An intensely lobbied bill that proposes a new class of dental provider is back this winter and is headed to the full Maine Legislature. The legislation would allow Maine to license dental hygiene therapists, a mid-level dental provider that hasn’t proliferated in the U.S. — dental therapists are allowed so far in only Alaska and Minnesota — but has become part of the dental team in more than 50 countries.
The proposal headed to lawmakers has evolved to include important provisions that would contain the costs of dental care and designate the dental therapist as a provider whose charge is to serve patients who have traditionally had limited access to dental care. The Legislature should pass it.
It’s not hard to make the case that Maine is in need of some policy solution to make dental care more widely available to low-income individuals — many covered by Medicaid — who have never had the means to seek regular dental care and develop effective oral hygiene.
Look no farther than Maine’s emergency rooms, where “dental disease” is the most common diagnosis for teens and adults who are covered by Medicaid or have no insurance.
The dental care options for someone with a low income are relatively limited, leaving many to seek emergency room care once the problem worsens. Maine is below the national average for the number of dentists for every 10,000 people, and Maine ranks second for the percentage of its dentists nearing retirement age — 48.4 percent who are older than 55.
While 90 percent of Maine’s general dentists in 2010 were accepting new patients, just 23.9 percent were accepting new Medicaid-covered patients, according to a 2012 report on Maine’s oral health commissioned by the Legislature. Fewer than half of Maine general dentists, 45.2 percent, treated Medicaid-covered patients in 2010 — though this is among the highest percentages nationwide. Nearly all of those dentists treated Medicaid-covered children while fewer than two-thirds treated adults with Medicaid.
Maine’s Medicaid program currently covers comprehensive dental care just for children; for adults, the program only covers extractions and operations necessary to relieve severe pain rather than the care needed to prevent it. One obvious solution — but likely one that would be deemed cost-prohibitive — is to change that.
Higher Medicaid reimbursement rates for dentists would also help. According to the Pew Research Center, Medicaid in Maine covered 46.5 percent of a dentist’s median retail costs compared with 60.5 percent nationwide.
A new dental school at the University of New England — Maine’s first — that opened its doors to an inaugural, 64-member class in the fall is certainly part of the solution to address the state’s provider shortage. So are 35 safety-net dental clinics located across the state, and especially in some areas with limited dental care access. A number of dentists also provide care for free to patients who can’t afford it.
Dental therapists can be another part of the solution. Therapists have more training — under the Maine bill, 1,000 hours of dentist-supervised clinical practice — than dental hygienists. They can perform fillings and minor surgeries and extract teeth. Their more important role, however, would be in reaching out to underserved patients, especially children, treating them and helping them develop good oral hygiene.
As the Maine bill is structured, introducing dental therapists wouldn’t increase the cost of care, since they wouldn’t be able to open their own practices and generate new overhead expenses. Instead, they would practice under the supervision of a dentist — so dentists could decide whether they want a therapist on staff — and half of their patients would have to be underserved.
As part of a dentist’s team, the lower-paid therapist could perform the procedures a dentist might prefer not to perform because of low reimbursement. That frees up the dentist to perform higher-margin procedures while making it more viable for the practice to open its doors to patients with lower-paying Medicaid. In fact, research published last year shows dental therapists contribute to dental practices’ bottom lines. Research also shows dental therapists, by and large, are effective and safe providers of care.
Further, Maine’s legislation would allow dental therapists to practice at nursing homes, assisted living centers and schools — where many children already receive dental sealants and where a therapist could also treat tooth decay and educate children on the importance of dental hygiene.
Maine can’t achieve its goals of improved oral health, especially among its lowest-income residents, with the care and payment structures in place right now. Dental therapists who become providers committed to expanding dental care’s reach can be part of the fix.