Maintaining a strong oral health workforce is critical to ensuring comprehensive care for Medicaid populations. Yet, significant challenges persist in sustaining and expanding this workforce, leading to gaps in services for members, particularly among historically marginalized communities.
Earlier this year, with support from CareQuest Institute for Oral Health, the Center for Health Care Strategies (CHCS) spoke with oral health stakeholders across the U.S., including state oral health officials, researchers, professional organizations, and other oral health experts to understand what workforce levers exist to improve access to vital oral health services to improve the health and well-being of Medicaid members. Through these conversations, CHCS identified four approaches Medicaid agencies and their partners can consider to support a strong oral health workforce that more effectively serves Medicaid members.
Four Levers to Advance the Oral Health Care Workforce
1. Expand the oral health workforce and empower providers to work at the top of their license to more comprehensively serve Medicaid members.
Expanding the oral health workforce and optimizing the role of providers are critical strategies to enhance access to care for the Medicaid population. States can support providers’ ability to work at the top of their licensure, including through training, increased practice autonomy, and integrated care models. States are increasingly exploring innovative workforce models, such as those that use dental therapists and dental hygienists to deliver preventive and routine oral health services with minimal supervision, particularly in underserved areas.
In Oregon, for instance, the dental practice model enables expanded practice dental hygienists with a permit to deliver care to specifically identified populations, as well as within select settings without the supervision of a dentist. This includes individuals with incomes below the federal poverty level, nursing home residents, nursery school students and their siblings, and those living within correctional facilities, among other populations. When dental hygienists can directly bill Medicaid and perform services independently in public health settings through models like these, there is a corresponding increase in use of dental care services among populations with low incomes.
Dental therapists can also fill access gaps. For example, Minnesota statute requires that dental therapists target their services in settings that serve low-income, uninsured, and underserved populations or are in dental professional shortage areas. In 2009, adults with low incomes in Minnesota increased their use of dental services following the authorization of dental therapists.
Additionally, integrating oral health care into medical settings, such as primary care, enhances access to care by embedding preventive oral health services into routine medical visits. One strategy is to embed dentists and other oral health professionals within medical care teams to provide comprehensive, coordinated care that addresses oral health in the context of overall health. Another strategy is to equip medical professionals in primary care offices with the skills to deliver and be reimbursed for basic oral health services, further addressing workforce shortages. Programs like “Smiles for Life” equip pediatricians, family physicians, physician assistants, and nurse practitioners with the skills to perform oral health assessments, apply fluoride varnish, and counsel families on preventive care. These approaches, paired with robust care coordination and referrals, can ensure Medicaid populations receive earlier, uninterrupted, and more comprehensive care. By thinking flexibly about the oral health workforce and supporting the use of innovative care models, states can create pathways to care that improve access and health outcomes for the Medicaid population.
2. Increase awareness of Medicaid among dental providers and improve the program’s coverage, benefits, and operations for providers and the communities served.
By providing targeted education and training to dental providers, state Medicaid programs can ensure that more providers are informed about Medicaid policies, covered services, and reimbursement processes. In addition, streamlining administrative tasks and clarifying program benefits enables the workforce to focus on delivering care, maximizing their impact in addressing the oral health needs of Medicaid enrollees.
For instance, the Missouri Coalition for Oral Health partnered with the state’s dental association and Medicaid program to increase dental provider enrollment through a coordinated media campaign that educated providers on: (1) the value of becoming a Medicaid provider, including information on a recent rate increase; (2) awareness of the patient population and their needs, including breaking down misconceptions and myths; and (3) available provider support, including a step-by-step walkthrough of how to enroll. The campaign resulted in 184 additional providers enrolling in the Medicaid program. Efforts like these strengthen the connection between providers and communities, ensuring better access to comprehensive care.
3. Encourage strategic coordination of oral health priorities across a broad coalition of stakeholders to tackle related workforce issues.
Structural barriers, including policy fragmentation, different funding streams, and educational/professional silos, among other factors, isolate oral health stakeholders from the broader health care system. Collaboration among policymakers, Medicaid programs, providers, health plans, educational institutions, and community organizations can align goals of oral health workforce-focused efforts. By uniting around shared priorities, stakeholders can galvanize their combined resources and knowledge base to better target efforts to address workforce shortages and improve access to comprehensive oral health care for communities that have been historically underserved, including Medicaid populations.
For example, the Future of Public Oral Health Workforce Workgroup, convened by Virginia Health Catalyst, brings together stakeholders to ensure the state’s oral health workforce meets the needs of all Virginians by: (1) supporting the current workforce to promote resilience and reduce burnout; (2) maximizing the existing workforce to ensure team-based, patient-centered care; and (3) investing in the future workforce.
4. Build a pipeline of engaged providers through creative solutions.
Integrating Medicaid education and opportunities to serve the population into professional training programs for dental providers could help future clinicians understand the Medicaid program’s critical role in providing oral health care, increasing access to care, and building provider confidence in serving the Medicaid population.
Dental schools already play a crucial role in their communities by improving access to oral health care services. In 2021 and 2022, 37 percent of patients served by dental school students and faculty were covered by public insurance, compared to nine percent of patients within private practices. Some states, including New York and Delaware, require dentists to complete a one-year postgraduate residency in a community-based setting to receive their dentist licensure. By fostering a deeper understanding of the Medicaid program and engagement with its members early in their careers, providers may be more likely to participate in the program. Empowering the existing and future workforce with clinical opportunities and a clear understanding of Medicaid’s mission can foster greater provider engagement and help build trust within the communities served.
Conclusion
There are emerging themes from Medicaid programs and their partners across the country that are strengthening the oral health workforce to better address the health care needs of individuals served by Medicaid. Other states can benefit from these lessons to contribute to a thriving oral health workforce within their communities by: (1) expanding who can participate as providers and supporting providers to work at the top of their license; (2) improving awareness and operations of Medicaid programs; (3) coordinating priorities among a coalition of stakeholders; and (4) building a pipeline of engaged providers through creative solutions.
