If Wisconsin allowed dental therapists, more kids would have access to care, proponents say

By Betsy Thatcher for the Badger Institute 
(This article appeared in the Fall 2018 issue of Diggings.)

Drew Christianson grew up in Tomahawk in the heart of rural, northern Wisconsin. But he wouldn’t be able to do his job — providing basic dental care for little kids with toothaches and decay — if he still lived in his native state.

Instead, the licensed dental therapist helps children stay healthy in Minnesota, our neighbor to the west where dentists have been much more accepting of his efforts and much less fearful of competition.

Christianson doesn’t buy the argument made by some in the Badger State that what he does is insignificant.

“It’s a lot harder for (opponents of dental therapy) to say I’m not making a difference when I’m sitting with a 5-year-old kid who’s had pain and couldn’t get into any dentist and is now able to see me,” he says.

Christianson recently treated a kindergartner who had missed a few days of school because of a bad toothache and extreme pain.

“As nervous as he was, I was able to calm and soothe him due to the amount of time I was able to spend with him. I did not need to rush. … I was able to complete the determined treatment that the dentist and I planned,” he says.

All the care provided by Christianson, who sees many special needs patients and children under age 5 requiring extra attention, is coordinated alongside the clinic’s dentist, he says.

“It was a win for the entire team that day but, most importantly, a win for the child … with nowhere else to go. In the end, he was able to walk out with a smile on his face,” says Christianson, who is also a clinical assistant professor in the Department of Primary Dental Care at the University of Minnesota.

Crisis in Wisconsin
The Badger State ranks last in the nation for providing oral health care to the more than 550,000 children with dental benefits through Medicaid, based on 2015 statistics.

Despite those Medicaid benefits, more than 67 percent of those kids — over 368,000 — received no dental care, according to the U.S. Department of Health and Human Services.

The problem, simply, is access.

More than 90 percent of Wisconsin’s 72 counties have at least one geographical area experiencing a shortage of dental providers. Last year, 1.5 million residents lived in areas that the federal government designated as “dental shortage areas.” That’s more than a quarter of the state’s population.

Nearly two-thirds of Wisconsin dentists do not accept Medicaid, largely because reimbursement rates are low. Professional dentist organizations, including the Wisconsin Dental Association and the American Dental Association, suggest an increase in public assistance reimbursements as a solution.

An effective free-market option
Some state legislators, health advocacy organizations and free-market advocates believe that allowing dental therapy in Wisconsin would increase access to care without throwing the burden back onto taxpayers.

Dental therapists are mid-level providers — the dental equivalent of medicine’s nurse practitioners and physician assistants. They can perform routine procedures, such as fillings and simple extractions, and at a much lower cost. Currently in Wisconsin, only dentists are permitted to perform those procedures.

While relatively new in the United States, dental therapists have been around since 1923 and now practice in more than 50 countries. Seven states allow dental therapy.

Minnesota was the first, approving legislation in 2009. The first dental therapist graduates began seeing patients two years later. Two Minnesota schools, the University of Minnesota School of Dentistry and Metropolitan State University, offer accredited dental therapy education.

Ongoing studies by the Minnesota Department of Health and the Minnesota Board of Dentistry (the state’s regulatory and licensing body) indicate that dental therapists are having a positive impact.

“They’ve found that dental therapists, in the practices in which they’re working, are treating more publicly insured patients, the wait times (for an appointment) are lower and they are generating profits for those public clinics and private practices,” says Jane Koppelman, senior manager for Pew Charitable Trusts’ dental campaign.

“Dental therapy is something that we have researched as a model. We see it as solidly effective,” she says.

Allowing licensed dental therapists to provide routine care frees up dentists to concentrate on more complex procedures that generate more revenue, advocates say.

“Dentists are finding that if they can hire somebody who can do simple restorative care — to drill and fill teeth and extract loose teeth — for one-half to one-third the cost of a dentist, they can make a higher margin on the Medicaid revenues,” Koppelman says. “They can make a profit in their practices, and they can serve people who couldn’t get in to see a dentist before.

“This is a supply-side answer to addressing the access-to-care problem,” she says, “because we’re not talking about states putting a line item in their budget for more funding for insurance.”

In addition to Minnesota, the states that allow dental therapists are Alaska, Arizona, Maine, Vermont and Washington (on tribal land). Oregon has a pilot program in Native American communities. Connecticut, Florida, Michigan, New Mexico and North Dakota have been considering legislation.

In Wisconsin, Rep. Mary Felzkowski (R-Irma) introduced dental therapy legislation earlier this year, but the proposal did not make it out of committee. She plans to reintroduce legislation in the next session.

Allowing dental therapists, who would be required to work under the supervision of a dentist, “will provide more access and better care,” Felzkowski says. “It’s a lot more cost-effective, especially in the Medicaid model.”

The consequences

Lack of access to oral health care in Wisconsin exacts a toll, Koppelman says.

“When people can’t get the dental care they need, problems fester and they end up in the emergency room,” she says. “This is no good for the patients, and it’s a wasteful use of taxpayer dollars.”

