Reactions to the ADA's midlevel provider (MLP) economic feasibility report released July 25 have ranged from allegations that the report uses inflated costs and ignores the public health program's existing infrastructure to a general consensus that the ADA has taken a positive first step in an evidence-based evaluation of the issues.
Frank Catalanotto, DMD, a professor and chair of the department of community dentistry and behavioral sciences at the University of Florida College of Dentistry, praised the ADA for confronting the issue but disputed some of the findings.
"I think it's terrific the ADA did this kind of study because they are finally starting to use evidence-based information to make their decisions about these midlevel practitioners that's been sorely lacking in their past perspectives in opposing these programs," he told DrBicuspid.com.
— Frank Catalanotto, DMD, University of Florida
The report, written for the ADA by ECG Management Consultants, examined the economic viability of dental health aide therapists (DHATs), dental therapists (DTs), and advanced dental hygiene practitioners in five states that are considering adopting one of these models: Connecticut, Kansas, Maine, New Hampshire, and Washington.
ECG based its modeling on the length and cost of training of each midlevel position, operating costs, likely salaries, academic debt, and projected revenues. The feasibility of each alternative provider model was evaluated for three payor-mix scenarios.
Of the 45 scenarios modeled (three payor mixes for each of three practice models in five states), only five indicated positive net revenues. Four positive net revenue scenarios involved the DHAT model; one involved the DT model.
Dr. Catalanotto did concur that location is the key to assessing whether MLPs are economically realistic.
"I think there probably is some factual basis to the [idea] that one has to be very careful about where and how these kinds of midlevel providers are employed," he observed.
However, Dr. Catalanotto and others assert the study uses incorrect assumptions about the costs involved for MLPs.
"The ADA model assumes the same kind of overhead costs that a dentist would have, but the reality is they would fit into an existing program," he pointed out. "They would not be going out and setting up their own business, they would be fitting into existing infrastructure."
Shelly Gehshan, director of Pew Children's Dental Campaign, agreed.
"The question to ask is: How do you use new providers in the existing systems we have to reach more people?" she told DrBicuspid.com. "But instead they're saying: Can these new providers fly on their own when cast out with a high overhead?"
The ADA report also didn't include revenue associated with public health programs and the savings that MLPs could provide, Gehshan said.
"If you're doing a public health program, you have grants which they don't factor in. You could be part of a community health center and you get higher reimbursements than they include," she noted. "For a public health analysis, you have to factor in the costs that you're averting in a community approach. They're missing sources of revenue and inflating the costs."
In 2010, the Pew Center on the States issued a report that found that most private-practice dentists who hire MLPs could serve more patients while maintaining or improving their financial bottom line.
Another Pew study found that millions of dollars are spent to treat patients who go to hospital emergency rooms with dental problems, a budget problem that many other states have reported.
"All those wasted millions would be saved for communities," she said.
The ADA report found that MLPs are financially viable under payor mix C, but Gehshan said even those costs are inflated.
"A scenario like that is likely to happen in Minnesota, but no one has these fee structures, Gehshan said. "Community health centers are required to provide care for free or on a sliding fee scale in addition to taking Medicaid patients, and they have a few private-pay patients, but you don't see anybody with this kind of mix."
In fact, Sarah Wovcha, executive director of the nonprofit Children's Dental Services in Minneapolis, said an advanced dental therapist who has been working at her clinic for eight months has saved her money because her salary is about half of what the licensed dentists are paid -- $43 an hour versus $75 an hour. And the MLP, who performs a range of restorations, has consistently been among the most productive providers among her staff, which includes 18 dentists.
Wovcha has been so impressed that she hired a second advanced dental therapist last month and will pay the tuition of two staff hygienists to go through the DT program as well.
"I think it's essential when evaluating models for dental therapists and other advanced dental practitioners to examine the data of actual dental therapists in practice," Wovcha observed.
Wovcha attributed the DT's productivity to the fact that most hygienists who enter the program have extensive clinical experience, often in public health clinics.
"She's already honed her skills and received the same kind of training for restorations that dentists get, and they have to pass the same tests that dentists get for those procedures," Wovcha noted.
Barriers to care
The report should have considered public health hygienists who can perform temporary restorations, as they are now allowed do in New Hampshire and California, Gehshan added.
"They would be fabulously cost-effective," she said. "We can use existing personnel with a short extra training program. It's reimbursable under Medicaid, you can do it using portable equipment, you can stabilize decay using temporary restorations, and dentists don't oppose it. Why didn't they model that?"
Jeffrey Cole, DDS, MBA, president of the Academy of General Dentistry (AGD), agrees with the ADA that gathering information is just the first step toward addressing the issue of midlevel providers.
"More work needs to be done," he stated in a press release.
The AGD believes that the more important part of the issue lies in moving the focus away from workforce models, focusing instead on the more important goal: knocking down the barriers to access to care, he added.
The California Dental Association (CDA) also agreed that the MLP model should be studied.
"The ADA study is consistent with CDA's position that further research is necessary before any proposal for a new provider model in California is considered," the group said in an email to DrBicuspid.com.
More focus on prevention
ADA President William Calnon, DDS, pointed out during a press briefing that coincided with the report's July 25 release that more focus should be on prevention than on surgical procedures.
"I absolutely agree with Dr. Calnon's assertion that much of the caries epidemic is preventable," Dr. Catalanotto said. "But what the ADA continually ignores about both the advanced dental hygienist and therapist models is that one of the key things they do is prevention. In Alaska, for example, if you look at what a therapist does in their work week, it is not sitting chairside filling teeth all day. They do a significant amount of community activity that focuses on prevention and changing behavior, and their advantage is they bring cultural competence to the issue."
Approximately 10 states are considering legislation to allow some type of alternative providers; the five states included in the report are getting close to passing laws permitting MLPs.
MLPs could provide dental care to millions of Americans who now have no access to it, according to Dr. Catalanotto and Pew's Gehshan.
"Despite the economic difficulties this study would predict, the reality is there are approximately 80 million people who cannot access services," Dr. Catalanotto said. "With modest increases in Medicaid funding, these models would probably be able to demonstrate that those people can get care which they cannot get now."
"Even with skewed assumptions this study confirms that the 2-year dental therapist model is a financially viable way to reach more underserved Americans so I think it’s a big green light for the dozen states that are actively considering these models," Gehshan added. "If you want to avert wasting hundreds of millions of dollars on ER visits for these poor people who have nowhere else to go, it behooves us to figure out how to use new providers to treat people whom dentists don't treat," .