Oral Health
Efforts Under Way to Improve Children's Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns
Gao ID: GAO-11-96 November 30, 2010
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) required GAO to study children's access to dental care. GAO assessed (1) the extent to which dentists participate in Medicaid and the Children's Health Insurance Program (CHIP) and federal efforts to help families find participating dentists; (2) data on access for Medicaid and CHIP children in different states and in managed care; (3) federal efforts to improve access in underserved areas; and (4) how states and other countries have used mid-level dental providers to improve children's access. To do this, GAO (1) examined state reported dentist participation and the Department of Health and Human Services's (HHS) Insure Kids Now Web site for all 50 states and the District of Columbia and called a non-representative sample of dentists in four states; (2) reviewed national data on provision of Medicaid dental services and use of managed care; (3) interviewed HHS officials and assessed certain HHS dental programs; and (4) interviewed officials in eight states and four countries on the use of mid-level and other dental providers.
Obtaining dental care for children in Medicaid and CHIP remains a challenge, as many states reported that most dentists in their state treat few or no Medicaid or CHIP patients. And, while HHS's Insure Kids Now Web site--which provides information on dentists who serve children enrolled in Medicaid and CHIP--has the potential to help families find dentists to treat their children, GAO found problems, such as incomplete and inaccurate information, that limited the Web site's ability to do so. For example, to test the accuracy of the information posted on the Web site, GAO called 188 dentists listed on the Web site in low-income urban and rural areas in four states representing varied geographic areas and levels of dental managed care and with high numbers of children in Medicaid. Of these 188 contacts, 26 had wrong or disconnected phone numbers listed, 23 were not taking new Medicaid or CHIP patients, and 47 were either not in practice or no longer performing routine exams. Although improved since 2001, available national data show that in 2008, less than 37 percent of children in Medicaid received any dental services under that program and that several states reported rates of 30 percent or less. Further, although some data indicate that children in Medicaid managed care may receive less dental care than other children, comprehensive and reliable data on dental services under managed care continue to be unavailable despite long-standing concerns. Although HHS has not required states to report information on the provision of dental services under CHIP, CHIPRA requires states to begin reporting this information for fiscal year 2010. Two programs that provide dental services to children and adults in underserved areas--HHS's Health Center and National Health Service Corps (NHSC) programs--have reported increases in the number of dentists and dental hygienists practicing in underserved areas, but the effect of recent initiatives to increase federal support for these and other oral health programs is not yet known. Despite these increases, both health centers and the NHSC program report continued need for additional dentists and other dental providers to treat children and adults in underserved areas. Mid-level dental providers--providers who may perform intermediate restorative services, such as drilling and filling teeth, under remote supervision of a dentist--are in limited use in the United States. The only currently practicing mid-level dental providers in the United States serve Alaska Natives. Efforts to supplement the U.S. dental workforce with mid-level and other types of providers are under way. GAO interviewed officials from eight states with varied state laws related to dental providers. Some states have made efforts to increase children's access by reimbursing dental hygienists and primary care physicians for providing certain dental services. Some countries have long-standing programs that use mid-level dental providers, also known as dental therapists, who the countries report have improved children's access to dental services. GAO recommends that HHS take steps to improve its Insure Kids Now Web site and ensure that states gather complete and reliable data on Medicaid and CHIP dental services provided under managed care. HHS agreed with the recommendations, citing specific actions it would take.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director:
Katherine M. Iritani
Team:
Government Accountability Office: Health Care
Phone:
(206) 287-4820
GAO-11-96, Oral Health: Efforts Under Way to Improve Children's Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
November 2010:
Oral Health:
Efforts Under Way to Improve Children's Access to Dental Services, but
Sustained Attention Needed to Address Ongoing Concerns:
GAO-11-96:
GAO Highlights:
Highlights of GAO-11-96, a report to congressional committees.
Why GAO Did This Study:
The Children‘s Health Insurance Program Reauthorization Act of 2009
(CHIPRA) required GAO to study children‘s access to dental care. GAO
assessed (1) the extent to which dentists participate in Medicaid and
the Children‘s Health Insurance Program (CHIP) and federal efforts to
help families find participating dentists; (2) data on access for
Medicaid and CHIP children in different states and in managed care;
(3) federal efforts to improve access in underserved areas; and (4)
how states and other countries have used mid-level dental providers to
improve children‘s access. To do this, GAO (1) examined state reported
dentist participation and the Department of Health and Human Services‘
s (HHS) Insure Kids Now Web site for all 50 states and the District of
Columbia and called a non-representative sample of dentists in four
states; (2) reviewed national data on provision of Medicaid dental
services and use of managed care; (3) interviewed HHS officials and
assessed certain HHS dental programs; and (4) interviewed officials in
eight states and four countries on the use of mid-level and other
dental providers.
What GAO Found:
Obtaining dental care for children in Medicaid and CHIP remains a
challenge, as many states reported that most dentists in their state
treat few or no Medicaid or CHIP patients. And, while HHS‘s Insure
Kids Now Web site-”which provides information on dentists who serve
children enrolled in Medicaid and CHIP”-has the potential to help
families find dentists to treat their children, GAO found problems,
such as incomplete and inaccurate information, that limited the Web
site‘s ability to do so. For example, to test the accuracy of the
information posted on the Web site, GAO called 188 dentists listed on
the Web site in low-income urban and rural areas in four states
representing varied geographic areas and levels of dental managed care
and with high numbers of children in Medicaid. Of these 188 contacts,
26 had wrong or disconnected phone numbers listed, 23 were not taking
new Medicaid or CHIP patients, and 47 were either not in practice or
no longer performing routine exams.
Although improved since 2001, available national data show that in
2008, less than 37 percent of children in Medicaid received any dental
services under that program and that several states reported rates of
30 percent or less. Further, although some data indicate that children
in Medicaid managed care may receive less dental care than other
children, comprehensive and reliable data on dental services under
managed care continue to be unavailable despite long-standing
concerns. Although HHS has not required states to report information
on the provision of dental services under CHIP, CHIPRA requires states
to begin reporting this information for fiscal year 2010.
Two programs that provide dental services to children and adults in
underserved areas”HHS‘s Health Center and National Health Service
Corps (NHSC) programs”have reported increases in the number of
dentists and dental hygienists practicing in underserved areas, but
the effect of recent initiatives to increase federal support for these
and other oral health programs is not yet known. Despite these
increases, both health centers and the NHSC program report continued
need for additional dentists and other dental providers to treat
children and adults in underserved areas.
Mid-level dental providers”providers who may perform intermediate
restorative services, such as drilling and filling teeth, under remote
supervision of a dentist”are in limited use in the United States. The
only currently practicing mid-level dental providers in the United
States serve Alaska Natives. Efforts to supplement the U.S. dental
workforce with mid-level and other types of providers are under way.
GAO interviewed officials from eight states with varied state laws
related to dental providers. Some states have made efforts to increase
children‘s access by reimbursing dental hygienists and primary care
physicians for providing certain dental services. Some countries have
long-standing programs that use mid-level dental providers, also known
as dental therapists, who the countries report have improved
children‘s access to dental services.
What GAO Recommends:
GAO recommends that HHS take steps to improve its Insure Kids Now Web
site and ensure that states gather complete and reliable data on
Medicaid and CHIP dental services provided under managed care. HHS
agreed with the recommendations, citing specific actions it would take.
View [hyperlink, http://www.gao.gov/products/GAO-11-96] or key
components. For more information, contact Katherine Iritani at (202)
512-7114 or iritanik@gao.gov.
[End of section]
Contents:
Letter:
Background:
For Children in Medicaid and CHIP, Finding a Dentist Remains a
Challenge, and HHS's Web Site to Help Locate Participating Dentists
Was Not Always Complete or Accurate:
States Report Improvement in the Provision of Dental Services to
Children in Medicaid, but Data to Monitor Service Provision under CHIP
or Managed Care are Limited:
Federal Efforts to Improve Access to Dental Services for Children in
Underserved Areas Are Under Way, but Effect Is Not Yet Known:
Use of Mid-Level Dental Providers Is Not Widespread in the United
States, and Other Countries Have Used Them to Improve Children's
Access to Dental Services:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Medicaid Dental Utilization Rates for Fiscal Year 2008:
Appendix III: NHSC and Health Center Funding in the Recovery Act,
PPACA, and Fiscal Year 2010 Appropriation:
Appendix IV: Additional HHS Programs That May Improve Access to Dental
Services in Underserved Areas:
Appendix V: Dental Health Aide Therapist Program for Alaska Natives:
Appendix VI: Types of Dental Providers, Excluding Dentists, in Eight
Selected States:
Appendix VII: Summary of Four Selected Countries' Use of Dental
Therapists:
Appendix VIII: Comments from the Department of Health and Human
Services:
Appendix IX: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Categories of Dental Services and Examples of Dental
Procedures:
Table 2: Types of Supervision for Other Dental Providers:
Table 3: State Reported Data on Dentists' Participation in Medicaid
and CHIP:
Table 4: Number of States Providing Missing or Incomplete Dentist
Information through HHS's Insure Kids Now Web Site in November 2009
and April 2010:
Table 5: Errors in Dentist Listings on HHS's Insure Kids Now Web Site,
May 2010:
Table 6: Characteristics of Mid-Level Dental Providers in New Zealand,
the United Kingdom, Australia, and Canada:
Table 7: Utilization of Any Dental Service, Preventive Dental Service,
and Dental Treatment Service by Children in Medicaid, Ranked in Order,
Fiscal Year 2008:
Table 8: Funding for National Health Service Corps and Health Center
Programs Under the Recovery Act and PPACA, and the Fiscal Year 2010
Annual Appropriation:
Table 9: HHS Programs that May Improve Access to Dental Services in
Underserved Areas:
Table 10: Selected Types of Dental Providers in Alabama, June 2010:
Table 11: Selected Types of Dental Providers in Alaska, June 2010:
Table 12: Selected Types of Dental Providers in California, June 2010:
Table 13: Selected Types of Dental Providers in Colorado, June 2010:
Table 14: Selected Types of Dental Providers in Minnesota, June 2010:
Table 15: Selected Types of Dental Providers in Mississippi, June 2010:
Table 16: Selected Types of Dental Providers in Oregon, June 2010:
Table 17: Selected Types of Dental Providers in Washington, June 2010:
Figures:
Figure 1: Comparison of Nationwide Medicaid Dental Utilization Rates
for Dental Services for Children, Fiscal Years 2001 and 2008:
Figure 2: Percentage of Children in Medicaid Receiving Any Dental
Service, Fiscal Year 2008:
Figure 3: Number of Dental Hygienists, Dentists, and Dental Patients
at Health Centers, Calendar Years 2006 through 2009:
Figure 4: Number of NHSC Dentists and Dental Hygienists Practicing in
Shortage Areas, Fiscal Years 2006 through 2009:
Figure 5: Dental Therapist Training Locations and Certification Status
in Alaska, June 2010:
Abbreviations:
ASTDD: Association of State and Territorial Dental Directors:
CHIP: Children's Health Insurance Program:
CHIPRA: Children's Health Insurance Program Reauthorization Act of
2009:
CMS: Centers for Medicare & Medicaid Services:
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:
FTE: full-time equivalent:
HHS: Department of Health and Human Services:
HIV: human immunodeficiency virus:
HPSA: health professional shortage area:
HRSA: Health Resources and Services Administration:
NHSC: National Health Service Corps:
OIG: Office of Inspector General:
PPACA: Patient Protection and Affordable Care Act:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
November 30, 2010:
The Honorable Max Baucus:
Chairman:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
The Honorable Henry A. Waxman:
Chairman:
The Honorable Joe Barton:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
Since 2000, our reports as well as reports by the Surgeon General,
congressional committees, and oral health researchers have underscored
the high rates of dental disease and the challenges of providing
dental services to children living in underserved areas and in low-
income families. In particular, children with health care coverage
under two joint federal-state programs for low-income children--
Medicaid and the Children's Health Insurance Program (CHIP)--often
have difficulty finding dental care even though dental services are a
covered benefit.[Footnote 1] For example we reported in 2000 that low-
income and minority populations--including children in Medicaid and
CHIP--had a disproportionately high level of dental disease. In a
related report, we found that the major factor contributing to the low
use of dental services among low-income persons was finding dentists
to treat them, even in areas where dental care for the rest of the
population was generally available.[Footnote 2] We also reported that
dentists generally cited low payment rates, administrative
requirements, and patient issues such as frequently missed
appointments as reasons why they did not treat Medicaid patients. In
2008, we reported that the situation was largely unchanged. National
survey data showed dental disease remained a significant problem for
children in Medicaid--we estimated that 6.5 million children had
untreated tooth decay and rates of dental disease among children in
Medicaid had not decreased over time.[Footnote 3] National surveys
also showed that only one in three children in Medicaid had visited a
dentist in the prior year, compared to more than half of privately
insured children. In a 2009 survey of state Medicaid programs, we
found that identifying a dentist who accepted Medicaid remained the
most frequently reported barrier to children seeking dental services.
We also found that, of the 21 states that provided Medicaid dental
services under managed care arrangements, more than half reported that
managed care organizations in their states did not meet any, or only
met some, of the state's dental access standards.[Footnote 4]
Since 2009, a number of actions have been taken to address these
challenges. For example, to help families find a dentist to treat
children covered by Medicaid and CHIP, the Children's Health Insurance
Program Reauthorization Act of 2009 (CHIPRA) required the Department
of Health and Human Services (HHS) to post on its Insure Kids Now Web
site a current and accurate list of dentists participating in state
Medicaid and CHIP programs.[Footnote 5] In April 2010, HHS launched a
departmentwide oral health initiative to expand oral health services,
education, and research, including promoting access to oral health
care and the effective delivery of services to underserved populations.
CHIPRA also required that we study and report on various aspects of
children's access to dental services.[Footnote 6] This report
discusses (1) the extent to which dentists participate in Medicaid and
CHIP, and federal efforts to help families find dentists to treat
children in these programs; (2) what is known about access for
Medicaid and CHIP children in different states and in managed care;
(3) federal efforts under way to improve access to dental services by
children in underserved areas; and (4) how states and other countries
have used mid-level dental providers to improve children's access to
dental services.
To examine the extent to which dentists participate in Medicaid and
CHIP, and federal efforts to help families find dentists to treat
children in these programs, we (1) analyzed survey responses from
states regarding dentists' participation in Medicaid and CHIP,
gathered by the Association of State and Territorial Dental Directors
(ASTDD), and (2) evaluated information posted on HHS's Insure Kids Now
Web site about the dentists participating in Medicaid and CHIP.
Specifically, we reviewed the information on the Web site for all 50
states and the District of Columbia to evaluate whether certain data
elements specified as required in guidance from the Centers for
Medicare & Medicaid Services (CMS)--the HHS agency that administers
Medicaid at the federal level--were posted and whether the Web site
was usable for a family seeking to identify a dentist for a child
covered by Medicaid or CHIP. We also tested the accuracy of
information posted to the Web site by calling a nongeneralizeable
sample of 188 dentists' offices in low-income urban and rural areas in
4 states.[Footnote 7] We also reviewed relevant academic and
association research on dental services for children with special
health care needs.
To evaluate what is known about access for Medicaid and CHIP children
in different states and in managed care, we reviewed documents and
interviewed officials from CMS. We also (1) analyzed survey responses
from states on the use of dental managed care in Medicaid, gathered by
the American Dental Association; and (2) examined annual state reports
on the provision of dental services under the Medicaid Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
[Footnote 8]
To identify federal efforts to improve children's access to dental
services in underserved areas, we focused on two programs administered
by HHS's Health Resources and Services Administration (HRSA)--the
Health Center program and the National Health Service Corps (NHSC)
program--designed, in part, to support the provision of dental
services in underserved areas. We also examined information regarding
other recent efforts to improve access to care for children in
underserved areas, including funding made available by the American
Recovery and Reinvestment Act of 2009 (Recovery Act) and the Patient
Protection and Affordable Care Act (PPACA).[Footnote 9]
To determine how states have used mid-level dental providers to
improve access to dental services for children, we examined laws,
regulations, and practices related to mid-level and other dental
providers and interviewed federal officials as well as officials in 8
selected states--Alabama, Alaska, California, Colorado, Minnesota,
Mississippi, Oregon, and Washington--that have varying degrees of
education, supervision, and scope-of-practice requirements for dental
providers.[Footnote 10] We selected these states based on responses we
obtained to a standard set of questions posed to oral health
researchers, professional associations, and advocacy groups regarding
states that use mid-level and other dental providers to expand access
to dental services. We visited Alaska to interview state and tribal
officials on efforts to expand access for Alaska Natives through the
use of mid-level dental providers. To determine how other countries
have used mid-level dental providers to improve access to dental
services for children, we examined documents and interviewed officials
from four countries--Australia, Canada, New Zealand, and the United
Kingdom. See appendix I for additional information on our scope and
methodology.
We conducted this performance audit from August 2009 through November
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
High rates of dental disease and low utilization of dental services by
children in low-income families and the challenge of finding dentists
to treat them are long-standing concerns. In 2000, the Surgeon General
reported that tooth decay is the most common chronic childhood disease
and described what the report called the silent epidemic of oral
disease affecting the nation's poor children.[Footnote 11] Left
untreated, the pain and infections caused by tooth decay may lead to
problems in eating, speaking, and learning. Tooth decay is almost
completely preventable and the pain, dysfunction, or on extremely rare
occasions, even death, resulting from dental disease can be avoided.
The American Academy of Pediatric Dentistry recommends that each child
see a dentist when his or her first tooth erupts and no later than the
child's first birthday, with subsequent visits occurring at 6-month
intervals or more frequently if recommended by a dentist.
Recognizing the importance of good oral health, HHS established oral
health goals as part of its Healthy People 2000 and 2010 initiatives.
[Footnote 12] One objective of Healthy People 2010 was to increase the
proportion of low-income children and adolescents under the age of 19
who receive any preventive dental service in the past year--including
examination, x-ray, fluoride application, cleaning, or sealant
application (a plastic material placed on molars to reduce the risk of
tooth decay)--from 20 percent in 1996 to 66 percent in 2010.
Federal Programs That Promote Dental Services for Children:
Medicaid, a joint federal and state program that provides health care
coverage for certain low-income individuals and families, provided
health coverage for over 30 million children under 21 in fiscal year
2008.[Footnote 13] States operate their Medicaid programs within broad
federal requirements and may contract with managed care organizations
to provide Medicaid medical and dental benefits. Under federal law,
state Medicaid programs must provide dental services, including
diagnostic, preventive, and related treatment services for all
eligible Medicaid enrollees under age 21 under the program's EPSDT
benefit.
Federal law also requires states to report annually on the provision
of EPSDT services, including dental services, for children in
Medicaid. The annual EPSDT participation report, Form CMS-416
(hereafter called the CMS 416), is the agency's primary tool for
gathering data on the provision of dental services to children in
state Medicaid programs. It captures data on the number of children
who received any dental services, a preventive dental service, or a
dental treatment service each year. Information on the CMS 416 is used
to calculate a state's dental utilization rate--the percentage of
children eligible for EPSDT who received any dental service in a given
year.
CHIP, which is also a joint federal and state program, expanded health
coverage to children--approximately 7.7 million children in fiscal
year 2009--whose families have incomes that are low, but not low
enough to qualify for Medicaid.[Footnote 14] States can administer
their CHIP programs as (1) an expansion of their Medicaid programs,
(2) a stand-alone program, or (3) a combination of Medicaid expansion
and stand-alone. Although states have flexibility in establishing
their CHIP benefit package, all states covered some dental services in
2009, according to CMS officials, though benefits varied. Children in
CHIP programs that are administered as expansions of Medicaid programs
are entitled to the same dental services under the EPSDT benefit as
children in Medicaid.
