BACKGROUND INFO

QUESTION


Who is Dental Care for Arizona?

ANSWER


  1. We represent and are continuing to build a broad coalition of diverse interests in support of dental therapists (DTs). Our supporters range from Tribes to the Goldwater Institute to rural business interests and the Arizona Farm Bureau, to name but a few. People across Arizona know the urgent need for increasing access to preventative care at lower costs and understand that DTs are a viable way to alleviate this crisis without the need for new government agencies or programs, and at lower costs that create new opportunities for Arizona’s dentists and its workforce.

QUESTION


How long have there been efforts in Arizona to license Dental Therapists?

ANSWER


  1. The Member Tribes of the Inter-Tribal Association of Arizona (ITAA)—21 tribal governments in Arizona—have long supported the Community Health Aide Program (CHAP), a program that was developed in the 1960s to respond to a number of health concerns in Alaska. The ITAA adopted a resolution in 2007 supporting the Indian Health Care Improvement Act (IHCIA) to include dental therapists (DTs) in CHAP.61 Unfortunately, IHCIA was amended in 2010 as part of the Affordable Care Act and it prevents the use of DTs in Tribal Communities (outside of Alaska) without approval by a state legislature.62
    The ITAA unanimously adopted a resolution to support the dental therapy sunrise application in November of 2016.63 The Naabik’iyati’ Committee of the Navajo Nation Council similarly adopted a resolution in support of the sunrise application in 2017.64
  2. There are as many as 100 different groups working to improve oral healthcare in Arizona, from both a health and workforce focus. If we are to move the needle in Arizona, we need continued focus on prevention and education, screening and coordination, and a modernized delivery mechanism for high quality oral healthcare.
  3. Dental Care for Arizona’s efforts, which include the Tribes as well as other organizations actively working toward these same goals, began late this summer. The coalition was created to serve as a vehicle to bring various supporters across the political and healthcare spectrum together.

QUESTION


Why the push for dental therapy?

ANSWER


  1. During the great recession, Arizona froze enrollment in KidsCare, the state’s Children’s Health Insurance Program (CHIP), and eliminated the adult dental benefit from the Arizona Health Care Cost Containment System (AHCCCS) the state’s Medicaid program. This past year, the legislature voted to restore KidsCare, which will provide benefits to 30,000 children statewide, and reinstate an emergency adult dental care benefit (emergency dental services and extractions up to $1,000).65 They also voted to authorize funds to provide $1,000 per person annually for dental services, including diagnostic, therapeutic, and preventive services and dentures, to Arizona Long Term Care System (ALTCS) members, age 21 and older.66 As we bring people back under the state’s Medicaid/CHIP program, the fiscally responsible approach is to allow dentists to use midlevel dental providers to minimize the financial burden of treating more people with lower reimbursements. Dental therapists lower the per-unit cost of care, allowing dentists to serve more Medicaid patients with the revenues they collect.
  2. Arizona is geographically large and diverse, with the vast majority of residents living in Maricopa and Pima counties. However, every one of Arizona’s 15 counties has at least some portion designated as a dental health professional shortage area.67 Living in a shortage area is just one of the many barriers Arizonans face to accessing dental care.68 Often, people cannot find a dentist who accepts public insurance, while others cannot get to a dental office due to mobility or transportation challenges.69 And many people, regardless of insurance status, are unable to afford the costly price of dental services.70 Research shows that oral health is connected to overall health.71 As such, it is time to start looking at mechanisms that will deliver quality care to diverse populations in a variety of settings using a variety of service delivery mechanisms.
  3. In the states that utilize dental therapists, it has been demonstrated that these practitioners safely and effectively increase access to care cost-efficiently. As required by Minnesota law, the Minnesota Board of Dentistry and the Department of Health issued a report on the impacts of dental therapists in the state. This report found that clinics and offices that employed dental therapists experienced many positive outcomes including:72
    1. Expanded capacity to serve more underserved patients due to cost savings;
    2. Decreases in travel times and wait times;
    3. Decreases in no-show rates;
    4. Increased productivity of the dental team; and
    5. High levels of patient satisfaction.
  4. Nowhere in Arizona is the gap in access to dental care more acute than in tribal communities. In Arizona, 76% of American Indian children have a history of tooth decay.73 Arizona is home to 22 individual sovereign nations with over 370,000 people living on and off tribal reservations.74 Alaska Native communities were similarly experiencing access challenges, and the introduction of dental therapists to their dental teams in 2004 has dramatically helped. Since then, 45,000 people in 80 previously underserved communities now have access to regular dental care.75

