Dental therapists are the wrong answer to improving oral health in Michigan

A recent guest commentary advocated for the creation of dental therapists in Michigan. However, the commentary did not include information that shows dental therapists have had a positive and successful impact on addressing the barriers to dental care.

Michigan has been very proactive in coming up with solutions to get people more care. Just this year, the Healthy Kids Dental program was expanded to all Michigan counties so that children ages 0-21 will now be covered by the program. Healthy Kids Dental has been proven to be very successful in increasing access to care. According to a report by the Child Health Evaluation and Research (CHEAR) Unit at the University of Michigan, the Healthy Kids Dental program has significantly increased utilization of dental care by underserved children. The program is working and the data shows it.

Under the traditional fee-for-service Medicaid program about 46 percent of children received care where as under Healthy Kids Dental the number increases to 61 percent (and that number continues to improve). For purposes of comparison, for children with private dental benefits the utilization rate is about 70 percent.

In fact, several programs serving Medicaid-eligible children throughout Michigan report decreases in the number of children being treated by their programs. The only reason they can determine why this is happening is that children are finding a dental home due to Healthy Kids Dental.

The dental therapist program proposed in Senate Bill 1013 is based on a program that exists in Minnesota, but the Minnesota program has not been shown to be successful. Since the law creating dental therapists passed in 2009, only 54 dental therapists have entered the workforce. Additionally, when the law passed proponents claimed that it would get providers into underserved rural areas. In fact, in the seven years since their creation, only seven dental therapists have gone into rural areas. The rest have gone into urban areas where they can make more money.

A recent study by the American Dental Association’s Health Policy Institute shows that in Michigan, 35 percent of low-income people report they have trouble finding a dentist. According to the same study, 44 percent of low-income people in Minnesota say they have trouble finding a dentist. Minnesota has had a dental therapist program since 2009. Michigan is doing a better job, and there is no reason to think a dental therapist would have a positive impact.

A better way to help is to improve utilization of Michigan’s existing dental workforce. Currently there are 7,500 dentists, 10,300 registered dental hygienists and 1,700 dental assistants. Of the 10,300 hygienists, over half are unemployed or underemployed. In addition, many dentists say that they could see more patients than they currently are seeing. It doesn’t make sense to add another provider when there is so much unutilized capacity.

The Michigan Dental Association (MDA) supports common-sense solutions with a better chance of helping fix the access problem than programs not proven to work. That is why the MDA is working with Sen. Pete MacGregor to introduce a bill that would allow individual dentists to send hygienists into underserved areas to provide hygiene services. If follow-up care is needed, the patient would be referred to the dentist who sent in the hygienist.

One of the many concerns with the dental therapist model is that it sends people who have much less training than a dentist (i.e. the dental therapist) to treat a population with the most complex dental and medical problems. Keep in mind, the dental therapist would be able to perform irreversible procedures that only the most trained providers should perform, such as extractions and drilling teeth. The underserved should have access to the same quality care as people with insurance or who pay out of pocket.

The danger with the dental therapist model is that it will create two standards of care: Those who can afford to see a dentist will enjoy the current high level of dental care, but those who cannot would receive irreversible procedures by a lesser trained dental therapist.

The MDA welcomes discussion on ideas to improve access to care, but it is important to look at the facts and put forward ideas that will work.

Bridge welcomes guest columns from a diverse range of people on issues relating to Michigan and its future. The views and assertions of these writers do not necessarily reflect those of Bridge or The Center for Michigan.

