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Utilizing Dental Therapists in FQHCs �

Jane Koppelman - The Pew Charitable Trusts

NNOHA Webinar

April 14, 2016

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Learning Objectives

Understand why dental therapists are being promoted in the U.S.

Understand the scope of practice and supervision requirements for different DT models now in practice in the U.S.

Understand recent state and tribal-level activity to authorize/implement dental therapists.

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The Problem: �Access to Care

Many Americans lack dental insurance
Maldistribution of dentists
Few dentists accept Medicaid
Too few children on Medicaid get dental care

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Mission of Mercy clinic in Cape Girardeau, Missouri on May 3, 2013. People camped out in line for two days to receive free dental care.

For decades millions of Americans – many of them low income—have been receiving inadequate dental care under a delivery system the Institute of Medicine has characterized as broken.

A number of factors create barriers to getting care. Too many Americans lack dental insurance. A maldistribution of dentists across the country means serious shortages in many areas. And, few dentists accept Medicaid. In the U.S., low-income children—in comparison to their wealthier peers -- are more likely to have health insurance in the form of Medicaid, and less likely to see a dentist. And, they are twice as likely to suffer from untreated caries.

More than 48 million Americans live in HRSA-designated dentist shortage areas U.S. Department of Health and Human Services, Health Resources and Services Administration, “State Population and Health Professional Shortage Areas Designation Population Statistics,” (data as of November 10, 2014).

52% of children on Medicaid (1-20) nationwide did not receive a dental service in 2014.

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Annual EPSDT Participation Report, Form CMS-416, (state) fiscal year 2014, accessed Oct. 22, 2015)

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In 2012, two million Americans visited ERs for dental problems at a total cost of $1.6 billion. Medicare and Medicaid paid $679 million.

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Why employ dental therapists?

Improve productivity and efficiency of dental practices�
Free the dentist up to focus on more complicated procedures�
Make community-based care models more economically sustainable

Midlevel providers are being used to address a number of delivery system problems. Because they cost less to train, both private and public practices are hiring midlevel providers as a lower-cost way to meet patient’s needs for routine restorative care. This frees up time for dentists to perform more advanced and costly procedures.

�About 5 or 6 FQHCs in Minnesota are employing dental therapists. Using them to be able to expand their capacity and serve more patients. Pew is working with a couple of FQHCs in MN to adopt hub and spoke models – send therapist to school, nursing home, community center. Other nonprofit dental clinics in Minnesota are using dental therapists this way.

Midlevel dental providers are also being used to extend the reach of a dental practice into underserved areas and settings such as schools, day care centers and nursing homes. These providers can perform assessments, prepare and place fillings, and refer patients with greater needs to their supervising dentists.

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State Legislative Activity

NH

MA

ME

NJ

CT

RI

DE

VT

NY

MD

NC

PA

VA

WV

FL

GA

SC

KY

IN

OH

MI

TN

MS

AL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

ID

OR

WA

NV

CA

3 states have dental therapists

17 states have/are considering authorizing dental therapists

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Models Examined:

Dental Therapist (hygiene based)�
Dental Therapist (non-hygiene based)

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Model (Location)	Supervision	Education	Allowable Procedures (not a complete list)
Dental Health Aide Therapist (Alaska tribal lands)	Can work without a dentist in the same location, performing procedures based on standing orders issued by supervising dentist	Certificate program (20 months + 400 clinical practice hours under dentist direct supervision)	Perform exams Take X-rays Conduct cleanings Apply fluoride varnish and sealants Prepare and restore decayed primary and permanent teeth Place pre-formed crowns Perform pulpotomies Extract (non-surgically) primary and permanent teeth

Dental Therapists (non-hygiene based)

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Dental Therapy �with a dental hygiene degree �

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2009: Advanced dental therapists authorized in Minnesota 2014: Dental hygiene therapists authorized in Maine�

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Dental Therapists (hygiene based)

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Model	Supervision	Education	Allowable Procedures (not a complete list)
Advanced Dental Therapist (Minnesota	Can work without a dentist in the same location, performing procedures according to standing orders issued by the supervising dentist.	Master’s degree (16 month degree; prerequisite bachelor’s degree in dental hygiene) + 2,000 clinical practice hours	Take X-rays Apply fluoride varnish and sealants Prepare and restore decayed primary and permanent teeth Place temporary and preformed crowns Perform primary tooth pulpotomies Extract primary teeth, perform simple extractions of permanent teeth Complete an oral evaluation and create a treatment plan
Dental Hygiene Therapists (Maine)	Must be supervised by a dentist in the same office.	4 years (or 2 years in addition to a hygiene degree)*	All dental hygiene procedures, plus: Perform oral health assessments Take X-rays Apply fluoride varnish and sealants Prepare and restore decayed primary and permanent teeth Place pre-formed crowns Perform primary tooth pulpotomies Extract (non-surgically) primary and uncomplicated permanent teeth

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Dental Therapists & FQHCs: Financial Impact

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Encounter Reimbursement

In an encounter rate environment, increasing the number of patients served while reducing costs is the way to increase the margin.

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A dental therapist at the People’s Center Health Services �(Minneapolis)

Cost to employ: $136,000

Medicaid revenue:$167,000�Medicaid revenue exceeds costs by over $30,000

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A management tool for FQHCs

Pew hired a healthcare economist �
Collaborated with several FQHCs in MA and ND �
Feedback from FQHCs that used it

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Tool quantifies effect of change decisions

Input unique clinic data (e.g., provider mix, clinic hours, encounter rate)

Change a variable(s)

Quantify change to revenue, costs, patient volume

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Data from Edward M. Kennedy CHC

5 dentists

3 limited license

5 hygienists,

0 DAs

New operatory to open fall 2015

Salaries/ benefits

Appointment schedules

Supplies/ equipment

Average $ reimbursed/ visit

Staff clinical, administrative, supervision time

Range / volume of patient complexity

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Adding a dental therapist

Scenario* With Dental Therapist	Productivity	Net Revenue
1 new DT 1 new hygienist	8 additional appointments/day (1920/year)	+$60,720 per year

*In this case study the CHC needed to build an additional operatory at a one-time cost of $63,000 to employ a dental therapist, as they were at maximum capacity.

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Growing Momentum

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National accreditation body for dental education programs
Voted to implement national dental therapy training program guidelines in August 2015
Accreditation process will launch in 2017

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“As the dean of a dental school accredited by CODA, this is the most significant signal to me that dental midlevel providers are safe, are meeting the needs of the public, and are sought after by dentists in the existing marketplace.”

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Bruce Donoff, M.D., DMD,

Dean of Harvard School of Dental Medicine

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Endorsement of Dental Therapists

AARP

Harvard School of Dental Medicine

National Congress of American Indians

National Caucus of Native American State Legislators

National Black Caucus of State Legislators

National Foundation of Women Legislators

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Questions?

Jane Koppelman

Research Director Pew’s Dental Campaign

jkoppelman@pewtrusts.org

Thank you