THERAPISTS & ADVOCACY

1. THERAPISTS & ADVOCACY Presented By Carter Brown, DMD, FAGD, FACD, FICD, FPFA Vice President, Academy of General Dentistry

2. Why the Interest?

3. What the Policy Makers See82 million with limited care

4. The Governmental Efforts& Safety Nets Populations underutilizing available services Up to a third of the population do not get care from the Private Market Depends on a set of uncoordinated programs and policies: Systems: FQHCs, VA, HIS Policies: Medicaid, CHIP Other: Volunteer Pro Bono Care, Free Clinics, Dental Schools, Corporate Medicaid practices, other community and public health programs Limited capacity and overall has not addressed the underutilization in substantive way

5. Policy Makers Are Lookingat the Wrong Things

6. They Don’t Understand, YouCan Never Get 100% DENTAL VISITS IN THE LAST YEAR Source: National Healthcare Disparities Report 2005, Department of DHHS

7. Source: IADR March 2007, Medical Expenditure Panel Survey

8. DHHS Responses: OIG Report on EPSDT Dental Service Utilization (1996) – < 1-in-5 getting any dental services HCFA/HRSA Oral Health Initiative (1990s) Surgeon General’s Conference, Workshop and Report on Oral Health (1999–2000) NGA Oral Health Policy Academies (2000–2001) Congressional Responses: GAO Reports, Midlevel trials proposed Legislation Hearings (Deamonte Driver)

9. WHO Alaska ANTHC Minnesota Legislature, University of Minnesota, Metropolitan State Normandale Renewed CMS attention/new administration Prominent foundation involvement: PEW Kellogg HRSA / CA Health Foundation-funded Institute of Medicine (IOM) studies Public Health Dentists, Small core group ADEA, interest expressed in the model

10. Access No set definition, clouds the debate Access: AGD Making Dentistry Available Patient Education and Responsibility Affordability – Sufficient Medicaid/insurance coverage to make healthcare affordable for patient Availability – Incentives/financial support to enable dentists to serve in underserved/rural areas

11. History on Midlevels In 1917, ‘Dental Dressers’ were established in some counties in England: The first dental therapists American hygienist with the addition of ‘filling those cavities without pulpal involvement’ and ‘the extraction of ‘temporary teeth in school clinics’ Desperate shortage of school service dental officers First World War The Dental Act of 1956 there were enough dentists to work in the service and the dresser’s duties were reduced to that of a hygienist

12. History on Midlevels In 1920, New Zealand established a School Dental Service: Called Dental Nurses Were the first contact point for rural patients with an onward referral to a dentist if necessary

13. History on Midlevels Back to the UK: In 1950, there was once again a desperate shortage of dentists in the school services Following visits to New Zealand the Dentist Act of 1956 was changed to allow the training of Dental Auxiliaries – however, Dental Auxiliaries would be referred patients by the Dentist

14. History on Midlevels In 2002, British Association of Dental Therapists caused the Dental Act to be amended Dental Therapists were allowed to work in general practice and along with that the SOP finally changed and ‘extended duties’ were added In every country that has therapists, these associations become a political force and SOP continually expand

15. Added Procedures in England Scaling and polishing Apply materials to teeth such as fluoride and fissure sealants Take dental radiographs Provide dental health education on a one to one basis or in a group situation Routine restorations in both deciduous and permanent teeth, on adults and children, from Class 1-V cavity preparations Can use all materials except pre cast or pinned placements Treats adults as well as children Extract deciduous teeth under local infiltration analgesia Pulp therapy treatment of deciduous teeth Placement of pre formed crowns on deciduous teeth Administration of Inferior Dental Nerve Block analgesia Emergency temporary replacement of crowns and fillings Take impressions Treat patients under conscious sedation provided the dentist remains in the surgery throughout the treatment