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Comments

Cathy
Thu, 07/21/2016 - 1:27pm
Thank you for the insight. As the daughter of one of the first hygienists in Detroit, the importance of dental hygiene cannot be stressed enough. My mother had a hard time getting work when she came here from University of Marquette. When the acceptance changed so did the job availability. Keep up the good work for our underserved citizens MDA!
John S.
Thu, 07/21/2016 - 1:50pm
The author should indicate how the estimates of the number of underemployed/unemployed dental hygenists are derived. The Bureau of Labor Statistics web site indicates that this is a fast growing job category: http://www.bls.gov/ooh/healthcare/dental-hygienists.htm. The median salary of dentists is $158,310; that of hygenists is $72,330. No profession is eager for more competition, so the argument of the author is understandable. Where you stand depends on where you sit. My uninformed view is that many dentists simply don't want to deal with the challenges of serving poor patients (especially adults) and dealing with the paperwork. My public spirited dentist said that over his career he'd done more than his fair share of serving this patient population but that he'd moved on. Why not conduct a survey and ask dentists who do not serve Medicaid patients why they don't. That's a direct way of determining the cause of the problem.
Ann
Sun, 07/24/2016 - 10:12am
Hygenists make $72,330? Wow, I know a few hygienists, one who has been working for nearly 30 years and she has never made anything close to that here in the metro Detroit area! Maybe she has been working for the wrong dentist the last 18 years. I know dental health needs to be taught to our families and we need to stress that at pediatric visits, preschools and communities. I see far too many preschoolers with fillings and yes crowns! Unfortunately there are also dentists out there trying to make a buck filling baby teeth that don't need fillings. I discovered this by accident. We went to one of those corprate dental places because our dentist wasn't taking our current insurance. That place told us my child had ELEVEN cavities! She had been to the dentist 6 months ago. I was appalled, and We just didn't see the evidence. We got a second opinion. She had ONE, very small cavity just starting. . Yes, they are still doing a booming business. Who is the oversight for these dentists? Parents need education. How many don't teach children to brush and floss properly, supervise it, take kids to visits and know what a cavity looks like and doesn't look like on an x-ray? Our dentist and hygienist taught those things and our kids were " brushing teeth" before they had teeth.
Michael Kiella
Thu, 07/21/2016 - 7:14pm
I've read the parochial arguments on both sides of this proposed legislation, including discussion here on both sides of the initiative. Unfortunately, the discussions to date are subjective and tainted by opinion, preference, and viewpoint bias. For example, the closing statement in this article, "...those who can afford to see a dentist will enjoy the current high level of dental care, but those who cannot would receive irreversible procedures by a lesser trained dental therapist..." presumes that 1.) all dentists currently provide high levels of dental care to each patient; 2.) in a way that a dental therapist is incapable; or that 3.) individuals would preferentially seek the services of a dentist over a dental therapist, in the context of routine dental care; under 3.) the presumption socio-economic partitioning. It would be better if a meaningful evaluation was conducted by independent researchers, where a presentation of the facts could help inform legislative and licensing opinion. In addition, I believe that 7 dental therapy practitioners working in currently under-served areas is a GREAT start....improving lives, one mouth at a time. It reflects a certain elitist arrogance to disparage improvements in health care delivery, regardless how small....unless of course, it is all about the money.
Michael
Fri, 07/22/2016 - 2:05pm
It is unfortunate that the Michigan Dental Association is using the same playbook and talking points that the Minnesota Dental Association lobbyists used in 2009 when the Minnesota Legislature enacted its dental therapy law. Nearly every consumer, health care and government group in Minnesota supported Minnesota’s legislation to respond to a major crisis in dental access, while the dental association was the primary opponent. The statements made in the MDA op-ed are egregiously false. Since Minnesota passed the law in 2009, the program has exceeded everyone’s expectations in improving access to dental care for a wide range of patients and communities without access before – rural areas, seniors, people with disabilities and low-income patients. To respond to the false statements made by MDA: (1) there is strong demand for hiring dental therapists so jobs are easy to find; (2) the education programs while new are graduating as many dental therapists as they can so every year more are added to the workforce; (3) the national education accreditation for dentists and other dental professionals has recently determined that dental therapists are needed and provide high quality care; (4) the interest of rural communities and private dental clinics in Minnesota in hiring dental therapists far exceeded our expectations; and (5) an evaluation of dental therapists conducted by the Minnesota Board of Dentistry and the Minnesota Department of Health found that dental therapists increase access to dental services, provide