QUESTION


What is the Committee of Reference (COR) and when is the hearing around the sunrise application happening?

ANSWER


  1. The Committee of Reference (COR)—subsets of the House and Senate Health Committees—will hear testimony in late fall 2017 and make a recommendation to the full Arizona legislature on whether or not legislation to create scope of practice and licensure for dental therapy should be considered. This 10-member committee will have a significant say in whether or not the other 80 members of the State House and Senate will be able to consider and debate this proposal.

QUESTION


What happens if the COR approves the Sunrise Application?

ANSWER


  1. Following the COR, legislation will be drafted and introduced in the 2018 legislative session. Together with the stakeholders, Dental Care for Arizona will coordinate the development of a bill draft that will be flexible enough to meet the needs of the various interests at the table while also increasing access to dental care and ensuring high-quality education, training, continuing education and licensure standards.
  2. Because of the urgent need for this proven dental care delivery model, if the 10 members of the COR continue to prevent the full legislature from debate this issue, we will consult with stakeholders in our broad, bi-partisan coalition about our efforts during the 2018 legislative session.
  3. While the COR hearing is about deciding whether or not to recommend that the full Arizona legislature should consider legislation to create a scope of practice and licensure for dental therapy, the Dental Care for Arizona coalition feels strongly that this 10-member body should allow the other 80 members of the State House and Senate to consider something that would have such an important impact on access and cost of dental care for all Arizonans.

QUESTION


How does the Arizona proposal compare to dental therapy proposals in other states?

ANSWER


  1. Each state law to implement dental therapists has included unique facets and components to meet the state’s oral health needs, respond to political concerns, and ensure the educational institutions have the guidance they need to create training programs. Currently, the model proposed in Arizona is one of the most free market proposals, and includes the fewest restrictions on dental therapy practice locations of any state that has considered this model. Arizona, because of its rural and remote areas, would greatly benefit from this free enterprise solution to its dental access crisis.

QUESTION


How receptive has the legislature been? Governor?

ANSWER


  1. Thus far, policy makers have been receptive to both the free market solution dental therapists present and increasing access to quality care at lower costs via dental therapy. This is a new proposal for Arizona law makers and we are preparing to seat a new House and Senate in January. Education will be key to these efforts, as will the broad stakeholders interested in improving oral healthcare in Arizona.

IMPACT

QUESTION


What would the impact be if dental therapists get the go-ahead to practice?

ANSWER


  1. There would be many impacts, not all of them predictable. But immediately, Tribal and Indian Health Service (IHS) facilities could bring in dental therapists from other states, as IHS already has a classification for dental therapists (in the IHS system, the term is Dental Health Aide Therapist or DHAT).
  2. Also, Arizona has eight CODA accredited dental hygiene programs that could develop training programs and apply for dental therapy program accreditation. In addition, national dental therapy experts have developed a sample open-source curriculum with the American Association of Community Colleges to assist in the program design and implementation of dental therapy around the country.
  3. Arizona Dental Hygiene Association supports this proposal, as it will expand professional opportunities for the existing dental health workforce in Arizona.
  4. But, as you know, laws alone do not make change, people make the difference, and that will take time to implement. Changing the law will empower a broad range of groups, professionals, dentists and health care providers the change to make a difference in the near and long term future for all of Arizona.

QUESTION


How far would licensing dental therapists go in making a dent in dental health care shortage areas?

