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Forum Category: Practice Administration

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The Future of Midlevel Providers

Over the past several years, midlevel providers (that being defined as a person who is not a dentist, but able to perform irreversible dental procedures on the public) have been increasing in number all around the United States. In the past, midlevel providers had been viewed as a way to extend dental care to the underserved communities around the country, but there has always been a debate as to the effectiveness and cost-efficiency of these programs. 

A recent study conducted by the American Dental Association alongside ECG Management Consultants found that out of 45 different scenarios tested, only 5 (or 9%) of these trials proved cost-effective and sustainable (http://www.ada.org/news/7438.aspx). These models were based on the length and cost of training needed for midlevel positions, facility operating costs, salaries, academic debt, and projected revenues. 4 of the 5 positive net reviews involved the Dental Health Aide Therapist model. The other 40 scenarios showed net losses from $1,000 to $176,000.


What impact might it have on your future as a dental practitioner if midlevel providers are found to be ineffective, and ultimately discontinued?

What might be some other ways that we can bring dental care to the underserved communities around the country?

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The Future of Midlevel Providers

10:48 AM | Nov 28,2016
While midlevel providers may prove to be a powerful asset in reducing barriers to care, these practitioners would also be faced with a much more medically and dentally compromised population, leaving less room for “simple procedures.” Additionally, the midlevel provider model could perpetuated the two tiered system, where rural patients continue to receive substandard care or care of less “quality” whereas those in more populated areas are able to receive care by more educated professionals. I fully support the expansion the clinical responsibilities of dental staff, such as hygienists, assistants, and dental technicians, under the supervision of a dentist. Some states have already legally expanded clinical activities of dental team members (Missouri comes to mind). This would allow dentists more time to accomplish more difficult clinical cases, increase the amount of patients that are able to be seen in a given day, and allow patients to be treated at a lower cost to the practice. This model, in conjunction with incentives such as those already mentioned, like loan forgiveness and increasing Medicaid reimbursement rates, could help increase access to care without compromising the quality of care.

The Future of Midlevel Providers

04:48 PM | May 07,2016
Instead of having dental therapists provide care to these groups, it is more beneficial to have highly trained dental professionals who have had the proper training and are capable of dealing with more complex oral cases, which are often seen in the Medicaid and minority populations. But in order for this to be feasible, barriers to dental care must be eliminated. To begin with, because access to dental care in rural areas is such a problem, more dental programs should be implemented in these areas. For example, the University of Washington School of Dentistry has a program called Regional Initiatives in Dental Education (RIDE). Through this program, eight students from the dental school are trained and taught in Spokane, one of the more rural areas of Washington state that suffers from a lack of dentists to provide dental care. It has been shown that students who are enrolled in programs like RIDE tend to start their own practices and work in rural areas after graduating from dental schools. By expanding the number of programs like RIDE or by increasing the number of students in these programs, better access to dental care in rural areas can be achieved. Additionally, since barriers to access are not just seen in rural areas but are also evident in major cities that are saturated with dentists, such as Seattle, increasing the Medicaid reimbursement rate would add incentive for these dentists to provide more care to Medicaid patients, which would hopefully resolve more access barriers in cities as well.

The Future of Midlevel Providers

05:42 PM | Mar 01,2015
I agree with many of the ideas expressed by the other posters. The problem of access to care is not due to a shortage of dentists. It is due to a lack of incentive resulting from inadequate reimbursement. As previously mentioned, with record high student loan debt, it is very difficult for a new graduate to even consider a rural area, especially if the population consists of predominately Medicaid patients. Instead of spending money on new and unproven programs to address this very real and progressing problem, we should invest in making the existing programs more practical. I really like the idea of loan forgiveness in exchange for working in these underserved communities. Midlevel providers may initially seem like a great idea but as the access to care problem continues, they will be regulated less and less in an attempt to "bridge the gap." Like any other provider, they will likely find increased earning potential in urban areas where many potential patients have insurance or can afford to pay for their dental treatment themselves. Instead of being utilized by dentists to see more patients, or serving the needs of those without access to care, midlevel providers will potentially be directly competing with dentists already struggling in saturated cities. Additionally, the underserved communities are comprised of many patients with complex cases who have not only had limited access to dental services, but likely little medical care as well. We can expect many of these patients to be challenging in a number of ways so the idea that a midlevel provider will be providing simple, routine, or preventive care is highly unlikely. In reality, they will be unqualified to address the actual needs of this population. This model is pairing lesser qualified providers with higher risk patients and this is an unethical disservice to these patients.

The Future of Midlevel Providers

01:36 AM | Dec 05,2014
Many parallels have been drawn between midlevel providers and physician assistants. Dentists would certainly benefit if there was such a possibility. The whole model of dentistry would shift tremendously. However, there are some major concerns that I have and I think they would be worth addressing. First off, current legislation is geared toward bringing in midlevel providers to improve access to care. In most of the places they have been approved, they are allowed to practice in their own offices without the supervision of a dentist. The idea is that if they get trained on basic procedures (drill & fill, etc.) they should be able to take care of a lot of the problems that many patients present with. Here's the kicker though - how many times do treatments go exactly as planned? Dentistry can be fairly unpredictable. One minute you're removing what appears to be a sliver of decay and the next minute your following a tiny passageway straight to the pulp chamber. Just like that a midlevel provider could find themselves in over their heads, especially if they are in geographically isolated areas and far from a dentist. I really like the practice model that many states are considering, which allows Expanded Function Dental Assistants (EFDAs) to do more around the office. More procedures can be delegated to these assistants under close supervision, such as denture adjustments or even placing and finishing composite restorations. Ultimately, this enables the doctor to serve more patients. All of this is done under the dentist's license and there would be better quality control than with midlevel providers. One thing is certain....something will have to be done about the disparity in access to care. It will be interesting to see what plays out. As for now, I think I'll continue to push for EFDA availability and enticing loan repayment plans for going rural.

The Future of Midlevel Providers

09:01 PM | Sep 30,2014
MLP's are a tricky subject because of the lack of dentists in certain rural areas. Dentistry is a skill that could provide a great career in any part of the country and that leaves little motivation for dentists to move to rural areas that are far away and secluded. Places that are in dire need of oral healthcare providers. In an ideal world dentist would graduate and seek out jobs in these areas but the reality is that our country's access to care problem is more likely to get worse over the future. For example, consider the increasing cost of dental education and student loan debt. If students were to have any desire to practice in these areas most of them would be handicapped by their debilitating debt. If we are looking for a real solution to this problem perhaps providing loan forgiveness for practice in these areas could help alleviate the problem. This would be great motivation!

The Future of Midlevel Providers

12:10 AM | Sep 30,2014
I would also like to hear your opinion on mid-level providers working in not just rural setting, but in a suburban and metropolitan area. What if their advancement progresses like Physician Assailants did in medicine. How would you adjust the way you practice?

The Future of Midlevel Providers

12:02 AM | Sep 30,2014
If Mid-level providers become as common as Physician Assistant, I would expect to see a paradigm shift of the delivery of basic care being solely done by mid-level providers. As Physician Assistant are at the front lines of minutes clinic so will DHAT/CDHC become with future minute dental clinics the financial savings on a group practice could be tremendous and part of that savings can be transferred to lower cost for care on the patient end. Overall, I think having a few pilot programs to study the actual impact, that mid-level provider can really aid in charting a proper path toward delivering quality care at a lower cost.

The Future of Midlevel Providers

05:53 PM | Aug 09,2012