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Legislating The Midlevel Practitioner

In response to the burgeoning access-to-care crisis, many states are considering the addition of a new member to the oral health care team—the midlevel practitioner.

The concept of midlevel practitioners in dentistry isn’t new, but it remains a hot-button issue among those who care about promoting access to oral health. The controversy continues, with many opposed to what they consider to be the setting of a dangerous precedent—permitting dental hygienists with advanced education and training a broader scope of practice. Yet, the primary driver for the creation of new oral health professionals is improving access to care. In order to help meet the dental needs of underserved communities, more practitioners are needed. With a projected shortfall of dentists, as outlined in a 2015 report by the United States Department of Health and Human Services National Center for Health Workforce Analysis, the access-to-care problem will only get worse, with demand exceeding supply by 2025.1

The issue isn’t just fewer dentists or patients not being able to get to clinics or practices. The inability to afford dental treatment is perhaps the most significant barrier to care, as many would-be patients in underserved communities have no dental insurance, are unable to pay out of pocket, and/or are covered by Medicaid, which is not accepted by many private dental practices. The National Governors Association (NGA) reported that in 2013, 57% of those with private insurance had seen a dentist during the previous year. However, just 27% of individuals without coverage and 32% of those with public coverage had visited a dentist in the same period.2 The catch-22 is that increasing numbers of dentists do not serve patients with Medicaid insurance, citing, among other issues, low reimbursement rates that do not cover the costs of procedures.

The American Dental Association’s (ADA) Health Policy Institute (HPI) predicts that Medicaid expansion under the Affordable Care Act will improve access to care for low-income adults. However, expanding dental benefits to those covered by Medicaid will not singlehandedly improve access to care, nor improve oral health. Rather, the HPI asserts that instituting reforms to Medicaid programs is also required.3 Until significant changes can be made, other strategies are needed to help those in need of dental care. The urgency is especially poignant when more than 16 million children covered by Medicaid went without the dental services to which they are entitled in 2013.4

CREATING ALTERNATIVES

Failing to address the access-to-care problem could result in continually escalating medical costs, as those experiencing dental problems who are unable to find dentists who accept Medicaid end up seeking treatment in hospital emergency departments. While there may be a shortage of dentists, the dental hygiene profession continues to grow. With more than 185,000 dental hygienists available to help fill the gaps, several states are broadening practice scopes and considering different supervision levels to improve access to care. In addition, according to the American Dental Hygienists’ Association (ADHA), 16 states now have practice acts that allow the direct reimbursement of dental hygienists by Medicaid, expanding opportunities for dental hygienists to provide care directly to patients in alternative practice settings.5

Thirty-seven states now allow dental hygienists direct access to patients. This means dental hygienists may initiate treatment of patients based on their own assessment and maintain a provider/patient relationship without the presence of a dentist. They may also enter into provider agreements and receive direct and third-party payments.6 Requirements vary from state to state, and many necessitate written collaborative agreements between a dental hygienist and a dentist. Direct access states are Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Idaho, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, and Wisconsin (Figure 1).7

Depending on the state, qualified dental hygienists may write limited prescriptions, administer local anesthesia, place temporary restorations, cement crowns, contour and finish restorations, perform dental assessments, and develop a dental hygiene treatment plan, in addition to providing traditional hygiene services. Additionally, many states allow dental hygienists to practice in a variety of alternative settings, such as long-term care facilities, public health agencies, and schools with limited or no supervision.7

 

FIGURE 1. Dental hygienists are allowed direct access to patients in 37 states (noted in light purple). This means they may initiate patient treatment based on their own assessment and maintain a provider/patient relationship without the presence of a dentist.

Examples of dental hygienists with additional education practicing independently, providing safe, high-quality care, can be found in California, Colorado, Maine, and New Mexico. Dental hygienists in these states can own a business and practice unsupervised. Colorado has had dental hygienists practicing independently without incident for 25 years. There is wide variation on the scope of practice allowed, and most states require a written arrangement with a dentist.7

Allowing dental hygienists more latitude appears to be a growing trend. According to the ADHA, in the past year several states have passed legislation expanding the scope of practice for dental hygienists.8 In addition to such gains, new oral health workforce models are also being developed. The proposed models approximate midlevel practitioners found in the medical field, such as nurse practitioners and physician assistants.