ANSWER


  1. Dental therapists CAN go a long way to increasing access to high quality care across Arizona, but especially in rural areas. Few dentists choose or prefer to work in rural areas. Regardless of financial resources, individuals in these areas have to travel long distances to see a dentist, if one is even available. Dental therapists, working in conjunction with dentists, can fill in these gaps to treat the most common needs and increase access to preventative and basic restorative care. Dental therapists can travel to rural areas to provide services while their supervising dentist remains in the office. They utilize teledentistry when they provide services outside of the office, receiving guidance from their supervising dentist. Any procedures that dental therapists discover beyond their scope of training and practice are referred to dentists. Here is a map that shows just how concentrated most dentists are within Arizona’s metro areas.
  2. Approximately half of dental therapists in Minnesota practice outside of the Twin Cities metro area, including in rural and remote areas of the state, which significantly increases the availability of dental care in areas with few dentists or in areas where dentists cannot meet the demand.76 A 2014 Minnesota report showed that in the study clinics seven full-time equivalent dental therapists served 6,338 new patients in the first two years dental therapists practiced. Further, nearly one-third of patients in practices employing dental therapists experienced reductions in travel and wait times since the start of the dental therapists’ employment, especially in rural areas.77

QUESTION


What will the education and training model be for dental therapists to be certified in Arizona?

ANSWER


  1. The coalition has been working with the CODA accredited dental hygiene schools to make them aware of the potential to authorize dental therapists in Arizona. We continue to ensure these programs are involved in the development of dental therapy legislation for Arizona and that their education and training recommendations are addressed.
  2. The American Association of Community Colleges recently prepared a sample curriculum and guideline for how the CODA standards can be crafted into a real licensing program. The goal with legislation is to authorize the provider to be licensed and practice. We look to our Arizona educational institutions to be the experts on what kind of program their students would be interested in, and how to structure that program to provide career ladders to former, existing and future students.

QUESTION


In Arizona, how much would this lessen the expensive problem of people going to the emergency departments (ED) for oral health problems?

ANSWER


  1. In 2014, there were over 26,800 visits to the ED for dental conditions that could have been avoided with routine dental care.78 Using national per visit cost data, these visits represent a total estimated cost of $20.4 million.79 Arizona Medicaid (Arizona Health Care Cost Containment System or AHCCCS) paid for 56%—over 15,000—of these visits.80
  2. Unfortunately, receiving dental care in the ED is not only expensive, it’s also insufficient. When people visit the ED for dental problems, they are generally treated only for their acute needs, receiving pain killers and antibiotics, and then referred to a dentist. However, often patients seek dental care in the ED because they do not have regular access to a dentist.
  3. Dental therapists, by focusing on the most commonly needed routine dental procedures and by providing this care in more accessible locations, can make routine dental care more attainable for people throughout the state. Dental therapists are critical providers to both see more patients for preventive and routine restorative care, and to free up dentists to absorb patients with more advanced dental care needs.

QUESTION


What would you say to a dentist who opposes this because he or she worries that it will “compromise quality”?

ANSWER


  1. The fact is dental therapists have been practicing in more than 50 countries around the world beginning in the 1920s. A global literature review of over 1,000 assessments showed that dental therapists provide technically competent, high quality, and safe care.81
  2. CODA requires dental therapists to have at least three academic years of education and training. In Arizona, the scope for dental therapists would include about 80 procedures. In contrast, dental school is four years, and general dentists can perform about 435 procedures.82
  3. It’s also important to note that dental therapists in Arizona will have to pass state exams, and exams assessing clinical competence, approved by the Dental Board, to receive their dental therapy license. In Minnesota, dental therapy and dental students are trained side-by-side, and the examiners are blinded as to who is a dental candidate and who is a dental therapy candidate. Dental therapists are required to meet the same competencies as dentists for the procedures they share.
  4. Medical malpractice insurance in Minnesota for an office employing a dental therapist is very similar to the coverage for a dental hygienist and dental assistant.83 For example, the rate from Marsh Professional Liability is less than $100 per year.84

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