Alternative Dental Provider Models - Academy of General Dentistry

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Alternative Dental Provider Models - Academy of General Dentistry

Alternative Dental

Provider Models

A State Advocacy Tool Kit

Background

An alternative dental provider model is a model of oral

health care delivery that utilizes a nondentist, acting

outside the direct supervision of a dentist, as a primary

provider of dental care.

While various alternative dental provider models have

been proposed in different states, all models promote

the position that the creation and incorporation of new

nondentist dental providers within state rules, regulations

or statutes, is essential to improving access to oral health

and improving the oral health status of Americans.

Proponents of alternative dental

provider models

Three sectors of the dental marketplace are currently driving

the movement for alternative dental providers: public health,

dental educators, and mid-level professional organizations.

These segments also promote faulty presumptions regarding

the challenges to improving oral health and the role that

new nondental providers will play. These presumptions are

discussed below.

Proponents of alternative dental provider models who

have voiced support for alternate dental provider models

and may advocate for these models in your state include The

Pew Center on the States, W.K. Kellogg Foundation, the

American Association of Public Health Dentistry (AAPHD),

the American Dental Education Association (ADEA), and

the Institute of Medicine (IOM).

Alternative dental provider models

The two leading alternative dental provider models that are

likely to be proposed in your state are the dental therapist

and the advanced dental hygiene practitioner (ADHP).

Additionally, the American Dental Association (ADA) has

presented an alternative to dental therapists or the ADHP in

its community dental health coordinator (CDHC).

1

Dental Therapists

Dental therapists (dental health aide therapist [DHAT]

and variations thereof) are favored by The Pew Center

on the States and the W.K. Kellogg Foundation, and are at

the forefront of the race for new nondentist providers.

Minnesota’s dental therapist models provide the blueprint

for most alternative proposals in the contiguous states.

In 2009, Minnesota passed legislation creating two types

of providers: the dental therapist who works within a practice

under the indirect or direct supervision of a dentist, and

the advanced (master’s level) dental therapist who works

remotely under the general supervision of a dentist. Both

may perform irreversible dental procedures.

It should be noted that Minnesota is the only state in

which non-dentist providers can practice independently

upon the general population, rather than being relegated

to treating tribal populations only. The Minnesota

practitioners were modeled after New Zealand, British, and

Canadian dental therapists.

2

ADHP

The ADHP, created by the American Dental

Hygienists Association (ADHA), may diagnose and

treat patients, including the restoration and extraction of

teeth, under general or no supervision of a dentist.

The Pew Center on the States has cast some doubt upon

the ADHP. In its report, “Help Wanted: A Policy Maker’s

Guide to New Dental Providers,” Pew voiced concern that

independent hygienists may not be able to afford to practice

in underserved areas.

June 2012 | www.agd.org | AGD Advocacy tool kit 1


3

CDHC

The ADA’s CDHC primarily provides education

and prevention under general, indirect, or direct

supervision, but leaves the door ajar for some treatment,

including scaling and excavation. However, the CDHC

has failed to gain significant traction and is unlikely to be

proposed in your state.

Faulty presumptions presented by

proponents of alternative models

A fundamental presumption relied upon by advocates of new

providers is that there will be a shortage of dentists.

The ADEA presented this presumption as fact in 2007;

as support, ADEA cited Dr. Jackson Brown’s ADA article,

“Selling Your Practice at Retirement: Are There Problems

Ahead?” (2000), to assert that, in the coming years, only one

dentist will graduate for every two dentists who retire.

However, with numerous new dental schools opening, and

many dentists with empty chairs, the truth is that there is not a

shortage of dentists but only an uneven distribution of dentists.