CHIPRA expanded federal requirements for state CHIP programs to cover
dental services. Specifically, CHIPRA required states to cover dental
services in their CHIP programs beginning in October 2009 and gave
states authority to use benchmark plans to define the benefit package
or to supplement children's private health insurance with a dental
coverage plan financed through CHIP.[Footnote 15] CHIPRA also required
states to submit annual reports to CMS on the provision of dental and
other services--similar to information provided by state Medicaid
programs each year on their CMS 416 reports.[Footnote 16] States were
previously required to submit annual CHIP reports, although these
reports did not contain detailed information on the provision of
dental services as required for Medicaid on the CMS 416.
To make it easier for families to find dentists to treat children
covered by Medicaid and CHIP, CHIPRA also required that HHS post "a
current and accurate list of all such dentists and providers within
each State that provide dental services to children" under Medicaid or
CHIP on its Insure Kids Now Web site. CHIPRA required the Secretary of
HHS to post this list on the Web site by August 4, 2009, and ensure
that the list is updated at least quarterly.[Footnote 17] In June
2009, CMS issued guidance specifying certain data elements required
for each dentist listed on the Insure Kids Now Web site--including the
dentist's name, address, telephone number, and specialty; whether the
dentist accepts new Medicaid or CHIP patients; and whether the dentist
can accommodate patients with special needs. HHS posts listings on the
Insure Kids Now Web site by state and in some cases provides a link to
such a list on an individual state's or managed care organization's
Web site.
To address the need for health services in underserved areas of the
country, HHS's HRSA administers programs that support the provision of
dental and other medical services in underserved areas. For example,
under HRSA's Health Center program, health centers--which must be
located in federally designated medically underserved areas or serve a
federally designated medically underserved population--are required to
provide pediatric dental screenings and preventive dental services, as
well as emergency medical referrals, which may also result in the
provision of dental services.[Footnote 18] Health centers must accept
Medicaid and CHIP patients and treat everyone regardless of their
ability to pay. HHS reported that in fiscal year 2009, over 1,100
health center grantees operated over 7,900 service delivery sites in
every state and the District of Columbia, and provided health care
services, including dental services, to approximately 19 million
patients, about one-third of whom were children.
Another HRSA program, NHSC, offers scholarships and educational loan
repayment for clinicians who agree to practice in underserved areas.
[Footnote 19] NHSC awards scholarships to students entering certain
health professions training programs, including dentistry, who agree
to practice in underserved areas when their training is completed.
NHSC also provides educational loan repayment for health care
providers, including dentists and dental hygienists, who have
completed their training and can begin serving in a shortage area.
HRSA designates geographic areas, population groups, and facilities as
dental health professional shortage areas (HPSAs) for purposes of
placing dentists and dental hygienists through the NHSC program. These
designations are based, in part, on the number of dentists in an area
compared to the area's population.[Footnote 20] As of July 13, 2010,
HRSA reported that there were 4,377 dental HPSAs in the United States
[Footnote 21] and estimated that it would take 7,008 full-time
equivalent (FTE) dentists to remove these designations.[Footnote 22]
To be eligible for a NHSC provider, a site must be located in a HPSA
of greatest shortage and meet other requirements, such as accepting
Medicaid and CHIP patients and treating everyone regardless of their
ability to pay.[Footnote 23] Providers can then choose where they wish
to serve from a list of eligible sites, although providers who have
received scholarships are limited to a narrower list of higher
priority vacancies.[Footnote 24] According to HRSA, about half of all
NHSC providers, which include dentists and hygienists, practice in
health centers.
Dental Services and Dental Providers:
Dental services cover a broad array of specialized procedures, from
routine exams to complex restorative procedures. For this report, we
grouped dental services into five main categories: (1) supportive, (2)
preventive, (3) basic restorative, (4) intermediate restorative, and
(5) advanced restorative dental procedures (see table 1).
Table 1: Categories of Dental Services and Examples of Dental
Procedures:
Supportive:
* Preparing a patient to be examined by a dentist;
* Passing instruments to a dentist.
Preventive:
* Examination and assessment;
* Counseling;
* Cleaning above and below gum line;
* Fluoride application;
* Sealant placement[A].
Basic restorative:
* Temporary fillings;
* Smoothing an existing restoration;
* Administration of local anesthetic.
Intermediate restorative:
* Tooth preparation (drilling);
* Tooth restoration (filling);
* Tooth extractions.
Advanced restorative:
* Periodontal treatment (gums);
* Endodontic treatment (root canals).
Source: GAO.
[A] Dental sealants are plastic material that are commonly applied to
the chewing surfaces of back teeth to reduce the risk of decay.
[End of table]
While a provider's specific scope of practice may vary by state, types
of dental providers who may provide some or all of these services
include:
* Dentists, who may perform the full range of dental procedures.
[Footnote 25]
* Mid-level dental providers, often dental therapists, who may perform
preventive, basic restorative, and intermediate restorative dental
procedures under remote supervision of a licensed dentist.
* Dental hygienists, who generally perform preventive procedures, such
as tooth cleaning, oral health education, and fluoride applications,
as well as basic restorative procedures in certain states, under
various supervisory agreements with a dentist.
* Dental assistants, who may provide supportive services and in some
states certain preventive and basic restorative procedures under on-
site supervision of a dentist.
* Primary health care providers (such as physicians and nurse
practitioners) who may also perform certain preventive dental
procedures, such as applying fluoride varnish, to children in some
states.
Dental therapists, dental hygienists, and dental assistants work under
various supervisory arrangements with a dentist. The type of
supervision required for these providers may vary depending upon the
state and the type of service provided. For this report, we
categorized dental supervision as on-site, remote with prior knowledge
and consent, remote with consultative agreement, or no supervision
(see table 2).
Table 2: Types of Supervision for Other Dental Providers:
Supervision type: On-site supervision;
Description: The dentist must be on-site when the dental provider
performs services and examines the patient at any point before,
during, or after the dental services are provided.
Supervision type: Remote supervision with prior knowledge and consent;
Description: The dentist may be off-site but must have prior knowledge
of and consent to the procedures, in some cases through a treatment
plan.
Supervision type: Remote supervision with consultative agreement;
Description: The dentist may be off-site but maintain a consultative
role, for example through a signed collaborative agreement with
another type of dental provider.
Supervision type: No supervision;
Description: Dental provider may perform services without dentists'
supervision.
Source: GAO.
Note: This table presents examples of the type of supervisory
arrangements that may exist between dentists and other dental
providers, such as dental therapists and dental hygienists.
[End of table]
For Children in Medicaid and CHIP, Finding a Dentist Remains a
Challenge, and HHS's Web Site to Help Locate Participating Dentists
Was Not Always Complete or Accurate:
States continue to report low participation by dentists in Medicaid
and CHIP. While HHS's Insure Kids Now Web site--which provides
information on dentists who serve children enrolled in Medicaid and
CHIP--has potential to help families find a dentist to treat children
in these programs, we found problems such as incomplete or inaccurate
information that limit its ability to do so.
States Report Low Dentist Participation in Medicaid and CHIP, and
Children with Special Health Care Needs Face Particular Difficulties:
While comprehensive nationwide data do not exist, available data
suggest that problems with low dentist participation in Medicaid and
CHIP persist. Additionally, among dentists who do participate in
Medicaid, many may place limits on the number of Medicaid patients
that they will treat. Most states responding to a 2009 ASTDD
survey[Footnote 26] reported low participation among dentists,
although not all states responded completely. Our analysis shows that
25 of 39 states reported that fewer than half of the dentists in their
states treated any Medicaid patients during the previous year.
[Footnote 27] Only one of 41 states reported that more than half of
the state's dentists saw 100 or more Medicaid patients during the
previous year (see table 3). Fewer states responding to the 2009 ASTDD
survey provided data on dentists' participation in CHIP separately
from data on participation in Medicaid and CHIP expansions, but the
data reported separately for CHIP indicates that dentists'
participation in CHIP is also low.
Table 3: State Reported Data on Dentists' Participation in Medicaid
and CHIP:
Level of Dentist Participation in Medicaid or CHIP: States reporting
more than half of the dentists in the state treat any patients;
State officials' responses to 2009 Association of State and
Territorial Dental Directors (ASTDD) survey: Medicaid or CHIP
expansion[A]: 14 of 39 states (36%);
State officials' responses to 2009 Association of State and
Territorial Dental Directors (ASTDD) survey: CHIP only: 4 of 11 states
(36%).
Level of Dentist Participation in Medicaid or CHIP: States reporting
more than half of the dentists in the state treat 100 or more patients;
State officials' responses to 2009 Association of State and
Territorial Dental Directors (ASTDD) survey: Medicaid or CHIP
expansion[A]: 1 of 41 states (2%);
State officials' responses to 2009 Association of State and
Territorial Dental Directors (ASTDD) survey: CHIP only: 0 of 12 states
(0%).
Source: GAO analysis of ASTDD survey data.
Note: This table presents data collected by ASTDD in 2009. ASTDD sent
its survey to dental directors in all states and the District of
Columbia and received 45 responses. Information collected was for
fiscal year 2008 (or the most recent available fiscal year).
[A] States have the option of administering their CHIP programs as
expansions of their Medicaid programs.
[End of table]
The results of the 2009 ASTDD survey indicating low levels of
dentists' participation in Medicaid are consistent with findings we
reported in 2000. We reported that 16 of 39 states responding to our
inquiry indicated that more than half of the dentists in the state
treated any Medicaid patients in 1999, but that none of the states
reported that more than half of the dentists treated 100 or more
Medicaid patients.[Footnote 28]
One group of children particularly affected by low levels of dentists'
participation in Medicaid and CHIP are children with special health
care needs. On its Web site, HRSA's Maternal and Child Health Bureau
has defined children with special health care needs as "those who have
or are at increased risk for a chronic physical, developmental,
behavioral, or emotional condition and who also require health and
related services of a type or amount beyond that required by children
generally." According to a March 2009 ASTDD evaluation of 17 state
oral health programs, the most common barriers to dental services for
children with special health care needs include low rates of dentists'
participation in Medicaid and CHIP, difficulty locating dentists who
accept children with special health care needs who have behavioral
challenges, and the high cost of specialized care.[Footnote 29]
Studies have also cited the lack of training for dentists to
accommodate children who have special treatment needs.[Footnote 30] In
response to the 2005-2006 National Survey of Children with Special
Health Care Needs--a periodic survey sponsored by HRSA's Maternal and
Child Health Bureau and carried out by the Centers for Disease Control
and Prevention--parents (or guardians) of children with special health
care needs reported that unmet dental care was the greatest health
care need for these children and reported problems getting dental care
at levels that exceeded those of healthy children. Unmet dental care
for children with special heath care needs can also vary by diagnosis.
For example, a study based on the 2005-2006 National Survey of
Children with Special Health Care Needs found that children with
Down's Syndrome were about twice as likely to have unmet dental needs
as children with asthma.[Footnote 31] The study also reported that the
odds of having unmet dental care needs were 13 times greater for low-
income children with more severe special health care needs compared
with higher-income children without special health care needs.
[Footnote 32]
Information on HHS's Web Site to Help Locate Participating Dentists
Was Not Always Complete or Accurate:
To help families locate dentists near them to treat children in
Medicaid or CHIP, CHIPRA required HHS to post information on
participating dentists on its Insure Kids Now Web site. However, we
found problems with the data available through the Web site--
specifically that the listings available on the Web site or through
links available from the Web site were not always complete and
accurate. CHIPRA required HHS to post a current and accurate list of
dentists participating in Medicaid or CHIP on the Web site by August
2009 and to ensure that the list is updated at least quarterly. In
August 2010, officials from CMS--the agency within HHS responsible for
implementation and that established the data elements that states
should provide--described the Web site as a "work in progress" and
reported that they are continually improving the site. Although we
found that improvements were evident over a 6-month period, problems
remained. Specifically, we found cases in which information posted on
the Web site was not complete, not usable, or not accurate.
* Completeness. Our review of dentist listings for all 50 states and
the District of Columbia in November 2009, 3 months after CHIPRA
required HHS to post the list of participating dentists, found a
variety of problems, including missing or incomplete information on
dentists' telephone numbers and addresses, whether dentists accepted
new Medicaid or CHIP patients, and whether dentists could accommodate
children with special needs. Our second review of dentist listings in
April 2010 for these data found some improvements had been made, but
that problems with missing or incomplete information continued for
some states (see table 4).
Table 4: Number of States Providing Missing or Incomplete Dentist
Information through HHS's Insure Kids Now Web Site in November 2009
and April 2010:
Required data element missing or incomplete: Medicaid; Missing or
incomplete contact information (i.e., name, address, telephone number)
for some or all dentists;
Number of states: November 2009: 10;
Number of states: April 2010: 10.
Required data element missing or incomplete: Medicaid; Did not
indicate for all dentists whether dentist accepts new patients;
Number of states: November 2009: 34;
Number of states: April 2010: 29.
Required data element missing or incomplete: Medicaid; Did not
indicate for all dentists whether dentist can accommodate patients
with special needs;
Number of states: November 2009: CHIP: 40;
Number of states: April 2010: CHIP: 37.
Required data element missing or incomplete: CHIP; Missing or
incomplete contact information (i.e., name, address, telephone number)
for some or all dentists;
Number of states: November 2009: 17;
Number of states: April 2010: 14.
Required data element missing or incomplete: CHIP; Did not indicate
for all dentists whether dentist accepts new patients;
Number of states: November 2009: 34;
Number of states: April 2010: 29.
Required data element missing or incomplete: CHIP; Did not indicate
for all dentists whether dentist can accommodate patients with special
needs;
Number of states: November 2009: 38;
Number of states: April 2010: 36.
Source: GAO analysis of HHS's Insure Kids Now Web site for 50 states
and the District of Columbia.
Note: This table presents the results of our review of the information
posted on HHS's Insure Kids Now Web site in November 2009 and April
2010. Specifically, we examined each state's listing of dentists to
determine if certain data elements, specified in CMS guidance as
required, were present for all dentists in all Medicaid and CHIP
programs operated by the state and recorded instances in which data
were missing or incomplete for all or some dentists.
[End of table]
* Usability. In May 2010, we reviewed all state dentist listings on
the Insure Kids Now Web site to determine whether families of a child
in Medicaid or CHIP could reasonably use the site to find potential
dentists near them and found that listings from 25 states and the
District of Columbia had usability problems that prevented or hampered
the search for a dentist participating in Medicaid or CHIP. For
example, menu or search functions for 14 states did not work for a
program or entire state--with no indication of when functions would be
restored or how the user could obtain alternate assistance while it
was unavailable. Other problems we encountered included broken or
incorrect links (for example, one state link that took the user to an
unrelated agency in another state) and confusing menus that could
hinder the search. For example, seven states listed multiple health
plans with similar names, some containing typographical errors and
some that produced different provider listings, increasing the
likelihood of selecting the wrong plan and generating an incorrect
list of dentists.
* Accuracy. To check the accuracy of information on dentists posted on
the Insure Kids Now Web site, in May 2010 we called the telephone
number listed for 188 general dentists shown on HHS's Web site as
practicing in selected low-income urban and rural areas in four
states[Footnote 33] and found problems in about half (96) of the
listings we checked, including dentists who were not accepting
children in Medicaid or CHIP and wrong or disconnected telephone
numbers (see table 5). We also asked respondents to tell us what the
typical wait time would be for an appointment with the dentists. Of 92
dentists we called that reported that they accepted new Medicaid or
CHIP patients under age 19, all but one reported that the wait time
was the same for Medicaid or CHIP patients and privately insured
patients.[Footnote 34]
Table 5: Errors in Dentist Listings on HHS's Insure Kids Now Web Site,
May 2010:
State (number of dentists whose offices we called): California (40);
Wrong or disconnected telephone number, percentage (number of errors):
5% (2);
Errors in other posted information,[A] percentage (number of errors):
8% (3);
Not accepting new Medicaid or CHIP children, percentage (number of
errors): 30% (12).
State (number of dentists whose offices we called): Georgia (45);
Wrong or disconnected telephone number, percentage (number of errors):
4% (2);
Errors in other posted information,[A] percentage (number of errors):
38% (17);
Not accepting new Medicaid or CHIP children, percentage (number of
errors): 11% (5).
State (number of dentists whose offices we called): Illinois (56);
Wrong or disconnected telephone number, percentage (number of errors):
36% (20);
Errors in other posted information,[A] percentage (number of errors):
36% (20);
Not accepting new Medicaid or CHIP children, percentage (number of
errors): 4% (2).
State (number of dentists whose offices we called): Vermont (47);
Wrong or disconnected telephone number, percentage (number of errors):
4% (2);
Errors in other posted information,[A] percentage (number of errors):
38% (18);
Not accepting new Medicaid or CHIP children, percentage (number of
errors): 9% (4).
Source: GAO analysis.
Note: In May 2010, we called the telephone number listed on HHS's
Insure Kids Now Web site for 188 dentists in California, Georgia,
Illinois, and Vermont--states we selected because they provided
variation in geography, use of Medicaid dental managed care, and the
number of children covered by Medicaid. Within each state we
identified 25 urban dentists and 15 rural dentists to call in the
areas with the largest number of children in poverty. For a dentist in
a group practice, a single telephone call could yield additional
dentists; thus more dentists were called in some states. We accounted
for each dentist separately, so an error such as a wrong telephone
number for a dental clinic with multiple dentists would account for
multiple errors.
[A] Other errors included incorrect addresses (11) or dentists no
longer in practice or not providing routine examinations (47).
[End of table]
In addition, while CMS issued guidance requiring states to indicate on
the Web site whether a dentist could treat children with special
needs, as of August 2010, CMS had not defined what capabilities
dentists who serve children with special needs should have, and we
found some confusion among dentists' offices regarding their ability
to treat these children. For example, several of the dentist offices
we called indicated they were unsure whether they could serve children
with special needs, while others indicated that they would try to
serve them. Of the dentist offices that responded to questions about
specific capabilities, nearly all (89 of 95) reported that their
offices were wheelchair accessible, but few (6 of 74) reported that
they could treat children requiring sedation--although a small number
indicated that they would refer the patient to another dentist who
could provide sedation.
Finally, we identified one dentist shown on a state's Insure Kids Now
listing of dentists treating children enrolled in Medicaid or CHIP who
was on HHS's register of excluded providers and should not have been
allowed to receive reimbursement from either program.[Footnote 35] We
contacted the dentist's office on May 5, 2010 as part of our review of
the accuracy of the information posted on the Web site and the
dentist's office confirmed that the dentist was accepting new Medicaid
patients. We also contacted the HHS Office of Inspector General (OIG),
which administers the HHS exclusion program and HHS-OIG officials
confirmed that the dentist had been excluded from participation in the
Medicaid program and that the dentist had been reinstated effective
May 13, 2010.[Footnote 36]
States Report Improvement in the Provision of Dental Services to
Children in Medicaid, but Data to Monitor Service Provision under CHIP
or Managed Care are Limited:
Although annual state reports on the CMS 416 indicate that the
provision of dental services to children in Medicaid nationwide had
improved between 2001 and 2008 (the most recent data available at the
time of our review), overall utilization rates remained low. In
addition, data to measure provision of dental services for some
children, such as those in managed care programs or in CHIP, are
limited.
