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Serious questions raised over whether midlevel providers can sustain themselves economically

Several alternative dental workforce models have been proposed as a way to extend care to underserved patients, but a series of reports issued by the ADA July 25 question whether these models can sustain themselves economically.

The reports detail economic modeling of the Dental Health Aide Therapists who provide care in Alaska Native territories; dental therapists currently working in Minnesota; and the proposed but as yet unrealized Advanced Dental Hygiene Practitioner. The studies examine practice parameters in five states where adopting one or more of these models has been under discussion in the legislature or the public health community—Connecticut, Kansas, Maine, New Hampshire and Washington. In addition to the individual state reports, the Association released a summary report covering all five states. (Note: The reports have been updated as of Sept. 18, 2012.)

Performed by ECG Management Consultants, an agency with extensive experience in research and policy issues, the studies modeled 45 different scenarios based on a comparison between estimated revenues and estimated expenses for each of the three providers under three payer mixes. ECG produced separate reports for the five states and a five-state summary report. 

"These studies represent a new way of examining whether alternative workforce models are an economically viable way to improve access to dental care for underserved populations," said ADA President William R. Calnon.

"The studies are a first step, and not the last word.  But certainly, lawmakers and public health authorities should consider the factors examined in the studies carefully before rushing to create dental providers that may be unable to fulfill their intended purpose of reducing oral health disparities," he said.

ECG based its modeling on the length and cost of training of each midlevel position, operating costs, likely salaries, academic debt and projected revenues. Researchers considered each model in the context of various combinations of public, sliding scale and private fee schedules (fee schedules varied by state).

Of the 45 scenarios modeled (three payer mixes for each of three practice models in five states), only five indicated positive net revenues, ranging from $8,000 in Kansas to $38,000 in Connecticut, assuming a 50/50 mix of public and private fees. Four positive net revenue scenarios involved the Dental Health Aide Therapist model; one involved the dental therapist model. The other 40 scenarios showed net losses ranging from $1,000 for a DHAT operating on a 50 public/50 private mix in Washington to $176,000 for an ADHP practicing in the same state, assuming a 75/25 public/sliding revenue mix.

"Certainly, this research is not all-encompassing. But to our knowledge, no one has considered the question this comprehensively," said Dr. Calnon. "The ADA encourages all stakeholders to study these models comprehensively, to avoid wasting constrained resources on programs that ultimately are not sustainable. We welcome others who are interested in breaking down barriers to oral health to join us in delving further into how best to maximize limited available resources-and advocating for increased resources-to improve the oral health of the tens of millions of Americans-including as many as one-quarter of the nation's children-who live without adequate access to regular dental care."

In a July 24 conference call with constituent society leaders, Dr. Calnon called the studies "a starting point for more research and more discussion."

"It is critical to understand that oral health disparities are a complex set of problems requiring an integrated set of solutions," he said. "Medicaid reforms, community water fluoridation, oral health education and helping people overcome cultural, geographic and language barriers are critical components of this. The ADA believes that allowing nondentists to perform irreversible surgical procedures is the wrong way to go. And based on these studies, midlevel dental providers would in most settings be unable to generate sufficient revenue to sustain themselves absent a continual source of financial underwriting. Given the current budget constraints at every level of government, and the already insufficient financing for dental care in most states, these three workforce models do not appear to be viable."

The ADA study results are a departure from the 2010 Pew Center on the States economic analysis of midlevel providers that found they could dramatically increase revenues of dental practices in which they work and the number of Medicaid patients receiving treatment in those practices. The ADA's study did not model private practice settings, because in most cases midlevel providers are being proposed to provide care to indigent or low-income patients, many of whom are not eligible for Medicaid, in public health settings. The ADA also performed a detailed analysis of Pew's report and found it to be based on unrealistic assumptions, which led to erroneous conclusions.

Read the Summary Report online at ADA.org.