Pew and other proponents also assert that dentists simply do

not want to practice in underserved areas or accept Medicaid

patients. Pew has repeatedly gone on the record as saying

that the rate of dentists accepting Medicaid is lower than

that of physicians; however, they fail to make any mention

of the differences in Medicaid coverage and reimbursement

rates between medicine and dentistry. While the Kellogg

Foundation echoes Pew’s characterization of dentists’ unwillingness

as a challenge, ADEA has not yet broached this subject.

A third presumption shared by the proponents of midlevel

providers is that an area can be deemed to be underserved

solely by examining the dentist-to-patient population

ratio, without consideration of practice capacity. However,

dentist-to-patient ratios used by proponents are outdated

and fail to consider technological advances and the increase

in capacity produced by the use of existing mid-level providers—dental

assistants, hygienists, and expanded function

dental assistants (EFDAs)—within the dental team under

the supervision of a dentist.

Additionally, proponents of alternative models have promoted

the following faulty presumptions, arguments that

you may hear or read in your state:

1. The new providers will practice in underserved areas.

2. The new providers are not truly independent practitioners,

but collaborative practitioners.

3. The new providers are still a part of the dental team and

will preserve and expand the prevention aspect.

4. The new providers fit into the dental home concept

by bringing the dental home to where the

underserved reside.

5. The new provider models provide safe care (Note:

Although Kellogg alleged that the Alaska DHAT had

proven to be safe, the Kellogg study was very limited in

scope and did not prove that the new provider models

were in fact safe).

6. The new provider models have successfully improved

oral health status in other countries and will therefore

work in the United States.

Rebutting the myth of the alternative

provider solution

In 2008, the Academy of General Dentistry (AGD) adopted

its “White Paper on Access to and Utilization of Oral Health

Care Services,” decrying the advances of independent midlevel

providers as obstacles that detract from the funding and

effort to further more than 30 proven solutions.

Since then, arguments presented in various states by

proponents of mid-level provider models have grown

increasingly more sophisticated. Notably, these entities do

not always claim a move toward independent practice, nor

do they claim to offer an alternative to the traditional dental

team model.

Independence from dentists has been rephrased as an opportunity

for expanded collaborations with dentists. Proponents

tout the Minnesota therapist models, which market advanced

dental therapists as off-site practitioners who work in collaboration

with dentists, not as independent practitioners.

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The divided dental

team concept proposed

by new provider

proponents creates too

many opportunities

for lapses in patient

diagnosis, planning,

and treatment.

Suzanne Beatty, DDSa dentist and curriculum coordinator

at Metropolitan State University for the advanced dental

therapist master’s program stated, “There are so many people

who are underserved. This [the advanced dental therapist]

would free up the dentist to do more complex procedures.

It’s not an independent practice. It’s part of a collaboration.”

Therefore, refocus your response on detailing the nature

of specific procedures that are likely to trigger the need

for a dentist to be readily available on-site (direct supervision),

rather than to take a defensive approach that seeks

to dismiss independent practice.

The proponents’ re-characterizations compel the AGD and

other organizations that stand for the preservation of the oral

health of the public to concentrate on the most fundamental

elements that generate concern about patient health and

safety. Simply echoing or restating terms such as “independent

mid-level provider” may not be effective much longer.

Instead, explain that the minimal level of “collaboration”

that is necessary to ensure the safety of the patient is

the direct supervision by a licensed dentist.

Further, rather than offering an alternative model of

oral health care delivery, proponents of the new practitioners

claim an enhancement of the “dental team concept.”

Advances in technology have also allowed these entities to

claim that teledentistry, historically a term indicating consultation

between a generalist and specialist, for example, allows

for an expansion of supervision.

Proponents of new providers argue that the dental team

concept is enriched by the addition of a nondentist who

can remotely collaborate with the dentist without his or her

direct supervision.

It may be beneficial to focus your response on the fact that

expansion of the dental team to include nondentists who

treat patients without the direct supervision of a dentist

undermines the most fundamental tenet of the dental

team concept—patient safety through the supervision of

a licensed and educated dentist—which has proven to be

the beacon of success of the prevention model.