States Report Improvement in the Provision of Dental Services to
Children in Medicaid between 2001 and 2008, but Utilization Remains
Low:
According to data provided by states on annual CMS 416 reports,
utilization of dental services among children in Medicaid had
improved, but reported utilization rates still varied among states.
[Footnote 37] Nationwide, reported utilization of any Medicaid dental
service increased--from 27 percent of children in federal fiscal year
2001 to 36 percent of children in federal fiscal year 2008--but
despite this increase, no dental service utilization was reported for
nearly two-thirds of Medicaid-enrolled children.[Footnote 38] Overall,
states also reported a higher proportion of children receiving
preventive dental services than dental treatment services in both
years (see figure 1).
Figure 1: Comparison of Nationwide Medicaid Dental Utilization Rates
for Dental Services for Children, Fiscal Years 2001 and 2008:
[Refer to PDF for image: horizontal bar graph]
Type of dental service: Any dental service;
2001: 27%;
2008: 36%.
Type of dental service: Preventive dental service;
2001: 22%;
2008: 32%.
Type of dental service: Dental treatment service;
2001: 14%;
2008: 18%.
Source: GAO analysis of CMS 416 data.
Note: This figure represents national dental utilization rates
calculated from data reported by states in their CMS 416 reports
submitted for federal fiscal years 2001 and 2008 on the number of
EPSDT-eligible Medicaid-enrolled children who received a dental
service during the fiscal year. Children enrolled in CHIP programs
that are expansions of the states' Medicaid programs are entitled to
the Medicaid EPSDT benefit package and are included in the states CMS
416 reports, but are not identified separately as CHIP enrollees.
[End of figure]
Although the percentage of children nationwide in Medicaid who
received any dental service increased, there continued to be wide
variation among states in the percentage of children reported to have
received any dental service, including eight states that reported
dental utilization rates at 30 percent or less in fiscal year 2008
(see figure 2). There was also wide variation among states in
utilization rates for preventive and dental treatment services--see
appendix II for a complete list of the utilization rates for any
dental service, preventive dental services, and dental treatment
services reported by states in their fiscal year 2008 CMS 416 reports.
Figure 2: Percentage of Children in Medicaid Receiving Any Dental
Service, Fiscal Year 2008:
[Refer to PDF for image: illustrated U.S. map]
0-30% (8 states):
California:
Florida:
Missouri:
Montana:
Nevada:
North Dakota:
Pennsylvania:
Wisconsin:
31-40% (26 states):
Alaska:
Arizona:
Arkansas:
Colorado:
Connecticut:
Delaware:
District of Columbia:
Illinois:
Kansas:
Kentucky:
Louisiana:
Maine:
Maryland:
Michigan:
Minnesota:
Mississippi:
New Jersey:
New York:
Ohio:
Oklahoma:
Oregon:
South Dakota:
Tennessee:
Utah:
Virginia:
Wyoming:
41% or more (17 states):
Alabama:
Georgia:
Hawaii:
Idaho:
Indiana:
Iowa:
Massachusetts:
Nebraska:
New Hampshire:
New Mexico:
North Carolina:
Rhode Island:
South Carolina:
Texas:
Vermont:
Washington:
West Virginia:
Source: GAO analysis of CMS Form 416 data; Map Resources (map).
Note: This figure represents dental utilization rates calculated from
data reported by states in their fiscal year 2008 CMS 416 reports (the
most recent available at the time of our review) on the number of
EPSDT-eligible Medicaid-enrolled children who received any dental
service during the fiscal year. Nationwide, 36 percent of children in
Medicaid received any dental service in fiscal year 2008. Children
enrolled in CHIP programs that are expansions of the states' Medicaid
programs are entitled to the Medicaid EPSDT benefit package and are
included in the states' CMS 416 reports, but are not identified
separately as CHIP enrollees. Dental utilization rates are rounded to
the nearest whole percentage.
[End of figure]
For Children in Managed Care and Children in CHIP, Data on the
Provision of Dental Services Are Limited:
Comprehensive and reliable data on dental utilization by children in
Medicaid managed care programs and children in CHIP are not available.
States do not distinguish between fee-for-service and managed care
programs when reporting annual Medicaid data to CMS (using CMS 416).
[Footnote 39] A comparison of fiscal year 2008 CMS 416 data with
available data on the proportion of children in Medicaid managed care
in a given state suggests that children in Medicaid managed care plans
may have lower dental utilization rates than children in fee-for-
service programs. Our analysis of 2008 data on Medicaid managed care
penetration rates from the American Dental Association found that 10
states provided dental services predominantly through dental managed
care programs.[Footnote 40] These 10 states reported that 34 percent
of children covered by Medicaid received any dental service, compared
to 41 percent of children reported by the 33 states that reimbursed
exclusively under fee-for-service.
Questions about the provision of Medicaid dental services under
managed care compared to fee-for-service payment arrangements are long-
standing. In 2007, we reported that CMS had taken steps to improve the
CMS 416 data, but that concerns remained about the completeness and
sufficiency of the data for purposes of overseeing Medicaid dental
services.[Footnote 41] In particular, we noted that the information
could not be used to identify problems with specific delivery methods.
Following our report, CMS officials had considered revising the CMS
416 to capture services delivered through managed care; however, as of
August 2010, CMS officials did not have any plans to do so.
In addition, national data were not available on the provision of CHIP
dental services, although CMS will require improved reporting per
CHIPRA in 2011 for dental services provided in 2010. Although states
must assess the operation of their CHIP programs each federal fiscal
year and report on the results of this assessment,[Footnote 42] CMS
had not required states to include specific information on the
provision of CHIP dental services, such as required for Medicaid
dental services in the CMS 416. However, beginning in fiscal year
2010, CHIPRA requires states to include information on CHIP dental
services of the type contained in the CMS 416 in their annual CHIP
reports and further requires the inclusion of information on the
provision of CHIP dental services in managed care programs.[Footnote
43] According to CMS officials, a CMS work group is developing
specific reporting requirements for CHIP dental services provided by
states in fiscal year 2010, with the first reports due to CMS in 2011.
Federal Efforts to Improve Access to Dental Services for Children in
Underserved Areas Are Under Way, but Effect Is Not Yet Known:
Two HHS programs that provide dental services to children as well as
adults in underserved areas--HRSA's Health Center and NHSC programs--
have reported increases in the number of dentists and dental
hygienists practicing in underserved areas, but the effect of recent
initiatives to increase federal support for these and other oral
health programs is not yet known. And despite these increases, some
gaps may remain. For example, even with recent increases, both health
centers and the NHSC program report continued need for additional
dentists and dental hygienists to treat children and adults in
underserved areas.
Health Center and NHSC Programs Report Recent Increases in the Number
of Dentists and Dental Hygienists, but Full Effect of Federal Efforts
Is Unknown:
One federal effort to improve access to dental services in underserved
areas is the Health Center program. To support the expansion of dental
services in health centers, HRSA reported that it provided grant
opportunities for health centers to expand oral health services,
making 312 awards between 2002 and 2009 totaling $56.4 million. The
number of patients, including children, that HRSA reported as
receiving dental services in health centers, the number of FTE
dentists, and the number of FTE dental hygienists providing those
services all increased by more than one-third between calendar years
2006 and 2009 (see figure 3).[Footnote 44] In addition to dental
services required of health centers, such as pediatric dental
screenings and preventive dental services, HRSA reported a 40 percent
increase in the number of patients receiving restorative dental
services over this period.[Footnote 45] Despite these increases, an
official with the National Association of Community Health Centers
reported continued need for additional health centers and dental
providers to practice in them to meet the needs of underserved areas.
[Footnote 46]
Figure 3: Number of Dental Hygienists, Dentists, and Dental Patients
at Health Centers, Calendar Years 2006 through 2009:
[Refer to PDF for image: vertical bar graph]
Year: 2006;
Full-time equivalent (FTE) dental hygienists: 714;
Full-time equivalent (FTE) dentists: 1,912;
Total number of dental patients: 2.6 million.
Year: 2007;
Full-time equivalent (FTE) dental hygienists: 806;
Full-time equivalent (FTE) dentists: 2.108;
Total number of dental patients: 2.8 million.
Year: 2008;
Full-time equivalent (FTE) dental hygienists: 892;
Full-time equivalent (FTE) dentists: 2,299;
Total number of dental patients: 3.1 million.
Year: 2009;
Full-time equivalent (FTE) dental hygienists: 1,018;
Full-time equivalent (FTE) dentists: 2,577;
Total number of dental patients: 3.4 million.
Source: GAO analysis of HRSA data.
Note: This figure presents information HRSA reported on the number of
FTE dental hygienists and dentists practicing in health centers for
each calendar year and the total number of dental patients. HRSA
reported the exact number of patients receiving dental services as
follows: 2,577,003 in 2006, 2,808,418 in 2007, 3,071,085 in 2008, and
3,438,340 in 2009.
[End of figure]
Another HHS program reporting an increase in the number of dentists
and dental hygienists practicing in underserved areas is the NHSC.
HRSA reported that 611 dentists and 70 dental hygienists were
practicing in HPSAs through the NHSC scholarship and loan repayment
programs at the end of fiscal year 2009.[Footnote 47] This was at
least 30 percent higher than the number of NHSC dentists and dental
hygienists HRSA reported as practicing in HPSAs through the program at
the end of the three preceding fiscal years (see figure 4). Despite
this increase, the NHSC reported vacancies for 673 dentists and 192
dental hygienists to practice in dental HPSAs in August 2010.
Figure 4: Number of NHSC Dentists and Dental Hygienists Practicing in
Shortage Areas, Fiscal Years 2006 through 2009:
[Refer to PDF for image: stacked vertical bar graph]
Fiscal year: 2006;
Dental hygienists: 48;
Dentists: 474;
Total: 522.
Fiscal year: 2007;
Dental hygienists: 44;
Dentists: 443;
Total: 487.
Fiscal year: 2008;
Dental hygienists: 36;
Dentists: 450;
Total: 486.
Fiscal year: 2009;
Dental hygienists: 70;
Dentists: 611;
Total: 681.
Source: GAO analysis of HRSA data.
Notes: This figure presents information HRSA reported on the number of
dentists and dental hygienists practicing in shortage areas through
the NHSC as of the end of each fiscal year.
[End of figure]
In 2009, the Recovery Act provided appropriations for both the Health
Center and NHSC programs, funding activities to improve access to
services, including dental services for children, in underserved
areas. For example, according to HRSA, Recovery Act funds were used to
support NHSC loan repayment awards for 96 of the dentists and 20 of
the dental hygienists practicing in HPSAs through the NHSC at the end
of fiscal year 2009[Footnote 48] as well as an additional 382 dentists
and 105 dental hygienists who received NHSC loan repayment awards in
fiscal year 2010. HHS also indicated that it used funds made available
through the Recovery Act to award more than 1,100 grants totaling
approximately $338 million to health centers to support efforts to
increase the number of patients served.[Footnote 49]
Another recent statute--PPACA--authorized and in some cases
appropriated funding for both the Health Center and NHSC programs. For
example, in August 2010, HHS announced the availability of $250
million in grants--from funds made available in PPACA--for new full-
time service delivery sites that provide comprehensive primary and
preventive health care services, including pediatric dental screenings
and preventive dental services, for underserved and vulnerable
populations under the Health Center program. The full effect of PPACA
funding on children's access to dental services in underserved areas,
however, remains to be seen. See appendix III for additional
information on the funding made available to the NHSC and Health
Center programs through the Recovery Act and PPACA.
HHS's Oral Health Initiative 2010 and Other HHS Programs May Improve
Access to Dental Services for Children in Underserved Areas:
In an effort to increase support for and expand the department's
emphasis on access to oral health care, including access for
underserved populations, HHS launched a departmentwide Oral Health
Initiative in April 2010 to improve the nation's oral health by better
coordinating federal programs. According to HHS, the initiative is
intended to improve the effective delivery of services to underserved
populations by creating and financing programs to emphasize oral
health promotion and disease prevention, increase access to care,
enhance the oral health workforce, and eliminate oral health
disparities.[Footnote 50] The initiative includes two new HHS efforts
targeted at specific groups of children that, although too early to
tell, may lead to improved access for children in underserved areas:
* HHS's Administration for Children and Families has started the Head
Start Dental Homes Initiative, to establish a national network of
dental homes for children in Head Start and Early Head Start. The
Administration for Children and Families Office of Head Start and the
American Academy of Pediatric Dentistry define a dental home as
comprehensive, continuously accessible, coordinated, and family-
centered oral health care delivered to children by a licensed dentist.
* HHS's Indian Health Service has started the Early Childhood Caries
Initiative to promote the prevention and early intervention of dental
caries (tooth decay) for young American Indian and Alaska Native
children--a population that experiences dental caries at a higher rate
than the general U.S. population.[Footnote 51]
In addition to the NHSC and Health Center programs, HHS administers,
or has authority to administer, a number of other oral health
programs. Although not all of these programs are targeted specifically
to children in underserved areas, they may improve their access to
dental services. Examples of such programs include: (1) the School-
Based Dental Sealant Program, which was authorized by PPACA to expand
grants for school-based dental sealant programs to all 50 states,
territories, and Indian tribes and organizations;[Footnote 52] and (2)
the State Oral Health Workforce Grant program which awards grants to
states to address workforce issues, including those associated with
dental HPSAs. See appendix IV for a list of these and other HHS
programs that may improve access to dental services in underserved
areas.
Use of Mid-Level Dental Providers Is Not Widespread in the United
States, and Other Countries Have Used Them to Improve Children's
Access to Dental Services:
Mid-level dental providers--providers who can perform intermediate
restorative procedures, such as drilling and filling a tooth, under
remote supervision of a licensed dentist--are not widely licensed or
certified to practice in the United States. Other countries, which
have used mid-level dental providers for many years, reported that
these providers deliver quality care and increase children's access to
dental services.
Efforts Are Under Way to Use Mid-Level and Other Dental Providers to
Improve Children's Access to Dental Services:
Within the United States, experience with mid-level dental providers
is limited to the Dental Health Aide Therapist program for Alaska
Natives and the advanced dental therapy program in Minnesota.[Footnote
53] Efforts are under way to increase access to dental services
through the use of dental therapists, dental hygienists, physicians,
and other new dental provider models.
Dental Health Aide Therapist Program for Alaska Natives:
The Dental Health Aide Therapist program in Alaska, the only mid-level
dental provider program with providers practicing in the United States
as of July 2010, began in 2003 in response to the extensive dental
health needs of Alaska Natives and high dentist vacancy rates in rural
Alaska.[Footnote 54] Dental health aide therapists (dental therapists)
in Alaska are not licensed by the state; rather the program is
authorized under the federal Community Health Aide Program for Alaska
Natives. The 2-year training program is based on a long-standing
dental therapy program in New Zealand. After completion of their
training and preceptorship, dental therapists become certified and
practice in their assigned villages under the remote consultative
supervision of a dentist.[Footnote 55] Services performed by dental
therapists may include assessments and basic and intermediate
restorative procedures. As of June 2010, 19 dental therapists were
serving in rural Alaska native villages or completing their
preceptorship with a supervising dentist.
Children are an important focus of the Dental Health Aide Therapist
program. According to an official from the Alaska Native Tribal Health
Consortium, about half of the patients seen by dental therapists under
this program are children. For example, between 2006 and 2009,
approximately 59 percent of encounters for one dental therapist were
with children under 18 years old. Consortium officials also noted that
Medicaid is a major payer for dental therapist services, indicating
that dental therapists provide a substantial portion of their services
to children under Medicaid.[Footnote 56] Although limited research
regarding the impact of this program has been completed, a 2008 study
examining the quality of restorative procedures performed by dental
therapists found that procedures provided by dental therapists do not
differ from similar procedures performed by dentists.[Footnote 57] In
addition, in October 2010, a study of the Dental Health Aide Therapist
program found that the five dental therapists who were included in the
study performed well, operated safely, and were technically competent
to perform procedures within their defined scope of practice. The
study also noted that the patients of the dental therapists were
generally very satisfied with the care they received from those
therapists. The study assessed the quality of services and procedures
provided by dental therapists using various methods including patient
and oral health surveys, observations of clinical technical
performance, medical chart audits, and facility evaluations.[Footnote
58] See appendix V for more information on the Dental Health Aide
Therapist program in Alaska.
Minnesota's Advanced Dental Therapist Program:
In 2009, Minnesota authorized the certification of the advanced dental
therapist and dental therapist positions to provide dental services to
low-income, uninsured, and underserved patients.[Footnote 59] Advanced
dental therapists are licensed dental therapists who, upon completion
of additional education and experience, may become certified to
perform a range of preventive, and basic and intermediate restorative
procedures--including drilling and filling and non-surgical
extractions of permanent teeth--under the remote consultative
supervision of a dentist. They may also develop patient treatment
plans with authorization by a consulting dentist.[Footnote 60]
Advanced dental therapy training is offered by Metropolitan State
University as a master's degree program which prepares students with
an existing dental hygiene license for licensure as a dental therapist
and certification as an advanced dental therapist upon completion of
2,000 hours of dental therapy practice.[Footnote 61] As of June 2010,
certification requirements for advanced dental therapists had not yet
been finalized, and there were no practicing advanced dental
therapists. State officials anticipated that the first advanced dental
therapists will graduate in 2011. Once licensed, advanced dental
therapists are required to enter into consultative agreements--which
outline any restrictions to their scope of practice--with licensed
dentists to whom they will refer patients for services beyond their
scope of practice.[Footnote 62] Minnesota health officials anticipated
that advanced dental therapists will be eligible to receive direct
Medicaid and CHIP reimbursement, but payment arrangements had not been
finalized as of June 2010.
Use of Dental Hygienists and Physicians in Selected States:
Certain states have made efforts to increase children's access to
dental services by allowing dental hygienists and primary care
physicians to provide certain dental services without the on-site
supervision of a dentist. In seven of the eight states we examined--
Alaska, California, Colorado, Minnesota, Mississippi, Oregon, and
Washington--dental hygienists may perform certain procedures, such as
fluoride application, under remote or no supervision of a dentist; in
some cases specifically to increase access for underserved
populations.[Footnote 63] For example, dental hygienists in
California, Minnesota, Mississippi, Oregon, and Washington may
practice in limited settings outside the private dental office under
remote or no supervision of a dentist, increasing access to dental
services for underserved populations, including children. Such
practices are generally limited to settings such as schools or
residential facilities and, in most cases, allow hygienists to provide
only preventive services upon completion of additional training or
clinical experience. Dental hygienists in these states increase the
available locations for individuals to access certain preventive
dental procedures. In addition, five of the eight states we studied--
California, Colorado, Minnesota, Oregon, and Washington--reported that
they allow direct Medicaid and in some cases CHIP reimbursement to
certain dental hygienists for providing some preventive dental
services.[Footnote 64] See appendix VI for additional information on
the scope of practice and requirements for dental therapists, dental
hygienists, and dental assistants in the eight states we examined.
In addition, many states have also engaged primary care medical
providers--such as physicians--in the provision of children's dental
services. A survey conducted in 2009 indicated that 34 state Medicaid
programs reimburse primary care medical providers for providing
preventive dental procedures, such as fluoride application, and this
represents an increase of nine states from a similar study conducted
in 2008.[Footnote 65] To track the provision of dental services by
physicians and dental hygienists to children covered by Medicaid, CMS
officials reported that they are in the process of revising the CMS
416 to collect information on the number of children receiving dental
services--such as sealants and oral assessments--from these providers
and expect states will use the revised forms in 2011.
