Resolved for 2011

Resolved for 2011

Edward J Vigna, D.D.S.*:

I trust everyone is ready for the New Year and totally committed to keeping the resolutions that, as in my case, have not already been abandoned. I expect this to be a good year for the ADA, with a focus on the many issues before us.

In my last article, I mentioned the success we had in electing another dentist to Congress, Paul Gosar (R- Arizona). Advocacy remains number one in member surveys, so the importance of adding to our ranks is significant. For now we will bask in the excitement of the moment, but very soon it will be back to work to reelect Congressmen Mike Simpson,DDS (R- Idaho) and Paul Gosar, DDS. Hopefully, we might also elect a new dentist member.

The “lame duck” session did bring long overdue good news for dentistry, with Congress passing legislation exempting dental practices form the Federal trade Commission’s Red Flags Rule. Tens of thousands of ADA grassroots dentists played a vital role in getting this legislation through Congress. Although it took longer than we hoped, in the end we got the permanent exemption we requested. Next time you are asked, remember this success and let our lawmakers know how dentistry feels about an issue. This law will save your practice hundreds of dollars in implementation costs. In fact, the ADA estimates the nationwide savings associated with this exemption to be $72 million for dental offices.

Another important event was the appointment of Michael Graham as Senior Vice-President of Government and Public Affairs. A long-time member of the ADA lobby team, Mike will now lead the State Government Affairs staff in Chicago as well as the ADA Washington office.

These gains aside, I feel like the same topic, workforce, still demands all of the BOT’s attention and still occupies most of our communications. Although I know you in Minnesota are past many of the early stages of this issue, gaining an understanding of the national picture is important. The following reports should be of interest to everyone.

GAO Issues Report on Children’s Dental Access

The Government Accountability Office (GAO)’s report on dental access for underserved children ( was prepared pursuant to a congressional mandate included in the Children’s Health Insurance Plan Reauthorization Act of 2009 (Healthcare Reform), requiring that the GAO study children’s access to dental services. The ADA provided information about the Community Dental Health Coordinator (CDHC) model to the agency’s research team.

We have performed a preliminary analysis of the report and have determined that it provides an objective overview. Although the report noted that dentist participation in Medicaid remains low, it made no conclusions about the adequacy of reimbursement rates.

The GAO recommended that the Department of Health and Human Services (HHS) improve its Insure Kids Now website and ensure that states gather complete and reliable data on Medicaid and CHIP dental services provided under managed care. According to the report summary, HHS agreed with the recommendations, citing specific actions it would take. The report also discusses a number of midlevel programs. In addition, it mentions the ADA CDHC program as a way to improve access for underserved populations.

I suggest readers view this interesting and important report.

Pew Study on Value of Mid-Level Providers

The Pew Center on the States has released a study addressing the value of mid-level providers as solutions to the access to care issue, as well as adding to dentists’ profits.

According to the study, most private practice dentists who hire new types of dental providers can serve more patients, including more Medicaid enrollees, while maintaining or improving their financial bottom line, according to a new report (<>). New types of providers play a role in delivering dental care similar to that performed by nurse practitioners in the medical system.

Pew’s report is the first to examine the impact that hiring new types of providers - dental therapists and hygienist-therapists - would have on the productivity and profits of a private dental practice, where more than 90% of the nation’s dentists work. The study also assesses the impact of dental hygienists, who are currently employed by most dental practices. Dental therapists and hygienist-therapists are trained to perform a broader range of services — including filling cavities — than hygienists.

It Takes A Team: How New Dental Providers Can Benefit Patients and Practices applies an economic tool that Pew commissioned, the Productivity and Profit Calculator, to evaluate the impact on dental practices that hire one of these three “allied providers”. The report, calculator, and related materials are accessible at <> , and individual dentists can use the calculator to evaluate the impact of allied providers on their own practices.

“This report is good news for dentists who work in private practices, patients who aren’t getting care, and policy makers who are eager to find cost-effective solutions to access problems,” said Shelly Gehshan, director of the Pew Children’s Dental Campaign.

Nationwide, 17 million low income children go without dental care each year. Multiple factors fuel this problem, including a shortage of dentists serving rural and poor communities. As a number of states consider authorizing new types of dental providers to fill this unmet need, dentists in private practice are looking at the effects of this potential change on their businesses.

Children facing barriers to care are more likely than their peers to suffer tooth decay, miss school days, and face broader health problems that end up costing their families and taxpayers much more money than basic dental care.

The health care reform law enacted this year guarantees medical and dental insurance for nearly all children. This means an estimated 5.3 million more kids will secure dental coverage by the year 2014. States will be hard pressed to ensure that the supply of dental providers meets this greater need for care. It Takes a Team shows that new types of providers offer policy makers a sound strategy to significantly improve access for low income and rural children.

The calculator commissioned by Pew tested multiple private practice scenarios, and most showed that hiring new types of providers can enable a practice to expand services and see more low income patients without experiencing a drop in the practice’s profits. Pew’s report found that:

• In solo dental practices devoted to serving the privately insured, adding any allied provider increased productivity and pre-tax profits. In every scenario tested, solo dental practices — where most dentists work — increased their earnings by a range of 17 to 54% when hiring a new provider.

