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Access to oral health care: Midwest states expand telemedicine, allow dental therapists among steps to open wider access to dental services

by Jon Davis ~ February 2019 ~ Stateline Midwest »
Often overlooked in the national debates and discussions about health insurance, dental care is having something of a moment in the Midwest as states embrace ways to expand oral health access.
The need is great, according to the Pew Charitable Trusts: More than 56.7 million people in the United States live in areas with shortages of dentists, and only about one-third of dentists accept public insurance, which limits access for the 72 million children and adults on Medicaid or the Children’s Health Insurance Program (CHIP).
The Midwest has 1,448, or one-quarter, of the nation’s 5,834 designated Health Professional Shortage Areas for dental care, according to the U.S. Health Resources & Services Administration. Which is why John Grant, project manager of Pew’s Dental Campaign, says the biggest problem “as far as the states go, especially in the Midwest, is expanding the dental workforce.”
“Basic dental care is out of reach for most Americans,” Grant says. “Unlike the flu, dental decay doesn’t get better with time; it gets worse. For a lot of people, there’s a quality-of-life issue; people miss work because of pain or can’t get a job because their teeth look bad.”
(Another benefit of improved oral health care access may be increased prevention of Alzheimer’s disease. New research suggests a possible link between the main bacterium in gum disease, Porphyromonas gingivalis, and Alzheimer’s; and gum disease is a known risk factor for the disease.)
Pew identifies trends that are likely to expand access to oral health care in 2019, many of which have already been adopted by Midwest states:
Medicaid expansion under the Affordable Care Act. States aren’t required to offer dental benefits to adults on Medicaid, but most of the 31 states that have adopted ACA expansion do. Nebraska voters approved Medicaid expansion 53.5 percent to 46.4 percent in the November 2018 general election; the state could include dental coverage in its expansion plan, which must be submitted to the federal government by April 1.
Integration of medical and dental care. Locating both services in one office or clinic can expand access to both kinds of service. The Advancing a Healthier Wisconsin Endowment is funding a three-year “Medical-Dental Integration” project that began in January to add dental hygienists to primary medical care teams serving pregnant women and children ages 5 and under. The program aims to place hygienists in 15 clinics statewide by the end of the $500,000 grant.
Authorization of dental therapists. This is a relatively new mid-level position that is roughly equivalent to a physician’s assistant; in 2009, Minnesota became the first U.S. state to authorize the position. In December, Michigan became the second Midwest state to do so when SB 541 became law.
Dental therapy?
Dental therapy bills were introduced, but failed to pass last year, in Kansas (SB 312 and HB 2139), Ohio (SB 98), North Dakota (HB 1256) and Wisconsin (SB 784).
Proponents in North Dakota introduced a similar bill, HB 1426, in January. Wisconsin Rep. Mary Felzkowski, who sponsored SB 784, says she introduced it late in last year’s session “to get the conversation started,” and will introduce a new version before the end of February.
Emily Mallory, president-elect of the North Dakota Dental Hygienists’ Association, says the new bill limits dental therapist practice settings to Federally Qualified Health Centers, not-for-profit or governmental dental practices, and clinics authorized by the federal Indian Health Services.
North Dakota’s HB 1426 also gives the state Board of Dental Examiners the authority to approve dental therapy programs (based on the American Dental Association’s Commission on Dental Accreditation). In comparison, HB 1256 would have cleared programs approved by other states that already authorize dental therapists.
The changes should address the concerns that helped defeat HB 1256, Mallory says. “I believe this supports the intent for which dental therapy was first introduced: to improve access to routine, quality dental care,” she adds.
The changes did not; HB 1426 was voted down, 62-31, in mid-February.
While dental therapy is a relatively new concept in the United States, the position originated in New Zealand during the early 1960s and has been in wide use across the globe.
Since 2009, Arizona, Maine, Vermont and, now, Michigan have followed Minnesota’s lead. Native American tribes in Alaska, Oregon and Washington have also hired or authorized dental therapists.
The general idea with dental therapy is that a trained therapist can concentrate on “lower level” work such as routine cleanings, which frees the dentist to concentrate on “higher level” work, says Dr. Karl Self, a dentist who is both an associate professor and director of the Dental Therapy Program in the University of Minnesota’s School of Dentistry.
That can make a big difference in small practices where a dentist might work on “everything from soup to nuts,” Self says.
In an example from northern Minnesota, he says that when a dental therapist joined a practice, the dentist then had time to study and become proficient in higher-level procedures, which meant people in that community no longer had to travel two and a half hours for specialty care.
“That increases access to care in a different way,” Self says.
Assessing the overall impact of dental therapists on access to care in Minnesota, even 10 years after the law took effect, is challenging because there are only 92 licensed dental therapists, which is less than one-half of 1 percent of all dental providers in the state, he says. That’s because state law restricts where they can practice and requires them to work under a dentist’s supervision, and many dentists are still reluctant to hire them, Self adds.
