Dental access problems aired as dueling bills seek to add providers
Emily Micucci
Dr. Edward Swiderski, a longtime Uxbridge dentist, believes dental care is underutilized in Massachusetts.
Massachusetts is second only to Washington, D.C. when it comes to the availability of dentists. According to the American Dental Association, the Bay State has the the second-highest population of dentists per capita.
Still, access to dental care isn’t necessarily easy. According to the U.S. Department of Health and Human Services, 13 percent of the commonwealth’s population is designated as lacking sufficient access to dentists.
While policy makers and dental experts agree there are barriers to dental care -- particularly for people who are covered by public MassHealth insurance -- there’s a difference of opinion about how to remove them.
‘A utilization problem’
As dueling bills aimed at expanding dental care are vetted on Beacon Hill, proponents of each one are raising important questions about dental care Massachusetts, especially for the disadvantaged.
Massachusetts lawmakers are examining a bill backed by The Pew Charitable Trusts, a nonprofit public policy organization that has been making inroads across the United States in a campaign to improve dental access, as well as an alternative bill proposed by the Massachusetts Dental Society. Both include provisions for creating a new class of dental providers that will purportedly expand access for the underserved.
But supporters of the bills disagree about the cause of dental care shortages in Massachusetts, and about training standards for mid-level dental providers, which both sides have likened to nurse practitioners or physician assistants in the medical field.
“We maintain it’s a utilization problem,” said Dr. Edward Swiderski, an Uxbridge dentist who has practiced for 36 years.
A member of the Massachusetts Dental Society, Swiderski said many Massachusetts dentists treat Medicaid patients, but people covered by both commercial plans and MassHealth don’t always seek dental care when appropriate, due to fear or lack of education about the impact dental health has on overall health.
Until recently, Swiderski was one of about 45 percent of Massachusetts dentists who, according to the Massachusetts Dental Society (MDS), treat MassHealth patients covered by the state’s Medicaid dental plan. Because of a billing glitch within the MassHealth system, Swiderski had to temporarily stop treating MassHealth patients at the beginning of the year, but he’s planning to resume service when the problem is solved.
But MassHealth has always been a losing proposition for dentists like Swiderski. Like commercial plans, MassHealth does not cover the full cost of service, but with Medicaid patients, Swiderski said dentists are unable to bill the balance to patients directly. Dentists lose money on these patients, and need to make it up on the commercial side, discouraging many from accepting MassHealth patients.
Not only do fewer dentists accept MassHealth insurance than commercial insurance, but MassHealth benefits are also generally more limited than commercial benefits. For example, an adult patient is more likely to undergo tooth extraction than receive a costlier root canal, which preserves the tooth. Benefits for children covered by MassHealth are more comprehensive.
Chandler backs national legislation
The Pew-backed bill would authorize the use of dental therapists, which would provide preventative and restorative care under the supervision of dentists throughout the state.
Massachusetts is one of the latest states to consider a bill that would allow dental therapists to practice.
Sen. Harriette Chandler, D-Worcester, introduced the bill along with Rep. Smitty Pignatelli, D-Lenox. It was referred to the Joint Committee on Public Health in January.
Chandler noted in a recent interview that dental therapists would be trained according to standards adopted by the national Commission on Dental Accreditation in 2015, which include a minimum of three years of training for certified dental hygienist.
Chandler said despite the large number of dentists in Massachusetts, only about one in four accept MassHealth patients -- a major contributor to the dental care shortage. This is despite efforts in recent years to encourage more dentists to accept MassHealth insurance, Chandler said, such as arranging third-party billing to ensure dentists who take MassHealth are paid on time.
“We have a lot of support for this bill,” Chandler said, noting that it was unanimously approved by the state Senate last year. “I think people are becoming more and more aware that dental health, oral health, is an area that cannot be seen as a sidebar to general health.”
Dentists float alternative
As an answer to the Pew-backed bill, the MDS filed its legislation in January. The MDS bill also creates a new class of providers, called Public Health Dental Practitioners (PHDP), who would work under the direct supervision of dentists (the Pew bill would allow dental therapists to be monitored remotely.)
In addition, the MDS bill requires a higher level of training for PHDPs, similar to the education a physician assistant or nurse practitioner receives, including a four-year degree followed by two years of post-baccalaureate education.
The MDS bill also includes a push for fluoridated drinking water in public drinking water supplies (not all cities and towns add fluoride, which prevents tooth decay) and mandates oral health screenings for children prior to kindergarten. Sen. Michael Moore, D-Millbury, is sponsoring the bill, which was referred to the Joint Committee on Public Health in January.
Dr. David Lustbader, who will become president of the MDS in June, said in an interview that training requirements included for PHDPs in the MDS bill are an important difference from the Pew-backed bill Chandler filed. He noted that dental therapists would be performing irreversible procedures in some cases, and that’s something that physician assistants and nurse practitioners don’t do.
“Once you cut a tooth, it doesn’t grow back,” Lustbader said.
This isn’t the first time Massachusetts has moved toward creating a new class of dental practitioners. In 2009, the Legislature passed a bill creating the role of Public Health Dental Hygienist to increase access to preventative care for the underserved, but the MDS cited data from the Massachusetts Department of Public Health showing that there are fewer than three dozen of these practitioners working today. The MDS points out that none of them are located in Berkshire County, where access to oral health care is in short supply.
Room for more
Whichever new bill is successful, if either, there’s certainly room for more apt practitioners in the dental care field, according to Dr. Brian Genna, vice president of dental care at Worcester-based Edward M. Kennedy Community Health Center.
While there are differences in training, Genna said both bills would accomplish the important objective of expanding access to vulnerable patients, a population that community health centers target for dental care.
Genna said at Kennedy CHC, there’s always need for more capacity to treat MassHealth patients. He said he prefers the advanced training for PHDPs that the MDS bill requires, but generally likes the Pew model.
“I think it will free up the dentists’ time a little bit to focus on the the more complex cases,” Genna said.
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