NEW WORKFORCE MODELS

The advanced dental hygiene practitioner was introduced by the ADHA, a leader in the midlevel workforce movement. The organization defines its midlevel model as “a licensed dental hygienist who has graduated from an accredited dental hygiene program and who provides primary oral health care directly to patients to promote and restore oral health through assessment, diagnosis, treatment, evaluation, and referral services. The midlevel oral health practitioner has met the educational requirements to provide services within an expanded scope of care and practices under regulations set forth by the appropriate licensing agency.”9 Minnesota became the first state to develop a midlevel practitioner model. In 2009, legislation authorized the licensing of dental therapists (DT) and advanced dental therapists (ADT).

The ADA is working on the problem of accessibility with a different approach. Its community dental health coordinators (CDHCs) require only 1 year of coursework, either online or in person, which includes a brief internship. CDHCs operate in underserved communities, providing outreach, collecting information, working with community members, providing education on preventive oral health care, and assisting dentists in triage situations. They are trained to provide services including radiography, screenings, basic prophylaxis, fluoride treatments, application of sealants, and coronal polishing.10

Both models subscribe to the benefits of prevention, but while some in the dental community feel the ADA’s model doesn’t go far enough, for many dentists, the ADHA model raises red flags. The views on lack of supervision and broadened scope of practice widely vary.

There are various levels of supervision depending on state practice acts. Direct supervision in most states means a dentist must be present. General supervision typically means the dentist must authorize services but need not be present. Broadening the scope of practice and supervision tend to be the main barriers to expanded oral health care services. Quite simply, dentists can’t be everywhere at once. With a shortage of dentists in some areas, especially in rural locations, a requirement for direct or indirect supervision limits the ability of dental hygienists and advanced-practice dental hygienists to provide care in alternative settings, directly impacting access to care.

DEPTH OF TRAINING

States considering new workforce models are building rigorous educational requirements for midlevel practitioners into their legislative proposals. Many require a minimum of a baccalaureate degree, if not a master’s degree, in addition to a certain number of clinical hours to be earned after graduating. Two states already have midlevel oral health providers on the ground. Alaska’s dental health aide therapists are recruited from Native communities. They undergo 2 years of training but are not licensed and can only practice in Native communities.

As noted previously, Minnesota became the first state to authorize the licensing of DTs and certification of ADTs. The minimum education for DTs is a bachelor’s degree, and ADTs must earn a master’s degree. Under the midlevel practitioner law, DTs provide restorative and surgical procedures under the indirect supervision of a dentist. After completing 2,000 hours as a DT, application for the ADT certification is made to the Minnesota Board of Dentistry. If certified as an ADT, the scope of practice includes the addition of oral evaluations and assessments, treatment planning, nonsurgical extractions of class 3 or class 4 periodontally involved teeth, and the ability to provide, dispense, and administer certain medications under general supervision (without a dentist on-site). Both DTs and ADTs must have a collaborative management agreement with a dentist that is annually updated.

Metropolitan State University in St. Paul, Minnesota, in partnership with Normandale Community College in Bloomington, Minnesota, offer a master’s program that combines the DT and ADT scope of practice. Admission to the program requires an active dental hygiene license and a bachelor’s degree. Upon graduation, students are dual licensed as dental hygienists and dental therapists. Until 2014, the University of Minnesota School of Dentistry in Minneapolis offered bachelor’s and master’s level dental programs but did not include the ADT scope of practice. Today, the University of Minnesota offers only a master’s degree that combines DT and ADT scope of practice but does not require applicants to hold a dental hygiene license.

Maine recently passed legislation authorizing a midlevel practitioner. The education and training programs, however, still need to be developed. Fortunately, the Commission on Dental Accreditation (CODA) approved the accreditation process for dental therapy education programs this summer. This should expedite program development and implementation in Maine and throughout the country.

STATES WITH PENDING LEGISLATION

According to the ADHA, while 37 states allow dental hygienists to directly initiate patient care outside of the private dental practice, approximately 20 states are pursuing or exploring licensed midlevel practitioner legislation. Fourteen states have oral health workforce model legislation pending. Most are dental hygiene-based, which means they admit only dental hygienists into their programs. While there are variations aplenty, all stipulate both a preventive and restorative scope of practice.9 The following is the status of the states with pending legislation as of this writing.

