Pew: Expanding Dental Workforce Can Benefit Private Dental Practices

It Takes a Team, a 2010 report by the Pew Children's Dental Campaign, analyzed the impact of new types of dental providers on private dental practices. These new providers would play a role similar to that performed by nurse practitioners in the medical field.

Pew's report found that these new practitioners can make it possible for most private practices to start serving Medicaid-enrolled patients without sacrificing profitability. Most dentists do not accept Medicaid patients.

On March 2, 2011, the American Dental Association (ADA) presented an economic model of its own that disputed the conclusions in It Takes a Team.

Pew stands firmly behind its financial model and identified four concerns with the ADA's analysis.

1. An ADA-funded study reached conclusions very similar to the ones reached by Pew's It Takes a Team—delegation of care can raise a dental practice's income.

The ADA contends that a private dental practice hiring a new type of provider (such as a dental therapist or a hygienist-therapist) will experience a drop in gross billings.  However, the ADA sponsored a 2009 study that produced findings that were very similar to Pew's It Takes a Team. This study examined the impact of Expanded Function Dental Assistants (EFDAs) on private dental practices in Colorado and found that when dentists delegated some restorative duties to EFDAs, their practices' net income rose. Dental practices in Colorado that had used EFDAs in this manner had average incomes that were $126,651 higher than practices that had not used EFDAs.

We understand that the EFDA model differs somewhat from dental therapy. Even so, it is difficult to see how the ADA study could find that a dental practice can delegate some restorative tasks to EFDAs and see its income jump more than 62 percent, but delegating restorative duties to a dental therapist would cause income to fall.

2. The ADA assumes that patient demand is fixed. However, it isn't. By increasing the capacity of a private dental practice, new types of providers can expand access to those who currently aren't being served.

In its March 2 analysis, the ADA contends that adding a new practitioner to the dental team “will affect the supply of and not the demand for dental services.” However, in the ADA-funded Colorado study, patient visits measurably increased for private practices in which dentists delegated some restorative duties—fillings, for example—to auxiliary staff.

In addition, the ADA fails to recognize an artificial barrier to increasing demand—the decision by most private practices not to accept Medicaid-enrolled patients. Pew's report envisions that practices hiring a new provider could begin serving more patients, including those insured by Medicaid.

Broader Medicaid participation by dentists can raise demand, especially if a state adopts effective strategies to provide enrollees with the supports they need to successfully make and keep dental appointments.

Contrary to the ADA's assertion, Pew's model was not based on "unlimited demand for dental services." In fact, the report discusses at length how varying levels of utilization will affect the financial sustainability of new providers. Moreover, the calculator allows users to test any level of utilization they desire.

3. The ADA's model imposes an artificial ceiling on a dental practice's productivity.

The ADA predicts that adding a new type of dental provider to a solo dental practice would only increase the total number of billable procedures by 88, or 0.7 percent per year. This calculation results from the ADA's assumption that new types of providers would not perform any preventive services.

This assumption is at odds with how dental therapists currently function in Alaska and in other countries. In effect, the ADA model only allows dental therapists to perform six of the nine procedures for which they would be licensed.

In other words, the ADA has used assumptions that are almost guaranteed to produce its findings that new providers will not enhance a dental practice's productivity. 

4. The ADA misconstrues the baseline scenarios used in Pew's report.

The ADA takes issue with our report for presenting baseline scenarios for private dental practices that "assume the absence of dental hygienists." This is not the case. Our baseline scenarios reflect a simple reality that every dentist makes choices about how to build his or her practice. Although most dentists do employ dental hygienists, nearly one-third of private practices do not. Pew felt that its baseline scenarios should respect the diversity of practices by not pre-determining a dentist's choices.

Similarly, the ADA contends that the income figures in It Takes a Team differ significantly from the association's survey data. This difference can be explained simply by the fact discussed in the report—that the calculator does not take taxes into account due to the wide variations in tax rates among states and localities. Pew's calculations for pre-tax revenue are in line with ADA's own data.

Conclusion

It Takes a Team used a rigorous methodology to develop the financial model. Pew developed the report and methodology with the support of a distinguished advisory group and private-practice dentists who validated the calculator.

More than 16 million low-income children go without even basic dental care each year. Pew wants to encourage more dentists to see Medicaid-enrolled children in a financially sustainable way. It is critical that policy makers and dentists learn about the potential impact of new providers on dental practices in order to make the best decisions possible about these critical access issues.

Pew agrees with the ADA that it will take multiple solutions—including better prevention and more funding—to address the barriers to dental health that have too long undermined children's ability to learn and grow into healthy adults. But expanding the dental workforce is one of those solutions. Addressing the access issue requires that there are enough providers to see patients who currently aren't receiving care.