Yet, state-sponsored studies have shown evidence that when a dental therapist joins a practice, access to care improves because the number of patients on government-run insurance increases, he says.
But Dr. Jane Grover, director of the American Dental Association’s Council on Advocacy for Access and Prevention, says dental therapists are not a guarantee of increased access because “people still have to find their way to care.”
Other states, other steps
In Illinois, SB 2587 (signed into law in 2018) added dentists to the list of practitioners allowed to use telemedicine. Ohio did likewise in January when SB 259 was signed at the end of the Legislature’s lame-duck session.
“We know there are situations, especially in rural areas, where [people] don’t have access, where a dentist can [remotely] supervise a dental hygienist working in a nursing home or in a mental health facility,” says Illinois Sen. Dave Syverson, one of SB 2587’s sponsors and ranking member on the Senate’s Human Services and Public Health committees. “We added [dentists], knowing things are changing.”
Syverson says legislators are now negotiating “a complete rewrite” of Illinois’ telemedicine law to clarify and broadly codify who can use telemedicine and under what circumstances, to keep abreast and possibly ahead of the changing technology.
And while the state’s 2019 budget includes (for the first time) funding of dental prevention services for adult Medicaid recipients — and requires reimbursement rates to comply with a 2005 court decree from the case Memisovski v. Maram — Syverson says legislators will also look at adjusting the state’s Medicaid dental reimbursement rates in 2019.
“Even with some adjustment, the reimbursement rate will be so low that few general dentists will be willing to see [Medicaid] patients,” he warns. “But, having said that, we have dental schools that see patients, we have federal health centers that see patients, and you have a number of family practice dentists who will see patients pro bono.”
In 2015, Illinois passed HB 500, which allows registered dental hygienists to place sealants on children’s teeth in school-based programs without the prior examination of a dentist. The idea is to let sealant programs run more efficiently, saving the state money, and to get more children access to treatment in a shorter amount of time.
Indiana’s HB 1116, which took effect July 1, allows dental hygienists to perform oral care procedures, such as annual cleanings, if they have a collaborative agreement with a practicing dentist, says Rep. Dave Frizzell, its main sponsor.
The legislation came from a collaboration between dentists and hygienists after Frizzell told them to work together if they wanted anything to advance in the legislature — a model he says will also be used for future measures.
“If you want to move forward with this stuff, you have to come together,” Frizzell says. “We always want to come with best practices, and I’m sure we looked at other states, but the dentists and hygienists came up with most of it on their own.”
In Ohio, HB 675 (of 2018) would have allowed counties and municipalities to devote a portion of property tax revenue to establish “Hope for a Smile” programs that deliver basic dental services to school-age children and elderly residents via mobile clinics.
Ohio’s Dental Association also worked with legislators to double funding for the Ohio Dentist Loan Repayment Program, whose money comes from a surcharge on dental license renewal fees. HB 463 (of 2014) doubled the surcharge from $20 to $40. That fund, and the Ohio Dental Hygienist Loan Repayment Program, offer loan repayment assistance to new dentists and dental hygienists who commit to practice for a minimum of two years at an eligible site in a Dental Health Professional Shortage Area or Dental Health Resource Shortage Area, accept Medicaid, and see patients regardless of ability to pay.
Iowa’s Department of Public Health launched the I-Smile program in 2006, one year after a law was signed requiring regular access to oral health care for children ages 12 and younger. The program contracts with 23 public and private nonprofit organizations that serve as the state’s Title V (a federal block grant) maternal and child health program. State-licensed dental hygienists serve as local coordinators.
According to I-Smile’s report for 2017 (the most recent one available), 128,338 Medicaid-enrolled children received dental services from dentists that year, up 57,145 from 2005, the year before the program began.
Another 33,362 children received services from dental hygienists or nurses, up 25,499 from 2005, the report said.
Access via education
Expanding access to oral health care also requires more outreach and public education about what services and clinics are already available, Grover says.
For example, she adds, if you look at the number of existing Federally Qualified Health Centers (federally funded, community-based clinics providing primary and preventative services to patients regardless of ability to pay) and dental/hygienist school clinics offering services at minimal fees, there are already more access points than people realize.
States can also create better overall access to oral health care by ensuring that dentists or hygienists are included in community primary care and outreach teams and placed in federally qualified health centers, Grover says.
States that provide dental care for adults in their Medicaid programs should include dentists in advising or supervising dental care, and lower the hurdles for dentists to get accredited for participation in Medicaid, she adds.
“Operational efficiencies and those reforms are two ways states can enhance access to care,” Grover says. “Patients need to be connected to oral care. People need to understand the importance of oral health.
“You’re talking about value-based, outcome-based, quality care. Those outcomes are enhanced when you have quality oral health,” she says. “Oral health is integrative to overall health.”



