Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.
Kevin: Good afternoon. This is Dr. Kevin Coughlin and you’re listening to Ascent Radio. This podcast is brought to you by Ascent-Dental-Solutions.
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This afternoon, we have three guests. The Kellogg Foundation is a foundation that is almost totally devoted to improving oral health for our most vulnerable population. And that’s the young children under the age of 18, but particularly, those most prone to dental disease under the age of ten.
This foundation has been providing services, finances and expertise and looking for solutions to improve this epidemic situation, which is dental caries and dental disease, primarily in our younger population, and primarily the population that’s underserved in need of the greatest assistance.
Today, our guests are Dr. Mary Willard, Ms. Sarah Wovcha and Dr. Terry Batliner. The three of you, thank you so much for your expertise and knowledge in the subject of improving the situation. And special thanks again to The Kellogg Foundation for their effort and expertise in this area. I’d like to start with Dr. Willard. Mary, what do you think is the most significant problem for dental education and dental care in this particular population?
Mary: The biggest issue is access to care, I believe. We have many populations living in inner cities that have trouble getting appointments with dentists. Sometimes in places like where I live in Alaska, it’s because there are very few dentists in our remote villages and communities. Sometimes in inner cities it’s because the dentists don’t accept Medicaid or uninsured patients.
Kevin: If you had the ability to snap your fingers tomorrow, with your expertise, knowledge and background, what would you say would be the single best solution, in your opinion, to improve the situation?
Mary: I don’t think there’s one single thing that we can do, but one very effective tool is to implement the use of dental therapists in our dental teams to expand access to underserved populations.
Kevin: Sarah, if I was to ask you the same question, is there anything you’d like to add or delete to those recommendations of Dr. Willard?
Sarah: No, I think Dr. Willard has hit the nail on the head. Those are precisely the issues that we face in Minnesota.
Kevin: Dr. Batliner, with your expertise and background, is there something you’d like to add or delete or do you think that’s the significant problem and that’s perhaps one of the strongest options or solutions?
Terry: Sure, let me just define the problem a little bit more. I live in two worlds. I have three dental practices in Boulder, Colorado and around Boulder and I also am the associate director for The Centre for Native Oral Health Research at The University of Colorado where we conducted research on Indian reservations.
There really are two types of problems and Mary touched on them quickly. One is that there’s not enough providers who take Medicaid. In my role in Boulder, I’m a Medicaid provider and there aren’t very many Medicaid providers, even though the compensation is pretty good in Colorado.
And then in my role as a researcher with native communities, we see that the dentist to population ratio, which averages 1:1600 in the United States, on reservations such as Pine Ridge in South Dakota and the Navajo Nation in Arizona and New Mexico has a dentist to population ratio of 1:4000 or worse than that. So it’s very difficult for people to access care.
In combination with that, in places such as native communities or in the Medicaid population, the amount of disease is much higher. And so we find that kids three years old, perhaps in Navajo at age three, 70 percent of those kids have untreated decay. On the Pine Ridge Reservation, about 55 percent of those kids have untreated decay in our latest data. So there’s a lot of issues.
We also found that the Hispanic Medicaid population in the Metro Denver area is comparable with their degree of disease to the kids on Pine Ridge. About 55 percent of kids have untreated decay.
Kevin: I thank the three of you for that feedback. I am a practicing dentist. I still practice. I was actually in my office practicing since 7:00 this morning and I deal with all different populations. My practice is fairly large. We see on an average of about 116, 000 patient visits a year and I am quite familiar with the problem.
Since we have a variety of listeners, in your opinion Dr. Willard, what would you say the dental therapist for those who may not be up on the topic, they may not be as informed or educated, and sometimes there’s misinformation.
My personal opinion here on the East Coast, but particularly in New England, you have two schools of thought. One school of thought is they’re very much against these mid-level practitioners, these dental therapists, these expanded duties. And my personal opinion, it may not be accurate, but my personal opinion is many in the dental community find this as a threat.
If we do the SWOT analysis — Strength, Weaknesses, Opportunities and Threats — they perhaps are concerned that there’s a threat to their business and to their income. Other individuals may be concerned with quality of care, the ability to monitor the quality of care. Could you address those issues and perhaps sway the listeners how those potential issues could be misguided?
Mary: Basically, the dental therapist is a primary care provider, new team member who brings additional services and brings a different team player to the dental office. What we have is a provider who is able to provide basic restorative, preventive services and is typically from the community.
For me, that’s the big aspect of what this dental provider brings, is a familiarity with the customs and needs of the community they’re serving, especially when they come from that same community. It’s a way to provide care closer to home and also having a therapist on board is a way to provide patient navigation services as well, so services that are out of the scope of a dentist.
What we see in Alaska right now is that the dental therapists are able to provide the basic restorative and preventive services that are needed and then they can provide referrals to the dentist for the higher level care. As a result, we’re seeing that the dentists are able to perform more of the higher level services and are not spending as much time on the basic restorative.
