Views differ on proposal to ease state's dental care woes

1/9/2012

By EDIE ROSS

By EDIE ROSS

Special to The Telegram

Chrysanne Grund happens to be living in a dental desert.

The project director for Greeley County Health Services isn't surprised by the designation, given by the Kansas Department of Health and Environment's Bureau of Oral Health. She's worked for years to find dental care resources for western Kansas residents.

As defined by the bureau, a dental desert is an area outside a 30-minute drive from a single dentist. There are 14 of these "deserts" in the state.

Grund says for most people a 30-minute drive isn't the problem. After all, western Kansas residents don't blink at driving an hour to the nearest Walmart. And they'll travel two hours to attend their children's sporting events.

But the few dentists in western Kansas keep extremely full schedules. Between the drive time, wait time and actual dentist visit, half the day is pretty well shot. The problem is worse for those in nursing homes, or who can't otherwise travel due to health or finances.

Any way you slice it, Grund says, access is an issue.

Of Kansas' 105 counties, 93 — or 86 percent — do not have enough dentists to serve their population. Thirteen have no dentists at all, according to the Kansas Dental Project.

Most don't argue that there is an access issue. The disagreement is about what exactly is keeping people from seeing a dentist — the cost or the distance — and what to do about it.

Three proposals — each with a varying amount of detail — have been submitted, including a campaign to encourage more dentists to accept Medicaid patients, efforts to strategically locate dentists in these dental deserts, and a proposal to create a new type of dental worker — a registered dental practitioner — who could go off-site to deliver a more narrow scope of care, leaving the more complex procedures to dentists. By law, these RDPs could practice only in areas with proven access issues.

The RDP program, proposed by the Kansas Dental Project in partnership with Fort Hays State University, is the most detailed, with legislation under consideration in both the Kansas House of Representatives and the Kansas Senate.

It is also the only proposal being opposed. The Kansas Dental Association disapproves of the creation of a registered dental practitioner position, raising concerns about safety and the creation of two levels of care.

Saying it wants to "lead" efforts to address access issues, the KDA has countered with efforts to expand the number of dentists who accept Medicaid and to create incentives for dentists to locate in rural areas.

Proposed legislation

The RDP proposal, Senate Bill 192/House Bill 2280, is currently in the Public Health and Welfare and the Health and Human Services committees, respectively. Both bills received hearings during the 2011 legislative session and are awaiting further action by the committees in 2012.

The bills outline the scope of practice, geographical restrictions and supervision requirements for a registered dental practitioner. Under the proposal, RDPs would have a narrower scope of practice including 34 procedures such as dental radiography, cleaning above the gum line and basic restorative services like tooth preparation (drilling) and tooth restoration (filling) and non-surgical extractions.

RDPs would not be allowed to practice independently. They would be employees of dentists and perform under their supervision, meaning the RDP could provide care off-site. According to the legislation, RDPs would need to complete 500 hours of practice under the direct supervision of a dentist prior to providing care off site, in, for example, a nursing home or Head Start program. Also, dentists employing RDPs could further restrict the list of procedures the RDP could provide.

Finally, the legislation limits the areas in which RDPs may practice to those that are federally qualified as medical workforce shortage areas.

The 'best' solution?

Fort Hays State University President Ed Hammond is ready to create a registered dental practitioner degree program at his university.

He sent his faculty to Minnesota to learn about its dental therapist program, which was put into place in 2009 and is the most similar to what is being proposed in Kansas.

And, he hosted a summit with representatives of the Kansas Dental Project, Wichita State University's College of Health Professions, various states' dental hygienists associations and representatives of dental schools at the University of Missouri-Kansas City, The University of Florida, Nova Southeastern University and the Indiana School of Dentistry, among others, to discuss the curriculum and equipment needs to train a registered dental practitioner.

"At the summit we saw that there is a very high level of support that exists throughout the state - except for the Kansas Dental Association," he said. "Almost everyone we've talked to recognizes the need and also sees the mid-level professional as a reasonable solution."

Hammond says he has a grip on what the program would look like. And, because several private foundations have shown interest in the program, he believes he can create it without the use of taxpayer dollars.

But first, he needs lawmakers to pass the legislation, creating the professional entity. In his mind, there is no reason not to.

"If there is a better solution, we're willing to support that," Hammond said. "But we've not seen a better solution."

The Kansas Dental Association disagrees, citing concerns over the safety of non-dentists doing dental procedures without direct oversight from a dentist.

"In the instance of extracting teeth, there are procedures that appear to be simple, but once you begin to perform the procedure you see other issues," said Kevin Robertson, executive director of the Kansas Dental Association. "We fear that a practitioner could get into those issues that they aren't familiar with and at that point they could be hundreds of miles from a dentist and don't have anyone to back them up."

Robertson added that proponents of the bills imply that the allowable procedures are "non-surgical" or routine, but the KDA doesn't see it that way. For example, as the legislation is written, restoration of primary and permanent teeth — which includes drilling — would be within the scope of practice for registered dental practitioners.

"DDS stands for doctor of dental surgery," Robertson said. "So within the scope of dentistry, surgery is the cutting of tissue or the drilling of hard tissue. So any time you pick up a drill, that is surgery. And there are a significant amount of issues that could come from that."

Hammond said he expects there to be some compromise on the scope of practice, and he is willing to agree to compromise that doesn't render the RDP position powerless to meet Kansans' needs.

"I'm willing to have a meeting of the dental society and other parties," he said. "I'll host whatever needs to be done to get us off dead center."