Connecticut: Advanced Dental Hygiene Practitioner
This midlevel practitioner must be a dental hygienist who earns a master’s degree. Graduates will hold dual licensure. Connecticut’s House Bill 6275 concerning certification of advanced dental hygiene practitioners was introduced in January 2015 and remains under consideration.

Georgia: Dental Hygiene Therapist
This designation will require a Bachelor of Science in Dental Hygiene and completion of four semesters of a dental hygiene therapist program. The provider may be dual licensed. Direct supervision is a requirement for this model. The Senate Bill 248, which would legislate the dental hygiene therapist model, was introduced in March 2015.

Hawaii: Advanced Dental Therapist
This provider will require a master’s degree and may be dual licensed. Hawaii also has a resolution pending to direct the state auditor general to conduct an analysis of dental therapy in other states. These findings and resulting recommendations would be submitted to the legislature in 2016 should the resolution be adopted.

Kansas: Dental Practitioner
Dental hygienists who complete an 18-month dental practitioner education program and achieve licensure can practice as dental practitioners. Introduced in January 2015, Senate Bill 49 and House Bill 2079 authorize the licensing of registered dental practitioners, but they have been shelved for the time being, as they take a back seat to budget bills.

Massachusetts: Advanced Dental Hygiene Practitioner
Dental hygienists who complete a 12-month to 18-month registered dental practitioner education program and earn licensure will be eligible for this midlevel practitioner role. Senate Bill 998 and House Bill 274 to establish an advanced dental hygiene practitioner were introduced in January 2013.

New Hampshire
Workforce legislation Senate Bill 193 was replaced with a bill that established a commission to study how well the dental care delivery system is meeting the needs of underserved populations. The commission is due to report its findings in November 2015.

New Mexico: Dental Therapist
This midlevel practitioner will require a total of 3 years of a combined dental hygiene/dental therapy curriculum. A task force was established to develop workforce legislation by October 1, 2015.

North Dakota: Advanced Practice Dental Hygienist
Dental hygienists who complete an advanced practice dental hygiene education program can become advanced practice dental hygienists. The state is assessing the addition of midlevel practitioners after legislators concluded that not enough dentists are available to provide dental care. Senate Bill 2354, which would have allowed advanced practice dental hygienists to practice in North Dakota, failed earlier this year in the face of stiff opposition from the North Dakota Dental Association.

South Carolina: Dental Therapist
Dental hygienists who finish a post-baccalaureate dental hygiene therapist education program and earn dual licensure can become dental therapists. The legislation—Senate Bill 245 to authorize dental therapists to practice in South Carolina—is currently under review by the Committee on Medical Affairs.

Texas: Dental Hygiene Practitioner
Dental hygienists who complete a 2-year dental hygiene practitioner program and a bachelor of science degree will be eligible for this midlevel practitioner role. Licensure is required. Senate Bill 787 and House Bill 1940 would create a midlevel model that would provide dental care to underserved communities under the supervision of a dentist. The bills were introduced in Texas in February 2015 and appear to be in state legislative committees.

Vermont: Dental Practitioner
Dental hygienists who complete a CODA-approved dental therapist program will be able to provide care as dental practitioners. Graduates will hold dual licensure. The legislation, Senate Bill 20, to allow dental practitioners to practice in Vermont, passed the State Senate on June 5, 2015, and will head to the House when the 2016 legislative session opens in January 2016. Once passage is secured, candidates will be educated and trained at Vermont Technical College in Randolph Center.

Washington: Dental Hygiene Practitioner
Dental hygienists who earn a post-baccalaureate certificate and licensure will be able to become dental hygiene practitioners. Introduced in January 2015, House Bill 1421 and Senate Bill 5465, creating midlevel practitioners, have been reintroduced and retained in the third special session. These bills would allow midlevel practitioners, such as dental health aide therapists, to practice in the state’s tribal clinics.

SELF-REGULATION

There is broad-based support in many states for the creation of midlevel oral health positions. In other states, members of state dental boards and dental organizations are mobilizing active opposition. Those in the dental profession cite concerns about safety and quality of care. However, some concerns about midlevel scope of practice may be allayed by developments in self-regulation.

