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Oct. 30, 2012
TOPEKA Hays dentist Melinda Miner is one of a handful in her profession who publicly support licensing a new type of mid-level dental provider as a way to increase Kansans' access to oral health care.
She's also among the relative few who will see Medicaid patients.
"Only 25 percent of us see the problems," Miner said. "Most dentists live in a different world. Their patients pay cash and can afford the expensive treatments. They don't see the dental decay and the problems in people who can't pay."
Miner was among about 25 people who met today in Topeka as part of the Kansas Dental Project, a coalition of advocacy groups seeking to improve dental care for children, the elderly and the medically underserved.
The group was formed in 2010 to urge Kansas policymakers to approve the licensing of mid-level practitioners as a way to help address the state's dental workforce shortage. Currently only Alaska and Minnesota license the mid-level caregivers.
Bills to authorize the licensing of "registered dental practitioners" in Kansas were put before lawmakers in each of the past two sessions of the Legislature. However, they did not make it to a vote in either chamber because of stiff opposition from the Kansas Dental Association, which represents about 75 percent of the state's approximately 1,400 dentists.
Kansas Dental Project members said they plan to propose a simliar bill again this year.
Miner was asked how more dentists could be won over to support the legislation.
"There are only 1,400 dentists in this state. I don't know that they need to be won over," Miner said. "Reaching out to the communities for support is probably a better avenue...seeking support from the people who see the problems."
Miner also suggested that supporters of the proposal stress the potential economic benefits of licensing mid-level providers.
For example, she said she would hire two mid-level practitioners as soon as it was possible and at least one other full-time employee to handle their appointments. She said she felt sure many dentists would do the same as soon as mid-levels are sanctioned.
"I don't see how the economic impact could be anything but positive," Miner said.
Jill Gottschamer, president of the state dental hygienist association, said she agreed with that approach. She said while only 28 new dentists were licensed in the state this year, there were 124 new hygienists licensed, some of whom cannot find work.
"I personally know three hygienists who can't find jobs," Gottschamer said. "We can't get dentists, but we've got a massive amount of hygienists in the state. So we have an extremely large workforce ready to fill the need."
Dentists acknowledge the workforce shortage, but say that licensing mid-level practitioners would not solve the problem.
Kevin Robertson — director of the Kansas Dental Association — has said 99.9 percent of the state's dentists do not support licensing mid-level dental providers because doing so would endanger patients.
He said extending Medicaid dental coverage to include adults would be a better way to improve access to care.
"Patients who cannot afford dental care from a dentist will not be able to afford treatment from a (mid-level provider) either without adult Medicaid," Robertson said.
Miner and her husband Daniel are two of 13 dentists in Ellis County and they are the only ones who will treat children on Medicaid, she said. Medicaid patients account for about 30 percent of those seen by her and her husband. And she said many of the approximately 7,000 appointments the couple schedule each year are for residents of nearby Trego and Ness counties, which have no dentists.
Access to oral health care in rural areas of the state is being squeezed even for those with dental insurance, Miner said.
"We have 110 people on our waiting list for new patients, and not just people on Medicaid," she said. "We're not meeting the needs of our community."
Miner estimated that each mid-level practitioner would enable her practice to schedule 2,000 to 3,000 more appointments per year, in part by opening satellite clinics in Wakeeney and Ness City for preventive and other basic dental services.
With the legislation proposed by the dental project, mid-level practitioners would be allowed to perform about 30 routine services and procedures — such as filling cavities, performing simple tooth extractions or administering local anesthetic — that currently are limited to dentists.
The practitioners, similar to a nurse practitioner, would be required to work under a dentist's "general" supervision, though the dentist would not be required at the technician's side or necessarily present in the same office.
Spokespersons for the dental association have argued that routine procedures quickly can turn dangerous and that allowing lesser-trained practitioners to do what dentists now do could put patients at risk.
But Miner said supervising dentists would be able to limit the procedures the mid-level practitioner's could perform commensurate to their experience.
"It's no different than a nurse practitioner," she said. "In Victoria, Kansas, right next door to us, there's an entire clinic that's only run by nurse practitioners. The doctors are overseeing it, but they're not there — and that's very common out in our area. And we all trust those nurse practitioners and we know they know what they're doing.
"To me, it's the same thing. I trust my hygienists now, but the law says I have to go check her, so I go check her work and talk to the patient. But I don't know that I've ever really disagreed with her. I feel like with a little more training this would be a natural transition."
There's little dispute that there is a pressing need to increase access to oral health care in Kansas.
At least 57,000 Kansans live in dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home, according to a report published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center. KDHE officials project that number to increase as more dentists retire.
The study found that most counties in the western half of the state have only one or two dentists, if any. A dozen western counties plus three more in eastern Kansas have no dentist at all.
More than half of Kansas' dentists are in four communities — metropolitan Kansas City, Wichita, Topeka and Lawrence.
But getting newly trained dentists to practice in underserved areas is challenging. Fewer people are living in rural communities and the costs to run a viable dental practice tend to steer recent graduates toward population centers.
Even where dentists are available, access to care for those of low income is often limited by the small number of dentists who accept Medicaid. Less than a quarter of dentists statewide accept Medicaid because, among other reasons, reimbursements are so low that they lose money on each patient, according to the Kansas Dental Association.
(Editor's Note: The Kansas Health Foundation, a major funder of the Kansas Health Institute, is among the supporters of licensing registered dental practitioners.)
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