The cohesive and concurrent acts of practitioners of different

levels of education and expertise, under the direction of a

dentist trained for that purpose, create the symbiosis needed

to ensure the integrity of each patient’s health.

Intentionally splintering the dental home constitutes

poor parenting of the oral health of the public and is mere

steps from possible neglect.

The divided dental team concept proposed by new provider

proponents creates too many opportunities for lapses in

patient diagnosis, planning, and treatment: The insufficient

training of the first point of contact (a nondentist without

direct supervision) will create a burden on the next point

of contact and the entire system, all the way down the line,

from the general dentist who must correct the alternative

provider’s errors which stem from a lack of training, all

the way to the specialist to whom the general dentist may

refer when the patient’s disease state is especially critical or

advanced, with each level adding to the cost of care.

With a alternative practitioners passing the baton to the

dentist, the alternative providers’ version of a dental team

functions as a relay team of sorts; this is not in the best interest

of the patient.

Further, it’s notable that none of the guidelines, articles,

and other documents produced by proponents of alternative

providers appears to challenge what the ADA Commission

on Dental Accreditation (CODA) has set out as minimal

competencies for graduating practitioners who can competently

practice dentistry.

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Failure to meet CODA’s minimum educational standards

for a dentist renders any alternative dental provider model

unsafe to provide those services currently relegated to

dentists without a dentist’s direct supervision.

Alternative provider models target those patients in

rural communities and of low socio-economic status.

These populations exhibit the greatest rate of medical

complications and therefore need health care providers

with the greatest of expertise.

Last, but not least, proponents of alternative providers

have not disagreed with our focus on oral health literacy and

patient utilization. Studies to develop benchmarks and data

on current and desired patient utilization, both in private

and public markets, may place the AGD in a significantly

stronger position to promote its long-standing and proven

solutions over these new provider proposals that may actually

jeopardize patients’ well-being.

Remind your state of the proven solutions presented

in the AGD’s White Paper, and the wisdom in funding

solutions that work, rather than experiments that may

not work.

Advocating in your state

Successful dental advocacy requires knowledge and action.

Now that you understand the issue, it’s time to take action,

which can be as simple as:

• Responding to a Capwiz action alert

• Visiting legislators

• Telephoning a legislator’s office or connecting with staffers

• Attending town hall meetings or fundraisers (maybe even

hosting one)

• Encouraging your colleagues to voice their concerns

• Presenting testimony at hearings

Each of these actions is easy and can be successful—

especially if it’s combined with the voices of your colleagues.

Become aware, educated, and informed

Becoming an effective dental advocate is easier than you

think. A little research, a little practice, and a little networking

are all that it takes to become a skilled representative

of—and for—your profession and the patients that you and

your colleagues serve.

Much of the basic information you need to know has

already been covered within the context of this tool kit. Of

course, you will need to read and become familiar with the

specific legislation being considered by your state legislature

or dental board. That information can be found on the

agency’s website, via the AGD’s StateNetmapTrac feature, or

through the AGD advocacy staff. Contact AGD advocacy

staff at advocacy@agd.org to request information.

Build grassroots support

While the AGD is the eyes, ears, and voice of the general

dentist, its representation of you and your profession are only

as strong as the involvement of individual members.

Since the AGD recognizes that constituents have limited

resources, the Government Relations staff at AGD

Headquarters monitors legislation and regulations relevant

to dentistry at the state level. They do this through a subscription

to State Net, an online service that monitors state

legislation and regulations, and provides regular updates on

key terms relevant to dentistry.

The AGD encourages each constituent to appoint a legislative

chairperson to monitor important issues and to alert the

board of any pending legislation and/or regulation that could

be problematic. In many cases, this individual also serves as

the conduit for promoting discussion with the state dental

association and other professional groups that might have a

stake in the issue.

