#Dentaltherapists are a movement. #Vermont just approved them; see who else is on board. #oralhealth. NM next??? pic.twitter.com/yR6BMIbBx1
— Barbara K. Webber (@bkwebber) June 20, 2016
Dental hygienists and other non-doctoral level clinicians are one of the major keys to a long run bending of the cost curve. There are two major reasons why allowing more intermediate skilled providers could bend the cost curve.
The first is that non-doctoral level clinicians are competition for low end services from doctoral level clinicians. Since their education is cheaper and the wage expectations are cheaper, a non-doctoral level clinician will be able to charge a whole lot less for basic care than a doctoral level clinician. This creates a bifurcated service marketplace where a dentist is filling cavities, replacing crowns and not spending his or her time checking the work of a routine cleaning. Instead, they’ll be receiving referrals from non-doctoral level clinicians for either routine but higher skilled work or the odd stuff that is past their level of expertise.
Secondly, most people most of the time hit the medical system for basic needs. I am a good example. I hit the medical system for an annual eye appointment, dental exam, PCP well visit and perhaps one or two urgent care visits for daycare crud identification. None of those needs are high end needs that need years of diagnostic training to differentiate between horses and zebras. Instead, my teeth get cleaned, my eyes are checked for glaucoma, my blood pressure is taken along with some blood work and I step on a scale. As people get slightly more intense care, most primary care is watching, monitoring and coaching. Again that is not care that needs to be administered or coordinated by someone who has 10+ years of post-graduate training.
Cheaper primary care and low end specialty care as well as targeted wellness interventions like the Type 2 YMCA diabetes program that Medicare now pays for can be effectively delivered by lower end providers who can put downward billing pressure on doctoral providers. More importantly, cheaper primary care leads to more primary care which should help in leading to either fewer chronic conditions or at least better managed chronic conditions.
Evidence suggests that for basic primary care, non-doctoral practitioners are roughly equivalent to doctoral level practitioners. Encouraging more basic care in the hope that less acute/crisis care is needed is a plausible cost curve bender that will lead to better outcomes. And since cost is a greater barrier to care for people with lower incomes than higher incomes, this is a Rawlsian improvement as well.
These types of policies are not policies that can be directly changed by the federal government. The Feds have some levers to open up the sub-doctoral level clinician market in states by structuring competition grants that are dependent on state level policy changes much like how the Department of Education did so in the Race to the Top grants. But realistically, these policies need to change at the state level. Licensing boards need to increase the allowable scope of practice to the edge of training. Supervision requirements need to be loosened for common care so that there is not a dentist checking teeth after a simple cleaning while adding little real value. Referral and privileging patterns need to change so that CRNP’s can admit patients to a hospital while still coordinating their care until hospitalists take over. None of this is sexy, but all of it is needed.
rikyrah
I support what could bring quality , affordable dental care to the people.
Aimai
I want to see dental hygienists back in grade schools giving kids thrir check ups as part of the public school year.
Jim
The same thing is happening throughout the medical community. Physician Assistants, Nurse Practitioners, and the opening of more and more urgent care centers to take the load (and cost) off emergency rooms. They are all doing things that physicians did in the olden days. And they’ll refer me to specialists when needed, just as the dental clinician is the gatekeeper for the dentist, who only has to spend a few minutes with me to check things out. Yes, there are downsides to the current process (ask me about hospitalists!), but all in all a good response to the problem of cost and limited numbers of physicians.
ThresherK (GPad)
The “WK Kellogg Foundation”?
This could only be funnier if there were a Super Sugar Crisp Institute of Dental Health.
MomSense
@Aimai:
Exactly. Cleanings and screenings for everyone.
dr. bloor
I suspect that this revolution is mostly guild infighting for autonomy and a lot less about cost savings.
I haven’t had anyone but a hygienist clean my teeth in thirty years. I also haven’t had a doctoral-level practitioner do any of the above on me for the last twenty-five years. Most general practice offices have already divvied up responsibilities in the way you’ve outlined, and those cost savings are already baked into office visit charges (that would otherwise be much higher).
At first glance, a PA operating autonomously might shave a few more bucks off the fees, but if s/he does so in an independent office, that PA is now responsible for overhead (including a healthy spike in their malpractice insurance) that is currently absorbed in the physician’s practice. Median PA salaries in urban areas are already into six figures; how much money do you really anticipate saving here?
C.S.Strowbridge
Dental Therapists sounds like someone who talks to your teeth to make sure they are not depresses.
Aimai
My daughter is spending the week shadowing at brigham and womens. She wanted to shadow an obgyn but they gave her to the prenatal and gyno “pod” of medical assistants, nurses, and doctors. Fascinating for her. She spent a day just with the MAs cleaning and setting up exam rooms and running pee to the pee lab.
Richard Mayhew
@dr. bloor: Honestly maybe a $1 pmpm…
There has been evidence that the PAs and more importantly the dental hygenists operate in more spartan offices in less desirable/cheaper locations so overhead is a bit lower as they aren’t keeping up with the Joneses.
muddy
Here’s an interesting article from 2012.
maurinsky
Dr. Bloor, the other side of that argument is that if the hygienists are separate, you aren’t paying to support the doctoral dentist and all her/his equipment and supplies when you go in for a check-up.
