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Washington State Dental Association

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).

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