Alaska Dental Society Positions on:
Providing Care for Underserved Alaskans
Expanding the scope of practice for Certified Dental Assistants
Tax on Soda Pop & Candy
Grant Program to support dental care in underserved areas
Dental Education Loan Program
Reforming Medicaid System
Community Water Fluoridation
Providing Care for the Underserved in Alaska
The majority of Alaskans enjoy access to excellent and affordable dental care – some of the best in the world. A segment of the Alaska’s population does not have ready access to basic dental care and struggles to pay for the treatment they need; particularly if they have delayed seeking care and their condition has gotten worse and more difficult and costly to treat.
The Alaska Dental Society has developed a long term strategic plan which will increase access to care for those Alaskans most in need and with the greatest challenges to getting regular care and treatment. It will require cooperation between the Alaska Dental and the Alaska Dental Board, the Legislature, as well as the other state and federal agencies responsible for dental and health care.
The Alaska Dental Society recommends the following steps to increase access to dental care:
1. Legislation to expand the duties that can be assigned to auxiliary dental personnel. Increasing the tasks performed by hygienists and assistants will increase efficiency while lowering costs.
2. Implement a 10% tax at the wholesale level on soda pop, soft drinks that contain significant percentages of sugar and candy products. Proceeds of the tax would be directed to the general fund and used to offset key programs to improve and increase access to dental care.
3. Implementation of a state grant program for delivery of preventive care in underserved areas.
4. Institute a loan program to encourage health care providers to deliver care in underserved areas.
5. Modifications to the Medicaid system by the Department of Health and Social Services that will encourage rather than discourage dentists to participate.
6. Incentives from the state to encourage communities to fluoridate community water systems and development of a state program to provide fluoride supplementation in communities without fluoridated water.
More detailed information on the above listed programs cam be found in the accompanying material.
As part of the 2009 Fiscal Year budget, the Alaska Dental Society urges the Legislature to:
· Provide full funding for the Dental Hygiene and Dental Assisting programs at the University of Alaska, Anchorage and the University of Alaska, Fairbanks
· Increase the funding for the Dental portion of the Medicaid and Denali Kid Care programs to
¡ Provide coverage to all qualified recipients
¡ Allow for recalculation of the dental fee schedule (last done in 1999 using rates collected in 1997.)
· Approve continuation of, and adequate funding for, the Enhanced Dental Services for Adults Program.
Taken alone each of these steps can do a little to ensure that those Alaskans who cannot now find access to care, will be better off. Taken in concert these steps will make a significant difference in improving the oral health of all Alaskans.
Expanding the scope of practice for Certified Dental Assistants
The Alaska Dental Society supports HB-319 & SB-239 -- Dental Assistants’ Expanded Duties
What bills do:
- Creates two-tier system for dental assistants.
§ Uncertified assistants would continue to perform duties currently authorized by present Dental Practice Law.
§ Certified (expanded) dental assistants would be authorized to:
· place restorative materials in tooth prepared by dentist. This is commonly referred to as “packing and carving.”
· perform coronal polishing (use of rubber cup to clean teeth above the gums). This should not be confused with an adult “prophy” performed by dental hygienists.
- Certification for the restorative function would be equal to training and testing established for dental hygienists in HB-136/SB-98.
- Certification for coronal polishing would be done under regulations established by the Board of Dental Examiners
How it can improve access to care:
- Restorative function and coronal polishing by assistants will help community health centers and itinerate dental teams in remote areas provide cost effective treatment.
- Coronal polishing by assistants will encourage dental offices to accept more Medicaid/EPSDT and more Denali Kid Care eligible patients.
- Retaining the existing “uncertified” dental assistant position will ensure that dentists in rural communities can continue to hire and train assistants in their office.
- Supported by Alaska Dental Society, Alaska Board of Dental Examiners, Alaska Native Tribal Health Consortium.
- Meets the goals of the preliminary report for the Governor’s Health Care Strategies Planning Council.
Soda Pop and Candy Tax
The Alaska Dental Society endorses a 10% tax on soda pop and candy at the wholesale level.
Excessive sugar consumption, especially in the form of soda pop, soft-drinks high in sugar and candy has been identified as prime contributor to obesity in children. Soda pop has the double effect on dental cavities of delivering sugar to the teeth as well as harmful acid. The Alaska Native Health Tribal Health Consortium has identified soda pop as a prime cause of dental cavities in rural areas.
Eighteen other states have recognized the effect soda pop plays in health, instituting taxes of varying degrees on soda pop. The accompanying chart illustrates the taxes imposed by various states. Most states have chosen to place a tax on syrup; however, this will not be practical in Alaska since soda is not bottled in state.