I would like to merge dental care and eye care into general health insurance, btw. They are important parts of your health!
dr. bloor
@maurinsky: That goes both ways, though. Without income from basic services to underwrite equipment costs, the price of that crown just went up. As would the price of the visit with your family practitioner if s/he wasn’t seeing any income from services carried out by nurses.
Mnemosyne
Strangely, my dentist doesn’t have a hygienist and does all of my cleanings himself. It’s just him, a dental assistant (i.e. less training than a hygienist), and a receptionist in the office, so it may be that he doesn’t want to pay that extra salary.
Nunca El Jefe
Hi Richard, could you expand on this: “…Licensing boards need to increase the allowable scope of practice to the edge of training.”? I think I understand what you are saying but I also think that there is some nuance in “practice to the edge of training” that is likely germane to what you’re talking about. It sounds to me to be something similar to practical experience in lieu of continuing ed for certification purposes.
Richard Mayhew
@Nunca El Jefe: I got stuck in jargon land.
A CRNP or a PA is trained up to a limit. Some states allow a licensed CRNP or PA to practice to that limit which means evaluating, treating, prescribing, admitting patients etc. Other states’ impose restrictions on what a CRNP or a PA can do, for instance, they might not be able to prescribe common drugs on their own authority as they would need an MD/DO to sign off on all orders, or they could not admit patients on their own authority etc.
Nunca El Jefe
@Richard Mayhew: Got it, thank you.
aimai
@Mnemosyne: Interesting. My dentist has two dental hygienists who do the teeth cleaning, he does a routine check and makes crowns or handles emergencies. I think there may be three chair set ups (which are hugely expensive and get upgraded periodically).
amygdala
For patients admitted electively, perhaps, but not from the ED, when diagnoses are often provisional. That’s a situation where a physician’s additional training is most useful.
MaxUtil
@dr. bloor: Maybe. But making routine, preventative care that everyone should be getting regularly MORE expensive so that fairly infrequent treatments (that would be even less common if people got more routine, preventative care) can be LESS expensive does not sound like a sound approach cost wise.
I can see some argument about overhead efficiency and why having all services grouped together makes sense. But I suspect the fact that dentists are just able to make routine cleaning work a profit source for themselves because a hygienist can’t set up their own office will overwhelm any lost “efficiency”.
jl
Thanks for an interesting post. I think this move will be a source of real savings, both in terms of providing better preventive care to maintain population health, and in general access to care and continuity of care. I haven’t kept up with the stats like I used to, but my understanding is that MD level practitioners provide more routine care in US than other comparable countries. The rule in the US (pushed by old-school AMA, AFAIK) seems to be the more overqualified the practitioner, the better, in any and all situations.. So primary care docs do things that don’t require an MD for routine stuff, and specialists (who are now one of the super high priced part of health care labor costs, and a much higher proportion of US health care labor force than another advanced country) do stuff a primary care physician can do whenever they can grab the work.
The degree that US has a low provider to population ratio, driving up fees and creating access problems is hidden if you only look at MDs, and that is already very low in the US. If you add in the large nursing supply, often with much more varied skill sets, in many European countries, and NZ, for example, the situation in the US looks even worse.
As I understand it, there are three barriers to overcome. First is getting state boards to provide regulatory frameworks that allow other health care workers to practice with more autonomy (basically, not having to throw some money at a doc for ‘supervising’, or approving every little thing they do). Second, which has been neglected in some states is providing authority to bill independently of an MD, and this is a big deal. Some early initiatives for f a r m a siiiists (not sure if that is still a forbidden work or not) and phys assts, went nowhere because the states forgot about the importance of the authority to bill for anything as an independent provider, bills had to go through an MD, which usually meant a higher bill and less for the actual provider. Third is more informal problem, which is very hierarchical nature of medical practice at the office and clinic level, where primary care provided by anything at dental facility, f a r m a cee, and by nurse practitioners isn’t integrated into care provided by MD, or health records (and that last is an example of how the sad US lag in integrated med records behind other countries with good health care systems causes problems.
I’d be interested to hear from Richard on what he knows about developments on the reimbursement side of this issue.
christopher murphy
“Evidence suggests that for basic primary care, non-doctoral practitioners are roughly equivalent to doctoral level practitioners. ”
If you are using this link to support the proposition that the overall quality of care provided by non-doctoral practitioners is equivalent to that provided by doctoral practitioners the linked article does not actually say this. Rather the article only states that non-doctoral practitioners are no more likely to recommend unnecessary tests/procedures than doctoral providers.
StringOnAStick
@Aimai: as a dental hygienist, I agree with that. I work in a middle class practice and it shocks me how many young people have a head full of cavities and poor self care skills. I make patient education a big part of what I do, and the number of times I’ve heard “I never knew that” from people in their teens and twenties shocks me.
StringOnAStick
@Mnemosyne: salaries for dental hygienists aren’t a whole lot more than what insurance reimbursement pays; that’s why a few dentists do their own cleanings. It also means they have a smaller than normal patient population because a typical DDS can keep 1.5 to 2 hygienists working full time while they handle fillings, crowns etc. Also, an RDH has a license that requires annual CE’s just like the DDS has to get each year; a dental assistant has no licensing and can just be someone the DDS trained.
Colorado allows independent RDH practitioners, but the costs of an office are high and a DDS supervisor is required since only a DDS can legally read x-rays. One if the biggest expenses in any dental office is sterilization if instruments and the monitoring of that device. I have yet to see an RDH make it work as an independent practitioner here, they all go broke.