Efforts to Train or Employ New Dental Providers:
In addition to state initiatives, PPACA authorized demonstration
projects to train or employ certain dental providers. In March 2010,
PPACA authorized $60 million to fund 15 demonstration projects to
train or to employ "alternative dental health care providers" to
increase access to dental services in rural and other underserved
communities. PPACA defines alternative dental health care providers to
include dental therapists, independent dental hygienists, advanced
practice dental hygienists, primary care physicians, and any other
health professionals that HHS determines appropriate.[Footnote 66]
Entities eligible to apply for the demonstration grants include
colleges, public-private partnerships, federally qualified health
centers, Indian Health Service facilities, state or county public
health clinics, and public hospital or health systems.
Two professional organizations have also proposed new dental provider
models to increase children's access to dental services.
* The American Dental Association developed the position of a
community dental health coordinator as a new type of dental provider
who may provide oral health education as well as some preventive
services (depending on the state dental practice laws) under the
supervision of a dentist in communities with little access to dental
care. The association has begun a community dental health coordinator
pilot training program, and as of July 2010, there were 27 students in
three locations in California, Oklahoma, and Pennsylvania. The
training includes a 12-month online training program through Rio
Salado College and a 6-month clinical internship.[Footnote 67]
Officials from the American Dental Association told us they plan to
train 18 additional community dental health coordinators by September
2012, and they anticipated all of these providers will serve in their
home communities after the training program. The American Dental
Association is currently designing an evaluation of the program to be
completed in 2013, one year after the pilot training program ends in
2012.
* The American Dental Hygienists' Association developed and proposed
the advanced dental hygiene practitioner as a mid-level dental
provider to work independently in a variety of settings to provide
preventive and certain basic and intermediate restorative services--
including procedures such as drilling and filling a tooth--to
underserved populations. The model is similar to the advanced dental
therapist position in Minnesota and proposes a master's degree
curriculum that builds upon existing dental hygiene education
programs.[Footnote 68]
Other Countries Have Used Mid-Level Dental Providers to Improve Access
to Dental Services:
Mid-level dental providers--dental therapists--have been used by many
countries to improve access to preventive and restorative dental
services. In particular, New Zealand, the United Kingdom, Australia,
and Canada have long-standing dental therapist programs.[Footnote 69]
These countries have used dental therapists to staff school-and
community-based dental programs aimed at improving access to dental
services for children and other underserved populations, such as those
in rural areas (see table 6).[Footnote 70] Since the mid-1990s, three
of the four countries--New Zealand, the United Kingdom, and Australia--
have combined their dental therapy and dental hygiene training
programs.[Footnote 71]
Table 6: Characteristics of Mid-Level Dental Providers in New Zealand,
the United Kingdom, Australia, and Canada:
Country (year program started): Type of mid-level dental provider[A]:
New Zealand (1921); Dental therapist/Oral health therapist;
Scope of practice:
* Preventive;
* Restorative (basic and intermediate);
Supervision: Remote: consultative;
Years of post secondary education[A]: 3;
Number licensed or practicing (year): 730 (2009).
Country (year program started): Type of mid-level dental provider[A]:
United Kingdom (1959); Dental therapist/Oral health therapist;
Scope of practice:
* Preventive;
* Restorative (basic and intermediate);
Supervision: Remote: prior knowledge and consent;
Years of post secondary education[A]: 3;
Number licensed or practicing (year): 1,480 (2010).
Country (year program started): Type of mid-level dental provider[A]:
Australia[B] (1966); Dental therapist/Oral health therapist;
Scope of practice:
* Preventive;
* Restorative (basic and intermediate);
Supervision: Remote: consultative;
Years of post secondary education[A]: 3;
Number licensed or practicing (year): 1,760 (2005).
Country (year program started): Type of mid-level dental provider[A]:
Canada (1972); Dental therapist;
Scope of practice:
* Preventive;
* Restorative (basic and intermediate);
Supervision: Remote: prior knowledge and consent;
Years of post secondary education[A]: 2;
Number licensed or practicing (year): 310[C](2010).
Source: GAO analysis.
Note: In these countries, most dental therapists are paid through the
government as salaried employees. However, some work in private
practice and are then paid by their employers. The information in this
table was obtained from interviews with health officials in the four
countries, professional organizations, government reports, and
published research. We did not conduct an independent review of the
legal authorities for this information.
[A] Since the mid-1990s, Australia, the United Kingdom, and New
Zealand have combined their dental therapy and dental hygiene programs
with many offered as a bachelor's degree. The required education for
the combined degree is between 2 and 3 years and graduates are trained
in both scopes of practice.
[B] Until July 2010, dental therapy registration differed among
Australia's states with three states allowing dental therapists to
provide services to adults. Australia implemented a national
registration scheme in July 2010 that will require all states to have
the same scope of practice.
[C] Approximately three-quarters of dental therapists (230 of 310) in
Canada practice in Saskatchewan, the only province where they are
registered providers and able to work in private practice.
[End of table]
Dental therapists in the four countries, including those trained in
combined oral health therapy programs, can perform preventive and
basic and intermediate restorative procedures for children and adults
without the on-site supervision of a dentist in both the public and
private sectors. New Zealand, Australia, and Canada also permit dental
therapists to determine patient treatment plans providing they
maintain a relationship with a dentist where they can refer patients
for services beyond their scope of practice. See appendix VII for more
information on the use of dental therapists in these countries.
Health officials from the four countries expressed no reservations
about the quality of care provided by dental therapists. Although
recent data on the quality of services provided by dental therapists
in these countries are limited, a study published in 2009 on
Australian dental therapists reported that the standard of restorative
procedures performed by dental therapists was comparable to the
standard expected of newly graduated dentists in that country.
[Footnote 72]
Health officials from New Zealand, Australia, and Canada reported that
the majority of dental therapists' patients are children and available
research found that dental therapists providing care in school-or
community-based programs were an important part of improving dental
outcomes for children.[Footnote 73] For example, a health official
from New Zealand--where dental therapists provide dental services in
school-based clinics--told us that nearly all children aged 5 to 12
(96 percent) were enrolled in the nation's publicly funded school-
based dental program in 2009. The program aims to see all enrolled
children annually (or more frequently in high-risk cases) and the
official told us that available data indicated that decay rates are
reduced for these children. A New Zealand national oral health survey,
planned for publication in December 2010, was expected to provide a
clearer picture of children's oral health status across the
population. In addition, one academic dental therapy official told us
that in 2010 between 40 and 70 percent of Australian children,
depending on the state, obtained dental services through publicly
funded school-based dental programs primarily staffed by dental
therapists. A 2008 study in Australia found that, from 1977 to 2002,
the number of decayed, missing, and filled teeth declined 37 percent
for primary teeth in 6-year old children and 79 percent for permanent
teeth in 12-year old children enrolled in school-based programs.
[Footnote 74] A Canadian health official reported that dental
therapists serving aboriginal children in rural provinces and
territories since the 1970s have often been the only reliable source
of dental care for those children, in part because dentists are
difficult to retain in rural areas. In the Canadian province of
Saskatchewan, research on the impact of the province's school-based
dental program estimated that the program served over 80 percent of
non-aboriginal children in the province from 1976 to 1980 and that
lower incidence of dental caries could be demonstrated with increased
exposure to the program.[Footnote 75] An official from the
Saskatchewan Dental Therapists Association--the dental therapy
regulating authority in the province--also reported that dental
therapists working in private practice in the province increase
children's access to dental services because they can provide
restorative services and free time for dentists to see more patients.
Since 2004, Canada has piloted and expanded the use of dental
therapists to provide preventive and restorative services to
aboriginal children in a community-based dental program. As of May
2010, Canadian health officials were completing an evaluation of the
program, which they expected to show improved dental outcomes.
Conclusions:
In the decade that has passed since the Surgeon General described the
silent epidemic of oral disease affecting children in low-income
families, dental disease and access to dental services have remained a
significant problem for these children--including those in Medicaid
and CHIP. States report that nationwide, only 36 percent of children
in Medicaid received any dental service in fiscal year 2008, far below
HHS's Healthy People 2010 target of 66 percent for low-income
children. States also continue to report low participation by dentists
in Medicaid and CHIP. Recognizing this challenge, HHS has taken a
number of steps to strengthen its dental programs, including its HHS
Oral Health Initiative 2010, and recent legislation has authorized and
in some cases appropriated funding specifically for programs that may
help increase access to dental services in underserved areas; but
results of these efforts are yet to be seen. And while states report
some improvement in the provision of Medicaid dental services between
2001 and 2008, CMS has not yet collected comprehensive data on
utilization of dental services for children in Medicaid managed care
programs and covered by CHIP. We have reported in the past that such
gaps limit CMS's oversight of the provision of dental services for
children, such as its ability to identify problems with specific
service delivery methods.
Providing complete and accurate information to help families with
children in the Medicaid and CHIP programs find dental care is an
important tool in improving access. The information that HHS is
required to post on its Insure Kids Now Web site could provide a
useful tool for connecting these children and their families with
dentists who will treat them. However, we found problems that limit
its ability to do so, such as incorrect, outdated, or incomplete
information; links to state Web sites that were not working; and even
a dentist taking Medicaid patients who had been excluded by HHS from
participation in the program. Addressing these problems--such as
providing alternative sources of information to assist users when the
Web site is not functioning or taken offline for maintenance, or
providing additional guidance on dentists' ability to serve children
with special needs--could help make the site more useful to
beneficiaries.
Recommendations for Executive Action:
We are making several recommendations to enhance the provision of
dental care to children covered by Medicaid and CHIP.
First, to help ensure that HHS's Insure Kids Now Web site is a useful
tool to help connect children covered by Medicaid and CHIP with
participating dentists who will treat them, we recommend that the
Secretary of HHS take the following actions:
* Establish a process to periodically verify that the dentist lists
posted by states on the Insure Kids Now Web site are complete, usable,
and accurate, and ensure that states and participating dentists have a
common understanding of what it means for a dentist to indicate he or
she can treat children with special needs.
* Provide alternate sources of information, such as HHS's toll-free 1-
877-KIDS-NOW telephone number, on the Insure Kids Now Web site when a
page or link from the Web site is not functioning or taken offline for
maintenance.
* Require states to verify that dentists listed on the Insure Kids Now
Web site have not been excluded from Medicaid and CHIP by the HHS-OIG,
and periodically verify that excluded providers are not included on
the lists posted by the states.
Second, to strengthen CMS oversight of Medicaid and CHIP dental
services provided by dental managed care programs, we recommend that
the Administrator of CMS take steps to ensure that states gather
comprehensive and reliable data on the provision of Medicaid and CHIP
dental services by managed care programs.
Agency Comments:
We provided a draft of this report for comment to HHS. HHS agreed with
our recommendations and provided written comments, which we summarize
below. The text of HHS's letter--which included comments from CMS,
HRSA, and CDC--is reprinted in appendix VIII. HHS also provided
technical comments, which we incorporated as appropriate.
In commenting on our recommendation that steps should be taken to
improve the Insure Kids Now Web site, CMS and HRSA concurred that more
attention needs to be devoted to improve the accuracy of information
submitted by the states. To that end, CMS and HRSA commented that they
will undertake several actions:
* To address errors on the site, CMS stated that the agency will
increase the type and frequency of checks performed and work with
states to ensure that they submit data that are free of the types of
problems we identified. HRSA commented that it will work with CMS to
develop a plan to periodically analyze a sample of data provided by
states to assess its accuracy.
* To ensure that providers that HHS has excluded from Medicaid and
CHIP are not listed on the site, CMS commented that it will ensure
states are aware that such providers must not be included in the data,
and HRSA reported that it plans to cross-check listed providers
against the HHS-OIG's database of excluded parties.
* CMS commented that it will ensure that there is a consistent
understanding of what it means to be identified on the site as a
dentist serving children with special needs.
CMS agreed with our recommendation that the agency take steps to
ensure that states gather comprehensive and reliable data on the
provision of Medicaid and CHIP dental services by managed care
programs, noting that the agency is in the process of revising the CMS
416 to include more information about dental services provided to
children in state Medicaid programs, including under managed care
payment arrangements. CMS's comments do not specify whether the agency
will require states to separately report utilization under managed
care for children in Medicaid or CHIP, a step that we believe is
necessary for effective oversight.
In addition, CDC commented that a statement in the introduction of our
report regarding the prevalence of tooth decay and dental disease in
children may be misleading. Although our statement accurately reflects
information that we previously reported, we revised the language to
clarify that the results of our analysis specifically refer to
children enrolled in Medicaid.
We are sending copies of this report to the Secretary of Health and
Human Services and other interested parties. In addition, the report
will be available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions regarding this report, please
contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix IX.
Signed by:
Katherine Iritani:
Acting Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To address the objectives in our review--to examine (1) the extent to
which dentists participate in Medicaid and the Children's Health
Insurance Program (CHIP) and federal efforts to help families find
dentists to treat children in these programs, (2) what is known about
access for Medicaid and CHIP children in different states and in
managed care, (3) federal efforts under way to improve access to
dental services by children in underserved areas, and (4) how states
and other countries have used mid-level dental providers to improve
children's access to dental services--we interviewed appropriate
officials from the Department of Health and Human Services (HHS),
academic institutions, professional associations, states, and dental
and children's advocacy groups; reviewed federal and state laws and
regulations; obtained, reviewed, and determined the reliability of
data; and reviewed relevant literature.
Specifically, to determine the extent to which dentists participate in
Medicaid and CHIP and federal efforts to help families find dentists
to treat children in these programs, we:
* Analyzed state reported data on the number of dentists in a state
treating Medicaid and CHIP patients, including data from the 2009
Association of State and Territorial Dental Directors (ASTDD)
survey[Footnote 76] and one of our prior reports.[Footnote 77]
* Reviewed articles in peer-reviewed journals and reports on access to
dental services by children with special health care needs.
* Examined states' dentist listings on HHS's Insure Kids Now Web site,
including whether listings were complete, usable, and accurate:
Completeness: To examine the completeness of the information on the
Web site, we conducted two reviews--in November 2009 and in April
2010--to determine whether information CMS guidance had identified as
required elements were present. We examined each state's listing of
dentists to determine if certain elements listed as required in the
Centers for Medicare & Medicaid Services' (CMS) June 2009 guidance
were present for all dentists in all Medicaid and CHIP programs
operated by the state (states can have multiple dental plans within
Medicaid and CHIP) and recorded instances in which data were missing
or incomplete for all or some dentists. Specifically, we examined each
state's listing for the presence of dentists' names, addresses, phone
numbers, and specialties; whether they accepted new Medicaid or CHIP
patients; and whether they could accommodate children with special
needs.[Footnote 78]
Usability: In May 2010, we conducted a review of the information
available on the Insure Kids Now Web site for each of the 50 states
and the District of Columbia. The purpose of this review was to
determine whether families seeking a dentist to treat a child covered
by Medicaid or CHIP could reasonably complete the task and, if not,
what types of errors prevented the site from being usable, such as
whether hyperlinks functioned as expected and linked pages contained
appropriate information. We tested the drop-down menus on the Web site
for the Medicaid and CHIP programs in each state, conducted a general
search of dentists for each program, and searched for dentists in each
state's capital city and in the District of Columbia.
Accuracy: To check the accuracy of information on dentists posted on
the Insure Kids Now Web site, we selected a nongeneralizable sample of
dentists listed on the Web site for four states (California, Georgia,
Illinois, and Vermont) that provided variation in geography, managed
care penetration for Medicaid (as reported by the American Dental
Association), and number of children covered by Medicaid. We selected
25 urban dentists and 15 rural dentists listed on the Insure Kids Now
Web site in each state. For urban dentists, we identified the urban
county with the most children in poverty, the largest city in that
county, and then the zip code within that city with the most children
in poverty. We then searched for general dentists nearest to the
selected zip code.[Footnote 79] For rural dentists, we selected
general dentists in the rural counties with the most children in
poverty, excluding rural counties adjacent to major metropolitan
areas. We limited our searches to dentists listed as accepting new
Medicaid and CHIP patients. We used U.S. Census data and an
urban/rural classification system developed by the U.S. Department of
Agriculture (called Rural-Urban Continuum Codes) to identify the areas
from which we selected dentists. In May 2010, we called the telephone
number listed for the selected dentists and asked the person
scheduling appointments if the listed dentist currently accepted new
patients, including new patients enrolled in the state's Medicaid and
CHIP programs. We also asked whether the dentist accommodated children
with special health care needs--generally, and specifically with
regard to wheelchair access and ability to treat children requiring
sedation. Finally, we asked if the listed address was accurate and
inquired about the next available appointment time. In the course of
making calls we contacted more than 40 dentists in some states because
some offices had multiple dentists listed on the Web site, resulting
in a total of 188 dentists included in our calls.
* Reviewed the literature, including our past reports and peer-
reviewed journals, on factors that impact dentists' decisions to
participate in Medicaid and states' efforts to address barriers to
dentists' participation.
To examine what is known about access for children in Medicaid and
CHIP in different states, including for children in managed care, we
examined dental utilization data on children covered by Medicaid,
including those covered under Medicaid expansion programs, reported by
states to CMS through the annual CMS 416 form. For each state and
nationally, we calculated utilization rates reported for any dental
service, preventive dental services, and dental treatment services. We
calculated utilization rates for federal fiscal year 2001, the year
after our first report on oral health, and federal fiscal year 2008,
the most recent year for which data were available. In addition, we
compared children's utilization of any dental service to data reported
by the American Dental Association on the proportion of children in
each state who receive their Medicaid dental benefits through managed
care.
To identify federal efforts under way to improve access to dental
services by children in underserved areas we interviewed cognizant HHS
officials, including those from CMS and the Health Resources and
Services Administration (HRSA), and obtained written responses from
agency officials to specific questions about relevant programs. We
obtained data on health center and National Health Service Corps
(NHSC) dental provider numbers and HHS program funding levels from HHS
officials and documents such as annual HRSA budget justifications. We
also reviewed provisions in the Recovery Act and the Patient
Protection and Affordable Care Act (PPACA) legislation and interviewed
HHS officials to discuss legislative changes and funding authorized
and in some cases appropriated for programs that promote dental
services in underserved areas.
To determine how states and other countries have used mid-level dental
providers to improve dental access for children, we examined laws,
regulations, and practices in eight states and interviewed or obtained
written responses from relevant officials in those eight states and
four countries. To select those eight states for review, we used a
standard set of questions posed to relevant officials from academic
institutions, professional associations, and advocacy groups regarding
states' dental practice laws, including practice of mid-level dental
providers. Using the standard set of questions, we obtained responses
on those states considered "expansive" and those considered
"restrictive" in their laws governing the practice of dental
providers. We assessed the responses and, to demonstrate the variation
in state laws, selected eight states--Alabama, Alaska, California,
Colorado, Minnesota, Mississippi, Oregon, and Washington. To obtain
information on the selected states' use of dental providers other than
dentists, we conducted interviews and obtained information from
Medicaid and CHIP officials and dental boards in the selected states.