Examples of recent state laws, proposals and programs in Midwest related to oral health care access

Illinois Gov. Bruce Rauner in August 2018 signed SB 2587, adding dentists to the list of practitioners eligible to use telemedicine. The state’s 2019 budget also includes, for the first time, dental benefits for adults on Medicaid; it also requires reimbursement rates for participating dentists to be at levels required by a 2005 court decree. A law from 2005 (HB 500 of that year’s session) allows dental hygienists to place sealants on children’s teeth in school-based programs without prior examination by a dentist.
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HB 1116, signed by Indiana Gov. Eric Holcomb in March 2018, allows dental hygienists to perform hygiene procedures such as annual cleanings without direct supervision if the hygienist has an agreement with a practicing dentist in the same or an adjacent county (that dentist must be available for emergency communication and consultation). The law took effect on July 1.
To meet the goal of a 2005 Iowa law requiring children 12 and younger to have regular access to oral health care, the Iowa Department of Public Health began the “I-Smile” dental home initiative in 2006. Coordinators in all 99 counties help families connect with dentists, promote oral health awareness, assess community needs and work to eliminate barriers to care. The program is now in elementary and middle schools, known as I-Smile @ School, and has a 10-county pilot project aimed at those age 60 and older, known as I-Smile Silver.
Kansas legislators in 2018 declined to advance either SB 312, or its companion bill, HB 2139, which would have allowed dental therapists (while SB 312 passed the Senate unanimously, it didn’t get a vote in the House).
Last year, with the signing of SB 541, Michigan became the second Midwestern state to allow dental therapists. HB 5173 also became law, exempting dental prosthetic devices such as crowns, dentures and bridges from the state’s 6 percent sales and use tax. HB 5241, which did not advance, would have added dental screenings to the health screenings required of children entering school for the first time.
Minnesota Gov. Mark Dayton signed HF 1712 in May 2017; the law allows dental hygienists to work in facilities such as nursing homes, group homes or Head Start programs without a dentist first seeing or diagnosing the patient, and without a dentist being present, if the hygienist has a collaborative agreement with a dentist and regularly completes a medical emergency course as part of his or her continuing education.
In March 2017, Gov. Pete Ricketts signed Nebraska’s LB 18, which created the positions of “licensed dental assistant,” “licensed expanded dental assistant” and “licensed expanded dental hygienist.” It also specified the educational requirements for each position and the functions each position is allowed to perform. The law further expanded the permitted duties for dental assistants and for public health dental hygienists.
In February 2017, North Dakota legislators voted down HB 1256, which would have authorized dental therapists. The subject has been revived with modified language for the current session; HB 1426 was introduced in January.
Ohio’s SB 98 (of 2017), which would have authorized dental therapists, died in committee. HB 184 (also of 2017) expands the procedures a dental hygienist can perform without a supervising dentist’s presence, and authorizes teledentistry. It was approved by the House and then folded into SB 259, which was passed during the Legislature’s lame duck session and signed into law by Gov. John Kasich. It takes effect on March 20. HB 675 (of 2018) would have allowed local governments to set up “Hope for a Smile” children’s oral health programs with local property taxes. It died in the House.
South Dakota Gov. Dennis Daugaard signed HB 1205 into law in March 2018; it requires health insurance plans issued after Jan. 1, 2019, to cover anesthesia and hospital or ambulatory surgery center costs for dental care for children under 5 years of age as well as people whom a licensed physician has determined to be severely disabled, to be developmentally disabled, or to have a medical condition that “places the person at serious medical risk.”
Wisconsin legislators in 2018 did not pass SB 784 or its companion bill, AB 945, which would have authorized dental therapists. But a 2017 bill, AB 146, did become law; it allows dental hygienists to practice without a dentist’s direct supervision in specific settings, including prisons, nursing homes or community-based residential facilities; nonprofit home health care or dental care programs; adult family homes or day care centers; charitable institutions open to the public; and hospitals or nonprofit dental programs serving indigent, economically disadvantaged or migrant worker populations.



