Special guest post from Kelly Vitzthum, oral health policy analyst at Health Care For All, a Massachusetts health policy and consumer advocacy organization. This post has been updated to reflect the non-inclusion of the Dental Hygiene Practitioner amendment in the final version of Massachusetts’ FY 2017 budget.
Former U.S. Surgeon General David Satcher described poor oral health as “a Silent Epidemic.” Oral health diseases are by and large preventable, and yet they are incredibly widespread. Disadvantaged and marginalized populations suffer disproportionately from poor oral health, and children are especially vulnerable. Many low-income individuals and families are priced out of needed care and struggle to find providers who accept Medicaid.
Though Massachusetts is a leader in health care and health reform, oral health is still often overlooked in state health policy discussions. Though MassHealth – Massachusetts’ Medicaid program – covers 40% of the state’s children, most dentists do not accept it. A shocking proportion of children have untreated oral decay, which affects their ability to eat, learn, and play. A full tenth of the population currently lives in a federally-designated Dental Health Professional Shortage Area (DHPSA), and emergency department visits for preventable dental conditions cost the state millions annually.
To help address this issue of dental access, states like Massachusetts are increasingly considering new workforce options, including mid-level dental providers. Dental Hygiene Practitioners (DHPs) are dental hygienists who – after completing additional training – are able to deliver basic but critically necessary care to underserved populations. Also known as dental therapists, DHPs would provide basic dental services, including fillings and simple tooth extractions that currently only dentists may perform.
Although DHPs would work under the supervision of the dentist, they can provide care to patients directly without a dentist being physically present. This means DHPs would be able to deliver care directly to people in schools, nursing homes, and other community settings. Since DHPs are lower cost providers, dentists who employ them would be able to take on more Medicaid patients. DHPs would thus increase access to dental care for people who struggle to find dentists in their area and/or who cannot find dentists who will accept their insurance. Access to oral health care is particularly challenging for older adults, for people with disabilities, for adults and children who lack private dental insurance, and for rural communities. Licensing this new mid-level dental clinician, as is done successfully in several other states, would expand access to essential health care for these underserved and vulnerable populations.
Attempts to pass state legislation enabling the licensure of DHPs have failed in past years. Although legislation was introduced this legislative cycle (see SB 2076), the bill faltered in the Joint Committee on Health Care Financing. That has not, however, dissuaded proponents. With Health Care For All’s solid support, the state Senate unanimously voted to include a provision creating DHPs in its version of the budget. But because there is no corresponding provision in the House budget, the issue is up to the joint House-Senate budget conference committee to decide, which began meeting last week.
Paralleling similar battles that have been fought elsewhere, the state dental society has openly opposed the proposal, spending many tens of thousands of dollars to convince the public that DHPs would provide substandard care and would not solve the access problem.
Meanwhile, objective experts are weighing in strongly in favor of the proposal.
Recently, Dr. Don Berwick, a former national administrator of Medicare and Medicaid and co-founder of the Institute for Healthcare Improvement, an evidence-based center devoted to quality care, wrote a detailed review in the Globe of studies supporting DHPs. He cited over 1,100 studies finding that DHP care is comparable, and often superior, to care from a dentist. Berwick, who also sits on the state’s Health Policy Commission, concluded,
“Proper dental care is as much a human right and as smart an investment as is proper medical care. By passing the Dental Health Practitioner legislation, Massachusetts now has a chance to add access to dental health to its list of proud commitments.”
This was amplified at the last meeting of the state’s Health Policy Commission (HPC), at which the HPC revisited key findings on emergency department visits for preventable oral health conditions. It noted that almost 50% of all preventable ED visits for oral health were paid for by MassHealth, while only 35% of all licensed dentists in Massachusetts accept MassHealth. In light of these glaring findings, the HPC pointed to licensing DHPs as a proven way to shift resources toward a more accessible dental care system.
Commissioners enthusiastically supported the proposal. Commissioner David Cutler stated that he was “convinced” of the model and Commissioner Berwick reiterated that establishing mid-level dental providers is a “slam dunk” policy that expands access, potentially decreases costs, and also serves as an opportunity for economic growth by providing a new health care career path. Commissioner Carole Allen admitted she was initially cautious as some providers have indicated concerns about establishing a “2-tiered system of care.” However, after further studying the significant amount of evidence affirming the quality of care delivered by mid-levels and their potential for expanding dental access, she is now a firm supporter of the model as well.
Health Care For All rejects the misleading calls for more study and delay. The evidence is overwhelming that DHPs would provide high-quality dental care to people who need it the most. We urge Massachusetts residents to call their state representatives and ask them to support this “slam-dunk” policy. Representatives should be encouraged to tell members of the budget committee to keep the dental midlevel provision in the final budget draft.
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Unfortunately, the Dental Hygiene Practitioner amendment was not included in the final version of the FY 2017 budget. Because of new projected budget shortfalls, the House-Senate conference committee became mainly concerned with fiscal considerations and ended up rushing out the budget to meet the deadline. With this, the majority of the proposed outside policy sections were largely ignored, with the Dental Hygiene Practitioner amendment being one of them. This wasn’t too surprising since House Speaker Robert DeLeo had previously indicated that he was concerned about delaying the budget and thought policy changes should be left to the joint committee process.
However, we are pleased that the bill got so far; progress on this topic in MA has moved remarkably quickly especially compared to the experiences of other states, where bills enacting midlevel dental providers have been present through many legislative cycles. The bill passed the Senate unanimously, which was one of the strongest chamber votes in the nation, was supported by a truly diverse set of stakeholders, and even gained the endorsement of the Boston Globe and Berkshire Eagle. The issue of poor access to dental care isn’t going away, and we expect the significant momentum for dental midlevels built in this legislative cycle will continue on to the next.