ADA reports question economic viability of midlevel providers

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The midlevel dental provider (MLP) model is not economically realistic or sustainable, according to a series of state-based reports released today by the ADA.

But a Minnesota program that is tracking the productivity of its dental therapists begs to differ.

The reports, 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 (ADHPs) in five states that are considering adopting one of these models: Connecticut, Kansas, Maine, New Hampshire, and Washington.

ADA President William Calnon, DDS, pointed out during a morning press briefing that the economic sustainability of MLPs have received insufficient attention.

“Lawmakers and public health authorities should not rush to create midlevel dental providers who may be unable to fulfill their purpose of reducing oral health disparities.”
— ADA President William Calnon, DDS

"Lawmakers and public health authorities should not rush to create midlevel dental providers who may be unable to fulfill their purpose of reducing oral health disparities," he said.

Underserved populations face a range of barriers that require integrated solutions, Dr. Calnon noted, not just adding MLPs.

"Taking on just one of those barriers won't work, so we must continue to approach these problems in a holistic fashion," he asserted.

As part of the solution, Dr. Calnon suggested improving programs like Medicaid and increasing Medicaid reimbursements.

"Medicaid is broken, but with some administrative reforms and relatively small financial investments it can be improved," he stated, noting that Connecticut, Michigan, and Alabama have already done this.

Three payor scenarios

For the reports, ECG obtained data from the ADA, each state's dental association, tertiary dental educational programs, community dental health centers, and online sources. ECG also interviewed dental association leaders, dentists in public practice clinics, clinic administrators, and representatives from dentist and dental provider educational institutions familiar with tuition and program finances.

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:

Payor mix Public fee schedule Sliding few schedule Private fee schedule
A 75% 25% 0%
B 50% 25% 25%
C 50% 0% 50%

"Across all five states, none of the three alternative midlevel provider models are economically viable under payor mixes A and B," the researchers wrote.

Of the 45 scenarios modeled (three payor mixes for each of three practice models in five states), only Chart courtesy of ECG Management Consultants.

','dvPres', 'clsTopBtn', 'true' );" >five indicated positive net revenues, ranging from $8,000 in Kansas to $38,000 in Connecticut, assuming a 50/50 mix of public and private fees. Four positive net revenue scenarios involved the DHAT model; one involved the DT model.

The other 40 scenarios showed net losses ranging from $1,000 for a DHAT operating on a 50 public/50 private mix in Washington to $176,000 for an ADHP practicing in the same state, assuming a 75/25 public/sliding revenue mix.

"The analysis for all five states suggests that the DHAT model is economically viable only in settings where at least 50% of patients pay market-based fees," ECG researchers wrote. "For all other payor mixes, none of the models are economically viable. Moreover, even under the generous payor mix of 50% private-pay patients, the DT and ADHP models are not economically viable."

In fact, the ADHP model is not economically viable in any state under any payor mix, primarily due to significantly higher expenses (higher provider salaries), the researchers noted.

The ADA believes that allowing nondentists to perform irreversible surgical procedures is not the way to go, Dr. Calnon added.

"And based on these studies, midlevel dental providers would in most settings be unable to generate sufficient revenue to sustain themselves, absent a continual source of financial underwriting," he said. "Given the current budget constraints at every level of government, and the already insufficient financing for dental care in most states, midlevel providers do not appear to be viable."

Success in Minnesota

However, Sarah Wovcha, executive director of the nonprofit Children's Dental Services in Minneapolis, says an advanced dental therapist who has been working at her clinic for eight months has consistently been among the most productive providers. In fact, 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 program.

The advanced dental therapists are paid about half of what the licensed dentists are paid -- $43 an hour versus $75 an hour -- and does a variety of restorative procedures, Wovcha pointed out. She calculated the costs by the amount of billing divided by the number of hours the MLP worked.

"She's very competitive," Wovcha told In May, the advanced dental therapist ranked third in productivity among 12 providers, including 11 dentists.

"She's consistently in the top half," Wovcha said. "I was very pleased and not all that surprised because she's well-trained. Hygienists typically have lots of clinical experience, and many have worked in community clinics with the patients we serve, and many are difficult to work with. Our data indicates they can do them as productively and as well as dentists."

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