Be sure not to overlook your state dental board since this

agency determines what is and is not allowed within the

various scopes of practice. Because this agency is so important,

AGD constituents are encouraged to have a member

appointed to the board or, at the very least, to have a

member attend dental board meetings to monitor the topics

discussed and to present testimony when appropriate.

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Cultivating relationships

is the cornerstone of any

successful grassroots

advocacy campaign.

Regardless of whether your constituent has a constituent

legislative chairperson or a connection to the state dental

board, it’s critical that grassroots members get involved. So

how do you do that? Start by getting the word out. Tell your

constituent members about the issue. Explain how it will

impact their patients. Tell them what they can do to communicate

their concerns. And reassure them that it’s easy to do.

One of the easiest things members can do is contact their

legislators regarding pending votes and major initiatives.

They can do this by using Capwiz, an online communication

vehicle that allows AGD members—and even their

colleagues and patients—to share their opinions about

important topics with state and federal legislators. In most

cases, constituent leaders work in partnership with AGD

Headquarters’ staff to develop blast emails and Capwiz action

alerts that members can email directly to their legislators.

Capwiz is available under the “Advocacy” tab on the

AGD’s website (www.agd.org) and can be found by clicking

on “Government Relations,” and then selecting the “Contact

Lawmakers” tab. Members will be asked to enter some basic

contact information and Capwiz will automatically identify

their legislators’ names, contact information, political affiliations,

voting records, and more.

Each time the AGD issues an action alert, members can

click through the blast email message to a webpage that contains

the message to send to legislators. Members can use the

text provided or customize the message. The entire process

takes just a few minutes.

Communicate any updates or new information to your

members via your constituent newsletter, website, Facebook

page, etc. Highlight any positives, including any members

who received responses from their efforts to reach out since

that might encourage other members to participate the next

time an action alert is issued.

Build coalitions

Cultivating relationships is the cornerstone of any successful

grassroots advocacy campaign. It doesn’t matter if those relationships

are with legislators, their staffers, leaders of other

dental associations, or members of other professions who

care about the issue.

Coalitions can make a difference as there is strength

in numbers and since other members might have access

to valuable information that can be shared with legislators.

Your constituent and your state dental association

likely already have an established relationship, which in

most cases can be used to send a strong and powerful

message to legislators.

Reach out to your legislators

Reaching out to legislators can be easy; after all, they’re

people too. Most legislators are deeply committed public servants

who want to:

1. Make effective public policy; and

2. Make decisions that will get them re-elected.

You and your general dentist colleagues are in an enviable

position to influence legislation since you are committed to

removing the barriers that prevent the public from getting

the safe, high-quality oral health care that everyone deserves.

Think about it: that’s just good public policy.

You also wield influence as a voting member of your legislator’s

constituent, and your legislator wants to hear from you

regardless of whether or not you supported his or her candidacy.

If you can, schedule a personal visit with your legislator

since face-to-face discussions are always the most effective

form of communication.

The state legislative process is essentially the same as the

federal process, with three primary differences:

• The lengths of legislative sessions vary by state, as some

meet for almost the entire year, while others meet for just a

few months, and still others meet for half the year.

• Some states require bills to be reintroduced in each legislative

session, while others allow bills to be carried over from

one legislative session to the next.

• The titles given to the legislators vary. Some are “assemblymen”

while others are “representatives” or delegates.

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State lawmakers can introduce bills or resolutions. A bill

is a proposal to enact new legislation or to amend an existing

statute. A resolution is a legislative proposal for an action

that does not affect statutory law. Bills are introduced and

sent to the appropriate committee for action, where the issue

is discussed, debated, and where public hearings might be

held. It is here, at the committee level, where you, as a citizen

of your state, have the opportunity to influence the outcome

of proposed legislation.

Since you already know about the issue and any specific

bills or resolutions that have been proposed in response to

it, it’s time to schedule a meeting with your legislator. First,

develop an agenda and determine what you want to accomplish.