quality care and have high patient satisfaction. Since Minnesota passed its law and dental therapists entered the workforce, hundreds of dentists, legislators, consumer groups, health care organizations and public officials from other states have come to Minnesota to learn about the program, talk with dentists and dental therapists and tour places where dental therapists work. All who visited left knowing that the program is very successful. Many arrived skeptics but left true believers. Minnesota’s legislation is an example of something that is increasingly rare these days – an idea that had bipartisan support, did not require new government spending and actually worked as intended to address a serious crisis in access to dental care. I invite those who wrote the article to come to Minnesota to see for themselves the truth about dental therapists. Michael Scandrett, Minnesota Health Care Safety Net Coalition
Fri, 07/22/2016 - 6:03pm
As the executive director of Children’s Dental Services, a nonprofit organization and primary provider of dental care to low-income children throughout Minnesota and as the employer of 5 dental therapists, I was disappointed to read claims that Minnesota’s dental therapy program has not been successful. In fact, I can personally attest to the high quality of dental care dental therapists provide to our children, the crucial role they play as part of the dental team, and the impact they have had in increasing access to dental care for recent immigrants, low-income children, rural communities and other people that have difficulty accessing the dental system. Under the general supervision of our dentists, the dental therapists have helped provide the most commonly needed dental procedures to thousands of children throughout the urban and rural areas in our state. This has resulted in more kids getting the dental care they desperately need and has led to a more productive dental team, as our dentists are now able to spend their time on the more complex cases. Since Children’s Dental Services was founded in 1919, it has been dedicated to improving the oral health of children by providing accessible treatment and education to our diverse community. Dental therapists help make our mission a reality.
Bill Piskorowski
Mon, 07/25/2016 - 11:34am
The University of Michigan School of Dentistry has been helping vulnerable populations at community clinics and health centers across the State. Community-Based Clinical Education (CBCE) has been increasingly incorporated into the curriculum to provide meaningful dental care to underserved and Medicaid populations and is enhancing our students’ dental education by providing expanded practice experiences for our students. This outreach model has been successfully implemented in our dental school curriculum. Because of its unique design and proven accountability, our program has gained national recognition by the American Dental Education Association, Delta Dental, the Michigan and American Dental Association as well as other schools outside Michigan. The University of Oklahoma College of Dentistry recently adopted this template for the development of their community-based dental education program and is under consideration by several other dental schools. How it started, data collected from a two-year pilot funded by outside grants and organizations in the early 2000’s lead to the development of Federally Qualified Health Centers (FQHC’s) affiliation agreements that allowed students to provide service in their clinic in exchange for reimbursement from the FQHC sufficient for covering all associated school costs. For the last 10 years revenue sharing contracts have been used with minor modifications for all external sites including FQHC’s and other organization types – Community Dental Clinics (CDC’s), Tribal/Indian Health Service (IHS) Clinics, private practices and donated service programs, allowing our students a diverse portfolio of clinical experiences they normally would not have in the School of Dentistry. The program further allows our students to understand state (local), federal and private funding mechanisms while enhancing access to care for underserved populations typically 200% below the poverty level, as well as disabled and homeless veterans with the Wolverine Patriot Project/ Victors for Veterans and Victors Open Arms that provides services for Human Trafficking Victims. Results: All models have resulted in Win-Win-Win-Win-Win outcomes. •Win for the underserved communities and their constituents who experienced increased access to quality care, •Win for the FQHC’s who experienced increased and more consistent productivity and recruitment and retention of oral healthcare providers, •Win for the students who increased their clinical skills and broadened their experience base •Win for our University by proudly demonstrating an ethic of caring in communities throughout our state and showing that “M” truly is making a difference Overall, student clinical experiences are robust and ACCOUNTABLE and our sites have noted a significant increase in recruitment of recent graduates as practitioners thus helping to solve a chronic manpower problem. These positive experiences have resulted in approximately 8 to 17 % of our previous graduating classes since 2006 choosing public health clinics as their first choice for employment after graduation. The national average by dental schools is approximately 2%. Last year an amazing 21% (24 of 114) students going to public health clinics after graduation. This exemplifies the long lasting impact of this program and if all 66 dental schools had similar