Our interviews with officials revealed that there is no commonly
recognized definition of mid-level dental providers, therefore we
defined mid-level dental providers as providers who may perform
intermediate restorative procedures, such as drilling and filling a
tooth, under the remote supervision of a dentist. In addition, we
defined scope of practice for the purposes of this report based on
interviews and review of literature and state laws. To gather
information on the only practicing mid-level dental providers in the
United States, we conducted a site visit to Alaska. We interviewed
state and tribal officials on the Alaska Dental Health Aide Therapist
program administered by the Alaska Native Tribal Health Consortium and
visited two clinics where dental therapists were training and
practicing. To identify efforts related to new dental provider models,
we reviewed policies and proposals by professional associations and
interviewed officials from academic institutions, professional
associations, HHS, and our selected states. To select countries for
further review, we identified four countries that use mid-level
providers, specifically dental therapists, and are comparable to the
United States (identified as developed countries by the CIA World
Factbook[Footnote 80] and with a similar percentage of children living
in households with incomes below:
50 percent of their country's median income). The four countries
examined were Australia, Canada, New Zealand, and the United Kingdom.
To obtain information on the selected countries' use of mid-level
dental providers, we conducted a literature review and interviewed
oral health experts and government health officials in each country.
[Footnote 81]
To verify the reliability of the data we used for all four objectives,
including HRSA's health center data, ASTDD survey data, the American
Dental Association's Medicaid managed care data, U.S. Census data, the
U.S. Department of Agriculture's Rural-Urban Continuum Codes, the CMS
416 annual reports, and Alaska Dental Health Aide Therapist encounter
data, we interviewed knowledgeable officials, reviewed relevant
documentation, and compared the results of our analysis to published
data, as appropriate. We determined that the data were sufficiently
reliable for the purposes of our engagement.
We conducted this performance audit from August 2009 through November
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Medicaid Dental Utilization Rates for Fiscal Year 2008:
States report annually to the Centers for Medicare & Medicaid Services
(CMS) on the provision of certain covered services, including dental
services. Specifically, services covered under Medicaid's Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit are
reported by states on an annual participation report, CMS 416. It
captures data on the number of children who received any dental
service, preventive dental service, or dental treatment service each
year. We used this information to calculate state and national dental
utilization rates--that is, the percentage of children eligible for
EPSDT that received services in a given year (see table 7).
Table 7: Utilization of Any Dental Service, Preventive Dental Service,
and Dental Treatment Service by Children in Medicaid, Ranked in Order,
Fiscal Year 2008:
Any dental service utilization, by state:
Idaho: 56.1%;
Vermont: 51.1%;
Texas 48.5%;
New Hampshire: 46.6%;
Nebraska: 45.9%;
Rhode Island: 45.8%;
Iowa: 45.8%;
South Carolina: 45.0%;
Washington: 45.0%;
Massachusetts: 44.0%;
North Carolina: 43.8%;
New Mexico: 42.9%;
Hawaii: 42.1%;
West Virginia: 41.7%;
Georgia: 41.7%;
Alabama: 41.6%;
Indiana: 40.8%;
Oklahoma 39.2%;
Kansas: 38.9%;
Arizona: 38.8%;
Colorado: 38.5%;
Mississippi: 38.5%;
Virginia: 38.4%;
South Dakota: 38.4%;
Illinois: 38.4%;
Kentucky: 38.1%;
Alaska: 38.0%;
Tennessee: 37.6%;
Maryland: 37.2%;
Connecticut: 36.7%;
Minnesota: 36.7%;
Wyoming: 36.5%;
Ohio: 36.4%;
Maine: 36.2%;
Utah: 35.0%;
District of Columbia: 34.0%;
Arkansas: 33.6%;
Delaware: 33.4%;
New Jersey: 32.9%;
Oregon: 32.8%;
Louisiana: 32.5%;
Michigan: 32.4%;
New York: 32.1%;
California: 30.2%;
Nevada: 29.8%;
North Dakota: 29.1%;
Pennsylvania: 26.9%;
Montana: 25.6%;
Missouri: 24.7%;
Wisconsin: 24.1%;
Florida: 20.9%;
Nationwide: 36.2%.
Preventive dental services utilization:
Vermont: 49.9%;
Idaho: 46.0%;
Rhode Island: 43.1%;
New Hampshire: 42.5%;
South Carolina: 42.4%;
Nebraska: 41.6%;
Texas: 41.6%;
Washington: 41.4%;
Massachusetts: 40.3%;
North Carolina: 39.9%;
Iowa: 39.4%;
Georgia: 38.5%;
Alabama: 38.4%;
New Mexico: 38.2%;
Indiana: 37.1%;
Hawaii: 36.9%;
Oklahoma: 36.5%;
West Virginia: 36.0%;
Kansas: 35.9%;
Illinois: 35.4%;
Virginia: 35.2%;
South Dakota: 34.6%;
Utah: 34.1%;
Maine: 33.9%;
Tennessee: 33.7%;
Colorado: 33.5%;
Arizona: 33.5%;
Minnesota: 32.7%;
Wyoming: 32.0%;
Ohio: 31.7%;
Mississippi: 31.7%;
Kentucky: 31.6%;
Michigan: 31.6%;
Maryland: 31.6%;
Arkansas: 31.4%;
Alaska: 31.4%;
Connecticut: 30.3%;
Delaware: 30.1%;
District of Columbia: 29.0%;
Louisiana: 28.0%;
New Jersey: 27.8%;
New York: 27.6%;
Oregon: 27.6%;
Nevada: 25.0%;
California: 24.5%;
North Dakota: 23.8%;
Pennsylvania: 22.3%;
Montana: 22.1%;
Missouri: 21.9%;
Wisconsin: 21.0%;
Florida: 13.8%;
Nationwide: 31.5%;
Dental treatment services utilization:
New Mexico: 42.1%;
West Virginia: 41.5%;
Idaho: 30.4%;
Arkansas: 29.9%;
Hawaii: 26.1%;
Massachusetts: 25.1%;
Maine: 25.1%;
Texas: 25.0%;
South Carolina: 22.1%;
Nebraska: 21.8%;
Vermont: 21.5%;
Kentucky: 21.2%;
New Hampshire: 21.1%;
Rhode Island: 20.7%;
Virginia: 20.5%;
Arizona: 20.4%;
Washington: 20.4%;
Alaska: 20.2%;
Indiana: 20.0%;
Georgia: 19.6%;
North Carolina: 19.2%;
Colorado: 19.1%;
Tennessee: 19.0%;
Iowa: 19.0%;
Wyoming: 18.9%;
Oklahoma: 18.4%v
New Jersey: 18.0%;
Kansas: 17.9%;
Utah: 17.7%;
Alabama: 17.7%;
Louisiana: 17.2%;
Minnesota: 17.0%;
Mississippi: 16.6%;
Maryland: 16.4%;
Ohio: 16.1%;
Delaware: 16.1%;
California: 16.0%;
Oregon: 15.8%;
Connecticut: 15.4%;
New York: 15.1%;
South Dakota: 14.8%;
Illinois: 14.7%;
Michigan: 13.6%;
District of Columbia: 13.6%;
Montana: 13.3%;
Missouri: 13.3%;
Pennsylvania: 12.9%;
Nevada: 11.7%;
North Dakota: 11.7%;
Wisconsin: 10.4%;
Florida: 7.8%;
Nationwide: 18.0%.
Source: CMS Form 416 data for fiscal year 2008.
Note: This table represents dental utilization rates calculated from
data reported by states in their fiscal year 2008 CMS 416 reports (the
most recent available at the time of our review) on the number of
EPSDT-eligible Medicaid-enrolled children who received any dental
service during the fiscal year. Children enrolled in CHIP programs
that are expansions of the states' Medicaid programs are entitled to
the Medicaid EPSDT benefit package and are included in the states' CMS
416 reports, but are not identified separately as CHIP enrollees.
[End of table]
[End of section]
Appendix III: NHSC and Health Center Funding in the Recovery Act,
PPACA, and Fiscal Year 2010 Appropriation:
The Recovery Act appropriated $500 million to address health
professions workforce shortages through means such as scholarships and
loan repayment awards, of which the Conference Committee directed $300
million be provided to NHSC for recruitment and field activities.
[Footnote 82] HRSA plans to use these funds in fiscal years 2009
through 2011.[Footnote 83] For the Health Center program, the Recovery
Act appropriated $2 billion for grants to benefit health centers--$500
million for grants to support the delivery of patient services and
$1.5 billion for grants to support and improve health center
infrastructure. According to HRSA, as of December 31, 2009, Recovery
Act funds for health centers had provided support to over 550 full-
time equivalent dental positions, including dentists, dental
hygienists, and dental assistants, as well as dental aides, and dental
technicians. HRSA reported that these positions have led to more than
575,000 dental visits to over 264,000 patients, including children, in
underserved areas.
PPACA authorized and appropriated a total of $1.5 billion for NHSC for
fiscal years 2011 through 2015. According to HRSA, this funding will
increase the number of dentists and dental hygienists participating in
NHSC. However, the agency reported that the exact number of
scholarship and loan repayment awards made using these funds will
depend on the number of qualified applications the program receives.
[Footnote 84] Additionally, PPACA authorized and appropriated $9.5
billion for health centers through the Community Health Center Fund
established by the Act as well as $1.5 billion for construction and
renovation of community health centers for fiscal years 2011 through
2015.[Footnote 85]
Funds specifically provided for these programs in the Recovery Act and
PPACA are in addition to the funds that may be specifically or
generally available for the NHSC and Health Center programs through
HHS's annual appropriations (see table 8).
Table 8: Funding for National Health Service Corps and Health Center
Programs Under the Recovery Act and PPACA, and the Fiscal Year 2010
Annual Appropriation:
Legislation/Program: Recovery Act: National Health Service Corps;
Funding (appropriated) (in millions): $300[A];
Funding time frame (fiscal years): 2009-2011.
Legislation/Program: Recovery Act: Health Center;
Funding (appropriated) (in millions): $2,000;
Funding time frame (fiscal years): 2009.
Legislation/Program: PPACA: National Health Service Corps;
Funding (appropriated) (in millions): $1,500;
Funding time frame (fiscal years): 2011-2015.
Legislation/Program: PPACA: Health Center;
Funding (appropriated) (in millions): $11,000[B];
Funding time frame (fiscal years): 2011-2015.
Legislation/Program: Fiscal Year 2010 Program Funding: National Health
Service Corps;
Funding (appropriated) (in millions): $142[C];
Funding time frame (fiscal years): 2010.
Legislation/Program: Fiscal Year 2010 Program Funding: Health Center;
Funding (appropriated) (in millions): $2,190[C];
Funding time frame (fiscal years): 2010.
Source: GAO analysis.
Note: This table presents data from the American Recovery and
Reinvestment Act of 2009, Pub. L. No. 111-5, 123 Stat. 115 and H.R.
Rep. No. 111-16 (2009) (Conf. Rep.); the Consolidated Appropriations
Act, 2010, Pub. L. No. 111-117, Division D., Title II, 123 Stat. 3034
and H. R. Rep. No. 111-220 (2009) and S. Rep. No. 111-66 (2009); the
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124
Stat. 119 (2010); and the Health Care and Education Reconciliation Act
of 2010, Pub. L. No. 111-152, 124 Stat. 1029. Funding time frames
represent the fiscal years during which funding detailed in the
"Funding (appropriated)" column will be available for obligation. All
amounts rounded to the nearest million.
[A] Based on direction provided by the Conference Committee for the
Recovery Act for specific use of the Act's appropriation to the
Department of Health and Human Services. H.R. Rep. No. 111-16, at 451
(2009).
[B] As amended by the Health Care and Education Reconciliation Act of
2010. Pub. L. No 111-152, § 2303, 111 Stat.1029, 1083.
[C] Based on direction provided by the House and Senate Committees on
Appropriations for specific use of the 2010 HRSA appropriation. H. R.
Rep. No. 111-220, at 46, 49 (2009); S. Rep. No. 111-66, at 38, 40-41
(2009) (providing direction for HRSA appropriation contained in
Consolidated Appropriations Act 2010, Pub. L. No. 111-117, Division D,
Title II, 123 Stat. 3034, 3239 (2009)).
[End of table]
[End of section]
Appendix IV: Additional HHS Programs That May Improve Access to Dental
Services in Underserved Areas:
In addition to the NHSC and Health Center programs, HHS administers a
number of programs that, while not targeted specifically to children
in underserved areas, may nevertheless improve their access to dental
services in underserved areas. These include programs that target the
provision of oral health services to specific populations such as
schoolchildren, as well as programs that support training of oral
health providers or prioritize the training of dentists and dental
hygienists that could serve in underserved areas (see table 9).
Table 9: HHS Programs that May Improve Access to Dental Services in
Underserved Areas:
Program (Authority) HHS Agency: Children's Hospitals Graduate Medical
Education (42 U.S.C. § 256e) HRSA;
Program Type: Supports the Provision of Dental Services: [Empty];
Oral Health Workforce Training and Support: [Check];
Description: Provides support to freestanding children's hospitals to
train medical residents, including dental residents and fellows.[A]
Program (Authority) HHS Agency: Grants for Training in General,
Pediatric, and Public Health Dentistry (42 U.S.C. § 293k-2) HRSA;
Program Type: Supports the Provision of Dental Services: [Empty];
Oral Health Workforce Training and Support: [Check];
Description: Awards grants to schools, hospitals, and other entities
that plan, develop, operate, or participate in an approved
professional training program that emphasizes training in general,
pediatric, and public health dentistry.[B]
Program (Authority) HHS Agency: Health Professionals Student Loan
Program (42 U.S.C. § 292q) HRSA;
Program Type: Supports the Provision of Dental Services: [Empty];
Oral Health Workforce Training and Support: [Check];
Description: Awards loans to financially needy health professions
students, including dental students.
Program (Authority) HHS Agency: Loans for Disadvantaged Students (42
U.S.C. § 292t) HRSA;
Program Type: Supports the Provision of Dental Services: [Empty];
Oral Health Workforce Training and Support: [Check];
Description: Awards loans to health professions students from
disadvantaged backgrounds, including dental students.
Program (Authority) HHS Agency: Ryan White Community-Based Dental
Partnership and Ryan White Dental Reimbursement Programs[C[(42 U.S.C.
§] § 300ff-111) HRSA;
Program Type: Supports the Provision of Dental Services: [Check];
Oral Health Workforce Training and Support: [Check];
Description: Awards grants to accredited dental education programs to
increase access to oral health services for people with human
immunodeficiency virus (HIV) in underserved areas by: (1) increasing
the number of dentists and dental hygienists with the capability of
managing the oral health needs of HIV positive patients; and (2)
defraying their unreimbursed costs associated with providing oral
health care to people with HIV (applicable to the Dental Reimbursement
program only).
Program (Authority) HHS Agency: Scholarships for Disadvantaged
Students (42 U.S.C. § 293a) HRSA;
Program Type: Supports the Provision of Dental Services: [Empty];
Oral Health Workforce Training and Support: [Check];
Description: Awards scholarships to health professions students from
disadvantaged backgrounds, including dental and dental hygiene
students.
Program (Authority) HHS Agency: School-Based Dental Sealant Program
(42 U.S.C. § 247b-14(c)) Centers for Disease Control and Prevention;
Program Type: Supports the Provision of Dental Services: [Check];
Oral Health Workforce Training and Support: [Empty];
Description: Expands grants for school-based dental sealant programs
to provide dental sealants to target populations of children.[D]
Program (Authority) HHS Agency: School-Based Health Centers (42 U.S.C.
§§ 280h-4, 280h-5) HRSA;
Program Type: Supports the Provision of Dental Services: [Check];
Oral Health Workforce Training and Support: [Empty];
Description: Authorizes HHS to award grants for the establishment of
or for the operation of school-based health centers. Requires or
authorizes HHS to give preference to applicants that serve a large
population of Medicaid and CHIP children or that serve communities
with high numbers of children and adolescents who are uninsured,
underinsured, or enrolled in public health insurance programs.[E]
Program (Authority) HHS Agency: State Oral Health Workforce Grants (42
U.S.C. § 256g) HRSA;
Program Type: Supports the Provision of Dental Services: [Check];
Oral Health Workforce Training and Support: [Check];
Description: Awards grants to states to address primarily workforce
issues associated with dental HPSAs.[F]
Source: GAO analysis of statutes and HHS information, including grant
guidance, summary information from HRSA and CDC Web sites, and
information provided by agency officials.
Note: This table presents selected HHS programs that may improve
access to dental services in underserved areas. While not targeted
specifically to children in underserved areas, these programs may
improve their access through support of the provision of dental
services to specific populations or through support for oral health
workforce training.
[A] HRSA reports that, in fiscal year 2009, 56 hospitals were funded
through the Children's Hospitals Graduate Medical Education payment
program. According to HRSA, the program enables the hospitals to
support graduate medical education, enhance research, and provide care
for underserved children.
[B] Statutory priority for awarding grants includes giving priority to
applicants that establish formal relationships with health centers as
well as applicants that have a high rate of placing residents in
underserved areas.
[C] While the Ryan White Act authorizes support for institutions that
may provide oral health services, these two grant programs--the Ryan
White Community-Based Dental Partnership Program and the Ryan White
Dental Reimbursement Program--are specifically focused on funding for
dental services.
[D] As of May 2010, 16 states had grants to operate school-based or
linked dental sealant programs, which generally target schools with
large populations of low-income children using the percentage of
children eligible for federal free and reduced-cost lunch programs.
The Patient Protection and Affordable Care Act (PPACA) authorized an
expansion of the program to all 50 states, territories, and Indian
tribes and organizations. Dental sealants are a plastic material
applied to the chewing surfaces of back teeth that have been shown to
prevent tooth decay.
[E] PPACA provided for the establishment of this program and
appropriated $200 million over 4 years for the establishment of school-
based health centers. PPACA also authorized such sums as may be
necessary for grants for program operations over 5 years, although
HRSA officials reported no funding had been appropriated specifically
for this purpose as of October 2010.
[F] HRSA reported that, as of October 2010, a total of 30 states had
34 grants, with California, Florida, Kansas and Ohio having two grants
each. Twenty-five of these 34 active, three-year, grants were awarded
in fiscal year 2009 and nine more were awarded in fiscal year 2010.
All 30 states may only use the funds received under these grants for
the 13 legislatively-authorized activities including, but not limited
to, loan forgiveness and repayment programs for dentists who agree to
practice in dental HPSAs, programs to expand or establish oral health
services and facilities in dental HPSAs, and community-based
prevention services--see Social Security Act 340G(b) (codified at 42
U.S.C. 256g(b)). HRSA reported that it awarded $10 million in grants
in fiscal year 2009 and $17.5 million in fiscal year 2010.
[End of table]
[End of section]
Appendix V: Dental Health Aide Therapist Program for Alaska Natives:
Based on a 1999 oral health survey, the Indian Health Service issued a
report detailing the extensive dental health needs and increasing
dental vacancy rates within the Alaska Native population.[Footnote 86]
In order to meet the extensive dental health needs of the Alaska
Native population, the Alaska Native Tribal Health Consortium
(Consortium), a tribal organization managed by Alaska Native tribes
through their respective regional health organizations, in
collaboration with others, developed the Dental Health Aide Therapist
program in 2003. This program selects individuals from rural Alaska
communities to be trained and certified to practice under remote
consultative supervision of dentists in the Alaska Tribal Health
System. Dental health aide therapists (dental therapists) in this
program in Alaska are not licensed by the state; rather the program is
authorized under the federal Community Health Aide Program for Alaska
Natives.
Under standards and procedures developed for this program, dental
therapists must complete a 2-year training program, a 400-hour
preceptorship under a dentist's supervision, and apply for
certification in order to practice. Alaska's first dental therapists
received their training from New Zealand's National School of
Dentistry in Otago with the first dental therapists graduating in
2004. In 2007, the Consortium in partnership with the University of
Washington opened the DENTEX training center and, in 2008, opened the
Yuut Elitnaurivat Dental Training Clinic in partnership with the Yuut
Elitnaurviat--People's Learning Center. These are the first Dental
Health Aide Therapist training centers in the United States. As of
March 2010, there were 13 dental therapy students enrolled in the
training program.
