Dental therapists could dramatically improve access to care via school-based programs run by federally qualified health centers (FQHC), according to a new report by the Pew Center on the States, "Expanding the Dental Safety Net: A First Look at How Dental Therapists Can Help."
The researchers estimate that using dental therapists and allied providers in school programs could make dental care available to 6.7 million additional Medicaid-eligible children at significantly reduced costs.
The theoretical analysis, conducted by researchers at the University of Connecticut, used data from 19 FQHCs and 53 delivery sites in 12 states. Specific cost reduction and utilization-rate increases were based on data from Connecticut and Wisconsin FQHCs due to the size and quality of their available data, the study authors noted.
The goal was to evaluate how dental therapists (DTs) could be deployed in FQHCs -- which receive subsidies to serve Medicaid patients -- to improve the availability of care and save taxpayers money at existing "fixed-site" clinics and mobile school-based programs.
"Even using narrow assumptions, which is what economists do, this is more good news," Shelly Gehshan, director of Pew Children's Dental Campaign, told DrBicuspid.com. "We have to stretch public dollars to see more people, and this study shows it's likely that dental therapists will allow us to serve more people economically."
Raising utilization rates
The findings for fixed-site settings showed that adding DTs could yield modest cost savings -- between 3% and 6% -- and increase the capacity of FQHCs to serve approximately 112,000 (6%) more children.
— Shelly Gehshan, Pew Children's
Dental Campaign
Most notably, the study found greater potential gains by deploying DTs in FQHC-operated school-based programs. The analysis suggests this significant increase in access could be realized for a cost of approximately $1.8 billion -- just one half of 1% of combined state and federal 2009 Medicaid spending.
Given current estimates of dental care utilization, this increase would be sufficient to raise Medicaid-enrolled children's utilization rate by nearly 20%, bringing it in line with that of privately ensured children, the report noted.
As of 2010, FQHC dental clinics provided care for more than 3.7 million patients nationwide. Children accounted for about half of all patients, and public insurance sources of Medicaid and State Children's Health Insurance Program (SCHIP) were the major payment sources, constituting 71% of revenues.
Using DTs rather than dentists to provide most restorative services offered through school-based programs could save nearly $94 million in program costs, the study found. This expansion could be realized at relatively little cost to taxpayers -- about $1.8 billion, nationally -- equivalent to 0.5% of total state and federal 2009 Medicaid spending.
The average FQHC could employ a DT at an annual cost that is $10,500 lower than the expense of paying a dentist, according to the study. The savings were derived exclusively from the difference in wages between dentists and DTs.
The researchers' model only factored in the value of DTs doing fillings and simple extractions because they can provide these services at a lower cost than higher-paid dentists. However, these two procedures account for just 17% of all the dental services children received in the FQHCs studied.
By contrast, the study authors noted that all the procedures -- including diagnostic and preventive -- that DTs could potentially perform would amount to roughly 92% of dental services that children in FQHCs require and about 86% of the revenue generated by the services provided to them.
Meeting a growing demand
Although some DT licensure proposals require four years of training, as in the Minnesota model, the researchers determined that the value of training alternative providers for four years would decrease savings at FQHCs and offer no advantage over two-year DTs unless they have additional skills.
When accounting for training, employment costs, and the annual value of services provided, these practitioners paid for themselves in an average of three and a half years, according to an analysis of Canadian DTs by Carlos Quiñonez, who did the study "The Political Economy of Dentistry in Canada" for his doctoral thesis in dentistry at the University of Toronto in 2009. Similarly, studies in the U.K. found that DTs can provide more than a third of the procedures performed by dentists (British Dental Journal, April, 14, 2001, Vol. 190:7, pp. 353-356).
DTs currently practice in Alaska and Minnesota. Connecticut and Oregon are planning pilot projects, while Kansas, Maine, New Hampshire, and Washington are considering legislation to allow such providers. FQHC school-based, mobile, and other offsite programs already exist in several states, including Connecticut and New Hampshire, but most states do not have them.
Healthcare reform will provide millions of more children with public dental coverage by 2014, and many of them will seek care from safety-net providers such as FQHCs, the Pew study authors noted.
"While more research is needed, these findings suggest that dental therapists -- and possibly other allied providers -- can help FQHCs improve the availability of care for underserved children across the country," they concluded. "The potential to serve millions more children at a comparatively low cost presents a critical opportunity for states to address their access problems, while preparing for the increasing demand for dental care that is anticipated from the Affordable Care Act."