16. Where Are They? Alaska Australia New Zealand Canada Great Britain Various other smaller projects

17. Alaska DHATPer the DHAT Website DHAT: 10 practicing DHATs trained in NZ Since 2003, only one has stopped practice in AK First training center in the US, partnership with UW MEDEX 9 graduates, 13 in training Predict: 32 DHATs in AK by 2012 PDHA -11 cert (22) EFDHA -12 cert (23) DHAH - 0 cert Role models for younger

18. Alaska DHAT • Curriculum breakdown, second year: • Biological Science: 15% • Social Science: 7% • Pre-Clinic: 0% • Clinic: 78% (1,215 hours) • Curriculum breakdown, two years combined: • Biological Science: 22.5% • Social Science: 8.5% • Pre-Clinic: 20% (632 hours) • Clinic: 49% (1,548 hours) Alaska DHAT training program information: First year: 40 weeks Second year: 39 weeks Total: 79 weeks (3,160 hours) Curriculum breakdown, first year: Biological Science: 30% Social Science: 10% Pre-Clinic: 40% (623 hours) Clinic: 20% (316 hours)

19. Alaska DHAT After graduation, 400 hours preceptorship Standards and procedures: Standing orders Renewal every two years

20. Australia Dental therapists have practiced in Victoria since 1975. Since 2000, movement of dental therapists into new work settings such as private, community, and hospital practices. Prior to 2000, dental therapists were limited to children attending school. Now provide up to eighteen years and, upon the prescription of a dentist, from nineteen to twenty-five years. In orthodontic practices, care prescribed by an orthodontist or dentist may now be provided by dental therapists to clients of all ages.

21. This Year, a New OversightGroup in Australia:National Oral Health Alliance Did not recommend enhanced Therapists, instead they recommended what the AGD has been saying for 5 years, namely: Phasing in a dental residency (foundation) year over 5–10 years as policy, infrastructure, professional mentoring, and support develop (initially $20m pa for operations and $60m pa for infrastructure) Introducing regional, rural, and remote incentives to improve the distribution of the workforce (initially $10m pa)

22. New Zealand Now, dental therapists train for three years at university or a polytechnic and are registered with the Dental Council of New Zealand The majority of dental therapists are employed by District Health Boards in schools, though a small numbers work in private practice alongside a dentist While dental therapists work independently, they will have a professional link to a dentist and refer your child to a dentist when more specialized care is required

23. New Zealand Treatments that can be carried out by a dental therapist include: Advice on oral health and cleaning practices for children and adults Cleaning the teeth Diagnosis of decay (cavities) in baby (deciduous) or permanent (adult) teeth – this may include using x-rays Restoration of decayed adult and baby teeth using fillings Extraction of baby teeth Preventive therapies to keep teeth healthy – for example using special sealants or topical fluoride Referrals to other oral health practitioners for assessment and treatment Keep records of dental treatment

24. New Zealand Therapists don’t stay long, not cost effective High career satisfaction but much less satisfied with remuneration Done in 10 years with dental therapy Younger DTs were more interested in moving to private practice A mean of 6.5 years in career Source: Ayers, K.M., et al. The working practices and career satisfaction of dental therapists in New Zealand. Comm Dent Heal 2007; 24:257-63.

25. New Zealand The dental health of young children continues to be among the worst in the developed world, figures reveal Forty-four per cent of 5-year-olds have at least one decayed, missing or filled tooth, a school dental services report has found The Government has spent $417 million on the problem since 2007 but the figures have shown little improvement In 2000, 48 per cent of 5-year-olds had cavities, and the figure has not dropped below 43 per cent since New Zealand rates are worse than the UK, US, and Australia Source: Gillis, Abby. NZ children's dental health still among worst. New Zealand Herald, March 2011.

