Testimony in Support of Senate Bill 89
Jason Hicks, Ph.D. candidate
Humphrey School of Public Affairs
University of Minnesota
Chairman Testin and members of the committee, my name is Jason Hicks, and I am a Ph.D. candidate at the Humphrey School of Public Affairs at the University of Minnesota. My research interests are the linkage between economics and public policy with a specialization in occupational licensing. More specifically, I look at the effects of occupational licensing on earnings and employment of workers and the effects of licensing on consumer outcomes.
Earlier this year, I co-authored a policy brief for the Badger Institute on the role of dental therapists as a potential solution to increasing access to dental care for disadvantaged and underserved populations in Wisconsin. I am here testifying in support of Senate Bill 89.
As Julie mentioned, Wisconsin has among the lowest rates of dental care use in the country for children who receive dental benefits through Medicaid and a usage rate of dental services that is lower than that of all states bordering Wisconsin. In 2015, only 25% of children from low-income families who were eligible for preventative dental care through Medicaid or the Children’s Health Insurance Program received care and only 11% of children from low-income families who were eligible for treatment of dental problems received care.
With regard to oral health, students of color who participated in Head Start in Wisconsin had higher rates of untreated tooth decay and cavities than white children in 2014. Further, African American and Hispanic adults were over twice as likely as white adults in Wisconsin to report needing, but not receiving, dental care in 2015. Low income adults, adults with disabilities and seniors in Wisconsin nursing homes also had disproportionately high levels of unserved dental needs. Wisconsinites who have untreated dental problems cite unaffordable cost of care, inadequate insurance coverage and lack of access to care as the biggest barriers to getting dental treatment. Wisconsin is one of only 13 states to experience a decrease in the dentist-to-population ratio from 2001 to 2016. Additionally, over 90% of Wisconsin’s 72 counties have too few dental care providers, with over 1.2 million Wisconsinites living in designated shortage areas.
There are significant economic and social costs associated with poor oral health. Emergency room visits for preventable oral health conditions result in significant increases in health care costs and, in some rare cases, mortalities. In Wisconsin alone, there were over 41,000 emergency department visits for preventable dental conditions in 2015, costing nearly $25 million. Medicaid recipients are overrepresented among patients who visit the ER for dental problems. In 2013, researchers found that over an eight-year period there were 66 deaths following hospitalization for tooth infections.
Poor dental care in children affects physical health, raises economic costs for future dental treatment and lowers academic performance, which potentially influences economic and societal outcomes later in life. Students who need dental care, but for whom care is inaccessible, and have poor dental health are disproportionately likely to miss school and have a low grade-point average. Early childhood kindergarten programs, such as Head Start, have been shown to have substantial long-run economic returns for disadvantaged children; however, reduced attendance and lower academic performance due to dental problems may diminish the long-run positive benefits from participating in pre-kindergarten programs.
To understand how dental therapists could help increase access to and usage of dental services for disadvantaged and underserved populations in Wisconsin and potentially reduce the economic and societal costs associated with these problems, it’s important to examine the effectiveness of the dental therapists in Minnesota, which was the first state to authorize the creation of dental therapists in 2009. The dental therapy model in Minnesota is very similar to that in Senate Bill 89, including the training requirements and scope of practice of dental therapists. As of 2018, there were 86 licensed dental therapists in Minnesota. Given the current shortage of 240 dentists identified by the Department of Health and Human Services, training an equivalent number of dental therapists in Wisconsin could reduce the shortage of dentists by up to 42%.
Numerous studies have found that the vast majority of patients seen by dental therapists are enrolled in public insurance programs, such as Medicaid, which suggests that dental therapists are expanding access to care for disadvantaged and underserved populations in Minnesota. Clinics have also experienced an overall growth in the number of new patients with public insurance after hiring dental therapists and seem to be serving a relatively high proportion of children, particularly in rural areas.