But Robertson said changes to the scope of practice likely will not be enough to garner KDA's support as long as RDPs are still allowed to practice without the direct supervision of a dentist.

Not all dentists agree with the KDA's stance. For example, two Kansas dentists - Dr. Daniel Minnis, of Pittsburg, and Dr. Melinda Miner, of Hays — testified in March before the Senate Public Health and Welfare Committee that Kansas needs to move forward with creating the RDP position.

Research claims argued

The Kansas Dental Project, which was spearheaded by Kansas Action for Children, the Kansas Association for the Medically Underserved and the Kansas Health Consumer Coalition, responds to the KDA's safety concerns with 10 academic articles they say prove registered dental practitioners provide safe care.

"Mid-level providers practice in more than 50 countries around the world," said Christie Appelhanz, vice president of public affairs for Kansas Action for Children. "There are also mid-level providers in Alaska and Minnesota, and the most recent research we have is focusing on efforts of providers in those states. There are no studies that show that mid-level providers do not provide safe care."

The KDA says proponents are overstating the findings of the research being cited. Robertson said that research conducted in places like New Zealand, Australia and even Alaska shouldn't be directly applied to Kansas.

"The research they are citing doesn't change our concerns," Robertson said. "Just because the research says it isn't "unsafe" doesn't mean that a person has had proper care provided to them. For example, the places they are looking at - especially New Zealand and Australia - have some of the worst dental care in the world. To maintain the standard of care in our country, we need to use dentists and not fall back onto individuals who have had only half of the training."

Affordability problem

Robertson said the KDA isn't convinced that distance is the greatest obstacle to accessing dental care. Exit surveys conducted at free dental clinics — such as the Kansas Mission of Mercy clinic - indicate that cost is what keeps Kansans from seeing a dentist.

"We ask why they haven't been to a dentist and 87 percent say that they can't afford the care. Three percent say they can't find a dentist," Robertson said. "So as we look at how to provide care to more people, to us it seems obvious that we need to find a way for adults to access that care financially."

To that end, the Kansas Dental Association has undertaken a campaign to increase dentists' participation in the Kansas Medicaid program in an effort to expand the services provided to Kansas children.

Called the Medicaid 140 initiative, the campaign seeks to increase the number of Medicaid-participating dentists by 140 dentists, coinciding with the KDA's 140th anniversary.

Currently, the majority of the state's dentists don't accept Medicaid patients, mainly because of low reimbursements. Dr. Brett Roufs, a dentist in Newton and past president of the KDA, has been accepting Medicaid patients for about eight years. He is a strong proponent of the Medicaid 140 initiative.

"Sometimes you need to do what is good for everyone involved," he said. "You step out and hope for the best."

Roufs said Medicaid can work in an office if it is actively managed.

"It's nothing you'll make money on, but it will at least pay for your materials and you can help people out in the long run," he said. "It can fit into a practice pretty easily, and if all of us do a little bit, it will make a huge difference."

Still, both Roufs and Robertson acknowledged some limitations of the program. While Medicaid does cover various children's procedures, it covers only tooth extraction for adults. So the initiative won't necessarily address financial access issues for adults.

Therefore, the KDA and other oral health advocacy groups are working on proposals to expand Medicaid to include more adult care.

Robertson said the KDA and others also are looking for ways to reinstate some waiver programs that offered care to developmentally disabled adults, frail and elderly persons, and pregnant women.

Robertson added that if the federal Affordable Care Act proceeds as written, it will include some federal incentives to allow states to expand care in 2014.

While Robertson doesn't believe RDPs would make care less expensive, saying that someone who can't afford to see a dentist also wouldn't be able to afford to see an RDP, Appelhanz disagreed.

"RDPs can make the care more affordable because they cost less to train than dentists, so they'd cost less to see," she said, adding that the RDP proposal has the support of many safety net clinics in Kansas that see the opportunity to add an RDP to their staff at a lower cost than a dentist.

"RDPs also would make treatment of Medicaid patients more economically feasible because they would be handling the more routine procedures, freeing the dentist up to do more complicated work, which makes the office more efficient," Applehanz said. "And, RDPs would be doing a lot of preventative services in the community, so they'd really be preventing the more costly dental emergencies."

Incentive program

Robertson said the KDA agrees that there are areas of Kansas — specifically in the western portion — that are in need of more dental care. But he says dentists should be providing it.

To that end, Robertson said the KDA is working with a private foundation to create a private loan repayment program that will target those areas.

"We are working on a loan forgiveness program with a foundation that would be an incentive for dentists to locate in specific areas," he said. "Some of the areas we would target would be Sublette, Medicine Lodge, Greensburg, Ness City, Sharon Springs and others."

Details of the loan forgiveness program are not yet available, Robertson said.

It won't be the first effort to draw more dentists to Kansas. In 2009, Wichita State University started a residency program for new dentists, with plans to add one or two additional years of training while paying down loans. The hope was that many of those who participated in the program would decide to remain in Kansas to practice after their residency. The first class of seven students graduated in July 2010, but only one decided to stay in Kansas.

Hammond said the economics of making a dental practice work in sparsely populated counties, where there is neither the volume of patients nor the income base to support a dentist, is tricky if not impossible.

"I'm not convinced that dentists who are going to school for seven years — with the limited practice and income capability — will be willing to locate in western Kansas," he said. "Dentists want to go someplace where they can maximize the return on their investment. I don't fault them for it, but then don't stand in our way when we are looking for a solution that works."

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