The Michigan House Health Policy Committee heard testimony on Senate Bill 541, which would create the dental therapist designation in the state, on October 3. The Michigan Primary Care Association spoke in favor of the bill, while the Michigan Dental Association (MDA) opposes it.
Senate Bill 541 would define the scope of practice for dental therapists as midlevel providers, including procedures such as diagnosis, charting, education, radiography, prophylaxis, pulp vitality testing, anesthetics, primary tooth extractions, direct restorations, and more, all with the approval of a dentist and with the dentist’s supervision.
Also, dental therapists would need to graduate from an accredited program and pass a clinical examination including material on Michigan’s laws and rules concerning dentistry to be licensed. Plus, licensure would require the completion of 500 hours of clinical practice under the supervision of a dentist and with time spent in underserved areas. When practicing, 50% of their patients would have to be covered by Medicaid.
“This is not a solution that will change the world of dentistry overnight, but it absolutely, over time, will create opportunities for better access across the entire spectrum,” said Sen. Mike Shirkey, sponsor of the legislation, whose office notes that 77 of Michigan’s 83 counties have at least one dental shortage area.
“Anyone who claims dental therapy is an experiment or unproven is sorely mistaken,” said David Gesko, DDS, dentist, senior vice president and dental director of Health Partners in Minnesota, where dental therapy is allowed.
“In fact, nearly every dentist in Minnesota who has hired a dental therapist continues to work with them, and many dentists now are hiring their second, third, fourth dental therapists to expand their dental practices and treat more underserved patients,” said Gesko, adding that most patients seen by dental therapists are on Medicaid or are uninsured.
“Dentists are now able to do more high-level and complex dental procedures because they don’t have to spend their days doing routine fillings. In other words, they float to the very top of their license. There are no safety concerns because they know their dental therapist is well trained,” said Gesko.
“I took courses in oral and human anatomy and oral health education and spent almost two years in a clinical setting before graduating. I spent hours learning a limited set of procedures a dental therapist in Minnesota is licensed to perform,” said Kathlyn Leiviska, DT, a licensed advanced dental therapist with Health Partners.
“How to prep and fill cavities, prep and place temporary crowns, work with children, repair dentures, all right alongside dental students,” Leiviska said. “I was graded to the exact same standards, took the exact same clinical boards as the dental students. In fact, I had more clinical hours of training than my fellow dental students on these procedures.”
“The reason we are in support of this bill is because we are struggling to fulfill the demand for care,” said Loretta Bush, CEO of the Michigan Primary Care Association, which provided half a million dental visits to 200,000 state residents last year across more than 300 urban and rural areas including dental shortage areas.
“Our doors are open to everyone regardless of if they have insurance or what type of health insurance that they have. Overwhelmingly we serve Michigan’s Medicaid population, and that’s why we need the help,” Bush said. “We look forward to the freedom to be able to hire dental therapists.”
“The major issue is the scope of practice for Medicaid insured patients is much narrower than what a lot of dentists would prefer to provide for their patients,” said Kevin Steely, DDS, dental director of Grace Health, a federally qualified health center in Battle Creek, Michigan.
“Hence, if we get a doc who’s going to come into the public health arena, they usually migrate out within two to three years, and they move to private practice. So I’m perpetually recruiting as dental director,” Steely said, noting that non-licensed dental students are already providing irreversible procedures under the supervision of licensed dentists at Grace Health.
The MDA opposes SB 541 and any other legislation that would create a dental therapist designation in Michigan because it is not needed, said MDA president Debra Peters, DDS. Peters cited the state’s number of providers, called dental therapy unproven for better access to dental care, and said Michigan residents did not want care provided by dental therapists.
“MDA is opposed to Senate Bill 541 because Michigan has an adequate supply of oral health providers. And by better utilizing the current dental team, and addressing reimbursement within the Medicaid system, the issues contributing to access to care in Michigan would have real solutions that are sustainable for residents that won’t take many years to implement,” said Peters.
“We have so many options available. We have clinics. We have volunteers. We have every area. We’ve got things for homeless veterans. We’ve got things for American Indians. We’ve got things for the underserved population, and the vast majority of them, people were standing around with their hands in their pockets,” said David P. Borlas, DDS, past president of the MDA and member of the Macomb Oral Health Department Access to Care Task Force.
“The reasons for not coming, many times, are lack of knowledge, lack of a sense of urgency—‘It doesn’t hurt, why should I go to a dentist?’ ‘How about your kids?’ ‘Well, they’re not complaining either.’ We’re getting a lot of that kind of stuff. So education of the population is key,” said Borlas. “If we had dental therapists in Macomb County? They’d be standing around with their hands in their pockets next to the dentists standing around with nothing to do.”
MDA representatives also noted the disease burden among the underserved and low-income population and the complexity of the cases found there, which challenge even veteran dentists. Meanwhile, simple procedures are the most poorly reimbursed and least time consuming, leading dentists to combine them with more complex cases to improve efficiency and contain costs, the representatives said. On their own, these procedures wouldn’t cover the cost of reimbursement for dentists or for dental therapists.
Michigan additionally is home to highly trained dental students who rotate through community clinics and provide care at very little costs since it is part of their education. When these students complete their rotations, MDA representatives said, they have a new appreciation for public health dentistry and often begin their careers with positions in the field, negating the need for dental therapists.
Michael Campeau, DDS, a private practitioner in rural Fremont, also opposed the bill. After seven years of serving with federally qualified health centers, he purchased a single-doctor practice that serves about 1,800 patients of all ages. He has two hygienists, two assistants, and an office manager and participates in many insurance programs. Yet he noted that while dental therapists promise lower salary costs, small practices still have high fixed costs.
“What I’m worried about is that this new provider is going to come into a situation where they have to see 50% Medicaid patients. My office would not be able to employ one of these people because Medicaid fee for service reimbursement at the adult level is 20% of my fee,” Campeau said.
And when legislators compared dental therapists to similar midlevel providers like physician assistants and nurse practitioners, Peters noted that SB 541 would enable dental therapists to perform irreversible or surgical procedures, which those other professionals are not allowed to do in their work. Peters further acknowledged the economic challenges that the state is facing but said that Michigan needs to focus on the best solutions.
“Healthcare these days is much more of a targeted approach. Medicine, dentistry, research. It’s about treating the person, not the disease. Much like what dentistry has long advocated for, education. We are proud to be science based. We’ve come a long way since the 1800s in our research and in advancing the profession. And I see therapy as much like shooting buckshot out there, as opposed to targeting at solutions,” Peters said.
Instead, Peters said the MDA supports Michigan’s PA 161 program, where dental hygienists and dentists collaborate in providing preventive oral health services to unassigned and underserved populations. The MDA also supports expansion of registered dental assistants and further utilization of new dentists. Every resident of Michigan deserves equal access to care, Peters continued, and these solutions would be more feasible and be implemented much sooner.
As of October 10, Health Policy Committee Chairman Hank Vaupel has no plans to hold a vote on the bill, which has until the end of the year to pass the Legislature before it dies. The MDA also notes that with the November election, the Legislature has a limited schedule for the remainder of the year, and the organization does not expect to see a vote.