Since 2005, dental therapists have practiced throughout Alaska. As of
June 2010, 19 dental therapists had completed the 2-year training
program. Of those 19, 10 dental therapists were trained in New Zealand
and were certified and practicing in rural Alaska. Another five
completed their preceptorships and were certified to begin practice.
The remaining four dental therapists were completing their
preceptorships. Figure 5 shows the areas and villages where the dental
therapists were practicing or were scheduled to practice upon
completion of their preceptorships. According to Consortium officials,
the population of the communities where dental therapists were
practicing varies from under 100 to nearly 9,000 individuals.
Figure 5: Dental Therapist Training Locations and Certification Status
in Alaska, June 2010:
[Refer to PDF for image: illustrated map of Alaska]
Training Location and Status (number of persons):
New Zealand trained, certified and in practice (10):
Kiana;
Kotzebue;
Metlakatia;
Savoonga;
Shishmaref;
Sitka;
Stebbins;
Togiak;
Unalakleet.
Alaska trained, certified and in practice (5):
Atka;
Hooper Bay;
Klawock;
St. Mary's;
Yakutat.
Alaska trained and in preceptorship (4):
Chistochina;
Fairbanks (2);
New Stuyahok;
Dental therapy training centers:
Anchorage;
Bethel.
Source: Alaska Native Tribal Health Consortium; MapInfo (map).
[End of figure]
In general, dental therapists are based in a sub-regional clinic in an
Alaska Native village and travel to surrounding villages to provide
services.[Footnote 87] For example, one dental therapist who has been
practicing at a sub-regional clinic since 2006 estimated that he
travels approximately two weeks per month to the surrounding villages
to provide dental services. Travel for the dental therapists,
particularly in the winter, is a challenge as there are limited roads
to and from the villages and in many cases air travel is the only
possible mode of transport. When traveling, dental therapists often
bring their own supplies into the villages and in some cases have to
pack a portable dental chair.
Dental therapists treat patients primarily in rural Alaska Native
communities. Although these patients are typically Alaska Native or
American Indian, services may be provided to other patients, for
example when the program has capacity to provide the services to
others without denying or diminishing care to Alaska Native or
American Indian beneficiaries or there are limited health care
resources in the area. Consortium officials stated that all the tribal
organizations for regions employing dental therapists generally make
services available to non-Native patients, except in larger
communities, such as Anchorage, Fairbanks, Juneau, and Sitka.
According to Consortium officials, dental therapists often have an
agreement with the schools in their communities to allow for students
to receive services during school hours. Dental therapists are trained
to focus on expectant mothers and pre-school and school-aged children.
Consortium officials estimate that about half of patients treated by
dental therapists are children. For example, encounter data for 2006
through 2009 for two practicing dental therapists suggest that, on
average, 64 percent and 59 percent of their encounters were children,
respectively.[Footnote 88]
[End of section]
Appendix VI: Types of Dental Providers, Excluding Dentists, in Eight
Selected States:
In the states we examined--Alabama, Alaska, California, Colorado,
Minnesota, Mississippi, Oregon, and Washington--a variety of dental
providers other than dentists, such as dental therapists and
hygienists, may provide certain services with varying degrees of
supervision. Supervision of other dental providers by a dentist may
take many forms. For the purposes of this report, we categorized
dental supervision as: (1) the dentist must be on-site during the
procedure; (2) the dentist may be off-site (remote) but must have
prior knowledge of and consent to the procedures, in some cases
through a treatment plan; (3) the dentist may be off-site (remote) but
maintain a consultative role, for example through a signed
collaborative agreement; or (4) the dentist provides no supervision
(none). In addition, within each state, there is a basic level of
required education and experience for each category of provider, which
may increase depending on the scope of practice authorized. For
example, dental hygienists in Alaska may perform preventive and basic
restorative procedures under a collaborative agreement if--in addition
to graduating from dental hygiene school--they have completed 4,000
hours of clinical experience. All required education and experience is
listed for each type of provider.
In the eight states we examined scope of practice, required
supervision, education and experience, and reimbursement varied by
state. Tables 10 through 17 present information on dental providers--
other than dentists--authorized to practice in those eight states.
Table 10: Selected Types of Dental Providers in Alabama, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* Approved dental hygiene school, college or state program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* None;
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[End of table]
Table 11: Selected Types of Dental Providers in Alaska, June 2010:
Type of dental provider: Dental health aide therapist for Alaska
Natives[B];
Scope of practice[A]:
* Preventive;
* Basic restorative;
* Intermediate restorative;
Supervision required: Remote: consultative;
Required education and experience:
* Two years post-secondary training program[C];
* Specified clinical experience;
Licensed or certified: Yes[D];
Direct Medicaid/CHIP reimbursement: Yes.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: Remote: consultative;
Required education and experience:
* Dental hygiene program;
* Specified clinical experience;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant:
Scope of practice[A]:
* Preventive;
* Basic restorative;
* Intermediate restorative[E];
Supervision required: On-site;
Required education and experience:
* Specific instructional program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant:
Scope of practice[A]:
* Supportive;
* Preventive[F];
Supervision required: On-site;
Required education and experience: None;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state and tribal officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] The Dental Health Aide Therapist program is authorized under the
federal Community Health Aide Program for Alaska Natives, not the
state.
[C] Dental health aide therapists are recruited from Alaska
communities.
[D] Dental health aide therapists are not licensed by the state;
rather they are certified by the Alaska Native Tribal Health
Consortium as part of the federal Community Health Aide Program for
Alaska Natives.
[E] State regulations establishing specific restorative function
requirements have not yet been established.
[F] Dental assistants may perform certain preventive procedures such
as coronal polishing, with appropriate certification which would
require the completion of a specific instructional program. They may
perform other preventive procedures such as the application of
sealants with no additional training.
[End of table]
Table 12: Selected Types of Dental Providers in California, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive [limited settings][B];
Supervision required: Remote: consultative;
Required education and experience:
* Dental hygiene program/bachelor's degree;
* Specified clinical experience;
* Approved post-licensure training;
Licensed or certified: Yes[C];
Direct Medicaid/CHIP reimbursement: Yes[D].
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* Dental hygiene program;
* Approved post-licensure training;
Licensed or certified: Yes[E];
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* Dental hygiene program;
* Specific instructional program;
Licensed or certified: Yes[F];
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* Specific instructional program;
* Specified clinical experience;
* Specified post-licensure training;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
Supervision required: On-site;
Required education and experience:
* Specific instructional program;
* Specified clinical experience;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
Supervision required: On-site;
Required education and experience: None;
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] Certain dental hygienists may provide preventive services in
specific settings, such as schools, homebound residences, and
residential facilities under remote consultative dentist's supervision.
[C] Dental hygienists with this type of license are known as
registered dental hygienists in alternative practice.
[D] California CHIP does not contract with providers directly; the
managed care plans reimburse providers. California Medicaid does
reimburse certain licensed dental hygienists.
[E] Dental hygienists with this type of license are known as
registered dental hygienists in extended function.
[F] Dental hygienists with this type of license are known as
registered dental hygienists.
[End of table]
Table 13: Selected Types of Dental Providers in Colorado, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
Supervision required: None;
Required education and experience:
* Dental hygiene program;
Licensed or certified: Yes[B];
Direct Medicaid/CHIP reimbursement: Yes[C].
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: Remote: prior knowledge and consent;
Required education and experience:
* Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: Yes[C].
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site[D];
Required education and experience: None;
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] Unsupervised dental hygienists are known as independent dental
hygienists and operate under the same license as other hygienists in
the state.
[C] Dental hygienists may be paid directly for dental services under
Medicaid. Under CHIP, only dental hygienists enrolled in a specific
state program are paid directly for their services.
[D] Performance of some procedures may require prior knowledge and
consent of a dentist, but not on-site supervision.
[End of table]
Table 14: Selected Types of Dental Providers in Minnesota, June 2010:
Type of dental provider: Advanced dental therapist [limited
setting][B];
Scope of practice[A]:
* Preventive;
* Basic restorative;
* Intermediate restorative;
Supervision required: Remote: prior knowledge and consent[C];
Required education and experience:
* Master's level program;
* Specified clinical experience;
Licensed or certified: Yes[D];
Direct Medicaid/CHIP reimbursement: Not yet determined.
Type of dental provider: Dental therapist [limited setting][B];
Scope of practice[A]:
* Preventive;
* Basic restorative;
* Intermediate restorative;
Supervision required: On-site[E];
Required education and experience: Bachelor's or Master's level
program;
Licensed or certified: Yes[D];
Direct Medicaid/CHIP reimbursement: Not yet determined.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative [limited setting];
Supervision required: Remote: consultative[F];
Required education and experience:
* Dental hygiene program;
* Specified clinical experience;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: Yes[F].
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: On-site[G];
Required education and experience:
* Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site[H];
Required education and experience:
* Specific instructional program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]: Supportive;
Supervision required: On-site;
Required education and experience: None;
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] Advanced dental therapists and dental therapists are limited to
practicing in settings that serve low-income, uninsured, and
underserved populations or in a dental health professional shortage
area.
[C] Pursuant to a collaborative agreement with a dentist, advanced
dental therapists may perform all the procedures of a dental
therapist--including restorative drilling and filling--under remote
supervision of a dentist, as well as develop treatment plans and
nonsurgical extractions of permanent teeth under remote supervision.
[D] Licensure for dental therapists and advanced dental therapists is
the same. Advanced dental therapists require special certification
which includes additional education, but specific requirements had not
been finalized as of June 2010. As of June 2010, students were
enrolled in advanced dental therapy and dental therapy training
programs, but none were yet practicing.
[E] Pursuant to a collaborative agreement with a dentist, dental
therapists may perform some preventive and basic restorative
procedures off-site with prior knowledge and consent of a dentist,
other procedures require on-site supervision.
[F] Pursuant to a collaborative agreement with a dentist, dental
hygienists may be authorized to provide services in a health care
facility, program, or nonprofit organization. These services may
result in direct-to-provider Medicaid reimbursement.
[G] Dental hygienists may perform certain preventive and basic
restorative procedures without the dentist being present in the dental
office if the procedures being performed are with prior knowledge and
consent of a dentist; other procedures require on-site supervision.
[H] Registered dental assistants may perform certain preventive and
basic restorative procedures without the dentist being present in the
dental office if the procedures being performed are with prior
knowledge and consent of a dentist; other procedures require on-site
supervision.
[End of table]
Table 15: Selected Types of Dental Providers in Mississippi, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]: Preventive;
Supervision required: On-site[B];
Required education and experience: Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive[C];
Supervision required: On-site;
Required education and experience: None[C];
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] Dental hygienists may provide preventive services outside a dental
office under remote supervision through a consultative arrangement
with a dentist when employed by the State Board of Health or public
school boards. In addition, dental hygienists employed by the State
Board of Health may apply fluoride in this context.
[C] Dental assistants must acquire a permit through the state board of
dental examiners in order to take radiographs.
[End of table]
Table 16: Selected Types of Dental Providers in Oregon, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive [limited setting][B];
Supervision required: None;
Required education and experience:
* Dental hygiene program;
* Specified clinical experience and coursework or approved course of
study including clinical experience;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: Yes.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: Remote: prior knowledge and consent;
Required education and experience:
* Dental hygiene program;
* Specific instructional program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience:
* Dental hygiene program;
* Specific instructional program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
Supervision required: Remote: prior knowledge and consent;
Required education and experience:
* Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site[C];
Required education and experience:
* Specific instructional programs[D];
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
Supervision required: On-site;
Required education and experience: None;
Licensed or certified: No;
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] Dental hygienists can obtain permits to provide preventive
services, including fluoride application, in limited settings such as
schools and nursing homes without the supervision of a dentist. These
services may result in direct-to-provider Medicaid reimbursement.
[C] Dental assistants may perform certain basic restorative procedures
without the dentist being present in the dental office if the
procedures being performed are with prior knowledge and consent of a
dentist.
[D] Dental assistants in Oregon can obtain certification to perform
various preventive and restorative services upon completion of
specific instructional programs.
[End of table]
Table 17: Selected Types of Dental Providers in Washington, June 2010:
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive [limited setting][C];
Supervision required: None;
Required education and experience[B]:
* Dental hygiene program;
* Specific instructional program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: Yes.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive [limited setting][D];
Supervision required: Remote: consultative;
Required education and experience[B]:
* Dental hygiene program;
* Specified clinical experience;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
Supervision required: Remote: prior knowledge and consent;
Required education and experience[B]:
* Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental hygienist;
Scope of practice[A]:
* Preventive;
* Basic restorative;
* Intermediate restorative[E];
Supervision required: On-site;
Required education and experience[B]:
* Dental hygiene program;
Licensed or certified: Yes;
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive [limited setting][F];
Supervision required: Remote: prior knowledge and consent;
Required education and experience[B]:
* Program-specific instructional program;
* Specified clinical experience;
Licensed or certified: Yes[G];
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site[H];
Required education and experience[B]:
* Specific instructional program or comparable credential;
Licensed or certified: Yes[G];
Direct Medicaid/CHIP reimbursement: No.
Type of dental provider: Dental assistant;
Scope of practice[A]:
* Supportive;
* Preventive;
* Basic restorative;
Supervision required: On-site;
Required education and experience[B]: None;
Licensed or certified: Yes[G];
Direct Medicaid/CHIP reimbursement: No.
Source: GAO analysis of information from state dental practice acts,
state dental boards, and state officials.
[A] Each scope of practice category contains a variety of specified
procedures. A provider may not be authorized to perform all procedures
in a particular category.
[B] All dental hygienists and dental assistants in Washington must
complete AIDS education and training.
[C] Dental hygienists can become endorsed to administer sealants and
fluoride varnishes and remove deposits and stains from the surfaces of
teeth in school-based settings by completing a specified instructional
program (hygienists licensed on or before April 19, 2001 were
automatically endorsed). These services may result in direct-to-
provider Medicaid reimbursement.
[D] Dental hygienists with at least two years clinical experience may
provide preventive services in certain health-care facilities or
senior centers under remote dentist's supervision. A consultative
agreement with a dentist is required to provide these services in
senior centers.
[E] Dental hygienists may place a restoration (filling) in a cavity
prepared by a dentist.
[F] Dental assistants can become endorsed to administer sealants and
fluoride varnishes in school-based settings by completing a program-
specific training program and 200 hours of clinical experience
(assistants employed by a licensed Washington dentist on or before
April 19, 2001 were not required to obtain an endorsement).
[G] All dental assistants in Washington must be registered or licensed
to practice in the state. Dental assistants must meet limited
requirements to become registered. Dental assistants must meet
additional educational requirements to become licensed or endorsed to
perform additional or preventive procedures under remote supervision.
[H] Licensed dental assistants may perform certain preventive
procedures without a dentist being present and with prior knowledge
and consent of a dentist.
[End of table]
[End of section]
Appendix VII: Summary of Four Selected Countries' Use of Dental
Therapists:
Dental therapists practice in many countries around the world.
[Footnote 89] In particular, New Zealand, the United Kingdom,
Australia, and Canada have long-standing dental therapy training
programs originally aimed at improving access to dental services for
children and other underserved populations. Below are brief
descriptions of the dental therapist programs in these four countries.
[Footnote 90]
New Zealand:
New Zealand began training dental therapists in 1921 to provide dental
care to children through school-based clinics--known as the school
dental service--in response to high rates of dental decay and a
shortage of dentists.[Footnote 91] Since 2006, dental therapy and
dental hygiene training have been combined into a single 3-year
bachelor's degree granting program offered through two
universities.[Footnote 92] Graduates of the combined programs can
register as both a dental therapist and a dental hygienist.[Footnote
93] Registered dental therapists can work throughout the country to
determine treatment plans and provide preventive and basic and
intermediate restorative services--including procedures such as
drilling and filling a tooth--for children and, in some cases, adults,
under remote consultative supervision of a dentist.[Footnote 94]
Dental therapists in New Zealand maintain a consultative relationship
with a dentist and refer patients to a dentist for services beyond
their scope of practice. Although dental therapists have been able to
work in private practice since 2004, according to a 2007 study, the
majority of dental therapists in the country work as salaried
employees for District Health Boards to provide dental services to
children through the school dental service in school-and community-
based dental clinics.[Footnote 95] An official from the New Zealand
Ministry of Health estimated that in 2009, 96 percent of children aged
five to 12 in the country were enrolled in the school dental service
and therefore received dental care from dental therapists.
The United Kingdom:
The United Kingdom established its first dental therapy training
program in 1959 to meet a growing need for dental providers to staff
school-and community-based dental programs.[Footnote 96] Students were
selected from across the United Kingdom and were expected to return to
their home areas after training. The number of dental therapy training
programs has expanded in recent years, and most are offered as 3-year
combined dental therapy and dental hygiene programs.[Footnote 97]
Dental therapists in the United Kingdom must be registered with the
General Dental Council to practice and registered dental therapists
may provide preventive and basic and intermediate restorative
services--including procedures such as drilling and filling a tooth--
for children and adults under a treatment plan developed by a dentist.
[Footnote 98] Until 2002, dental therapists were restricted to
salaried employment in the public sector. Since then, they have been
able to work in independent practice, and since 2006, dental
therapists have been permitted to own their own practice and employ
other dental professionals. According to a 2007 survey of registered
dental therapists; 50 percent worked in private practice, 31 percent
worked in public dental services, and 10 percent worked in both.
[Footnote 99] Overall, 39 percent of dental therapists reported
spending most of their time treating children.[Footnote 100]
Australia:
Dental therapy training programs began in certain Australian states in
1966 and 1967 and expanded to all states and territories to train
dental therapists to provide dental services to children through
school-based dental programs--known as the school dental service.
[Footnote 101] In 2010, there were nine dental therapy training
programs in Australia, eight of which offered a combined 3-year dental
therapy and dental hygiene bachelor's degree.[Footnote 102] In the
past, Australia's eight states and territories were responsible for
dental therapy registration, but as of July 1, 2010, Australia
implemented a national registration and accreditation scheme requiring
standard qualification for all dental therapists and oral health
therapists registering after that date. Australian health officials
reported that prior to national registration, dental therapists could
generally provide primary oral health care including treatment
planning, preventive and basic and intermediate restorative services--
including procedures such as drilling and filling teeth for children
under the remote consultative supervision of a dentist. Three
Australian states--the Northern Territory, Victoria, and Western
Australia--also allowed dental therapists to provide services to
adults according to an Australian expert. Until recently, the majority
of states and territories restricted employment of dental therapists
to the public sector, however according to a 2005 national survey, 78
percent of dental therapists worked in the public sector--mostly as
salaried employees of school-and community-based dental programs.
[Footnote 103] In Western Australia, however, which has always
permitted dental therapists to work in private practice, about 55
percent of dental therapists worked in the public sector in 2005.