Some staggering facts cited by Koppelman:

  • In 2015, Wisconsin hospitals clocked more than 41,000 ER visits for which a preventable dental condition was the primary or secondary diagnosis; 56 percent of such visits were paid for by Medicaid.
  • If accounting for only primary diagnosis visits, of which there were 33,133, at an average cost of $749 per visit (in 2012), this represents nearly $25 million in hospital costs.
  • The lack of dental care in underserved communities is contributing to the opioid crisis. Clinics in rural Wisconsin report that painkillers, often opioids, are the common treatment in ERs. Therefore, toothaches first treated in the ER rather than at the dentist’s office can become a gateway to addiction.

Impact in Minnesota
Dental therapy has been extensively studied.

“All the data is pretty consistent,” says Michael Helgeson, CEO of Apple Tree Dental in Minnesota, a nonprofit “safety net” provider. More than half of its care centers and mobile sites are in rural areas where dental access is critically low, similar to Wisconsin. Other locations are in the Twin Cities.

“The fact is, dental therapists are making a huge impact,” Helgeson says. Apple Tree employs nine therapists throughout Minnesota.

Lake Superior Community Health Center, another nonprofit safety net provider, has a unique situation of being able to employ dental therapists at its clinic in Duluth, Minn., but not a few miles south at its clinic in Superior, Wis.

Dental therapists would greatly improve access, says the center’s dental director, Eric Iwen, a Marquette University School of Dentistry graduate.

“The lion’s share of procedures that are backlogged on a long waiting list here are restorative,” he says.

The opposition
The Wisconsin Dental Association and Marquette’s School of Dentistry have strongly opposed the effort here. Felzkowski is disappointed with Marquette’s stance as Wisconsin’s only dental school. The school’s dean did not respond to requests for comment.

Felzkowski is working with Chippewa Valley Technical College in Eau Claire and Northcentral Technical College in Wausau, which have dental hygiene programs, to develop a dental therapy program in conjunction with a four-year institution.

The WDA would rather see increased funding of the state’s dental Medicaid program to improve access.

“Wisconsin’s Medicaid reimbursement rates for children’s dental care are the third-lowest in the nation and fifth-lowest for adult dental care. The state of Wisconsin spends less than 1 percent of its Medicaid budget on dental care,” the WDA said in a statement earlier this year.

In a more recent statement, the WDA said dental therapy has not boosted access in Minnesota, citing a decrease in Medicaid patient visits from 2012 to 2016.

“That’s a flawed argument,” says Helgeson, a dentist for 34 years. He cites Medicaid’s expansion for the 5 to 6 percent dip: “There are now about 1.2 million children, disabled adults and families, and frail elders (who) are enrolled in Minnesota’s public programs. That’s almost double what it was eight or nine years ago.”

During the same period, Minnesota dentists saw their Medicaid reimbursement for children’s care decrease by the largest margin among all states. As a result, more dentists dropped out of Medicaid, he says.

“It wasn’t that dental therapy didn’t work,” Helgeson says. Rather there was a “combination of fewer dentists participating and more people being enrolled, more children in particular,” he says.

In addition, Minnesota’s two dental therapy programs can turn out only about a dozen therapists a year. Therefore, Helgeson says, it’s “misleading” to expect a major impact after just seven years of dental therapy.

Minnesota has 92 licensed dental therapists, says Bridgett Anderson, executive director of the Minnesota Board of Dentistry.

She echoes Helgeson’s sentiments: “There is no way, statistically, that you can take 92 individuals and expect a statistical impact on a workforce of 17,500 people.” Likening the impact of nurse practitioners on the medical field, she says, “It takes decades to see meaningful data.”

Initial resistance, including fears that therapists would take business away from dentists, has become a non-issue in Minnesota, Anderson says. Dental societies also cite safety concerns and potentially substandard care. There have been no complaints in Minnesota indicating substandard care, she says.

The support
A 2016 poll by Americans for Tax Reform showed that 79 percent of voters — across the political spectrum — favored allowing dental therapy.

The Children’s Health Alliance of Wisconsin, a nonprofit agency that develops health initiatives to bring expanded and improved health care to children, is an ardent supporter.

The organization oversees a program that deploys dental hygienists and portable dental equipment to schools statewide to provide preventive care. Having dental therapists on those teams would be valuable, says Matt Crespin, the agency’s associate director.

About 40 percent of the children seen in school programs need more care than a hygienist can provide, he says. Dental therapists can provide mobile care at schools, nursing homes and community centers.

“It’s really unfortunate that Marquette University has decided to oppose it,” Crespin says, “because their counterpart in Minnesota has not only not opposed it, but they’ve embraced it.”

Other supporters include the Wisconsin Dental Hygienists’ AssociationChildren’s Hospital of WisconsinUW HealthWisconsin Oral Health Coalition and Wisconsin Association of Local Health Departments and Boards.

Dental therapy is a common-sense fix, Helgeson says. Having 92 therapists in care settings in Minnesota “would be like 10 community clinics with nine dentists in each one. That is a hell of a lot of access for underserved populations,” he says.

Christianson encourages his native state “to be open to the idea of the dental therapist.” He believes mainstream acceptance of dental therapy across the U.S. is just a matter of time.

Betsy Thatcher of Menomonee Falls is a freelance writer.