Quality Care Should Be Accessible for All: Expanding Access through Innovation and Employing Mid-level Providers in the Medical and Dental Fields

Despite the renewed efforts of activists, racial disparities remain widespread throughout many areas of the American economy. Yet while stories about criminal justice and education problems dominate the news, an under-reported gap exists between races in the health care field, which is every bit as sinister and dangerous to people of color.

Fortunately, the Affordable Care Act (ACA) is making a positive impact; in the past two years, insurance coverage for people of color has improved significantly thanks to the ACA's federal and state exchanges. In New York last year, 16 percent of new enrollees were African-American, 13 percent were Asian/Pacific Islander and 25 percent were Hispanic. These numbers - which are probably conservative due to lower self-reporting on race - indicate objective success in expanding coverage to at-risk populations.

Still, gaps remain. As too many people have found out the hard way, guaranteed coverage does not mean guaranteed access to care. And nowhere is this more pronounced than in the dental field. Year after year, oral health is cited as a major area of disparity between white and non-white populations. According to the American Student Dental Association, as of June 2014 there were 4,900 Dental Health Professional Shortage Areas.
Too few dentists are practicing to treat the number of patients who need care; in low-income and minority communities, the problem is even worse. Due to financial and geographical constraints, poor and minority children have a harder time getting to the dentist than other children. Moreover, getting newly trained dentists to set up their practices in under-served areas is challenging. And even where dentists are available, access to care for low-income patients is often limited by the small number of dentists who accept Medicaid.

All of these factors are forcing medical and dental professionals to find new solutions to increase treatment capabilities - solutions that are desperately needed by minority communities in the United States. A new report by the National Minority Quality Forum http://www.nmqf.org/wp-content/uploads/2015/11/Reassessing-the-Dental-Care-Paradigm.pdf examines existing disparities in oral health as well as potential solutions to address the access gap. in the medical field, nurse practitioners, once feared as a vehicle for "bad doctoring," are now widely-accepted providers of health care. Branded pharmacies have taken to adding them in-house, and they were finally granted Medicare provider status in 1999. The same innovation must occur in the dental care field, which is still holding on to an outdated cottage industry model of one-dentist operations.

For proof that this model works, health policy professionals need only look abroad. In New Zealand, where dental therapists practice widely as mid-level providers, access has expanded and costs have been lowered for schoolchildren. According to a report from the W.K. Kellogg Foundation, the average cost of school-based dental services in New Zealand was $99 per child per year.
Closer to home, the growing use of the dental service organization (DSO) model has helped to reduce costs and provide treatment to low-income Medicaid dependent children and adults. Similar to the mid-level providers in the medical world, this support construct is designed to make the treatment of low-income populations, including Medicaid beneficiaries, financially feasible. DSOs are individual dentist owners which have joined together, typically with the support of an independent business support center, pooling resources in order to improve efficiencies and share best practices.
One study in Texas found that DSOs, on average, charged $225 less per treatment than non-DSO dentists, where nearly a third of Medicaid enrollees receive their dental care from DSO dentists.

There is real evidence from the medical field that adding new avenues of treatment have facilitated much-needed access to care for under served poor and minority populations. It's time that the same model be applied in the dental field too, in order to ensure that all children, regardless of race or socio-economic status, get the care they need.

Gary A. Puckrein is President and Chief Executive Officer of the National Minority Quality Forum. Dr. Puckrein also serves as Executive Director of the Alliance of Minority Medical Associations--a collaborative effort of the Asian and Pacific Physicians' Association, the Association of American Indian Physicians, and the National Medical Association. In 1998 he founded the Forum's predecessor program (the National Minority Health Month Foundation) to help communities and policy makers eliminate the disproportionate burden of premature death and preventable illness in special populations through the use of evidence-based, data-driven initiatives.

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