Moves to address access to dental care

By Tracy Overton

When asked to list the top challenges in rural health care, almost all respondents to a survey listed dental care in the top three, according to David Wahlberg, a reporter for the Wisconsin State Journal who moderated the Health Journalism 2012 session on “Moves to address access to dental care.”

Panelist Shelly Gehshan, M.P.P., director of the Pew Children’s Dental Campaign, Pew Center on the States, noted that dental care is the biggest unmet need among adults and children in the United States.

She provided a surprising statistic from the U.S. Department of Defense: 52 percent of Army recruits had severe enough dental problems to delay deployment in 2008. [See report, page 62]

One issue is the huge shortage of dentists. In the late 1970s, the recession led to dental schools declaring an oversupply that forced many to close. New schools have not opened to deal with the current demand, Gehshan said.

The system serves only two-thirds of the population. Gehshan estimated 6,000 to 7,000 more dentists are needed to meet the needs of U.S. patients.

Those unable to receive regular dental care are increasingly turning toward emergency care. Emergency room use for dental care increased by 16 percent from 2006 to 2009.

One source of the lack of access can be linked back to the unavailability of those receiving government assistance to obtain care, said Gehshan.

The American Dental Association (ADA) considers keeping dental care out of the Medicare program to be one of its highest achievements, she noted. The ADA also lobbied against children’s dental care being included as an essential health benefit in the new state health care exchanges.

While dental care is included in the Medicaid program, most dentists choose not to participate as providers.

“Medicaid underpays on dental care, but all health care providers are underpaid,” Gehshan said. “Dentists seem particularly upset about it.”

Adults are not required to be covered under Medicaid in most states.

Gehshan referred to an Institutes of Medicine report that indicated the dental system needed “multiple solutions that use an array of providers in a variety of settings.”

Employing dental therapists and adding more training for hygienists may help, Gehshan said.

Panelist Michael Helgeson, D.D.S., chief executive officer of Apple Tree Dental in Coon Rapids, Minn., is one doctor who promotes the use of dental therapists.

Dental therapists have bachelor’s degrees and can perform preventive and restorative services, such as fillings, under the supervision of a dentist. Advanced dental therapists, with more extensive training and master’s degrees, can treat patients under general supervision (meaning the dentists need not be physically present). They may perform surgical procedures with the approval of the supervising dentist.

These therapists are authorized to work in underserved dental shortage areas in Minnesota and several other states.  

Panelist Jeffrey Parker, M.P.A., chief executive officer of Sarrell Dental Center in Anniston, Ala., strongly counters the argument that dentists are not compensated well enough through Medicaid. His clinics operate on Medicaid and Children’s Health Insurance Program monies, not grants.

Parker said his group has reduced its cost of care per patient from $328 in 2005 to $131 today, and he noted they did not accomplish this by hiring low-cost employees.

“We have the highest wages in the state,” he said.

Parker said they were able to reduce costs by screening all children in schools and decreasing the no-show rate of Medicaid patients who traditionally have a very high rate of failing to attend appointments.

If the screenings indicate an issue, children are either referred to a private-practice dentist or those who are Medicaid-eligible are seen by Sarrell Dental Center practitioners.

Sarrell has a 99 percent Medicaid show rate, Parker said. He attributed this to their call center and the way patients are treated at the clinics.

Parker also noted that costs are low because they do more preventive work than restorative work thanks to their early intervention.

After the speakers concluded, journalists addressed the panel with an array of comments and questions. Topics included dental practice acts, dental schools and limitations to expanding access to care. All speakers agreed changes could be made and that models of care could be replicated.

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Tracy Overton is managing editor of AOA News. She was a 2012 AHCJ-Missouri Health Journalism Fellow.