Proceeds from this tax should be directed to the general fund – as required by the Alaska Constitution – but ear marked to provide funding for health care programs. The soda pop and candy tax should be used to provide:
· A education loan program to encourage health care workers to provide care in underserved areas;
· a state grant program for delivery of preventive care in underserved areas;
· a state program to encourage communities to fluoridate water systems and to provide fluoride supplementation in communities without fluoridated water, and
· funding of the Medicaid Enhanced Dental Services for Adults programs.
The excess revenue generated beyond the needs of these programs would be used to offset the costs of the Medicaid program.
Grant Program for Delivery of Preventive Care in Underserved Areas
Delivery of dental and medical care in rural Alaska is inherently more expensive then the in large communities. Village Dental Health Aide can cover only a portion of rural Alaska. There will always be communities too small to support even a health aide or that do not qualify for coverage from the Indian Health Services.
Delivery of care to communities that can not support a full time dental provider should be a responsibility jointly borne by the State of Alaska and the dental community and private practice dentists. A grant program to provide funding for travel, lodging and equipment costs would be a valuable asset to encourage dentists and allied dental care givers to provide services in these communities.
The grant program would cover:
· Travel expenses to and from communities. The costs of delivering dental care involving the use specialized portable equipment are particularly prohibitive for a private dentists.
· Lodging expenses. The cost of lodging in remote communities make it cost prohibitive for private practitioners to spend sufficient time in these locations.
· Equipment costs for nonprofit organizations. Some of the components used in a dental office can be used in remote locations. However, the equipment that is unique for use in remote areas (portable chairs, suction units, x-ray machines) is costly.
Dentists and dental non-profit organizations, with the help of the grant program, would be able to travel to underserved areas to provide services. The ability of the residents of these communities to pay the standard fee for service fees would be unlikely for the majority of treatment provided. This means most of the billings would be to the Medicaid system, where reimbursement rates are approximately 45-60% of standard fees. These rates are less than the cost of providing treatment in major communities. With the burden of the high costs of travel and lodging to these remote communities, private practitioner find it cost prohibitive to provide services to the residents.
Grants to help with equipment costs would help non profit organizations provide health care services in remote areas. The equipment would allow organizations to travel to areas without dedicated facilities. This equipment, by its nature, would be transportable so the overall cost when figured on a per community basis would not be large.
Dental Education Loan Program
Rural areas across America have found it challenging to have health care providers commit to providing care. This problem is especially acute in Alaska.
Several states have been successful with variations of loan programs where health care providers receive prorated help for repayment of education costs. The spiraling cost of education is more pronounced in dental schools with the average graduating dentist leaving school with educational loans of over $200,000.
Reinstituting a variation of the old Alaska Student Loan program would provide an incentive for dentists to provide care in underserved areas. The prior student loan program forgave a year’s loan payment for each year the dentist resided in Alaska after graduating – this program would do the same thing but tie that forgiveness to delivery of care. In order to earn forgiveness of a portion of their loans dentists would be required to deliver care in rural areas or provide a stipulated dollar amount of Medicaid treatments.
Tying the forgiveness to delivery of care would make this an easier program to administer. The burden of proof would be on the dentist to demonstrate that the requisite patient services have been provided in order to receive the forgiveness of loan repayment. Programs that attempt to add a penalty after the loan program for recipients who fail to meet requirements are difficult to enforce and require tracking the loan recipients.
The Alaska Dental Society believes a program to encourage health care providers to provide care in underserved areas should include:
· Loans for education and supply costs for health care programs
· Preference given for Alaskan residents
· $15,000 yearly limit
· 10% interest rate
· 10 year payback
· year for year “forgiveness” for
o Maintaining Alaskan residency and
o Providing coverage for a community designated as underserved or providing comprehensive care for an average of 10 or more Medicaid patients during that year.
o For each year meeting the requirements one years repayment of the loan would be waived – a participant for 5 years would repay 50% of the loan + interest and have the remaining 50% waived
Medicaid System Reform
Low participation by dentists has plagued the Medicaid system for years. Despite numerous attempts by the Alaska Dental Society to correct problems Health and Social Services has not made any changes to increase participation levels.
Several factors are responsible for dentists declining to participate in the Medicaid system.
· Medicaid participants failing to keep scheduled appointments
· Chronic drug seeking patients who travel from office to office
· Low reimbursement rates
· “Hold Harmless” clause contained in the Medicaid contract
· “Any Favored Nation” clause contained in the Medicaid contract.
