill of continuously treating carious lesions. The New Zealand model holds important interest, because it’s a model widely espoused by dental therapist advocates.

Robert Roda, DDS, MS, president of the Arizona Dental Association, blamed failures in access to care on reimbursement rates, not on a lack of providers. He highlighted his perspectives on alleged failures of the dental therapist program in Minnesota.¹³   

“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 (dental therapists), while ignoring the real barriers to access,” said Roda.

The standing white paper “Midlevel Dental Providers” of the American Academy of Oral and Maxillofacial Surgeons (AAOMFS) leads off with a direct quote from the Pew Center: “State leaders, dentists, public health advocates and other stakeholders should be heartened to know that expanding the dental team is an effective strategy to improve access to care, but they cannot overlook the importance of setting adequate Medicaid reimbursement rates.”¹⁴ 

However, the AAOMFS goes on to refute findings of the Pew report on dental therapists in New Zealand: “This report, which advocates for increased training and use of midlevel dental providers, incorrectly concludes that access to care is impaired by a shortage of dentists and fails to recognize the difference between lack of access and lack of utilization.” 

The AAOMFS white paper also discounts in detail what group sees as a flawed comparison between dental therapists and nurse practitioners and physician assistants. The white paper has concerns about the generation of a lower standard of care for the disadvantaged as well.

The American Association of Public Health Dentistry (AAPHD) takes a different position from most of organized dentistry on the dental therapist issue.¹⁵ This should be fully expected, as the vast majority of members are employed in the public sector. The AAPHD recently stated in support of the dental therapist model, “Although financial viability is an important outcome, it is not the only outcome and certainly not the most important outcome to evaluate.”

The inherent differences in viewpoints can’t be overemphasized between those whose healthcare careers are enmeshed in the public sector versus marketplace competition of the private sector. For those in the private healthcare sector, if a model for healthcare delivery is fiscally untenable, it very quickly disappears. By contrast, public sector policies and decision making can be fully subsidized by moneys from nonprofit grants and government.

W.K. Kellogg Foundation and the Pew Charitable Trusts

Simple fixes to correct access to care are what’s seemingly offered in earnest by the Pew Charitable Trusts and the W.K. Kellogg Foundation.^16-18 Expanding the dental industry workforce with personnel of reduced skill, training, and labor cost is their solution. They contend dental therapists provide a positive answer and often point to models in New Zealand, Alaska, and Minnesota. These progressive, politically focused organizations have significant influence on state legislators with grant money, which is often tantamount to lobbyist funding.^19,20

Oddly, these progressive liberal organizations also draw support from arguments of unfettered laissez faire capitalists, whose groups are supported by corporate dentistry seeking to reduce the cost of labor, as opponents might argue, regardless of patient outcomes. Politics often make strange bedfellows, as John Grant, Pew’s director of the Dental Campaign, joins hands with Grover Norquist, founder and president of Americans for Tax Reform.¹⁶

Further, these nonprofits espouse an expansion in the number of dentists, as well as therapists entering the workforce, to ease a presumed access to care problem.²¹

“America needs more dentists, especially those who reflect the communities they serve. And we need to expand the dental workforce, adding mid-level providers to the dental team to make it easier for children and families in underserved communities to get high-quality, affordable dental care where they live,” the Kellogg Foundation says on its website.

Another nonprofit foundation, the Henry J. Kaiser Family Foundation, also professes a national shortage of dental care and connects that to an assumed shortage of dentists.²² However, is that a reasonable assumption to draw?

Apparent disconnects from the economic realities exist for some of a socialist vent, versus free market small business. Dentists graduating today often face $350,000 to $500,000 in student loan debt and limited prospects for viable employment to repay their debt load. Repayment programs for dentists providing care in underserved communities often amount to little more than debt service on the interest of educational loans.²³     

Great need for services may be presented by a particular demographic.²⁴ Market forces will satisfy that need, if there is a concurrent viable economic demand (means to pay for those services). Need doesn’t necessarily equate to demand. Karl Marx wrote in 1875, “From each according to his ability, to each according to his needs.” That economic policy failed in the former Soviet Union, as it’s failing today in Venezuela. One wonders why some may assume that flawed construct might work out for the dental Medicaid program in the United States. 

Dental Education-Industrial Complex

This group is too rarely formally cited, although it has a significant impact on healthcare policy outcomes. These people operate in the public sector in leadership capacities of dental education and Medicaid service organizations. Their interest is frequently in expanding the size of dental schools, the types of programs offered, the overall number of dental education programs, and the size and scope of Medicaid. As the dental-education industrial complex expands, so does their potential for power and income. All this comes at a cost: student debt, oversupply of dentists, university fiscal deficits, and ethical reputations of institutions.

