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State Health Exchanges: A Federal Perspective

Special to the WSDA News from Jon Holtzee, Director, State Government Affairs at American Dental Association

With the enactment of the Patient Protection and Affordable Care Act (PACA) on March 23, 2010, many questions have been asked and many remain on how the state health exchanges which are required to take effect on January 1, 2014 will impact the accessibility and delivery of dental care in our country. While the answer will vary, depending on the nature of the exchange in each state, there are some things that are certain:
• While the Supreme Court considers the case, work will continue on exchange development;
• States may create discrete individual exchanges and small business exchange or create one unified system;
• Those purchasing through the exchange can do so through the web, by phone or through an insurance agent;
• The only dental benefit required is what’s called the “Pediatric Essential Oral Health Benefit” for those children whose coverage is purchased through the exchange. With the recent announcement by the feds that instead of establishing a national benchmark for that benefit, they will instead permit states to choose between a variety of approved benchmarks. It has become vital for constituent societies to become vocal advocates to be sure the best option is selected for that state;
• If a state declines to submit an exchange plan for approval to Health & Human Services (HHS) by January 1, 2013 for activation on January 1, 2014, the federal government will establish the exchange in that state;
• That despite these deadlines, the federal process for rulemaking and guidance to the states will most likely continue to be painfully slow;
• With over 75 percent of dental coverage being family coverage, requiring only a pediatric benefit may change the dental benefit design and market for those in the exchange; and 
• The law requires that stand-alone dental plans be allowed as qualified plans within the exchange in addition to having a dental rider as an option to a medical plan.
A primary concern in the development of state exchanges is ensuring fair and robust competition among various plans offering dental benefits, and providing a variety of plan models within the exchange. Clearly an exchange that only offered a capitated benefit plan may have a difficult time creating a network of participating dentists to provide care to their enrollees. An example of these difficulties is highlighted by the existing exchange in Massachusetts, where a 2009 study funded by Blue Cross Blue Shield of Massachusetts found that access to dentists continued to be problematic. Only a limited number of providers are willing to accept the Dental HMO offered by Doral, which is the dental vendor for both Mass Health (the Massachusetts Medicaid & CHIP program) and three of the four Commonwealth Care (exchange) plans.

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Mid-Level Debate Intensifies

Proponents of HB 2226 and SB 6126, a pair of bills aiming to create two new mid-level dental practitioners in Washington, squared off with the WSDA's testimony team in front of both the House and Senate Health Care Committees on Thursday in Olympia. Watch how it all went down and please feel free to comment on this hotly debated issue facing our State and many others around the Country.

House Health Care Committee Hearing on HB 2226
Thursday, January 19, 10:00am

Supporters 1st Panel

WSDA's Panel

Supporters 2nd Panel

Senate Health Care Committee Hearing on SB 6126
Thursday, January 19, 1:30pm

Supporters 1st Panel

Supporters 2nd Panel

WSDA's Panel


Video: Dental Hygiene Practitioners would make $13.87 an hour

The Washington State Dental Association has put together a short economic analysis of a proposed dental hygiene practitioner found in HB 2226 and SB 6126. This analysis lays out the revenue and expenses a dental hygiene practitioner would have if he or she treated Medicaid patients in a signle chair clinc. WSDA believes that practitioners created in HB 2226 and SB 6126 are not economically viable without extensive government subsidy. This is one of many reasons why we are asking legislators to vote NO on HB 2226 and SB 6126.

Why the Proposed WA State Dental Therapist Doesn't Make Economic Sense from WA State Dental Association on Vimeo.


Two New Studies Raise Patient Safety and Economic Feasibility Concerns about Midlevel Providers in HB 2226/SB 6126

The Journal of the California Dental Association published two studies this month which raise concerns about patient safety and economic feasibility of dental practitioners envisioned in HB 2226 and SB 6126. Proponents of HB 2226 and SB 6126 have claimed dental practitioners provide results as safely as dentists and will make dental care more affordable.

In the first study, Researchers from NYU and Columbia University conducted a systematic review of existing safety studies on dental auxiliaries from around the world and concluded that there is insufficient evidence to conclude dental auxiliaries can perform irreversible (surgical) procedures safely. The systematic review makes the following conclusion:

"Available evidence is sufficient to a larger extent to conclude that the auxiliary providers are capable of providing safe and high quality reversible procedures....However, the evidence in relation to the irreversible procedures related outcomes is insufficient" (CDA Journal, Vol 40, °1, page 78, bold and underline added by WSDA).

The most recent safety study on Dental Health Aide Therapists (DHATs) in Alaska was completed in 2010 by RTI International and the Kellogg Foundation. The RTI study only evaluated 5 DHATs who performed 37 extractions (seven done on children) and 54 restorations (25 done in children). The systematic review made the following statement on this study:

"The cross-sectional nature, smaller number of DHATs (five), lack of direct comparison of DHAT procedures to that of dentists, and convenience samples and records, prevented this study from drawing robust conclusions regarding the true safety and other aspects of the DHAT program. [RTI International] authors also cautioned that the findings are not generalizable" (CDA Journal, Vol 40, °1, page 71).

In the second study, researchers from ECG Management Consultants assessed the economic viability of three alternative practitioner types for provision of dental care to the underserved. Two of the three models correlate with the dental practitioner and dental hygiene practitioner in HB 2226 and SB 6126. This study estimates that total tuition and cost-of-living associated with training midlevel practitioners will exceed $130,000 and none of the models “are sustainable without tuition subsidies, grants, or other approaches to decreasing the debt burden” (CDA Journal, Vol 40, °1, page 56).

A series of revenue projections for dental practitioners working in public health clinics with different combinations of Medicaid and private insurance patients were also included in the economic analysis. This analysis found the model most similar to dental hygiene practitioners to be “not sustainable in any scenario.”  The model most similar to dental practitioners was able to break even (revenues exceeding expenses by $5) with a payer mix consisting of 50 percent reimbursement from private dental plans and the other 50 percent from Medicaid, which is drastically different from payer mixes found in community health centers in Washington State (CDA Journal, Vol 40, °1, page 58).

Both studies in their entirety can be found here:

For more information, call or email Bracken Killpack, Director of Government Affairs at or 206-973-5227 (direct).