The most common reason dentists give for not participating in the Medicaid system is surprisingly not reimbursement rates, which run approximately 45-60% of standard fees, but the high number of Medicaid patients who fail to keep scheduled appointments. Dental appointments are treatment based, requiring dedicated time from the dentist and staff to provide treatment. Most appointments in medical offices are evaluations and can be double or triple booked. No shows in medical offices can be factored into scheduling; no shows in dental offices cannot. Most dentists are willing to see Medicaid patients, even at the low reimbursement levels, but are unwilling to accept the frustration that comes with patients who fail to keep appointments.
The Alaska Dental Society proposal: create a two part Medicaid system where patients have eligibility for Medical and eligibility for dental. Be willing to remove that dental eligibility for no show appointments.
Patients who invent dental problems to receive pain medication are an additional source of frustration for dentists. Drug seeking patients will travel from office to office using any ruse to acquire pain medication and can become disruptive if not given pain medication. If they are successful in getting pain medication they will continue to call the dental office and the dentist at home to obtain additional medication. Patients can have a large cavity in a tooth without any pain. When a dentists sees a patient who reports pain they generally have to take their word on symptoms. Unfortunately, for the other Medicaid patients there is a larger percentage of Medicaid patients engaged in drug seeking behavior than the non-Medicaid patients.
The Alaska Dental Society Proposal: Create a two part Medicaid system as above and monitor the drug usage of Medicaid patients. If a dentist reports a Medicaid patient they suspect is drug seeking review prescription history and be willing to remove them from the system.
Medicaid reimbursement rates average 45-60% of standard fees while overhead for the average dental office is about 70% of collected fees. The result is time spent for dentists treating Medicaid patients actually cost dentists monetarily. Medical Medicaid reimbursement rates are adjusted yearly while dental reimbursement rates are adjusted on varying spans, the last 10 years ago.
The Alaska Dental Society Proposal: Provide yearly readjustments to the dental Medicaid reimbursement rates.
Participation in the Medicaid system requires providers to sign a “hold harmless” clause. This clause requires the dentist to agree to accept responsibility for both the state and the dentist in the event of a lawsuit regardless of fault. The result is the dentist would have to indemnify the state even if the states actions are the direct cause of a negative finding in a lawsuit. Dentists carry malpractice insurance to provide protection in the event of a negative finding in lawsuit. Dentists should accept the consequences of their own actions but it is not reasonable to expect them to accept the consequences of the state’s actions.
The Alaska Dental Society Proposal: Remove the hold harmless clause from the Medicaid participation agreement.
Participation in the Medicaid system also requires providers to agree to an “any favored nation” clause. This requires dentists to agree to charge Medicaid the lowest fee for a procedure they otherwise charge. The intent behind this is admirable giving the appearance of good consumer shopping on the Medicaid systems part. The idea would be if a dentist signs an agreement with an insurance plan to provide care at a reduced rate in exchange for patients directed to that practice Medicaid would also benefit. The actual result is something else, however. If a dentist reduces their fee for someone who is financially struggling then they would also be required to submit that fee to Medicaid for reimbursement. An example would be Mrs. Jones who is elderly, on a fixed income and needs a new denture. If the dentist discounts their fee 50% then they would be required to bill that reduced fee to Medicaid. Medicaid fees are already discounted severely from standard fees. The additional protection provided by this clause is unnecessary and provides a disincentive for dentists to discount fees to needy patients or participate in the Medicaid system.
The Alaska Dental Society Proposal: Remove the any favored nation clause from the Medicaid participation agreement.
Community Water Fluoridation
Fluoridation of water systems has been proven to be the most cost effective way to reduce dental cavities. The Center for Disease Control lists water fluoridation as one of the 10 greatest health improvements in the last 50 years.
Several communities in Alaska have fluoridated water. Other communities should be encouraged to integrate water fluoridation into their community systems. For those communities that do not have water fluoridation and for those individuals who do not have access to fluoridated water a state program should be instituted to provide fluoride supplementation to ensure that they can benefit from the cavity prevention benefits of fluoridated water.
Communities should be encouraged to begin fluoridating their water systems. HCR5 from the 24th legislature should be reintroduced and passed.
Communities without fluoridated water systems would benefit from a fluoride supplementation program. A state run program distributing fluoride tablets in public schools would help reduce the rate of dental caries. Topical fluoride rinses and gels are not as effective as fluoride incorporated into developing teeth. Ideally the program would cover grades K-6. A second program to cover children aged 1 to school age could be administered through dental and medical offices, pharmacies and village health centers.