New federal law will support local oral health initiatives

Beyond the Affordable Care Act, federal legislation in recent years regarding oral health care has focused on improving access to care rather than expanding insurance coverage.
Late last year, the Action for Dental Health Act of 2018 (H.R. 2422) was signed into law. It will allow more groups and organizations to qualify for federal grants to develop programs and expand access to oral health education and care in states and tribal areas. The new law also reauthorizes those grant programs through federal fiscal year 2022 and provides $13.9 million a year through 2023.
Grantees are expected to include dentistry and hygiene programs working in rural and under-served locales, organizations helping to increase oral health literacy and disease prevention in low-income and minority communities, and mobile/portable dental projects to deliver care to patients in settings such as nursing homes and schools.
As of late January, legislation introduced in the new congressional session included:
S.22, which would create a new dental benefit for seniors under Medicare (Part B) by repealing the Social Security Act’s statutory exclusion on Medicare coverage of dental care and dentures;
H.R. 576, which would expand Medicare coverage beyond dental services to include eyeglasses and hearing aids; and
S.192, which would extend mandatory funding for the federal Community Health Care program, which works in under-served communities and includes oral health care; and for the National Health Service Corps, which provides scholarships for medical students, including those in dental school.


ACA, CHIP, Medicaid, EPSDT? What federal law requires for children's access to oral health

Federal law is specific about dental services for children — they are required both under states’ Medicaid programs and the Children’s Health Insurance Program (CHIP).
The Affordable Care Act deems dental coverage an essential health benefit for children age 18 and younger, meaning insurance policies must cover it, but not an essential benefit for adults.
Stand-alone dental insurance plans are not eligible for ACA subsidies, however. Nor can people purchase such a plan from the federal or most states’ ACA exchanges on its own without first having, or buying, full health care coverage. Colorado, Connecticut, Maryland and Vermont are currently the only exceptions to that restriction on stand-alone dental plans.
Required Medicaid services for individuals under the age of 21 are collectively known as the “Early and Periodic Screening, Diagnostic and Treatment” (EPSDT) benefit. According to the U.S. Centers for Medicare & Medicaid Services, that means “at a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services.”
Under federal rules, all “medically necessary” services must be covered. States, however, determine medical necessity. But if a condition requiring treatment is discovered during a Medicaid-covered screening, the state must provide the necessary services to treat that condition, whether services are included in a state’s Medicaid plan or not.
States are also required to develop dental periodicity schedules — lists of which procedures should be done at specific ages — in consultation with recognized dental organizations involved in child health. According to the American Academy of Pediatric Dentistry, all Midwestern states, save Ohio, use its dental periodicity schedule.
Under CHIP, states can cover children either via Medicaid or other programs apart from Medicaid. CHIP coverage via Medicaid follows those rules; non-Medicaid programs must include services “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.”
States with non-Medicaid CHIP programs have two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements, or a “benchmark” dental benefit package that must be substantially equal to the most popular federal employee dental plan for dependents; the most popular plan selected for dependents in the state’s employee dental plan; or dental coverage offered through the most popular commercial insurer in the state.
States must also post a listing of all participating Medicaid and CHIP dental providers and benefit packages at the website InsureKidsNow.gov.