Kansas coalition believes mid-level therapists can alleviate dental work force shortage

Anna Lambertson hears about the ill effects of the state’s dental work force shortage time and again.

The rural western Kansans who have to drive a couple of hours to see a dentist, taking time off work and taking their children out of school.

The 5-year-old boy who has holes in his teeth because his mother is unable to find a nearby dentist who accepts Medicaid. She can’t afford to drive far.

“Not having enough dental care is affecting the daily lives of Kansans,” said Lambertson, executive director of the Kansas Health Consumer Coalition. “If you have a need that worsens while you are waiting to see a dentist, or you have to drive two or three hours to see a dentist — the gas, time you are taking off of work — all of that plays into how expensive it might be for a family. In this economy, every penny counts.”

The Kansas Health Consumer Coalition and Kansas Association for the Medically Underserved have partnered with Kansas Action for Children to seek solutions to the dental shortage.

The problems

Fourteen counties do not have a dentist, including Wabaunsee, Chase and Elk. And, another 14 of the state’s 105 counties do not have enough dentists to serve their county populations.

A typical dental practice with one dentist can handle about 2,100 patients per year, according to KAC. Here’s the ratio of people per one dentist in some of the 28 counties:

Jefferson — 6,069.

Osage — 5,368.

Doniphan — 7,624.

Pottawatomie — 4,999.

In Douglas County, there are 1,847 people per dentist. But, the county is among 63 that don’t have enough dentists who accept Medicaid or help the uninsured. There are 63 licensed dentists in the county and, of those, 22 are registered to accept the 9,094 Douglas County residents on Medicaid. But few of these dentists do.

The Douglas County Dental Clinic, 316 Maine, has taken care of 1,377 Medicaid patients since Jan. 1. These are mostly children because dental services are included as part of their Medicaid benefits package. For adults, it only pays for pulling teeth.

Julie Branstrom, executive director of the clinic, said the practice accepts Medicaid patients from other counties, including Jefferson, Franklin and Shawnee.

“We know that a shortage exists because we have people that are willing to drive 45 minutes to come to Lawrence to get their kids care,” she said.

According to KAC, only 25 percent of Kansas dentists accept Medicaid, compared with 95 percent of medical providers. The Medicaid reimbursement rate is debated among dental providers, clinics and agencies. Some private practice offices and for-profit clinics that accept Medicaid patients are profitable. While others argue that they lose money.

Dr. Jim Otten, of Lawrence, accepted Medicaid patients for a few years when he first started practicing 25 years ago, but quit because of all the governmental red tape and low reimbursement rate.

Instead, he donates about 5 percent of his total care to the uninsured for free.

“We are eliminating all of the bureaucratic nonsense and really getting down to just what’s best for the patient,” he said.

Calls to the offices of Wilkerson, Saunders & Anderson and Legends Drive Dental Center were not returned.

Dr. Cheryl Biesterfeld, left, and dental assistant Kristin Parrish work on 11-year-old Ethan Bryan, Lawrence, at the Douglas County Dental Clinic on Thursday, Dec. 12, 2010. The clinic helps fill a need in the region by accepting Medicaid patients because so few dentists do.

Dr. Cheryl Biesterfeld, left, and dental assistant Kristin Parrish work on 11-year-old Ethan Bryan, Lawrence, at the Douglas County Dental Clinic on Thursday, Dec. 12, 2010. The clinic helps fill a need in the region by accepting Medicaid patients because so few dentists do. by Kevin Anderson

Possible solution

The three state agencies — KAC, KAMU and KHCC — have formed the Kansas Dental Project, a coalition that will pursue legislation in January to permit midlevel dental providers to practice in Kansas.

These would be licensed dental therapists, similar to a medical nurse practitioner, who can do more work than a hygienist, but not as much as a dentist. They would be able to fill cavities and do simple extractions, among other things.

The coalition is determining what kind of training this individual would need and is looking at other states and countries who use dental therapists.

“They really help provide much-needed dental care to individuals who live in rural parts of the state and maybe can’t access a dentist because the dentist is too far away,” Lambertson said. “There’s a lot of research that has proven that the care that the dental therapist provides is safe, appropriate and competent. We’ve yet to see a study that shows the contrary.”

Lambertson said dental therapists also are cost-effective because dental practices and clinics can see more patients, and dentists would be able to concentrate on the more complex cases.

“It could potentially create jobs, so I think there are a lot of benefits to this model from the financial prospective,” she said.

The initiative already is creating a buzz in the dental industry. Many dentists, like Otten, are skeptical about the training and expertise of a dental therapist. Others are taking a wait-and-see approach to the legislation that is introduced.

But nobody will deny that there is a dental work force shortage that is only going to get worse as dentists retire and there are fewer graduates to replace them.

