A Path to Expanded Dental Access in Massachusetts

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In Massachusetts. dental hygiene practitioners would increase dental access for vulnerable populations and make care more affordable.

This fact sheet was updated Nov. 19, 2015, to correct the number of Medicaid patients; March 14, 2016, to incorporate recent MassHealth and Department of Public Health data; and Jan. 25, 2017, to reflect that the bill number had changed.

In Massachusetts, the burden of dental disease is disproportionately borne by low-income residents, communities of color, seniors in long-term care, people with disabilities, and those living in rural areas and inner cities. Many in these groups struggle to access dental care, often because they cannot find a dentist who accepts public insurance, are unable to get to a dental office because of mobility challenges, or cannot afford a dentist.

Although Massachusetts has made great progress in expanding health insurance coverage among its residents and increasing the availability of primary health care,¹ the state has not had the same success in expanding access to dental care. These gaps in access have high and growing costs. When people cannot obtain dental care, they sometimes visit emergency rooms for relief; the state’s Medicaid program, MassHealth, paid $11.6 million from 2008 to 2011 for emergency room dental care for adults.² However, because ERs are not equipped to treat dental problems and usually only provide prescriptions for antibiotics and painkillers, a patient still requires a dentist to treat the underlying problem.

To ease these financial and health burdens, Massachusetts needs more providers who can deliver cost-effective dental care to those who most need it, especially in settings beyond the traditional dental office. New legislation (S.D. 1005/H.D. 2156), introduced by state Senator Harriette Chandler, Representative Kate Hogan and Representative Smitty Pignatelli, would authorize a new type of midlevel dental professional, a dental therapist in Massachusetts. Dental therapists would increase dental access for vulnerable populations and make care more affordable. This important bill presents a critical opportunity for Massachusetts to close gaps in dental access for seniors, low-income families, children, and people with special needs.

Dental therapists are dental hygienists who complete additional training in order to deliver basic but critically necessary care—such as filling cavities, placing temporary crowns, and extracting loose teeth—to underserved populations. They work under the general supervision of a dentist, using telehealth technology to share X-rays and patient records with the dentist and consult on complicated cases. This system enables them to bring care directly to people in schools, nursing homes, and other community settings.

Challenges in accessing dental care

Vulnerable groups face substantial barriers to accessing dental care:

• 47 percent of young people ages 1 to 21 (more than 290,000 individuals) who were enrolled in MassHealth did not see a dentist in 2014.³
• In 2014, only 35 percent of dentists treated a MassHealth patient and only 26 percent billed at least $10,000 to the program.⁴
• As of January 2016, more than 500,000 Massachusetts residents lived in areas with a shortage of dentists.⁵ A previous study found that residents from shortage areas were less likely than those in other areas to see a dentist.⁶

Disparities in oral health persist

Vulnerable populations have disproportionately high levels of dental disease:

• A study of schoolchildren living outside Boston found that 40 percent of children in pre-K through fourth grade had a history of tooth decay, and 23 percent had untreated decay in the 2008-09 school year. Asian, African-American, and Hispanic students had significantly higher rates of untreated decay than their white peers.⁷
• One study found significant differences in Massachusetts oral health status by county in 2007. The proportion of kindergarten-age children with untreated dental decay ranged from 8 percent in Norfolk County to 31 percent in Hampshire County. For third-grade children, untreated dental decay ranged from 13 percent in Middlesex and Plymouth counties to 31 percent in Suffolk County.⁸
• In 2014, low-income seniors were seven times more likely to have lost all their teeth than seniors with household incomes exceeding $75,000. African-American seniors were twice as likely as their white counterparts to have lost all their teeth.⁹
• 59 percent of Massachusetts seniors (age 60-plus) in long-term-care facilities had untreated decay in 2009.¹⁰
• 30 percent of adults with disabilities in Massachusetts were missing six or more teeth in 2014, compared with 10 percent of those without disabilities.¹¹ Midlevel providers deliver quality care and improve access.

Midlevel practitioners have been providing preventive and basic restorative care in a variety of settings (private practices, community health centers, schools, nursing homes) in the United States since 2004, when they began serving native communities in Alaska. They started working in Minnesota in 2011, and Maine authorized them in 2014. In Minnesota, the state Board of Dentistry and Department of Health reported that dental therapists provide safe, high-quality care in rural and underserved urban settings and that clinics employing them are expanding capacity and decreasing travel and wait times for patients.¹²

• In Alaska, dental therapists have increased access to care for 40,000 people living in 81 rural communities.¹³
• In one case study, two dental therapists generated more than $216,000 in estimated net revenue after accounting for employment costs, including full-time dental assistants.¹⁴ Savings from the lower costs of dental therapists have allowed Minnesota dental practices to treat more Medicaid and uninsured patients. One private practice that employs a dental therapist made an additional $24,000 in profit and served 500 Medicaid patients in the therapist’s first year, even though the state has the lowest pediatric dental reimbursement rate in the country.¹⁵

Massachusetts lawmakers can help more low-income children, seniors, and other vulnerable people in their state get the dental care they need by passing S.D. 1005/H.D. 2156.