Self-regulation pertains to supervision of licensure and practice standards. Traditionally, dental boards, composed primarily of dentists, regulated the dental hygiene profession. Increasingly, due to the evolution of the dental hygiene profession, states are creating dental hygiene committees, which can address issues unique to dental hygienists. Many feel that such a move gives more credence to the issues surrounding the dental hygiene profession as a whole.

MIDLEVEL PRACTITIONER BENEFITS

The lessons learned in Alaska and Minnesota provide evidence that fears about the new provider role are unjustified. A legislative-mandated evaluation report by the Minnesota Department of Health and the Minnesota Board of Dentistry in 2014, found that dental therapists, practicing since 2011, were making a positive contribution by providing quality care. Another result was the reduced cost of care. The study found that care provided by a midlevel practitioner costs about half as much as a dentist. One clinic is reported to have calculated a $62,000 savings per midlevel worker, while others estimated the savings between $35,000 and $50,000 per midlevel practitioner.11

A study by the Pew Charitable Trust found yet another benefit of employing midlevel practitioners. Not only were more patients—including those covered by Medicaid or government subsidies—able to receive care, but dentists were able to focus on more complicated procedures, such as crowns, bridges, root canals, and surgical extractions. Combined, this translated into higher revenue and higher Medicaid reimbursements for practices.12

The US is at a crossroads between providing access to oral health care for all or maintaining the status quo in not meeting the needs of the nation’s most vulnerable populations. Though there is no shortage of conflicting viewpoints, all involved seem to agree that in order to ensure access to care for everyone we must bridge the gap. Moving forward with midlevel practitioner legislation is likely the most promising option.

REFERENCES

  1. United States Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. National and state-level projections of dentists and dental hygienists in the US, 2012-2025. Available at: bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/nationalstatelevelprojectionsdentists.pdf. Accessed September 21, 2015.
  2. Dunker A, Krofah E, Isasi F. The role of dental hygienists in providing access to oral care. Available at: nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf. Accessed September 21, 2015.
  3. Yarbrough C, Vujicic M, Nasseh K. Medicaid Market for Dental Care Poised for Major Growth in Many States. The health policy institute research brief. Available at: ada.org/%7E/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1214_3.ashx. Accessed September 21, 2015.
  4. US Department of Health and Human Services and Centers for Medicare & Medicaid Services. Annual EPSDT participation report, form CMS-416 (national) fiscal year: 2013. Available at: medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html. Accessed September 21, 2015.
  5. American Dental Hygienists’ Association. Medicaid Direct Reimbursement of Dental Hygienists. Available at: adha.org/reimbursement. Accessed September 21, 2015.
  6. American Dental Hygienists’ Association. How A Dental Hygienist May Achieve Direct Reimbursement. Available at: adha.org/resources…/7528_Reimbursement_At_A_Glance.pdf. Accessed September 21, 2015.
  7. American Dental Hygienists’ Association. Direct Access States. Available at: adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf. Accessed September 21, 2015.
  8. American Dental Hygienists’ Association. Bills Into Law 2015. Available at: pubs.royle.com/article/STATELINE/2225252/266791/article.html. Accessed September 21, 2015.
  9. American Dental Hygienists’ Association. The benefits of dental hygiene-based oral health provider models. Available at: ncsl.org/documents/summit/summit2013/online-resources/ADHA_handout.pdf. Accessed September 21, 2015.
  10. American Dental Association. Action for Dental Health: CDHC Education and Training. Available at: ada.org/en/public-programs/action-for-dental-health/community-dental-health-coordinators/cdhc-education-and-training. Accessed September 21, 2015.
  11. Minnesota Department of Health and Minnesota Board of Dentistry. Early Impact of Dental Therapists in Minnesota: Report to the Minnesota Legislature 2014. Available at: mn.gov/health-licensing-boards/images/2014DentalTherapistReport.pdf. Accessed September 21, 2015.
  12. The Pew Charitable Trusts. Expanding the Dental Team: Studies of Two Private Practices. Available at: pewtrusts.org/en/research-and-analysis/reports/2014/02/12/expanding-the-dental-team. Accessed September 21, 2015.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2015;12(10):14–16,18–20.

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