“Right now, we are seeing a situation where low-income and rural citizens can’t get access to a dentist, but I think as that shortage grows everyday people — even those with dental insurance — are going to have trouble finding a dentist, and that’s what we want to solve before that happens,” said Stephanie Mullholland, communications director for KAC.


COUNTY COMPARISON

There’s a shortage of dentists in Kansas. In 28 counties, there are not enough to care for the population, and in 63 others there’s not enough who accept Medicaid or help the uninsured.

Here’s how Douglas County and its surrounding neighbors are faring:

Douglas County — 63 dentists, 1,847 people per one dentist, 22 dentists accept Medicaid, and 9,094 Medicaid patients.

Jefferson — 3 dentists, 6,069 people per one dentist, 2 dentists accept Medicaid, and 1,668 on Medicaid.

Leavenworth — 24 dentists, 3,134 people per one dentist, 7 dentists accept Medicaid, and 6,388 on Medicaid.

Johnson — 425 dentists, 1,277 people per one dentist, 75 dentists accept Medicaid, and 32,819 on Medicaid.

Franklin — 7 dentists, 3,777 people per one dentist, 8 dentists accept Medicaid, and 3,994 on Medicaid.

Osage — 3 dentists, 5,368 people per one dentist, 0 dentists accept Medicaid, and 2,212 on Medicaid.

Shawnee — 94 dentists, 1,875 people per one dentist, 41 dentists accept Medicaid, and 28,714 on Medicaid.

Tagged: Kansas Health Consumer Coalition, dental shortage, Kansas Association for the Medically Underserved, Kansas Action for Children

Comments

gccs14r 4 years ago

There is a fix for this. Train new dentists for free in exchange for providing Medicare/Medicaid service (plus whatever regular business they can drum up) in an under-served area (chosen by Medicare based on need) for ten years. That could be done with general practicioner MDs, too.

phogdowg 4 years ago

I am wondering where they are getting this 2100 patients per average dentist. My father in law is a dentist in Topeka and I know for a fact he see's over 4100 patients per year on a low end. He has a 4 person office, himself and 3 dental assistants.

mikeyboy 4 years ago

My guess is that your father-in-law's office accomodates 4100 patient visits, but does not have anywhere near 4100 individual patients. An office of that size would likely require 2--3 dentists to keep up with the workflow.

There is not a shortage of dentists in Kansas as a whole, but the distribution of providers is heavily skewed toward metro areas. I'm skeptical of this plan, but will wait to see the specifics.

mikeyboy 4 years ago

My guess is that your father-in-law's office accomodates 4100 patient visits, but does not have anywhere near 4100 individual patients. An office of that size would likely require 2--3 dentists to keep up with the workflow.

There is not a shortage of dentists in Kansas as a whole, but the distribution of providers is heavily skewed toward metro areas. I'm skeptical of this plan, but will wait to see the specifics.

jilly 4 years ago

I wonder how many patients a dentist actually see when they state that they take Medicaid paying patients. My gut tells me probably a limited number. I believe creating a new dental provider could only benefit the people of Kansas. Its easy to say train new dentists, but seems the dental industry is more interested in restricting that number to tip in favor of creating a monopoly for the dentists.

mikeyboy 4 years ago

Dentists that I know who take Medicaid fall into two camps; Those who see about 50-60 patients per day, and those who heavily restrict Medicaid appointments to protect the business cashflow. The reimbursement rates for private practitioners are pretty pathetic, sometimes not even covering overhead. Many dentists have opted to do as Dr. Otten has done, seeing patients who are in need pro bono.

I have experience in the public health sector, where Medicaid was revered as a Golden Goose of sorts. Of course the reimbursement rate for a FQHC at that time was several times that which a doctor in the private sector would be compensated. I am not sure if this is still the case.

My question concerning the proposed "midlevel" provider is for the general health of the patient. Will the midlevel be diagnosing the patient? Maybe the more important question is SHOULD the midlevel have diagnostic ability? What happens if a complication occurs during extraction? Should a provider not trained to the level of a dentist be allowed to make an incision and remove bone around a tooth to remove it? Yikes.

The regional dental schools have already increased class sizes within the last ten years. The hope was that these dentists would fill a need in underserved areas. The reality is that the metro areas of Kansas City, Wichita, Topeka, and Lawrence have an abundance of providers, with little difference having been made in the rural communities. I'm not exactly sure what kind of a "monopoly" the dental industry would be creating by restricting number of dentists. Jilly, can you explain that further?

Now, if the new midlevel provider was restricted to seeing Medicaid patients ONLY, for minor procedures, that might be a good start. Perhaps more dentists would then be willing to participate in the care of more difficult treatment and diagnosis of pathology. That might make a dent in the underserved population.

I am open to ideas, but still skeptical of a plan to flood the market with providers that are "not quite dentists", but could practice independently as if they were.

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