In 2012, nearly 68,000 adults went without dental care because they could not afford it, according to the advocacy group Vermont Oral Health Care for All.
That group is behind a push to create a state license for a mid-level dental practitioner position that would be a step above a dental hygienist and a step below an actual dentist.
Such positions exist in Minnesota and Alaska, and there are bills to license so-called dental therapists or dental practitioners in several other states. Legislation to license dental practitioners in Vermont stalled in the House last biennium, but was reintroduced this year in the Senate.
Advocates say that the state’s access problem stems from a shortage of dentists, especially in rural areas.
The bill would require dental practitioners to be employed by a dentist; that would allow a practice to serve more patients.
The dental practitioner’s scope of care would be limited by a contract with the supervising dentist.
The Vermont Dental Society opposes the bill. Vaughn Collins, the organization’s director, said Vermont’s issues with access to oral care don’t stem from a shortage of dentists, but rather how dentists are distributed geographically and how Medicaid compensates them.
In addition, Collins and the Dental Society have raised concerns about whether dental practitioners would get sufficient training to perform certain surgical dental procedures.
The advocates counter that dentists would define the dental practitioners’ scope of practice, allowing dentists final say over what procedures they could perform.
The most recent figures from the state show the state has 368 dentists, or roughly 59 per 100,000 residents, nationally the rate is only slightly higher at 61 per 100,000, according to data from the federal Centers for Disease Control and Prevention.
However, some counties such as Rutland and Chittenden have plenty of dentists, Collins said, while there are only a handful in the entire Northeast Kingdom.
“There’s nothing in the bill that says whether they (the dental practitioners) would be required to go out to these rural areas,” Collins said.
Vermont Technical College, which currently trains dental hygienists, has signed on to provide the curriculum for the dental practitioners as well.
“They have curriculum ready, just waiting to get started,” said Sheila Reed, of Vermonters for Oral Health Care for All.
It takes a three-year program to become a hygienist, and the certification for a dental practitioner would require an additional year of classes and 400 hours of clinical training.
While nothing in the bill requires they practice in an underserved part of the state, Vermont Technical College’s graduates are predominately local, according to Reed, and that increases the odds they would return home to practice.
Hiring dental practitioners could also help dentists accept more Medicaid patients, Reed said.
Medicaid reimburses dentists at half of what commercial insurance pays.
The same is true for providers of medical care, but the different economies of scale in dentistry force dentists who accept Medicaid patients to treat them at an even greater loss.
Dentistry is a cottage industry compared to the rest of the medical professions, with dentists typically operating freestanding practices that nonetheless have higher fixed costs than most independent physician practices, Collins said.
“Dentists are basically dental surgeons and their offices have to be operatory,” Collins explained.
Dentists are forced to evaluate how many Medicaid patients they can treat without losing money, he said.
Just under half of Vermont dentists didn’t take a single new Medicaid patient in 2011, according to a Green Mountain Care Board report.
Employing dental practitioners would allow practices in Vermont to expand their Medicaid patient population, because they would make less than dentists but be able to provide many of the same services, Reed said.
Collins said he would prefer to see the state increase Medicaid reimbursement rates for oral health services. Increasing rates from 50 percent of commercial payments to 75 would cost Vermont between $4.2 and $13.8 million more than what it currently spends on Medicaid depending on the corresponding spike in use of services, according to the Green Mountain Care Board report.
Though expensive, Arthur said raising the reimbursement rate has increased the number of Medicaid patients dentists will see in other states.
The Department of Health favors licensing dental practitioners, Arthur said, in large part because if Vermont doesn’t have a shortage of dentists currently, it will in the next decade.
Vermont has the oldest dentists in the United States, with 34 percent over age 60 and many are likely to retire over the next decade, Arthur said.
With only roughly 4,000 people graduating from dental school nationally each year and no dental school in Vermont, it’s difficult to imagine the state maintaining an adequate number of dentists through recruitment alone, Arthur said.
The average dental student graduates with $200,000 in student loan debt, and the financial pressures facing them is likely to make rural Vermont a difficult option. Allowing dental practitioners to train in the state is one way Vermont could help existing dental practices expand, Arthur said.
The Senate bill was passed out of the Government Operations Committee earlier this session, but landed in the Finance Committee because of the fees involved with issuing licenses.
There was not sufficient support from his committee to pass the bill before crossover, according to Sen. Tim Ashe, D/P Chittenden, the committee chair.
It’s still possible the committee could pass the bill on its own under suspension of the rules or tack it onto other legislation, but its sponsor, Sen. Clair Ayer, D-Addison, was not sanguine about its prospects.
“I’m thinking it’s kind of late to do anything now,” she said.
One step the Legislature may take to improve the oral health of Vermonters is aimed helping people on WIC – the federal assistance program for women infants and children – learn better oral health practices, Ayer said.
There is legislation to expand the number of Agency of Human Services offices assisting people on WIC that employ dental hygienists to work with beneficiaries. The Senate would need to fold the appropriation into the larger budget bill for it to pass at this point in the session, Ayer said.
Each year there are over 400 children age 5 or younger admitted to emergency rooms for dental surgeries. That costs the state over $2 million per year in hospitalization costs alone, and the state spends another $1 million on routine dental problems for young children, Arthur said.
The bill calls for $375,000 to put eight additional part-time public health dental hygienists in district offices across the state.
“That’s really high impact for low cost,” Ayer said.
Half of Vermonters don’t have dental insurance
Vermont may have one of the smallest uninsured populations in the United States, but the health insurance residents have typically doesn’t provide dental coverage.
More than half of Vermonters don’t have dental insurance, according to a recent study of oral health in the state commissioned by the Green Mountain Care Board.
While that’s not out of line with statistics nationally, Vermont’s covered population isn’t getting the oral health coverage they need either, the report concludes.
“Significant numbers of adults 18-64 have lost all their natural teeth to decay or disease and do not access recommended preventative services,” the report states.
In some areas of the state as high as 9 percent of the total population have lost all their natural teeth to disease or decay.
Oral health impacts overall health and is known to affect or contribute to a variety of conditions and diseases including diabetes and heart disease.
People who don’t receive regular oral health services are more likely to end up requiring costly hospitalizations or procedures.
The status of oral health in Vermont doesn’t rise to the level of a public health crisis, said Dr. Steve Arthur, director of the Health Department’s Oral Health Office, but the state would do well to take steps now to avoid it becoming one in the future.
Statewide less than 50 percent of Medicaid beneficiaries accessed oral health services, and for the privately insured it was just over 60 percent, according to the Green Mountain Care Board report.
Part of the problem is that people just don’t go to the dentist, even if they’re covered, but for some it’s unaffordable or difficult to find an appointment.