Canada:
The first Canadian dental therapy training programs were established
in the Northwest Territories and Saskatchewan in 1972 to increase
access to dental services for rural and aboriginal populations with a
focus on children.[Footnote 104] Dental therapy practice differs
across Canadian provinces and territories.[Footnote 105] Dental
therapy training is offered as a government funded 2-year program
through the National School of Dental Therapy at the First Nations
University, whose charter is to train dental therapists to treat
aboriginal populations. Although the National School of Dental Therapy
program is not accredited, graduates either become licensed by and
practice in Saskatchewan or work for the federal government or
aboriginal tribes. Canadian dental therapists may provide preventive
and basic and intermediate restorative services--including procedures
such as drilling and filling a tooth--for children and adults under a
treatment plan provided by a dentist. As of May 2010, the majority of
Canadian dental therapists worked in Saskatchewan where they must be
licensed by the Saskatchewan Dental Therapists Association according
to an association official.[Footnote 106] Most of the dental
therapists in Saskatchewan work in private dental practices, although
some are directly employed by the federal or provincial government or
aboriginal tribes.[Footnote 107] In all other Canadian provinces and
territories except Ontario and Quebec, dental therapists are generally
restricted to employment through the federal or territorial government
or tribes to provide care to aboriginal populations living on
reservations.[Footnote 108]
[End of section]
Appendix VIII: Comments from the Department of Health and Human
Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
November 4, 2010:
Katherine Iritani:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Iritani:
Attached are comments on the U.S. Government Accountability Office's
(GAO) correspondence entitled: "Oral Health: Efforts Underway to
Improve Children's Access to Dental Services, but Sustained Attention
Needed to Address Ongoing Concerns" (GAO 11-96).
The Department appreciates the opportunity to review this
correspondence before its publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled:
"Oral Health: Efforts Underway To Improve Children's Access To Dental
Services, But Sustained Attention Needed To Address Ongoing Concerns"
(GAO-11-961):
The Department appreciates the opportunity to review and comment on
this draft report.
CDC agrees in general with the report. However, based on data from the
National Health and Nutrition Examination Survey (NHANES) and citing a
previous report, the GAO "estimated that 6.5 million children had
untreated tooth decay, and rates of dental disease among younger
children in Medicaid had increased." This statement may be misleading
in light of more recent analysis of NHANES data by CDC's National
Center for Health Statistics.
This 2010 analysis reported that among poor young children (age 2-5
years) there has been no change in rates of dental disease between
1988-94 and 1999-2004. Among poor children age 6-8 years, there has
been an increase in caries experience. Among children age 2-5 years,
however, the actual increase in caries seems to be significant only
among the non-poor boys. Regarding untreated tooth decay, only non-
poor boys have shown an increase in untreated caries among all 2-8
year-old children between NHANES 1988-94 and 1999-2004. Rates of
untreated tooth decay for poor children age 2-8 years has remained
unchanged.
These findings and others are published in: Dye BA, Arevalo 0, Vargas
CM. Trends in pediatric dental caries by poverty status in the United
States, 1988-1994 and 1999-2004. International Journal of Pediatric
Dentistry 2010; 20: 132-143.
It should also be noted that when reporting on caries experience or
"dental disease" in young children, these constructs include both
treated and untreated caries. An increase in caries experience could
be driven by an increase in the dental fillings/restorations component
while the untreated disease component remained unchanged. An increase
in the dental restoration component could indicate an increase in
dental utilization, hence improvements in access to dental care,
especially for low income children. Healthy People 2010 has shown an
increase in utilization of preventive services among low income
children age 2-19 years.
CDC appreciates the efforts that went into this report and looks
forward to working with GAO on this and other reports.
The GAO issued two recommendations for executive action. CMS concurs
with each recommendation with the following comments:
GAO Recommendation:
The Department of Health and Human Services should take steps to
improve its Insure Kids Now Web site.
CMS Response:
We agree with this recommendation and that improvement undertaken by
States and the Federal government, such as those identified in this
report, is much needed. Under the current process, States submit the
information on their participating dental providers to the IKN website
through a download tool that was developed for this purpose or through
another acceptable method. A contractor (working under a Health
Resources and Services Administration (HRSA) contract but in
collaboration with CMS) then includes the information in a database
that links to the dental provider search engine. The data is subject
to a screening process in which addresses are matched against public
records. However, evaluating the quality of those records has not been
part of the scope of the contractor's responsibilities.
The CMS will undertake the following approaches to address this
concern:
First, to address the errors found on the Web site, the Department
will increase the frequency and type of quality checks performed on
State-reported dental provider information, and work with States to
ensure they submit data that is complete, accurate and current.
Specifically, we will follow up with States identified in the GAO
report to ensure that they correct existing information on the Web
site. We will also continue the process of requiring States to submit
data on providers directly instead of providing links to State Web
sites. We will also ensure States are aware of their responsibility to
not list providers who have been excluded from participation under
section 1128B of the Social Security Act; explore Federal options for
cross checking lists of providers with the disenrolled provider
database; and create a consistent understanding of what it means to be
identified as a dental provider able to serve a child with special
needs.
We will consider additional ways, including regulatory guidance, to
assure better information in implementing the provisions of CHIPRA,
which may include specific requirements, parameters and timeframes for
public listings of eligible, enrolled providers who are providing care
to Medicaid and CHIP children, including those with special needs.
GAO Recommendation:
The Administrator of CMS take steps to ensure that States gather
comprehensive and reliable data on the provision of Medicaid and CHIP
dental services by managed care programs.
CMS Response:
We agree with this recommendation. CMS is in the process of
implementing major changes that will improve collection of data
related to dental services for children delivered through fee-for-
service or managed care payment arrangements. A revised CMS-416 form,
which is CMS's primary tool for gathering data on the provision of
services to children in State Medicaid programs, is in the final
stages of the clearance process and will be released to States, along
with written guidance, in the near future. This revised form has been
expanded to include dental data elements as required by CHIPRA. The
instructions for completing the CMS-416 specify that additional data
reported on the form must include data for services delivered to
individuals in both fee-for-service or managed care arrangements.
Several provisions of CHIPRA also establish the foundation for CMS to
build an infrastructure for a quality measures program in which data
are collected and reported in a uniform way for children in Medicaid
and CHIP. The collection of data on dental services will benefit from
CMS-wide efforts underway to improve the collection and reporting of
data on quality of care measures more broadly.
The CMS is also establishing a workgroup consisting of national and
local stakeholders in the field of child health that will focus on
improving access to the benefits required under Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) and will ask the
workgroup to identify, among other things, ways to obtain more
reliable data on dental services provided for children in managed care
plans. This workgroup will be established by early 2011.
Other CMS Activities:
The CMS has also undertaken a number of efforts to improve children's
access to oral health services. To accelerate our efforts to improve
access to oral health services and to provide focus and visibility to
our efforts, CMS announced in April 2010 at the National Oral Health
conference two national oral health goals. The goals are: 1) to
increase the national rate of children and adolescents enrolled in
Medicaid or CHIP who receive any preventive dental service by 10
percentage points over 5 years; and 2) to increase the rate of
children ages 6-9 enrolled in Medicaid or CHIP who receive a dental
sealant on a permanent molar tooth by 10 percentage points over 5
years. The dental sealant goal will be phased in during the next two
to three years. Data for monitoring ongoing progress on this goal will
be collected through the CMS-416 report and the CHIP State Annual
Reports. Data collected for Federal fiscal year 2011 will serve as
baseline data for this goal.
The CMS is collaborating with States on how to achieve these goals and
we have developed an oral health strategy that identifies the
principal barriers to children receiving dental care as well as some
recommended approaches to overcoming these barriers. Much of the
strategy was developed based on information learned during State
dental reviews undertaken by CMS. In 2008, CMS examined the policies
and practices of 16 States that had low dental utilization rates. In
2009, CMS began reviews of eight States that had higher than average
dental utilization rates or were recommended to CMS as having an
innovative practice for increasing dental access. Each State review
and a summary of the State reviews will be available on the CMS Web
site (http://www.cms.gov/MedicaidDentalCoverage) by the end of
December 2010. The results of these State reviews can help other
States improve access to dental services.
To support States in improving access to dental care, CMS will provide
technical assistance to States to help improve access to children's
dental care and to make progress toward achieving these goals,
including:
* Identifying promising practices that States have used to increase
children's access to oral health care;
* Annual meetings with States and national experts to share
experiences;
* Assessing progress toward the goals;
* Identifying barriers to access; and;
• Support opportunities for dental providers to receive incentive
payments for meaningful use of electronic health record technology.
CMS is holding two technical assistance workshops for States to
discuss CMS' dental goals and strategy. The first workshop, held on
October 7, 2010 in conjunction with the National Academy for State
Health Policy conference in New Orleans, Louisiana, was attended by 20
officials from CHIP or Medicaid programs, including several oral
health directors. The second workshop will be held on November 10,
2010 in Arlington, Virginia following the annual conference of the
National Association of State Medicaid Directors. CMS will hold a
meeting with external stakeholders this year to identify areas where
they may wish to support our efforts in improving access to oral
health services. CMS will take feedback from all of these meetings
into consideration as we finalize our oral health strategy.
The CMS' goals and dental strategy support the larger HHS Oral Health
Initiative 2010 and the Department's comprehensive commitment to
improved oral health. CMS is coordinating with other components of the
Department on this important initiative as a member of the HHS
Assistant Secretary for Health's Oral Health Coordinating Committee,
which brings together fourteen agencies to direct the Department's
oral health activities. In order to further the collaborative efforts
on oral health, CMS has entered into a Memorandum of Understanding
with HRSA and the Centers for Disease Control and Prevention.
Improving access to children's dental services in Medicaid and CHIP is
one of our key priorities. We appreciate the efforts that went into
this report and look forward to working with the GAO on this and other
issues.
HRSA has offered the following recommendations:
Under the Children's Health Insurance Program Reauthorization Act
(CHIPRA), the Department of Health and Human Services (HHS) is
required to post a list of oral health providers who provide services
to eligible Medicaid and Children's Health Insurance Program (CHIP)
children on the Insure Kids Now (IKN) web site. This list is to be
updated on a quarterly basis. This initiative was a huge undertaking
given that this is the first national list of any type of Medicaid and
CHIP health care providers. Despite the challenges, HRSA, under an
Interagency Agreement (IAA) with the Centers for Medicare and Medicaid
Services (CMS), met all statutory deadlines outlined under CHIPRA and
have developed an Oral Health Locator (Locator). This Locator provides
information to Medicaid and CHIP enrollees on how to find dentists and
other oral health providers that accept Medicaid and CHIP.
HRSA concurs with many of the findings and recommendations from the
GAO report. HRSA has spent much effort in the past year working with
states to improve the Locators capacity to accept and post data from
states. It should be noted that while the law requires that the data
on the IKN web site be updated on a quarterly basis, the system allows
data to be updated on a daily basis ensuring that the most up-to-date
information is available to enrollees.
HRSA has specific comments regarding the following aspects of the
report found under Section titled "Information on HHS's Web Site to
Help Locate Participating Dentists is Not Always Complete" beginning
on page 14, first paragraph:
HRSA concurs that more attention needs to be devoted to improving the
accuracy of information submitted by states. Much attention in the
past year has been devoted to developing the system to allow for data
submissions from states. It should be noted that data are submitted
from states that utilize fee-for-service programs, and from health
plans that utilize capitated or managed care programs. Given that data
are received from multiple sources for one state, it is difficult to
ensure the accuracy of all information.
A sampling of the data could be done on a periodic basis. It should be
noted that data files are reviewed systematically to ensure that all
data fields have acceptable data (e.g., a field that requires a zip
code has a 5 or 9 digit numerical value). Data files that do not
adhere to the business rules outlined in our technical guidance to the
states are returned and not posted.
Completeness: The GAO outlines through their review, cases of missing
or incomplete information including "...telephone numbers and
addresses, whether dentists accepted new Medicaid or CHIP patients,
and whether dentists could accommodate children with special needs."
It should be noted that information concerning whether a provider is
accepting new patients or accommodates children with special needs is
not required under CHIPRA. This is information that CMS and HRSA
thought would be important to enrollees trying to identify an oral
health provider. We will continue to work with states to improve the
quality of this information.
Usability: GAO noted that they found "...7 states listed multiple
health plans with similar names, some containing typographical errors
and some that produced different provider listings, increasing the
likelihood of selecting the wrong plan and generating an incorrect
list of dentists." HRSA will continue to work with the Assistant
Secretary for Public Affairs (ASPA) to improve the usability of the
IKN web site. It should be noted that a widget is currently being
developed to make it easier for enrollees to search for an oral health
provider. HRSA will also work with ASPA to ensure that all the web
links are working. The system was developed bearing in mind that many
enrollees may not know if they are in Medicaid or CHIP but rather may
more easily associate with the health plan. HRSA has instructed states
to utilize the program names identified on their Medicaid or CHIP
enrollee cards.
Accuracy: HRSA will work with CMS to develop a plan for periodically
analyzing a sampling of the data provided by states.
First paragraph ” page 18: In the first paragraph GAO reported
concerns with providers being listed on the IKN web site that were
excluded from participating in Medicaid by the HHS Office of Inspector
General (OIG). HRSA will cross check the excluded parties list
independently and check with CMS on the currency of the data provided,
as the system was not developed to cross check data with OIG.
[End of section]
Appendix IX: GAO Contact and Staff Acknowledgments:
GAO Contact:
Katherine Iritani, (202) 512-7114 or iritanik@gao.gov:
Staff Acknowledgments:
In addition to the individual named above, Kim Yamane, Assistant
Director; Rebecca Abela; Susannah Bloch; George Bogart; Alison
Goetsch; Mollie Hertel; Anne Hopewell; Martha Kelly; Perry Parsons;
Terry Saiki; Pauline Seretakis; and Suzanne Worth made key
contributions to this report.
[End of section]
Related GAO Products:
Medicaid Managed Care: CMS's Oversight of States' Rate Setting Needs
Improvement. [hyperlink, http://www.gao.gov/products/GAO-10-810].
Washington, D.C.: August 4, 2010.
Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services, but More Can Be Done.
[hyperlink, http://www.gao.gov/products/GAO-10-112T]. Washington,
D.C.: October 7, 2009.
Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services, but Gaps Remain. [hyperlink,
http://www.gao.gov/products/GAO-09-723]. Washington, D.C.: September
30, 2009.
Medicaid: Extent of Dental Disease in Children Has Not Decreased, and
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink,
http://www.gao.gov/products/GAO-08-1121]. Washington, D.C.: September
23, 2008.
Health Resources and Services Administration: Many Underserved Areas
Lack a Health Center Site, and the Health Center Program Needs More
Oversight. [hyperlink, http://www.gao.gov/products/GAO-08-723].
Washington, D.C.: August 8, 2008.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink,
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2,
2007.
Medicaid Managed Care: Access and Quality Requirements Specific to Low-
Income and Other Special Needs Enrollees. [hyperlink,
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.: December 8,
2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor
Children's Access to Care. [hyperlink,
http://www.gao.gov/products/GAO-03-222]. Washington, D.C.: January 14,
2003.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to
Health Screening Services. [hyperlink,
http://www.gao.gov/products/GAO-01-749]. Washington, D.C.: July 13,
2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-149]. Washington, D.C.:
September 11, 2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations. [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-72].
Washington, D.C.: April 12, 2000.
[End of section]
Footnotes:
[1] Children in Medicaid are generally entitled to comprehensive
dental services under the program's Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) benefit. And, beginning in October
2009, states were required to offer a package of dental benefits under
their CHIP programs.
[2] See GAO, Oral Health: Dental Disease Is a Chronic Problem Among
Low-Income Populations, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-72] (Washington, D.C.: Apr.
12, 2000), GAO, Oral Health: Factors Contributing to Low Use of Dental
Services by Low-Income Populations, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-149] (Washington, D.C.: Sept.
11, 2000), and Related GAO Products at the end of this report.
[3] We used national survey data from 1999 through 2004 to estimate
the number of Medicaid-enrolled children with untreated tooth decay.
We also examined survey data for the 1988 through 1994 and 1999
through 2004 time periods and found that rates of dental disease had
not decreased, although the data suggested the trends varied somewhat
among different age groups. See GAO, Medicaid: Extent of Dental
Disease in Children Has Not Decreased, and Millions Are Estimated to
Have Untreated Tooth Decay, [hyperlink,
http://www.gao.gov/products/GAO-08-1121] (Washington, D.C.: Sept. 23,
2008).
[4] GAO, Medicaid: State and Federal Actions Have Been Taken to
Improve Children's Access to Dental Services, but Gaps Remain,
[hyperlink, http://www.gao.gov/products/GAO-09-723] (Washington, D.C.:
Sept. 30, 2009).
[5] Children's Health Insurance Program Reauthorization Act of 2009,
Pub. L. No. 111-3, § 501(f), 123 Stat. 8, 88.
[6] Pub. L. No. 111-3, § 501(f), 123 Stat. 88.
[7] We selected 4 states that represented a variation in geography,
use of managed care, and the number of children covered by Medicaid.
Within each state we called the offices for at least 25 urban and 15
rural dentists in the areas with the largest number of children in
poverty.
[8] Annual EPSDT reports contain information on children who are (1)
in Medicaid and received EPSDT benefits and (2) in CHIP and received
EPSDT benefits because they are part of a Medicaid expansion program.
[9] American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5,
123 Stat. 115; Patient Protection and Affordable Care Act, Pub. L. No.
111-148, 124 Stat. 119 (2010). References to the Patient Protection
and Affordable Care Act (PPACA) in this report refer to Pub. L. No.
111-148, as amended by the Health Care and Education Reconciliation
Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029.
[10] Our interviews with officials from HHS, states, academic
institutions, professional associations, and advocacy groups found
that there is no commonly-recognized definition of mid-level dental
providers.
[11] U.S. Department of Health and Human Services, National Institute
of Dental and Craniofacial Research, National Institutes of Health,
Oral Health in America: A Report of the Surgeon General (Rockville,
Md.: 2000).
[12] HHS established Healthy People 2010 as a statement of national
health objectives designed to identify the most significant
preventable threats to health and to establish national goals to
reduce these threats. See [hyperlink,
http://www.healthypeople.gov/About/] (accessed Aug. 3, 2010).
[13] The 30 million children represent the fiscal year 2008
unduplicated annual enrollment (the total number of children, each
child counted once, who were enrolled in Medicaid at any point in
federal fiscal year 2008) reported by CMS.
[14] In February 2009, the Children's Health Insurance Program
Reauthorization Act of 2009 renamed the State Children's Health
Insurance Program (SCHIP) to the Children's Health Insurance Program
(CHIP).
[15] Pub. L. No. 111-3, § 501, 123 Stat. 84. CHIPRA allowed states to
provide dental coverage for children in the CHIP income range who have
health insurance through an employer, but who lack dental coverage.
[16] Pub. L. No. 111-3, § 501(e), 123 Stat. 87.
[17] Pub. L. No. 111-3, § 501(f), 123 Stat. 88. HHS's Insure Kids Now
Web site was established in 1999 to help parents and guardians find
state Medicaid and CHIP program eligibility information. To improve
access to information on dental providers participating in Medicaid
and CHIP, in February 2009, CHIPRA required HHS to post a list of
participating dentists within each state on the Insure Kids Now Web
site and also provide such information through its toll-free hotline
(1-877-KIDS-NOW).
[18] 42 U.S.C. § 254b. Health centers are funded in part through
grants under the Health Center program--administered by HRSA--and
provide comprehensive primary care services for the medically
underserved.
[19] 42 U.S.C. § 254d. The NHSC scholarship program provides tuition,
fees, and living stipends for students in primary care, including
dentistry, in exchange for at least 2 years of service. 42 U.S.C. §
254l. The NHSC loan repayment program provides up to $50,000 toward
repayment of student loans for providers, including dentists and
dental hygienists, in exchange for at least 2 years of service. 42
U.S.C. § 254l-1. HRSA also administers the State Loan Repayment
program that provides matching grants to states to run their own loan
repayment programs for health providers who agree to practice in
underserved areas, which in some states includes awards for dentists
and dental hygienists. 42 U.S.C. § 254 q-1.
