Meeting the Demand: Strategies to Improve Access to Oral Health Services Julie Stitzel, MPA Campaign Manager, The Pew Children’s Dental Campaign The Pew Charitable Trusts jstitzel@pewtrusts.org

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2

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

A Dental Workforce Shortage

Less than 10%

10-14.9%

15-19.9%

20% or more

• 45 Million people living in Dental HPSAs nationwide

• 6,000 additional dentists needed to eliminate shortage areas

% of State Population living in Dental Health Professional Shortage Area (HPSA)

3

4

5

6

7 Source: American Dental Association. (2011) Distribution of Dentists In the United States By Region and State, 2009.

An Aging Dental Workforce

≥45 %

40-44.9%

35-39.9%

<35%

42.6 (NH)

36.2 (MA)

48.4

36 (NJ)

42.8 (CT) 41.7 (RI)

39.2 (DE)

48.7 (VT)

37.1

46.4 (DC) 39.2(MD)

35.9

42.6

38.1 42.3

37

33.8

39.9

38.4

38.1 42.2

39.6

43.3

37.3 37.1

45.8

36.9

40.4

38.7

44.8

41.5

39.7 40.1

36.2

41.1

40.3

43.1

40.4

36.5

44.4

47.6

32.9

36.4

40.7

31.9

45.5

32.2 37.1

37.5

27.4

32.6

Percentage of Dentists over age 55 (2009)

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The Affordable Care Act

Requirement (unless stand alone

dental plan exists) that a pediatric

dental benefit be included in the

essential health benefits package in

the new state exchanges (Title I, Secs.

1302, 1311)

Option that states set Medicaid

eligibility cap no lower than 138

percent of Federal Poverty Level and

cover all individuals meeting the

eligibility standard (Title II, Section

2001)

Extension of funding for the Children’s

Health Insurance Program (CHIP)

through FY 2015 and authorization of

program through 2019 (Titles II, X)

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The Affordable Care Act

Provisions authorized but not appropriated:

Demonstrations and evaluation of

alternative dental care providers (Title

V, Section 5304) (current block on

funding)

Expanded dental training programs

(Title V, Section 5303)

New or expanded primary care

residency programs, including dental

programs (Title V, Section 5508)

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Challenges

• Shortage/Maldistribution of

dentists

• Emergency room utilization

costs

• Too few providers accepting

Medicaid patients

• Fiscal reality of states

• Lack of adult dental

coverage

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Raising Medicaid Reimbursement Rates

Increases in reimbursement rates have been shown

to increase dentist participation in Medicaid and the

number of patients treated,1 but studies have also

shown that rate increases on their own are not

sufficient to improve access to dental care. 2

Source 1: Institute of Medicine (2011) Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Source 2: Alison Borchgrevink, Andrew Snyder, Shelly Gehshan, The Effects of Medicaid Reimbursement Rates on Access to Dental Care, March 2008, National Academy of State Health Policy, http://www.nashp.org/sites/default/files/CHCF_dental_rates.pdf

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Improving Medicaid Participation

More Steps Needed to Increase

Dentist Participation in Medicaid:

• Easing administrative processes

• Involving state dental societies

and individual dentists as active

partners in program improvement

• Working with patients and their

families about how to use dental

services

13

Free clinic in Cape Girardeau, Missouri on May 3, 2013. People

camped out in line for two days to receive free dental care.

Desperate for Care

http://www.columbiamissourian.com/a/161623/mission-of-mercy-clinic-serves-patients-who-have-gone-without-dental-

care/

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Expanding the reach of the dental team with additional providers

Dental Health Aide Therapists (AK)

Dental Therapists (MN)

Advanced Dental Therapists (MN)

Community Dental Health Coordinators (new model piloted by the ADA)

Other state solutions similar to a physician’s assistant on a medical team

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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

2003 Dental Workforce Map

Dental Health

Aide

Therapists

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Expanding the reach of the dental team

Alaska

Dental Health Aide Therapists

(DHAT)

40,000 people in rural AK

now have direct access to

care.

DHATs see an average of

830 individual patients per

year.

700 of those visits are for

prevention.

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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

2009 Dental Workforce Map

Dental Health

Aide

Therapists

Dental Therapists/

Advanced Dental

Therapists

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Expanding the reach of the dental team

Minnesota: Children’s Dental Services

Dental Therapists (2)

367 patients seen in 2013

334 on state insurance

20 private insurance

11 full pay

2 sliding scale

Advanced Dental Therapist (1)

922 patients seen in 2013

826 on state insurance

41 private insurance

32 full pay

18 free care

5 sliding scale

Source: email from Sarah Wovcha, executive director of Children’s Dental Services, August 5, 2013

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Total Revenue Generated by Advanced Dental Therapists and Dental Therapists in Minnesota (in blue) and Dental

Health Aide Therapists in Alaska (in green)

According to a May, 2013 study on the economic viability of dental therapists in Alaska and Minnesota, dental therapists cost their employers less than 30 cents for every dollar of revenue they generate.

Source: Community Catalyst, Economic Viability of Dental Therapists, available at: http://www.communitycatalyst.org/doc_store/publications/economic-viability-dental-therapists.pdfReport conducted by Dr. Frances M. Kim, May 2013

Financial Impact of Expanding the Dental Team

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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

2013 Dental Workforce Map

States considering

additional dental

providers

States with

additional dental

providers

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Conclusions

• We are experiencing a dental crisis in the United States

• State budgets are being punished as a result of lack of access to

dental care

• It is a complex problem that requires multiple solutions

• The data show that expanding the reach of the dental team with

additional providers, similar to physician’s assistant on a medical

team, improves access to care for vulnerable populations in a

financially sustainable way

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