Know your legislator’s position on the issue so you can

customize your remarks to gently redirect his or her position.

Then, practice your “pitch” and be sure to include relevant

personal anecdotes that illustrate your point and that position

you as a knowledgeable and caring professional.

Keep the meeting brief and stay on point. Introduce yourself

and state your case. Offer your solutions and explain why

they present better outcomes. Be polite if he or she declines

to commit on the spot. Leave a one-page fact sheet on the

issue, printed on your business stationery, and offer to provide

any other information that might be useful.

Be sure to send a thank you note after the meeting. Use

that note as an opportunity to remind the legislator about

areas where you were in agreement, to present any promised

information, and to again offer to serve as a resource on this

proposal and any future health care legislation.

Make this first meeting with your legislator the start of a

long-term relationship. Reach out to your legislator again

in the future, even on other issues. Doing that will help you

develop a positive relationship and could one day result in

your legislator reaching out to you for input.

Testify before state boards or legislature

Presenting testimony in front of your dental board or legislators

need not be intimidating. Odds are you’re already an

experienced public speaker who’s addressed the AGD House

of Delegates, members of a civic organization, an educational

board, etc. Here are some tips for successfully communicating

your position to a legislative or regulatory committee.

First, keep in mind that actually presenting the testimony

isn’t the real first step. The first step is determining how to

get on the roster of individuals presenting testimony.

Now identify the purpose of your testimony. You already

know the issue, the specific legislation being considered, and

what its impact will be. Your objective is to gain support for

Your advocacy

efforts in your state

are fundamental to

halting the potentially

dangerous spread of

alternative provider

models.

legislation you support, or to dissuade legislators from supporting

legislation you oppose. It’s helpful to know in advance

which legislators are on which side of the fence, as well as

which have a leg dangling over each side of that fence.

Next, develop a written statement. While you won’t read

that statement to the committee, you can share photocopies

of your statement (on your professional letterhead) with the

committee members so they can review it once the hearing is

completed. Be sure your written statement contains accurate

facts and data that support your position.

Use your written statement to prepare note cards to use

during your testimony. Do not read your testimony and do

not ad-lib your remarks. Keep your verbal testimony brief

and to the point, generally between three and five minutes

in length. Allow time to thank the committee for the opportunity

to speak, and to give your name, and the name and

purpose of the organization that you represent. State whether

you support or oppose the legislation being considered.

Speak in a conversational tone and make eye contact with

each member. Try to include real-life examples that support

your position. When opposing a bill, open and close your

remarks with positive comments about the legislature’s interest

in addressing a problem that impacts many citizens. The

middle of your presentation should offer workable solutions,

not complaints. Of course, if you support the proposed legislation,

your remarks can be brief.

Close your testimony with another thank you and ask if

members have any questions. Be prepared to answer questions

that might be intended to support opposing viewpoints.

Keep your answers brief and if you don’t know the

answer, offer to research the answer and then be sure to

follow-up and provide it to committee members.

Your advocacy efforts in your state are fundamental to

halting the potentially dangerous spread of alternative provider

models. Please check out the resources provided below,

and contact AGD Advocacy staff at advocacy@agd.org if

you have any questions.

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Available Resources

The Academy of General Dentistry (AGD) offers its members many resources to guide them in effective advocacy at the

local, state, and federal levels. Many of those valuable resources are highlighted here:

“White Paper on Increasing Access to and

Utilization of Oral Health Care Services”

This document presents workable solutions in response

to many of the barriers to care reported by patients in

communities across the country.

The Academy of General Dentistry Position

on Workforce Issues

Only the dentist has the education and training

necessary to form a diagnosis, create a comprehensive

treatment plan, and perform irreversible procedures.

Direct supervision of the dental team by the dentist

is critical to ensuring the safety and well-being

of the patient.