[20] 42 C.F.R. pt. 5, app. B (2009); 42 U.S.C. § 254e(a)(1).
[21] Of the 4,377 dental HPSAs, 790 were for geographic areas, 1,526
were for population groups, and 2,061 were facilities such as health
centers that were designated as HPSAs. See [hyperlink,
http://bhpr.hrsa.gov/shortage/] (accessed July 14, 2010).
[22] HRSA estimates the number of full-time equivalent dentists needed
to remove HPSA designations by taking into account the actual level of
service provided by a given dentist. For example, a HPSA needing a
dentist working half-time to remove its HPSA designation would be
estimated to need 0.5 FTE, although adjustments are made for a variety
of factors, such as the number of dental hygienists and dental
assistants.
[23] To identify HPSAs of greatest shortage, HRSA scores each HPSA
based on relative need. Only HPSAs meeting a certain threshold score
are considered HPSAs of greatest need. This threshold may differ for
scholarship recipients and loan repayment recipients in a given year.
[24] The number of choices available to scholarship recipients is
provided for in statute: no more than twice the number of scholarship
recipients who will be available for assignment during the year. For
example, if there were 25 dentists who received NHSC scholarships
available for service, NHSC would provide a list of no more than 50
vacancies for them. See 42 U.S.C. § 254f-1(d)(2).
[25] In the United States, dentists are licensed to practice by the
states and states are generally responsible for establishing education
requirements and determining scope of practice of dental providers.
They can obtain additional training in a dental specialty, such as
pediatric dentistry or orthodontics.
[26] ASTDD's annual survey, called the Synopses of State and
Territorial Dental Public Health Programs, is conducted under a
cooperative agreement with HHS's Centers for Disease Control and
Prevention.
[27] ASTDD sent the survey to dental directors in all states and the
District of Columbia. However, not all states provided responses to
the questions on the number of dentists treating children in Medicaid
and CHIP. For example, 39 states reported how many dentists treated
children in Medicaid (including children in CHIP programs that are
Medicaid expansions) and 11 reported the number of dentists who
treated children in a CHIP program separate from Medicaid. See
[hyperlink, http://apps.nccd.cdc.gov/synopses/] (accessed July 21,
2010).
[28] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149].
[29] Association of State and Territorial Dental Directors, ASTDD
Support for State CSHCN Oral Health Forums, Action Plans And Follow-Up
Activities; Interim Evaluation Summary (March 2009).
[30] Burton L. Edelstein, "Conceptual Frameworks for Understanding
System Capacity in the Care of People with Special Health Care Needs,"
Pediatric Dentistry, Vol. 29, No. 2 (March/April 2007).
[31] The study found that overall, 8.9 percent of children with
special health care needs who needed any dental care were unable to
obtain it. Children with Down's Syndrome had the highest proportion of
unmet dental care needs at 17.4 percent, and children with asthma the
lowest at 8.6 percent. C.W. Lewis, "Dental Care and Children with
Special Health Care Needs: A Population-Based Perspective," Academic
Pediatrics. Vol. 9, No. 6: 420-426 (2009).
[32] Specifically, the study noted that the adjusted odds of unmet
dental care needs for severely affected, poor/low-income children with
special health care needs were 13.4 times that of unaffected, higher-
income children.
[33] The dentists were listed on the Insure Kids Now Web site as
practicing in California, Georgia, Illinois, and Vermont. Our case
study approach did not yield results that could be projected to entire
states or managed care organizations.
[34] One dentist reported that the wait time for a new Medicaid or
CHIP child was 6 months, compared to 2 months for other new patients
with private insurance. Twenty-three of the dentists we called who
were otherwise treating children were not accepting any new Medicaid
or CHIP patients.
[35] HHS may exclude providers from receiving payment from federally
funded health care programs, including Medicare and Medicaid, for
incidents such as conviction for program-related fraud and patient
abuse, license revocation or suspension, and default on Health
Education Assistance Loans. See [hyperlink,
http://oig.hhs.gov/fraud/exclusions.asp] (accessed July 20, 2010).
[36] HHS-OIG officials told us that the dentist has been excluded from
Medicaid in 1986 after pleading guilty to Medicaid fraud.
[37] Children enrolled in CHIP programs that are expansions of the
states' Medicaid programs are entitled to the Medicaid EPSDT benefit
package and are included in the states CMS 416 reports, but are not
identified separately as CHIP enrollees in the CMS 416.
[38] We calculated and report the nationwide Medicaid dental
utilization rate--that is, the percentage of total EPSDT-eligible
Medicaid enrollees in the nation who received any dental service. CMS
reports a national average of 37.7 percent in 2008 that is calculated
by averaging the 51 state-utilization rates. We report the national
utilization rate rather than the average rate because it accounts for
differences in the number of enrollees in each state.
[39] In prior work, we found concerns that data on the provision of
Medicaid services by managed care programs reported by states on their
CMS 416s were not complete or reliable. See GAO, Medicaid: Stronger
Efforts Needed to Ensure Children's Access to Health Screening
Services, [hyperlink, http://www.gao.gov/products/GAO-01-749]
(Washington, D.C.: July 13, 2001). According to CMS officials, states
have improved the quality of data gathered and reported on their CMS
416 reports.
[40] See American Dental Association's Medicaid Compendium Update
[hyperlink, http://www.ada.org/2123.aspx] (accessed Feb. 12, 2010). We
considered states with 75 percent or more Medicaid-enrolled children
in dental managed care as predominantly dental managed care states.
[41] GAO, Medicaid: Concerns Remain about Sufficiency of Data for
Oversight of Children's Dental Services, [hyperlink,
http://www.gao.gov/products/GAO-07-826T] (Washington, D.C.: May 2,
2007).
[42] Social Security Act § 2108(a) (codified at 42 U.S.C. § 1397hh(a)).
[43] Pub. L. No. 111-3, § 501(e), 123 Stat. 87.
[44] In addition to dentists, health centers employed 1,018 dental
hygienist FTEs and over 4,800 FTEs for dental assistants, aides, and
technicians in calendar year 2009.
[45] HRSA reported that 942 health center grantees offered restorative
dental services--either directly, through contracts, or through formal
referral arrangements--as of June 2010.
[46] We previously reported that 43 percent of medically underserved
areas lacked a health center as of 2007. GAO, Health Resources and
Services Administration: Many Underserved Areas Lack a Health Center
Site, and the Health Center Program Needs More Oversight, GAO-08-723
(Washington, D.C.: Aug. 8, 2008). In August 2010, an official with the
National Association of Community Health Centers told us that,
although the number of underserved areas with a health center site
increased since 2007, the change has not been significant and many
underserved areas still lacked a health center to provide dental and
other medical services.
[47] Of the 611 dentists and 70 dental hygienists in NHSC at the end
of fiscal year 2009, 112 dentists and 13 hygienists were funded
through the State Loan Repayment Program.
[48] These loan repayment awards made in fiscal year 2009 represent 16
percent of the 611 dentists and 29 percent of the 70 dental hygienists
practicing in HPSAs through the NHSC at the end of fiscal year 2009.
[49] These grants for increased demand for services from health
centers were awarded to fund activities such as adding new providers,
expanding hours, or expanding existing health center services.
[50] See Promoting and Enhancing the Oral Health of the Public: HHS
Oral Health Initiative 2010 for a description of the agency's efforts
under this initiative: [hyperlink,
http://www.hrsa.gov/publichealth/clinical/oralhealth/hhsinitiative.pdf]
(accessed June 16, 2010).
[51] The Early Childhood Caries Initiative activities include early
oral health assessment by community partners such as Head Start,
nurses, and physicians; fluoride varnish application by these
community partners and dental teams; and the application of dental
sealants on primary teeth for young children.
[52] See Pub. L. No. 111-148, § 4102(b), 124 Stat. 551.
[53] For the purposes of this report, in the United States, mid-level
providers are known as dental therapists in Alaska under the Dental
Health Aide Therapist program and advanced dental therapists in
Minnesota.
[54] Alaska Native children had rates of dental caries (cavities) that
were 2.5 times the U.S. average and Alaska tribes experienced dentist
vacancy rates of 25 percent.
[55] Under standards of the Community Health Aide Program
Certification Board, prior to certification, each dental therapist is
required to complete a clinical preceptorship under the direct
supervision of a dentist for a minimum of three months or 400 hours,
whichever is longer.
[56] Alaska Medicaid reimburses dental therapist services at the same
encounter rate as services provided by a dentist.
[57] K.A. Bolin, "Assessment of treatment provided by dental health
aide therapists in Alaska; a pilot study," Journal of the American
Dental Association, Vol. 139 (2008).
[58] Scott Wetterhall MD, et al., Evaluation of the Dental Health Aide
Therapist Workforce Model in Alaska (Research Triangle Park, N.C.: RTI
International, October 2010).
[59] 2009 Minn. Laws Ch. 95, Art. 3.
[60] In Minnesota, a dental therapist may perform a range of
preventive and basic restorative procedures under remote consultative
supervision of a dentist and intermediate restorative procedures under
the on-site supervision of a dentist. Because of the on-site
supervision requirement for intermediate restorative procedures, we do
not consider Minnesota dental therapists as mid-level providers in
this report.
[61] The University of Minnesota School of Dentistry also offers a
bachelor of science and a master's degree program which prepare
students for licensure as dental therapists, but does not include the
training required for advanced dental therapist certification.
[62] Licensed dental therapists are also required to enter into
consultative agreements.
[63] Dental hygienists in Alabama may only perform dental procedures
under the on-site supervision of a dentist. In addition to dental
hygienists, dental assistants may provide a variety of services--
depending on the state--including preventive and basic restorative
procedures, however in general they require on-site supervision by a
dentist.
[64] In the remaining three states--Alabama, Alaska, and Mississippi--
Medicaid covered services provided by dental hygienists are reimbursed
through their supervising dentist.
[65] Chris Cantrell, Engaging Primary Care Medical Providers in
Children's Oral Health (Portland, Me.: National Academy for State
Health Policy, September 2009). This study did not include a separate
review of state CHIP reimbursement. According to officials from the
Pew Center on the States, Children's Dental Campaign--the organization
that funded the 2009 survey and monitors state Medicaid reimbursement
policies--as of November 2010, 40 state Medicaid programs reimburse
primary care medical providers for providing preventive dental
procedures. Seven of the eight states we examined provided such
reimbursement.
[66] Pub. L. No. 111-148, § 5304, 124 Stat. 621. According to HRSA
officials, as of June 2010, no funds had been appropriated
specifically for these demonstration projects.
[67] Rio Salado College is based in Tempe, Arizona.
[68] The model proposed by the American Dental Hygienists' Association
describes the supervisory arrangement for the advanced dental hygiene
practitioner as a collaborative partnership with dentists for referral
and consultations.
[69] The countries are presented in chronological order by the date
that their dental therapy programs started; New Zealand has the oldest
dental therapy program. The United Kingdom consists of the countries
of England, Northern Ireland, Scotland, and Wales.
[70] These countries have other types of dental providers; however
dental therapists are the only providers practicing in these countries
who provide preventive, basic restorative and intermediate restorative
dental procedures under remote supervision of a dentist. For example,
Australia has a provider called a dental prosthesist who diagnoses and
creates denture prosthesis, but does not provide primary (preventive
and restorative) dental services.
[71] Graduates of the combined programs are generally known as oral
health therapists and are trained to provide dental hygiene services
such as preventive teeth cleaning in addition to dental therapy
services such as intermediate restorative tooth drilling.
[72] The study examined 258 restorations on 80 adult patients six
months after treatment. H. Calache, et. al, "The capacity of dental
therapists to provide direct restorative care to adults," Australian
and New Zealand Journal of Public Health, Vol. 33 (2009). An
Australian official noted that the use of dental therapists is widely
accepted and that because the programs are long-standing, few recent
studies have been conducted. However, available research on the dental
therapists in New Zealand (1951) and Canada (1974) showed that they
provided restorative procedures that were similar in quality to
restorative procedures provided by dentists.
[73] Health officials from the United Kingdom reported that dental
therapists have not had a major impact on children's access in the
United Kingdom because patients must first see a dentist before being
referred to a dental therapist.
[74] The number of decayed, missing, or filled teeth calculated for
both primary (baby) and permanent (adult) teeth is a common measure
for dental disease experience. See J.M. Armfield and A.J. Spencer,
"Quarter of a century of change: caries experience in Australian
children, 1977-2002," Australian Dental Journal, Vol. 53 (2008).
[75] The Saskatchewan school-based dental program was staffed by
dental therapists and in existence from 1974 to 1993. D.W. Lewis,
Performance of the Saskatchewan Health Dental Plan, 1974-1980,
(University of Toronto, Toronto, Ontario, 1981). Although enrollment
in the program by aboriginal children was much lower, enrollment of
and access for these children increased over the period of study.
[76] ASTDD surveyed dental directors in all states and the District of
Columbia. Respondents were asked to provide the most recent data
available or data for the most recently completed fiscal year--
generally 2008 data for the 2009 survey. See [hyperlink,
http://apps.nccd.cdc.gov/synopses/AboutV.asp] (accessed July 21, 2010).
[77] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149].
[78] CHIPRA required that HHS post a complete and accurate list of
dentists participating in state Medicaid and CHIP programs on the
Insure Kids Now Web site by August 4, 2009. In June 2009, CMS issued
guidance specifying certain data elements required for each dentist
listed on the Insure Kids Now Web site, including the dentists' name,
address, telephone number, and specialty; whether the dentist accepts
new Medicaid or CHIP patients; and whether the dentist can accommodate
patients with special needs.
[79] For all 4 states, HHS's Insure Kids Now Web site allowed the user
to enter a zip code to identify dentists nearest to the selected zip
code.
[80] The World Factbook 2009. Washington, D.C.: Central Intelligence
Agency (2009). See [hyperlink,
https://www.cia.gov/library/publications/the-world-
factbook/appendix/appendix-b.html#D] (accessed Nov. 20, 2009).
[81] We did not perform an independent review of laws and regulations
of foreign jurisdictions, but relied on information provided by
officials, government reports, and peer-reviewed research.
[82] H. R. Rep. No. 111-16, at 451 (2009) (Conf. Rep.).
[83] Seventy-five-million dollars of the amount appropriated for NHSC
is to remain available through September 30, 2011.
[84] PPACA also authorized a total of approximately $31 billion for
health centers for fiscal years 2011 through 2015, with authorization
for funding in subsequent years to reflect the growth in costs and the
number of patients served. However, these amounts remain unavailable
for expenditure until appropriated.
[85] PPACA established and authorized and appropriated funding to the
Community Health Center Fund and directed amounts from this fund to be
transferred to HHS to provide $9.5 billion in enhanced funding for
health centers and $1.5 billion in enhanced funding for NHSC. It also
authorized and appropriated $1.5 billion for construction and
renovation of community health centers. Pub. L. No. 111-148, § 10503,
124 Stat. 1004, as amended by Pub. L. No. 111-152, § 2303, 134 Stat.
1083.
[86] U.S. Department of Health and Human Services, Indian Health
Service, An Oral Health Survey of American Indian and Alaska Native
Patients: Findings, Regional Differences and National Comparisons
(Rockville, Md.).
[87] The Alaska Tribal Health System operates using a four-tiered
approach: (1) statewide services are provided in Anchorage, (2)
regional services are provided at hubs within the various regions, (3)
sub-regional clinics operate in some villages, and (4) small village
clinics are where individuals obtain their primary health care.
[88] The 2009 encounter data for one dental therapist was only for a
portion of that year.
[89] D.A. Nash, J.W. Friedman, T.B. Kardos, et al. "Dental Therapists:
a global perspective," International Dental Journal, Vol. 58 (2008).
[90] The countries are presented in chronological order by the date
their dental therapist program started.
[91] New Zealand pays for dental services for all children up to age
13, with most of the services provided by dental therapists in the
school dental service.
[92] Historically, dental therapists were trained in a 2-year non-
degree granting program.
[93] Dental therapists must be registered with the Dental Council of
New Zealand--a self-regulating body for oral health professionals.
[94] Dental therapists register for general dental therapy scope
practice which allows practice for children up to age 18. Dental
therapists can register for additional scopes of practice including
adult care, radiology, and crowns.
[95] K.M.S. Ayers, A. Meldrum, W.M. Thomson, J.T. Newton. "The working
practices and career satisfaction of dental therapists in New
Zealand," Community Dental Health, Vol. 24 (2007).
[96] The United Kingdom consists of the countries of England, Northern
Ireland, Scotland, and Wales. Each country has a National Health
Service administered by Departments of Health that are responsible for
administering health care. Countries in the United Kingdom have had
subsidized dental services since the 1920s--known as the salaried
dental service or community dental service--for which dental
therapists were originally trained to serve.
[97] Graduates of the combined programs can register as both a dental
therapist and a dental hygienist. Historically, dental therapists were
trained in 2-year hospital-based diploma programs, but since the 1990s
programs have been offered through bachelor's degree granting programs.
[98] The General Dental Council is the regulating body for oral health
professionals.
[99] The remaining dental therapists worked in hospitals, were
teaching, or in a combination of positions. The National Health
Service in each country contracts with independent dental practices--
known as the general dental service--to provide services. Independent
practices can be reimbursed by the National Health Service for dental
services to children up to age 18.
[100] J.H. Godson, J.S. Rowbotham, S.A. Williams, J.L. Csikar, S.
Bradley, "Dental therapy in the United Kingdom: Part 2. a survey of
reported working practices," British Dental Journal, Vol. 207 (2009).
[101] All eight Australian states and territories subsidize dental
care for children age 5-12, with certain states also paying for care
to younger or older children.
[102] Graduates of the combined programs are known as oral health
therapists and can register as both a dental therapist and a dental
hygienist. Historically, dental therapists were trained in 2-year non-
bachelor degree granting programs.
[103] Australian Institute of Health and Welfare, Dental Statistics
and Research Unit, Dental Therapist Labour Force in Australia 2005
(Adelaide: Australia, July 2008).
[104] Aboriginal populations in Canada are known as First Nations and
Inuit. Health Canada--the government department responsible for
administering health care--pays for dental services to all aboriginal
populations. Private practices and tribes can be reimbursed by Health
Canada for services rendered to those populations.
[105] In the 1970s two provinces, Saskatchewan and later Manitoba,
established school-based dental programs that utilized dental
therapists to provide preventive and restorative dental services for
children. The Saskatchewan program had high rates of enrollment and
successfully reduced the rates of dental caries in children, and was
privatized in 1987 and eliminated in 1993. Dental therapists that
previously provided dental services in rural areas either moved to
urban areas to work in private practice or lost their jobs according
to a Canadian expert. D.W. Lewis, Performance of the Saskatchewan
Health Dental Plan, 1974-1980. (Toronto: University of Toronto: 1981).
The Manitoba program has also since been eliminated.
[106] The Saskatchewan Dental Therapists Association is the self
regulating body for dental therapists constituted under Saskatchewan
law.
[107] According to a Canadian health official, 52 dental therapists
were employed directly by Health Canada and 30 were employed by First
Nations tribes which are funded by Health Canada.
[108] Dental therapists are not permitted to practice in Ontario or
Quebec. In Manitoba, a number of dental therapists work in the private
sector.
[End of section]
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