Importantly, dental therapists may be reducing the number of emergency room visits for dental treatment in Minnesota. Patients visiting clinics that hired dental therapists frequently experienced reductions in wait times for scheduled appointments and reduced travel times to appointments, which likely decreases emergency room visits. Additionally, patients who previously visited an emergency room for dental treatment were twice as likely to experience a reduction in travel times to their appointment with a dental therapist relative to a previous appointment with a dentist.
From an economic perspective, the addition of dental therapists to the dental workforce in Minnesota has resulted in cost savings for dental clinics. Dental practices that serve a large percentage of patients who are covered by public insurance, which pay lower reimbursement rates for dental services, experience positive financial returns from hiring dental therapists. A survey of dental clinics in Minnesota found that clinics frequently reported significant personnel cost savings by hiring a dental therapist instead of a dentist with the average cost of a dental therapist being roughly half that of a dentist. However, dental therapists also can serve as complements to dentists, not competitors. After dental therapists join a practice, dentists take on more complex and higher-fee dental procedures, such as oral surgeries, which can increase efficiency and overall revenues for a dental practice.
With respect to quality of care, extensive research, both internationally and within the U.S., clearly shows that dental therapists provide patients with high-quality dental care. Studies directly comparing care provided by dentists and dental therapists found that therapists performed at least as well as dentists. For example, in Alaska, the presence of dental therapists in rural, Native American communities was associated with fewer tooth extractions and more preventative care treatment for both children and adults. In Minnesota, nearly all clinics that participated in an evaluation of dental therapists reported lower malpractice premiums for dental therapists than for dentists, which indicates that allowing dental therapists to provide dental care does not reduce patient safety.
When considering the appropriate scope of practice and supervisory levels for dental therapists, it’s helpful to consider other mid-level practitioners in the health care industry. Nurse practitioners and physician assistants are mid-level health care providers who play a very similar role in the provision of medical care as that of dental therapists in the provision of dental care. The proposed professional and practice relationship between dental therapists and dentists under Senate Bill 89 is like that between nurse practitioners or physician assistants and physicians in Wisconsin. Both mid-level practitioners work under the general supervision of physicians, which means that they operate under the overall direction and control of physicians, but physicians do not have to be physically present when physician assistants or nurse practitioners perform a task or procedure.
Nurse practitioners in Wisconsin also must operate in a documented collaborative relationship with physicians that defines the joint practice and working relationship of a nurse practitioner and the physician. Similarly, Senate Bill 89 requires dental therapists, also a mid-level practitioner, to work in a collaborative management agreement with and under the general supervision of dentists. Importantly, there is no evidence that collaborative agreements or general supervision requirements in Wisconsin result in a lower quality of care for patients, which indicates that these requirements are appropriate for dental therapists in Wisconsin.
Collaborative agreements give dentists the choice as to which tasks and duties dental therapists can perform within the limits designated by law, so if some dentists don’t feel comfortable allowing dental therapists to perform certain tasks or duties, then they will not be included in the collaborative agreement. This allows individual dentists to have significant input into the scope of practice of dental therapists.
With regard to the impacts of nurse practitioners and physician assistants in health care, the academic research clearly shows that outcomes of patients treated by nurse practitioners and physician assistants are at least as good or better than those of patients treated by physicians. Further, research indicates that utilizing mid-level health care providers can lower the cost of care, decrease the number of ER visits and increase the frequency of routine checkups by reducing costs for patients.
It's important to note that the medical lobby in the 1970s strongly opposed the creation of nurse practitioners; however, physicians today clearly recognize mid-level providers as an integral component of the health care workforce.
The creation of the dental therapy profession in Wisconsin through Senate Bill 89 would be an important step in improving access to and usage of dental care for disadvantaged and underserved populations in Wisconsin and potentially reducing negative economic and societal costs associated with poor oral health. These improvements in Wisconsin’s oral health care system would occur without reductions in the quality of care provided to patients and could increase financial returns to dental practices.