Dental Assistant and Dental Hygienist

Duties and Functions

The level of supervision required and the duties allowed

for dental assistants and dental hygienists varies greatly

from state to state. See how your state measures up.

National Legislation

The AGD publishes regular updates on national legislation

that may affect general dentists.

CAPWIZ Manual

Facilitate education about the issues and boost member

involvement in legislative issues via Capwiz.

Legislative Manual

This handbook can help your constituent work with the

AGD Legislative & Governmental Affairs Council to

represent the state legislative and regulatory interests of

general dentists.

Primer on Collaboration Between

ADA and AGD Constituents

This primer highlights the benefits to emphasize the

need for greater collaboration between ADA and AGD

constituents so that AGD constituents can be an effective

voice for general dentists in their respective states.

Advocacy Policies

Access the AGD’s advocacy policies, including legislative

and dental care policies, which affect general dentistry

and advance the profession and allied agencies involved in

the maintenance and improvement of quality dental care.

State Legislation

This weekly state legislative update details local legislation

of interest to the profession.

Contact Lawmakers

Make your voice heard by participating in email

campaigns to lawmakers about legislation or simply

inform yourself about the issues by reading the brief

descriptions.

June 2012 | www.agd.org | AGD Advocacy tool kit 7


AGD Articles on Alternative Provider Models

CURRENT ISSUES

Legislation Prevents Funding for Mid-Level Providers

www.agd.org/issuesadvocacy/hotissues/Default.asp?PubID=113&IssID=1414&ArtID=10040

Dentists in MO Say NO to 2 Tiered Oral Health Care Delivery System

www.agd.org/issuesadvocacy/hotissues/Default.asp?PubID=113&IssID=1362&ArtID=9554

Get Engaged and Commit to Your Profession

www.agd.org/issuesadvocacy/hotissues/Default.asp?PubID=113&IssID=1426&ArtID=10182

STATE/FEDERAL LEGISLATION

Senate Defeats Funding for Mid-level Provider Demonstration Program

www.agd.org/issuesadvocacy/advocacynews/nationallegislative/Default.asp?PubID=1&IssID=1325&ArtID=9210

Members Promote AGD to the Public

www.agd.org/IssuesAdvocacy/AdvocacyNews/stateLegislative/Default.asp?PubID=1&IssID=1452&ArtID=10442

AGDTRANSCRIPT

An Opinion on Access to Care Solutions

www.agd.org/support/articles/?PubID=47&IssID=1011&ArtID=5937

Solutions for State Dental Boards on Access to Care

www.agd.org/education/transcriptnews/Default.asp?PubID=47&IssID=957&ArtID=5278

CONSTITUENT PAGES

Mid-Level Dental Providers in Missouri?

www.agd.org/constituent/main/?CHAP_ID=MO

Webinar: The Relationship Between Dentists and Their State Dental Boards.

Presentation by Dr. Malcmacher

www.agd.org/files/webuser/website/constituent/leaderresources/malcmacher_presentation.ppt

Dentists and State Boards podcast October 17, 2011

www.agd.org/files/dept/CST/Relationship%20between%20Dentists%20and%20State%20Boards.mp3

Webinar: Keep Alternative Providers From Making Inroads in Your State

Presentation by Dr. W. Carter Brown and Dr. Myron “Mike” J. Bromberg: Making Inroads

www.agd.org/files/webuser/website/advocacy/keep alternative dental providers from making inroads in your state

webinar nov 10 2011 cb.ppt

AGD IMPACT & NEWS RELEASES

AGD Again Speaks Out Against W.K. Kellogg Foundation and New No-Dentist Provider Models

www.agd.org/about/newsmedia/pressreleases/Default.asp?PubID=45&IssID=1415&ArtID=10019

Questioning the Need for Independent Mid-Level Providers, AGD Impact

www.agd.org/files/webuser/website/advocacy/questioning the need.pdf

8 AGD Advocacy tool kit | www.agd.org | June 2012

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