Dispelling myths about barriers to care and Ga. House Bill 684

The Georgia Legislature recently considered a bill (HB 684) that would have purportedly allowed greater access to dental care for Georgians in safety-net settings by allowing dental hygienists to perform cleanings without requiring that a dentist be present or an exam be given.

Initially, the Georgia Dental Association (GDA) opposed the bill. Subsequently, the association worked on amendments with the sponsor. After numerous negotiations, the GDA agreed to accept the amendments, and the bill passed out of the House Health and Human Services Committee.

Frank Capaldo, executive director, Georgia Dental Association. Image courtesy of the GDA.

Why did the GDA, after making suggestions for numerous amendments, change its position of support on the bill when it reached the Rules Committee? Simple -- at the end of the day, our member dentists could not compromise their first order of ethical care: to do no harm -- as would inevitably result from patients believing that a cleaning was the same as an exam.

Yes, the passage of the bill would have financially benefited many dental practices, which could have deployed unsupervised hygienists to provide cleanings to Medicaid patients. Instead, to their selfless credit, dentists chose the safety of the most vulnerable citizens of Georgia over themselves.

Why should the poor and underserved and medically compromised citizens of Georgia receive a lesser standard of care? The answer is obvious. They should not receive a lesser standard of care, and that is why the GDA reasserted its collective conscience and changed its position.

Further, the GDA humbly thanks the super majority of legislators who also understood that a reduced standard of care would not be in the best interests of their constituents. They realized that such a compromise cut to the very sinew of a dentist's belief in patient safety and whole-body health, first and foremost. While the GDA regrets that this decision unsettled the leadership in other advocacy groups, as my grandfather always said, it is never too late to do the right thing.

The bill was initially promoted as a "safety-net setting" bill that would provide greater access to dental care. This was a flawed premise from the bill's inception, for two reasons:

• One, "access" is not the issue. Rather, the issue is "barriers" as a recent study by the Georgia Health Policy Center at Georgia State University clearly sets forth ("A Study of Georgia's Dental Workforce 2012").
• Two, the bill contained a provision that went well beyond safety-net settings by reducing the level of supervised care in the private practice office of a dentist. This second point is never mentioned by the proponents, because casting the bill as a safety-net solution has more emotional appeal.

Facts

Is a cleaning equal to an exam?

Well-intentioned proponents of the bill stated numerous times that a "cleaning is better than nothing." This is a medically unsound premise. Such a statement misinforms the public's perception of good oral health, because the bill failed to address treating dental pain, infection, or cavities as only a dentist may diagnose and treat these conditions.

Proper equipment in safety-net settings

Although the bill was amended to require suction equipment for cleanings in nursing homes -- a critical safety issue for patients who cannot swallow -- there is no corresponding requirement for nursing homes to provide the equipment. In fact, in testimony by the representative of a nursing homes association, he stated the nursing homes could not afford the equipment! So who will? The dental hygienist?

Public health clinics are underutilized

The same study cited above from the Georgia Health Policy Center also found that 43% of public health clinics reported that they have excess capacity, because patients failed to show up for treatment. The data were supported by the testimony given in committee by Kara Moore, DDS, a GDA member dentist who partners with a federally qualified health center located in a rural area of the state. She estimated that, despite offering free dental services in her community and accepting Medicaid patients, roughly 75% of her patients do not show up for their appointments, and most have infection and decay that must be treated by a dentist before a cleaning can be considered. Dr. Moore's testimony is at 1:59 of the February 9 Georgia House of Representatives committee meeting video.

Known barriers were not addressed

The bill provided no solutions to "barriers" such as, language barriers, cost, fear, time off from work, or securing parental permission in school settings that keep Georgians from accessing proper oral healthcare.

Offices are nearby

Residents in the 16 counties without a dentist are within a 30-minute drive to the closest dentist in a neighboring county, according to the Georgia Health Policy Center report.

The proponents of the bill continually attempted to compare the practices in public health settings to safety-net settings. The bill as written compared with public health protocols is light years apart. Like 45 other states, Georgia allows licensed dental hygienists to perform certain duties in specific settings without a dentist physically present. However, the protocols in place provide the highest quality care for the patient. In the correctional system, a dentist must examine the patient before a cleaning can take place. The patient-protective protocols submitted by the Gwinnett/Rockdale/Newton Public Health Clinic state that a dentist must be onsite for the cleaning if the patient has specific health conditions (such as diabetes, heart issues, tuberculosis, prolonged bleeding, HIV infection, and others), and a patient with signs of oral health disease, such as cavities, must be referred to a dentist.

Moreover, under current rules promulgated by the Department of Community Health, Georgia's nursing homes must include a physician, dentist, and nurse as members of the professional staff. Our senior population has high incidences of diabetes and heart conditions, and, as noted above, these patients require medical considerations and safeguards before a cleaning.

One of the most important amendments the GDA proposed would have required that the dentist conduct an initial examination of the patient before authorizing the hygienist to perform the unsupervised cleaning. Our members felt that this was a reasonable requirement that would balance our concerns for patient safety while still adhering to the intent of the bill. This amendment was expressly rejected by the bill's proponents.

Sustainable solutions

The GDA's Action for Dental Health Plan is a comprehensive multiyear plan, and the GDA is establishing public-private partnerships to advance real solutions. The association is also forming emergency room diversion partnerships among local dentists, hospitals, and community leaders to reduce healthcare costs and improve patient care by treating dental disease in the dental practice instead of the emergency room.

There are other real solutions, such as bringing more dentists to rural communities via the Rural Student Loan Forgiveness Program funded by the Legislature. Funding for that program, which was a GDA legislative goal for 2015, did not initially appear in the proposed budget this year, and the GDA fought hard to have it placed back into the budget. One of association's 2017 legislative initiatives will be a tax credit for rural dentists.

Moreover, GDA dentists are offering to fund a program that will help pay a portion of the salary for a dentist to fill the state's vacant dental public health director position to prioritize improving oral health and education. In addition, the GDA is working on a partnership with the Dental College of Georgia at Augusta University and the Georgia Department of Public Health to provide a volunteer network of adjunct dentists to oversee dental student internships in public health settings, thereby providing free dental resources to the state.

The Georgia Dental Association is self-funding a donated dental services social work coordinator to match at-risk patients with dentists who are volunteering their services to help those in need. More than 150 dentists are already on board to volunteer their services.

Other efforts to remove barriers to care include working with state officials to enhance the existing Medicaid program to include preventive and restorative dental treatments for adults; supporting legislation that will establish a single dental administrator for dental Medicaid; supporting the presence of a dentist in school-based clinics; establishing partnerships with dental clinics that serve children and adults in need; developing and implementing an oral health caregiver education program in nursing homes; and promoting oral health education and several other long-term initiatives.

Every member of the dental team has a valuable role to play in maintaining and restoring Georgians' oral health. It is a relationship that is both symbiotic and interdependent. Therefore, it is imperative that all of us work in concert to maximize the patient's investment of time and resources in the dental visit and deliver the care they need.

The Georgia Dental Association encourages the Georgia Dental Hygienists' Association, the Georgia Council on Aging, and other stakeholders to join us in the above efforts via meetings between the 2016 and 2017 legislative session to formulate and advance real sustainable solutions to address barriers to oral healthcare in our state.

Frank Capaldo is the executive director of the Georgia Dental Association.

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