It’s easy to pigeonhole this group as overly cynical and self-serving. Incomes for deans and department chairs are often in the stratosphere compared to rank-and-file faculty. Leadership may also gain added income from undisclosed (or nominally disclosed) dealings with the insurance industry, corporate dentistry, and dental product manufacturers.

The University of Missouri School of Dentistry recently announced a permanent, 50% expansion of class size from 42 to 63 students.²⁵ The university president stated, “Expanding the school’s class size will assist with alleviating the shortage of dentists in underserved communities.” One wonders upon what precepts that decision was made and if there were undisclosed motivations.

Texas Tech University is planning to expand its El Paso campus with the addition of a dental school.²⁶ Yet the House of Delegates for the Texas Dental Association (TDA) went to great lengths in demonstrating the wastefulness of this project. The TDA proffered numbers of reports dismissing a dentist labor shortage and noting that access to care was proximally available for Medicaid eligible children throughout almost all of Texas, inclusive of the El Paso area. 

The University of Washington School of Dentistry has generated a huge fiscal deficit of tens of millions of dollars that has now resulted in staff and faculty layoffs.²⁷ The former dean was hauling in a huge paycheck, in addition to questionable dealings with an insurance company and its associated private equity investment firm. The pediatric dental specialty program also was expanded into a world-class facility, which Medicaid revenues fell very short in covering.

One should never discount university grant money procured in support of the access to care industry.²⁸ One former dean at the University of Florida who advocates for access to care through the dental therapist model has successfully generated millions of dollars in grant funding for his university. A program’s integrity and ethical standing might be questioned by even an apparent conflict of interest.

Conclusion

No one group is assured of winning the bracelet in this World Series of Poker. Interesting alliances are playing out. Some are gambling strictly for money. Others apparently play for a “greater good” of the public interest. This may or may not actually represent ideological arrogance, ignorance, or simply deceit. Some bluff their true intent, while others are transparent in showing all their cards.

Odds always favor those sitting behind the tallest pile of chips, with the most money. However, never discount passion, skill, and luck. The dental therapist issue within the context of access to care will cause some to fold, others to check, and still others to go “all in.” 

“Poker is a microcosm of all we admire and disdain about capitalism and democracy,” once said professional poker player Lou Krieger. “It can be rough-hewn or polished, warm or cold, charitable and caring, or hard and impersonal, fickle and elusive, but ultimately it is fair, and right, and just.” 

References

1. Gulliford M, Figueroa-Munoz J, Morgan M, et al. What does ‘access to health care’ mean? https://www.ncbi.nlm.nih.gov/pubmed/12171751 J Health Serv Res Policy. 2002;7:186-188. 