Endnotes

1. Kaiser Family Foundation, Massachusetts Health Care Reform: Six Years Later (May 2012), https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8311.pdf.
2. Center for Health Information and Analysis, “Massachusetts’ Emergency Departments and Preventable Adult Oral Health Conditions: Utilization, Impact and Missed Opportunities (2008-2011)” (2012), http://www.chiamass.gov/assets/docs/r/pubs/12/dental-ed-report.doc.
3. This figure counts young people ages 1 to 21 eligible for the Early and Periodic Screening, Diagnostic, and Treatment Benefit—Medicaid’s mandatory health benefit for children—who received any dental service. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Annual EPSDT Participation Report, Form CMS-416, (State) Fiscal Year: 2014, accessed July 29, 2015, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html.
4. Participation calculated as a percent of professionally active dentists in Massachusetts. American Dental Association via Redi-Data via Kaiser Family Foundation, State Health Facts: Professionally Active Dentists (September 2014); Tracy Gilman, executive director, MassHealth, DentaQuest, via email to The Pew Charitable Trusts (Jan. 22, 2016).
5. U.S. Department of Health and Human Services, Health Resources and Services Administration, Designated Health Professional Shortage Areas Statistics (Jan. 1, 2016), http://datawarehouse.hrsa.gov/Tools/quickreports.aspx.
6. Massachusetts Department of Public Health, Office of Oral Health, The Status of Oral Disease in Massachusetts: A Great Unmet Need (Boston: 2009), http://www.mass.gov/eohhs/docs/dph/com-health/oral-health-burden.pdf.
7. Cambridge Public Health Department, Children’s Oral Health Surveillance Report 2000–2009: A Summary of the Cambridge Healthy Smiles Screening Program (2013), http://www.cambridgepublichealth.org/publications/Oral%20Health_Youth%20Report_2013-07-30.pdf.
8. No data were available for Barnstable, Dukes, and Nantucket counties. Catalyst Institute, The Oral Health of Massachusetts’ Children (January 2008), http://www.bu.edu/creedd/files/2009/05/Oral-Health-Of-Massachusetts-Children-2008.pdf.
9. Ta-wei Lin, epidemiologist, Massachusetts Department of Public Health, unpublished data from the 2014 Behavioral Risk Factor Surveillance System survey, email to The Pew Charitable Trusts (Feb. 10, 2016).
10. Massachusetts Department of Public Health, Office of Oral Health, The Commonwealth’s High-Risk Senior Population: Results and Recommendations From a 2009 Statewide Oral Health Assessment (Boston: July 2010), http://www.mass.gov/eohhs/docs/dph/com-health/oral-health/senior-oral-health-assessment-report.pdf.
11. Massachusetts Department of Public Health, A Profile of Health Among Massachusetts Adults, 2012: Results From the Behavioral Risk Factor Surveillance System (April 2014), http://www.mass.gov/eohhs/docs/dph/behavioral-risk/report-2012.pdf.
12. Minnesota Department of Health and Minnesota Board of Dentistry, Report to the Minnesota Legislature 2014: Early Impacts of Dental Therapists in Minnesota (February 2014), http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf.
13. Native Health News Alliance, “Other States Considering the Alaska Midlevel Dental Model,” accessed March 9, 2016, http://www.nativehealthnews.com/alaska-dental-health-aide-therapists-mark-10-years-in-practice-provided-expanded-access-to-40000-alaskanative-people.
14. The Pew Charitable Trusts, Expanding the Dental Team: Increasing Access to Care in Public Settings (June 2014), http://www.pewtrusts.org/~/media/Assets/2014/06/27/Expanding_Dental_Case_Studies_Report.pdf.
15. The Pew Charitable Trusts, Expanding the Dental Team: Studies of Two Private Practices (February 2014), http://www.pewtrusts.org/en/research-and-analysis/reports/2014/02/12/expanding-the-dental-team; American Dental Association, Health Policy Institute, “A Ten- Year, State-by-State Analysis of Medicaid Fee-for-Service Reimbursement Rates for Dental Care