• In a state with an average Medicaid reimbursement rate (60% of dentists’ standard fees), solo practice dentists serving only the privately insured could hire a dental therapist, shift their patient mix to 80% privately insured and 20% Medicaid patients, and still see their pre-tax profits increase between six and seven percent.

• In states with Medicaid reimbursement rates that are 30%, dental practices see reduced profits when they serve Medicaid enrollees. Yet even in these instances, Pew’s study found that dentists fared better financially serving low income patients with an allied provider rather than without one.

Although these scenarios represent typical dental practices, the specific impact of allied providers will differ from state to state and practice to practice. For this reason, Pew has made their calculator accessible online to dentists and policy makers. Users can assess the potential impact of new providers by inserting data from their own dental practice to reflect the costs and market conditions in their area, as well as test the effect of providers with different scopes of service. The calculator is not intended as a business-planning tool to forecast actual profit and loss.

It comes as no surprise to me that some feel this proves good economic sense for the dental practice, as expressed in the following:

“We want to replace guesswork with data by giving dentists and policy makers a tool to help them understand the impact of new types of providers in their states,” Gehshan said. “This report shows that hiring allied providers can produce a win-win outcome. Dentists can serve more low-income children without seeing their earnings decline.”

I have included a few link addresses if you choose to get more information on this report and the calculator. To my knowledge, this is the first study attempting to show economic value to employing a mid-level provider. Although this is an interesting tool, in my mind it reinforces that below breakeven Medicaid fees it is economically disadvantageous to have any type of additional workforce models.

ADA Response to Kellogg Report on the DHAT in Alaska

In the report published late last year, the ADA cautions against using the findings in the paper to generalize to dental care systems beyond Alaska because the evaluation was narrow in scope and is more a “case study” rather than a program evaluation. DHATs followed in this study were trained primarily at the University of Otago in Dunedin, New Zealand. Additional studies will be needed to see if the training provided in New Zealand differs from that received through the DENTEX program. The latter is a collaborative effort between the Alaska Native Tribal Health Consortium and the University of Washington, School of Medicine Physician Assistant Training Program.

The ADA also agrees with the authors that it is far too soon to evaluate what impact, if any, the DHAT program is having on health outcomes in the affected tribal communities in Alaska. As the authors state, the oral health survey utilized in this study “does not enable attribution to a program or a particular provider as having either a positive or negative impact” on the communities’ oral health. The study focused on implementation of the DHAT program in five practice sites in Alaska, involving only five DHATs. The study found that:

• the duration the therapists had been practicing was brief;

• large proportions of broken appointments were noted in sites where therapists permanently resided;

• periodontal disease was largely not addressed; and

• longstanding community practices (no water fluoridation, soda consumption, oral hygiene habits) will be difficult to change.

Research protocol and sample construction make it impossible to draw any valid conclusions about the clinical performance of DHATs.

• An unknown number of comparison dentists were included in the study.

• A small number of procedures were observed and/or evaluated after varying lengths of time.

• There was some uncertainty about who provided some of the restorations evaluated.

• Similar restorative materials were compared, but it is not clear that the complexities of the restorative treatments were similar or that similar time periods were compared. (For example: Were single surface restorations by therapists compared to multiple surface restorations by dentists? Were recently placed restorations compared with restorations functioning for up to two years in a patient’s mouth?)

• No criteria were stated about what constituted “eligible” restorations or “eligible extractions” for the study.

• No extractions were directly observed by the examiners.

• The only comment about the removal of teeth by DHATs was made through chart audits, stating there were no complications experienced in a very small sample of “eligible” tooth removals.

• The efficiency of utilizing DHATs was not addressed. This omission is significant because the economics of a system clearly have a great deal to do with its sustainability. The authors noted that there were patient-perceived differences between resident DHATs and itinerant (traveling) DHATs, with better patient-perception of the former. They noted that the effectiveness of the DHAT model will depend upon tribal support of the therapist including housing, obtaining ancillary personnel to assist the DHAT, and providing dental supervision. It is becoming more difficult to recruit qualified individuals to serve as DHATs in the smaller villages; two of the five therapists in the study left their assigned villages to get better educational opportunities for their children.

DHATs and the Issue of Prevention

The authors of the paper recognize that it is not possible for a society “to treat its way out of an epidemic.” The report states that the DHATs cannot do as much prevention as desired because there is such a backlog of accumulated disease that needs immediate treatment. They recognize that the DHAT program is only one component of a more comprehensive approach that includes a role for other dental health aides who are village-based and can provide educational outreach.

The report was limited in focus to case studies of five individual DHATs. It does not address the efficiency of the DHAT model and does not provide a conclusive evaluation of the clinical technical performance of DHATs. Significantly, the authors stressed that the impact of the program beyond Alaska cannot be determined at this time.

This paper does appear to reinforce the ADA position that an ancillary dental team member such as the Community Dental Health Coordinator (CDHC) would work quite well in remote villages in Alaska, as such individuals are dedicated to community education, triage, and facilitation of dental encounters, as well as preventive dental care outreach. These services combined with high level care provided by dentists can potentially be the most efficient means to significantly improve access to quality oral health care in remote villages in Alaska and other underserved communities.

There are only about 70 days now until the first day of spring. That leaves us only two more months of really heavy snow and cold. Enjoy the winter, and stay warm!

As always, please contact me with any questions or concerns at or (402) 770-7070.


*Dr. Vigna is the Trustee to the Tenth District of the American Dental Association, representing Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.