So what you’re going to have as a dentist working with a therapist is an increase in your production, especially in those higher levels like partials, dentures, implants, crowns and visits because you got that fixed during the restoration. We’re finding that it’s increasing the bottom line for the dental practices as a whole.
Kevin: And that’s possibly a motivation to move the dental profession perhaps in a more positive direction. Ms. Wovcha, Sarah, if you were to add or comment to Dr. Willard’s assessment, would you agree, disagree, add or delete anything?
Sarah: I agree with Dr. Willard’s assessment. I would also say that if we look at the facts in terms of not only the training, but what we are seeing when dental therapists are engaged in a practice, they bear out that they are quality, efficient providers. To give a specific example of that in Minnesota, dental therapists at our training programs in Minnesota are educated side by side with dentists. When they become licensed, the exam that they undergo is in a blind setting.
In other words, the evaluators do not know whether they are evaluating a dentist or a dental therapist for the procedures that they are assessing. So it’s completely competency based. Again, they’re trained with dentists at the same institutions and they are evaluated in the same way in a blind setting.
I think the difference is that dentists are trained to do around 500 some procedures in Minnesota, for example, and dental therapists are trained to do about 50 some procedures.
So they are learning in-depth how to do these less complex restorative procedures and they’re gaining a repetitive skill set. If you just look at the sort of objective external factors of the training and the assessment, it bears out that they are competent and at least at the same level of quality as dentists.
Then when we look at how they actually perform in practice, the State of Minnesota Department of Health has done an assessment of all licensed dental therapists and have found that they are productive in practice and there have been no confirmed incidents of malpractice since they have been licensed in our state. Again, there are very objective metrics that show quality, efficiency and expanding access to care.
Kevin: Dr. Batliner, is there anything you would like to add or comment or delete from the previous two experts? Is there something that you’d like to present to our listeners?
Terry: Sure, I think the quality has been studied. Dental therapists have been studied more than any other type of providers in the last ten years and have been shown to provide quality comparable to dentists doing the procedures that they perform, which is a smaller number than dentists. I think the other thing to consider is that they can operate more cost effectively.
For example, in my practice, I pay our associates 30 percent of collections. So let’s say they do — just to make it easy — $300 an hour, so they get paid about $90 an hour.
We hire hygienists in Colorado. We pay them quite a bit in Colorado, around $40 an hour. It’s reasonable to think that I could hire, if they were legal in Colorado, a dental therapist for somewhat more than a dental hygienist. I think that’s what Sarah has found in Minnesota.
So let’s say we pay the dental therapist $45 to $50 an hour and then they can do, in our studies of their performance around the country, around 75 or 80 percent of the things that people need when they walked in the office. So it’s a cost effective arrangement. It would allow more offices to provide care to underserved groups that may be parts of programs such as Medicaid that pay based on a discounted fee schedule.
Kevin: Dr. Batliner, I’m going to do a follow up question with you. If we could snap our fingers and based on the information and data, there’s roughly 500,000 dentists in the United States at any given time. And my understanding is that roughly around 200,000 to 250,000 are actually practicing fulltime. If we could snap our fingers and create another 250,000 dental therapists tomorrow morning, what would be the motivation to have those individuals go to the population in the locations that we need?
Is there a solution or a discussion that The Kellogg Foundation and the experts in this area are looking into? Let’s just say a miracle happens tomorrow, we’ve reached through the political quagmire and we’ve got these hundred thousand plus therapists, how do we get them to the areas that we need?
Terry: The first thing is we have to recruit them from those areas. As Mary has learned in Alaska, by recruiting people from the villages and they’re trained quickly in somewhat between two and three years, where they don’t lose touch with their home community and then we found that they return to their communities. That’s number one. Number two, if you want to involve more people of color, socio-economically disadvantaged people in the education system, you have to keep it as inexpensive as possible. Because it’s difficult for people to borrow hundreds of thousands of dollars and then pay that back, as many dentists have to do.
Keeping the training as short as possible, CODA, the Council on Dental Accreditation, has kept it at three years after high school. I think that’s good. The programs need to be cost effective and quick, and that will involve more people. I think those are really the issues; recruit people from the communities, keep the training as short as possible and as inexpensive as possible so that the people we need to get trained can get trained.
Kevin: Ms. Wovcha, Sarah, let me ask you a follow up question in regards to this situation. These therapists, how would they be compensated? Do you see this as they would be compensated not only through maybe a clinic such as Dr. Batliner owns, or do you see this as a State or Federal government sponsored, and they would be compensated for their services and their education through tax dollars in some shape or form?
Sarah: What we are seeing in terms of actual practice is that they are compensated as a credentials provider with medical assistance and private insurance as well. So they’re compensated in the same way that other dental providers are compensated.