26. Canada Large country Many rural, isolated populations Transportation challenges Dentists concentrated in population centers Access to dental care limited

27. Canada Fillings on primary and permanent teeth Vital pulpotomies on primary teeth Stainless steel crowns on primary teeth Extractions of primary teeth (Prov & Fed) Extractions of permanent teeth (Fed) Sealants Cleanings Fluoride Radiographs Education

28. Canada Too many dental staff for the amount of dental work that needed to be done Large provincial deficit, conservative government Government scrapped the program in 1987, except for the northern program Expanded dental hygiene schools

29. Dental Team Concept Prevention, prevention, prevention! Expanded Auxiliaries within the practice can play key role in prevention Establishment of Dental Home* Dental benefits designs to support establishment of dental home from childhood** Cost savings for patients & carriers! *Advisory Committee on Training in Primary Care Medicine & Dentistry’s (ACTPCMD) 8th Congressional Report (2010) recommends expansion of dental home to medicine as key to prevention and cost-savings **See the American Academy of Pediatric Dentistry’s (AAPD) Policy on Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs (2008)

30. Midlevel Providers Examples: hygienists/dental assistants/expanded function dental assistants (EFDA) within the dental team model, Dental Health Aide Therapist (DHAT)*(AK), Registered Dental Hygienist in Alternative Practice (RDHAP) (CA), Dental Therapist/Advanced Dental Therapist (MN), independent practice of hygienists (CO, ME), Advanced Dental Hygiene Practitioner (ADHP)(Not yet implemented), limited access permits (OR), public health hygiene endorsements (OR, ME), collaborative practice dental hygienists(NM), Level III Hygienist (KS). Concern: Independent practice w/o direct supervision of a dentist (a.k.a. “Alternative model of oral healthcare delivery”)

31. Midlevel Providers In the Affordable Care Act: SEC. 5304.  ALTERNATIVE  DENTAL  HEALTH  CARE PROVIDERS  DEMONSTRATION PROJECT Subpart X of  part D  of  title III  of  the   Public Health  Service Act  (42  U.S.C.   256f  et   seq.)   is  amended  by  adding at  the   end  the  following: “SEC. 340G–1. DEMONSTRATION PROGRAM “(a) IN  GENERAL.—”(1) AUTHORIZATION.—The Secretary is authorized to award grants to 15 eligible entities to enable such  entities to establish a demonstration program to establish training programs to train, or to employ, alternative dental health care providers in order to increase access to dental health care services in rural and other underserved communities.

32. Midlevel Providers In the Affordable Care Act: “(2) DEFINITION.—The term ‘alternative dental health care providers’ includes community dental health coordinators, advance practice dental hygienists, independent dental hygienists, supervised dental hygienists, primary care physicians, dental therapists, dental health aides, and any other health professional that the Secretary determines appropriate.

33. Alternative Models Advanced Dental Hygiene Practitioner (ADHP) Community Dental Health Coordinator (CDHC) Dental Therapist (DHAT and numerous variations)

34. ADHP Created by ADHA Completion of hygiene program + 2 years of Master’s study Diagnose and treat, including restorations and extractions General or No Supervision Pilot Study in CO indicated hygienists failed to practice in underserved areas Not implemented in any state

35. New Data, Implicationsof New Legislature Possible funding for the ALTERNATIVE DENTAL HEALTHCARE PROVIDERS  DEMONSTRATION PROJECT Expansion of National Health Service Corps to specifically include dental therapists Create demonstration programs for training and employment of alternative dental health care providers, including within the Departments of Defense and Veteran Affairs, Federal Bureau of Prisons and Indian Health Service Amend Medicaid reimbursement criteria to include services provided by alternative dental providers.