results there would be no need for alternative education models such as mid-level providers. This template would be a quicker and I believe a better solution in solving the access to care problem. Originally the CBCE program at the University of Michigan School of Dentistry expanded over time to accomplish 2 goals: 1.To provide quality service to underserved populations in the State of Michigan 2.To change student attitudes and create value regarding public health service careers by providing students with immersion experiences in public health clinics During a decade of expansion the University of Michigan’s CBCE program has further enhanced the student dental school educational experience by providing patient-centered dental care to the underserved while gradually transforming the curriculum to develop an Interprofessional Clinical Education (IPE) immersion experience with our valued partners. The success of the CBCE program paved the way for the first step in creating the Interprofessional Care (IPC) model by collaborating with other units on campus (medicine, nursing and pharmacy to name a few) to develop a capstone IPC experience, the future of healthcare. Evidence from similar endeavours in medicine suggests this approach will significantly impact the quality of healthcare provided to underserved communities throughout the state of Michigan.. The School of Dentistry is continually looking to enhance the CBCE experiences for our students. As a result of our continuous quality assessment and assurance program we are making modifications and sharing information regarding best and promising practices based on feedback from our students using a cloud based program. Students’ descriptions of their experiences through the use of this assessment tool, use of reflective assignments, preceptor evaluations and attested procedure reports have helped us monitor our progress towards our goals and enact change to deliver better care for our patients and further enhance our students’ education. Over the last 16 years the School of Dentistry has allied itself with various organizations throughout Michigan because of the CBCE. We are familiar with all oral health delivery models that treat Medicaid populations and have a keen understanding of the challenges they face and the competition of the funding mechanisms that all organizations rely on whether it be local, state or federal monies. We have shared with our sites comparative productivity reports and best practices in the interest of improving quality, quantity and access to care. The UMSOD has proven that organizations that embraced the academic thread have witnessed outcomes that are more predictable and more productive. As our assessment tools continue to be refined we will continue to enhance our clinical sites not only in the oral heath arena but also total patient well-being because of the of the IPC immersion experiences. The vision is to develop a universal template that is discipline independent for Public Health Clinics and universities to utilize for seamless integration at host healthcare sites and to collect data in a centralized process. Our goal is to continue assessing, improving, evaluating outcomes of care, enacting change to improve care and disseminating this information to all sites that accept students as part of their healthcare delivery team. This is our effort in educating our students to an ethic of caring that is different than the consideration of a mid-level provider. Since 2006 we have treated over 200,000 patients that resulted in better and timely patient care in a more efficient and cost saving structure. We have proven to be ambassadors for communities throughout our State and are addressing the access to care for vulnerable populations. I would be happy to discuss any questions or clarifications you may have. Thank you for your consideration of our ongoing mutual efforts to provide critical healthcare to the residents of Michigan. Sincerely, Bill W.A. Piskorowski, D.D.S. Asst. Dean of Community-Based Dental Education Clinical Associate Professor Department of Cariology, Restorative Sciences and Endodontics University of Michigan School of Dentistry 1011 N. University (Dent 1205) Ann Arbor, Michigan 48109-1078 cell: 734.353.9502 office: 734.764.7389 wapdds@umich.edu
Thu, 09/08/2016 - 8:12pm
It is unfortunate that the special interest groups are trying hard to promote the idea that Michigan does not need ‘Dental Therapy’ programs. Of-course the fear of the unknown and competition is always an incentive for those already in the business or profession to keep others out. The groups from Minnesota have given enough statistics to show that the program works but unfortunately, our Dental Schools and Dental Association doesn’t want to hear about it. Dominican International Institute (www.dominicaninternationalinstitute.org), a small vocational/career college in Macomb County, which offers programs in physical therapy, Recreational Therapy, Massage Therapy, etc. has been trying to set up ‘Dental Therapy’ program for years. We have dozens of potential students who would like to enter this profession, but the effective lobbying of Dental professionals is indeed powerful. There may be other institutions interested in promoting this program. We urge the legislators and the community activists to begin lobbying and at least allow offering Dental Therapy programs immediately. The underserved communities want and need such a profession, not just in rural areas but also urban areas. In spite of all the talk and programs, Michiganders are suffering from lack of proper dental care and we all know it.