2. Advisory Board. ‘Patient access’ means something different to everyone—but they all agree it’s essential. September 2, 2014. https://www.advisory.com/research/market-innovation-center/the-growth-channel/2014/08/patient-access-means-something-different-to-everyone Accessed May 16, 2018.
3. US Department of Health and Human Services. Access to health care. In: National Healthcare Disparities Report, 2011. Rockville, MD: Agency for Healthcare Research and Quality; 2014. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr11/chap9.html Accessed May 16, 2018.
4. Association of Dental Support Organizations. Our vision. https://www.theadso.org/about-the-adso/#vision_mission Accessed May 16, 2018.
5. Wisconsin Dental Association. Barriers to care—Medicaid facts. https://www.wda.org/healthy-choices/barriers-of-care Accessed May 16, 2018.
6. Wisconsin Dental Association. Cost-shifting. https://www.wda.org/healthy-choices/barriers-of-care/why-dentists-dont-and-wont-cost-shift Accessed May 16, 2018.
7. California Dental Association. Access to care. https://www.cda.org/advocacy/access-to-care Accessed May 16, 2018.
8. American Dental Association. State and Community Models for Improving Access to Dental Care for the Underserved—A White Paper. Chicago, IL: American Dental Association; 2004. http://www.ada.org/~/media/ADA/Advocacy/Files/topics_access_whitepaper.ashx Accessed May 16, 2018.
9. American Dental Association, Health Policy Institute. Geographic access to dental care. https://www.ada.org/en/science-research/health-policy-institute/geographic-access-to-dental-care Accessed May 16, 2018.
10. American Academy of Pediatric Dentistry. AAPD responds to Kellogg Foundation report on dental therapists [press release]. April 10, 2012. http://www.aapd.org/aapd_responds_to_kellogg_foundation_report_on_dental_therapists/ Accessed May 16, 2018.
11. Academy of General Dentistry. White Paper on Increasing Access to and Utilization of Oral Health Care Services. Chicago, IL: Academy of General Dentistry; 2008. https://www.agd.org/docs/default-source/policies-and-white-papers/access-to-care-white-paper.pdf?sfvrsn=d5e75b1_2 Accessed May 16, 2018.
12. Academy of General Dentistry. Barriers and solutions to accessing care. https://www.agd.org/docs/default-source/policies-and-white-papers/barriers-solutions-to-accessing-care-white-paper.pdf?sfvrsn=c5e75b1_2 Accessed May 16, 2018.
13. Roda R. Don’t follow Minnesota’s failed dental therapist experiment. Arizona Capitol Times. March 29, 2018. https://azcapitoltimes.com/news/2018/03/29/dont-follow-minnesotas-failed-dental-therapist-experiment/ Accessed May 16, 2018.
14. American Association of Oral and Maxillofacial Surgeons (AAOMS). Midlevel Dental Providers [white paper]. Rosemont, IL: AAOMS; 2017. https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/policy_dental_midlevel.pdf Accessed May 16, 2018.
15. American Association of Public Health Dentistry. AAPHD responds to recent ADA report on study of alternative dental providers [press release]. August 9, 2012. http://www.aaphd.org/assets/press-releases/aaphd%20responds%20to%20ada%20alternative%20dental%20providers.pdf Accessed May 16, 2018.
16. Grant J. What might help—or hurt—access to dental care this year. The Pew Charitable Trusts. January 22, 2018. http://www.pewtrusts.org/en/research-and-analysis/analysis/2018/01/22/what-might-help-or-hurt-access-to-dental-care-this-year Accessed May 16, 2018.
17. W.K. Kellogg Foundation. Most comprehensive review of dental therapists worldwide shows they provide effective dental care to millions of children [press release]. April 10, 2012. https://www.wkkf.org/news-and-media/article/2012/04/nash-report-is-evidence-that-dental-therapists-expand-access Accessed May 16, 2018.
18. Grant J. Dental therapy expands access to care, would aid most Arizonans. Arizona Capitol Times. April 19, 2018. https://azcapitoltimes.com/news/2018/04/19/dental-therapy-expands-access-to-care-would-aid-most-arizonans/ Accessed May 16, 2018.
19. Philanthropy News Digest. Kellogg Foundation launches $16 million initiative to support oral healthcare efforts in five states. November 17, 2010. https://philanthropynewsdigest.org/news/kellogg-foundation-launches-16-million-initiative-to-support-oral-healthcare-efforts-in-five-states Accessed May 16, 2018.
20. W.K. Kellogg Foundation. Grants. https://www.wkkf.org/grants#pp=100&p=1&q=dental Accessed May 16, 2018.
21. W.K. Kellogg Foundation. Oral health. https://www.wkkf.org/what-we-do/healthy-kids/oral-health Accessed May 16, 2018.
22. Henry J Kaiser Family Foundation. Dental care health professional shortage areas (HPSAs). December 31, 2017. https://www.kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Accessed May 16, 2018.
23. American Dental Association Office of Student Affairs. Dental student loan repayment programs & resources. July 2014. https://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/dental-student-loan-repayment-resource.pdf Accessed May 16, 2018.
24. Stitzel J. Meeting the demand: strategies to improve access to oral health services. The Pew Charitable Trusts. 2013. http://www.ncsl.org/documents/summit/summit2013/online-resources/Pew_LegSummit13_OH_PowerpointPDF.pdf Accessed May 16, 2018.
25. Missouri School of Dentistry to expand class sizes. Dentistry Today. April 17, 2018. http://www.dentistrytoday.com/news/industrynews/item/3175-missouri-school-of-dentistry-to-expand-class-sizes Accessed May 16, 2018.
26. Olivas D. El Paso dental school gaining momentum. KIVA. August 8, 2017. http://www.kvia.com/education/el-paso-dental-school-gaining-momentum/601366150 Accessed May 16, 2018.
27. Long K. Layoffs at debt-ridden dental school raise anger at University of Washington. The Seattle Times. April 13, 2018. https://www.seattletimes.com/seattle-news/education/layoffs-at-debt-ridden-dental-school-raise-anger-at-university-of-washington/ Accessed May 16, 2018.
28. University of Florida College of Dentistry. Frank A. Catalanotto, DMD, Department of Community Dentistry and Behavioral Science (current grants). https://cdbs.dental.ufl.edu/catalanotto/ Accessed May 16, 2018. 

Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.

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