36. CDHC Created by ADA 18 Months of training Community, public health, and private practice settings Provides education/case worker services under general supervision Limited treatment with door open for modification of SOP New Mexico to implement

37. Dental Therapists Favored by Pew and W.K. Kellogg Modeled after New Zealand, Great Britain, Canada Two years or so of education Diagnosis, restorations & extractions General supervision Implemented in AK (native) & MN Benchmark for Proponents - Minnesota

38. Minnesota Model Dental Therapist (DT): Both indirect and general supervision Only 26 to 28 months of training 16 licensed so far Advanced Dental Therapist (ADT): 2,000 hours Prerequisite DT license General Supervision Practice Settings: Both DT and ADT are limited to primarily practicing (about 50%) in settings that serve low-income, uninsured, and underserved patients or in a dental health professional shortage area.

39. Other States W. K. Kellogg targeting 5 states for dental therapist pilot programs: KS, NM, OH, VT, and WA Washington: Eastern Washington Univ. – ADHP Masters Program HB 1310 (Advanced Dental Therapist) Bill withdrawn (2011) Kansas: HB 2280 (Registered Dental Practitioner) defeated (2011) Does now have new Level III Hygienist

40. States with Mid-Level Provider Legislation Legend: Pending Enacted Failed

41. Nash Review of 1,100 Reports • Released by W.K. Kellogg Foundation, April 2010 • Claims that dental therapists can provide “technically competent, safe and effective” care • Fails to measure true patient health outcomes • More of position paper than a clinical research report (as noted by title, A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States)

42. ADA Systematic Review Sought to find the science to back up claims 7,700 articles reviewed Only 18 possibly useable, of which 12 were high bias, 5 were medium bias, and only 1 was low bias Found no improvement in the oral health of the community by adding therapists Quality of data was poor and refutes the foundations claims of hundreds of articles

43. California Study SB694 – A bill to study use of midlevel providers in CA No dentist shortage in CA Bill died in appropriations The sponsor has called for a special session of the legislature to discuss the bill – will take place in Dec. ‘12

44. Jackson Brown Articles The Economic Aspects of Unsupervised Private Hygiene Practice and Its Impact on Access to Care (2005) www.ada.org/sections/professionalResources/pdfs/report_hygiene.pdf “Unsupervised private dental hygiene practice has not had a notable effect on access to care in Colorado” “They are located in areas served also by dental offices with traditional dental hygienists” “The economic viability of the unsupervised hygienist business model is questionable because their prophylaxis fees, on average, are not different from traditional dental practices, which have the advantage of providing a full range of practice services”

45. Study of Alternate Dental Providers, Five State Comparison Five states, three models, three payment systems Only in a couple of scenarios would using therapist be minimally economically sustainable – they would have to be heavily subsidized “The current public payor and indigent reimbursement levels is not economically feasible for providers with salaries at 50% of the Dentists” “The limitations to greater access to dental care is that existing fee schedules do not cover the cost of treating the patients” The addition of additional providers does nothing to address this issue

46. AAPD Answers Kellogg In addition to AGD and the ADA, the AAPD also responded to the Nash/Kellogg Report Key points of AAPD: • Report fails to account for variations between 54 countries • Based on opinions, not data • Fails to address economic viability • Technical competence ≠ long-term patient outcomes

47. The Perth Meeting The Presidents of the American Dental Association, the British Dental Association, the Australian Dental Association, the Canadian Dental Association, and the New Zealand Dental Association had a discussion on the success or failure of the therapist programs In ALL of the countries utilizing therapists, there was no improvement in Access and NO cost savings

48. ADEA and Public Health They claim that this workforce issue is being driven by: Access to care  Oral health disparities Some believe that the DT could be an answer to these problems

49. Dental Extenders at CHC’s WSDA introduces legislation to introduce AFDAs (Advanced Function Dental Auxiliaries) for community health centers approved by the Dental Quality Assurance Commission (DQAC) Essentially, public health EFDA with added surgical privileges under direct supervision

50. Prevention-Focused Care A fully trained dentist and a full oral health team (dental team concept), CDA, EFDA, RDH The dentist utilizes the team to increase efficiency in order to treat more patients but without decreasing the level of care Just adding more hole fillers doesn’t increase the level of overall oral health