We’re also seeing that they’re eligible for loan forgiveness, for example. So they are receiving in Minnesota, for example, some government dollars and there are actually private foundations that are helping to offset the cost of education. Is that answering your question?
Kevin: It is. Part of it is selfishly, I’m embarrassed to say that I’m not as well educated in that area as I should be. I’m assuming, like Dr. Willard working in the Alaska area, there are limited number of private practices. So I’m thinking out loud now on this podcast, is the therapist coming from the community would potentially have their own facility because there’s not enough dental facilities and is there an issue or a problem? Again, in full disclosure, I personally am 100 percent for expanded duties and always have been. I think it creates competition, it provides better access to care.
And selfishly from a financial stand point, I think most business people, particularly in dentistry, realize that a dental assistant provides an enormous increase in income and so does a dental hygienist and so do dental associates. So from my simplistic point of view, why wouldn’t dental therapists also? And I think Dr. Willard touched on those bases.
But in the areas where there’s just not enough dental facilities, do you see any issues or problems with these therapists striking out on their own to create more environments for the populations to be treated?
Sarah: I don’t see problems with that. In fact, the model is well adapted to be able to expand access in regions that don’t have dentists or don’t have traditional facilities.
Let me give you an example, again, speaking from the perspective of Minnesota. In Minnesota, dental therapists can practice in any setting in which there are 50 percent or more patients on medical assistance or uninsured patients in poverty. That can be a private practice setting, it could be a community clinic, it could be a mobile dental clinic, a hospital, a school based setting. There’s a large array of settings in which they can practice.
They must be in a relationship with the dentist. In other words, they must have it’s called a collaborative practice agreement, so that they can have a level of supervision by a dentist. But they are able to work independently.
In other words, in a large state, a dentist could be practicing in Saint Paul, Minnesota and the dental therapist could be five hours away in the wilderness in Ely, Minnesota practicing. So they’re certainly well situated to do that, and they are, in fact, doing that.
Just to give an example of distribution of dental therapists compared to dentists in Minnesota, our most underserved regions are our rural regions. And according to the study of the Minnesota Department of Health, right now 74 percent of dentists practice in urban settings and only 26 percent practice in rural settings. And with dental therapists, the numbers are almost double in rural and significantly less in urban.
So 47 percent of dental therapists practice in rural regions and 53 percent in urban. So we’re seeing better distribution of dental therapists that reflects the community in need.
The last thing I would say that Dr. Batliner touched on is that the way that we compensate dental therapists in Minnesota is much more sustainable for a clinic. For example, on average, a dental therapist in Minnesota receives $45 per hour and dentists receive $75 per hour. If you calculate the savings for a clinic, and this is really quite a conservative estimate.
If they see around 1,500 patients per year and I’ll say that the providers I employ see more like 2,000 per year, the cost savings is $1,200 per week or $62,400 per year. And what we do with that funding is reimbursed in our dental providers. In other words, I can hire two dental therapists for the cost of one dentist and they can provide 50 of the most commonly needed restorative procedures in our clinic.
Kevin: First of all, I want to thank The Kellogg Foundation for putting their emphasis and financial backing to this problem. It has to be addressed, there’s no reason it can’t be addressed, and with experts like we have on today’s panel and the conversation starts to get discussed, action steps can be made.
I want to thank our three speakers and guests today. Dr. Mary Willard, Director of Dental Health Aid Therapist Educational Program at the Alaska Native Tribal Health Consortium. Ms. Sarah Wovcha is the Executive Director of Children’s Dental Services in Minnesota. And Dr. Terry Batliner is a member of the Cherokee Nation and currently working on faculty at the University of Colorado and is also the owner of Sage Dental Care with three private practices also in Colorado. Your expert opinions, in my opinion, are so important.
I can tell our audience, I know that this is a difficult subject for many, but quite honestly it’s pretty straightforward. Let’s get together as a profession. Let’s recognize the seriousness of the problem. Let’s put our heads and minds together and try to eliminate our selfish own wants and needs and see if we can tackle this from a political standpoint and educational standpoint. As I see it, it’s a nutritional issue, a motivational issue, an educational issue and with experts like on today’s panel, there’s no reason we can’t improve the current situation.
I want to say thank you to all three of you very, very much for your expertise and time. I would like to follow up. I can tell from responses that there will be many other conversations and other points of view. But you’ve been listening to Ascent Radio.
My name is Dr. Kevin Coughlin. Please, for this podcast and other information, turn to Ascent-Dental-Solutions, with a focus on knowledge, consultation, training and development.
In closing, special thanks to Mr. Doug Foresta and his company, Stand Out and Be Heard, for sponsoring this expert podcast and the production of those podcast. And I also want to give special thanks to VOCO and their financial support and their excellent products and services to the dental community.
Thank you all for listening. This is Dr. Kevin Coughlin and I look forward to speaking to you soon.