Experts in Maryland’s dental care field are collaborating with other states to devise innovative ways to improve statewide oral health outcomes and reduce costs.
At the Maryland Oral Health Task Force’s meeting on June 16th, representatives from dental associations, dental schools, and policymakers heard presentations on two focus areas: increasing the number of dental therapists and community dental health workers, and improving senior dental care.
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Dental therapists are primary care dental practitioners who receive training and work under the supervision of a licensed dentist. An increasing number of states, such as Minnesota, are working to increase the number of dental therapists to fill gaps in dental care, particularly for underserved communities.
The responsibilities of dental therapists fall into two categories, according to Karl Self, DDS, the Director of the Division of Dental Therapy at the University of Minnesota School of Dentistry. Preventative care and non-invasive procedures take place under general supervision in the primary care setting, where the licensed dentist may not need to be on-site. Restorative procedures, extractions, and more complex tasks take place under indirect supervision, with the licensed dentist on-site.
A wide range of stakeholders, including policymakers and representatives from the Minnesota Department of Health and the Minnesota Department of Human Services, worked together to establish clear education and certification requirements for dental therapists. These policies also address a concern that dental therapists might be directly competing with dental practitioners.
Consequently, Minnesota statute now requires dental practitioners who hire dental therapists to establish a Collaborative Management Agreement (CMA), which outlines a therapist’s work conditions and quality measures. This agreement must be filed with the Minnesota Board of Dentistry and updated every year.
Self said the areas that saw the most initial use of dental therapists were federally qualified health centers (FQHCs) and nonprofit clinics, but noted private practices are also beginning to see their value and are increasing their demand.
He also said dental therapists who focus on fillings and other routine procedures can produce more effective care delivery and lower costs.
“The dental therapists’ schedules are more efficient,” he said. “They’re a lower-cost provider doing procedures that quite frankly bring lower-cost reimbursement.”
Community Dental Health Coordinators
Another approach to improving dental care is by employing community dental health workers (CDHC). According to Jane Grover, DDS, Director of the Council on Advocacy for Access and Prevention at the American Dental Association (ADA), focusing on addressing social determinants of health such as access to transportation is critical to reaching underserved communities.
“How much wasted time is spent from a patient trying to navigate their way to a community clinic that they didn’t know existed?” Grover said. “[The CDHC] program provides that essential linkage between a delivery site and the patient population.”
ADA has successfully implemented CDHC training programs in several states across the country, either through community colleges, FQHCs, or community health centers. Some programs have received federal funding from the Health Resources and Services Administration (HRSA). One program in Tennessee received $60 million in funding and allowed 3 CDHCs to link over 1,000 seniors to dental care in just 8 weeks.
Senior Population Workgroup
The Oral Health Task force also has workgroups committed to studying the unique dental needs of various demographics in the state. Diane Romaine, DMD, a dental practitioner representing the senior population workgroup, presented barriers to care and possible policy solutions for Maryland seniors.
Cost is by far the top barrier to care. According to Romaine, 65% of Maryland seniors do not have dental insurance, and are 2.5 times less likely to maintain regular dental visits than those who are covered. Furthermore, seniors without regular dental care are more likely to defer care and seek treatment at emergency departments, which translate into higher costs.
Romaine also identified that only 13% of seniors covered by Medicare Advantage (Part C) receive any dental benefits. She said access to Medicare in Maryland is lower compared to other states, partly because of Maryland’s unique all-payer model, where private, commercial, Medicare, Medicaid, and self-payers are charged the same rate for services.
Another issue the workgroup identified is the lack of senior dental coverage available to purchase on the Maryland Health Benefit Exchange.
Romaine presented a list of suggestions to begin improving care for seniors, which includes expanding Medicare Part C to more rural counties in Maryland and adding dental coverage for seniors to the state marketplace. She also presented potential policy changes, such as mandating long-term care facilities to have a dentist on medical staff and conduct more comprehensive oral exams.
Some coverage improvements are already taking place. For example, a recently passed bill will expand coverage of dental services to all adults on Medicaid over the age of 21 beginning January 1st, 2023. Romaine estimates that this change will cover about 9% of seniors who currently live at or below 133% of the federal poverty level.