The oral health care workforce shortage is a significant nationwide issue, creating particular challenges for people living in underserved and rural communities. The shortage of traditional dental health professionals (e.g., dentists, hygienists) limits access to essential dental care, creating unmet oral health care needs and worsening health disparities. State Medicaid agencies have opportunities to address some of these challenges by expanding the role of dental hygienists and other dental health care providers, integrating oral health care into other care settings, and exploring innovative care delivery models.
With support from the CareQuest Institute for Oral Health, the Center for Health Care Strategies spoke with oral health Medicaid stakeholders across the country to understand challenges and opportunities to equip the oral health workforce to better serve people covered by Medicaid. This blog post features a conversation with Christine Farrell, RDH, BSDH, MPA, oral health program director in the Michigan Department of Community Health, who has over 22 years of experience working on behalf of Michigan’s Medicaid program.
Q. What actions have you taken in Michigan to support the oral health workforce?
A. For the past 14 years, Michigan has allowed dental hygienists to be Medicaid providers. Through our public prevention dental programs, they can bill for their preventive dental care when they go out into the community through one of our community-based programs in nursing homes, schools, and migrant camps, among other locations. A unique aspect of Michigan law (PA 161 of 2005) allows dental hygienists to treat underserved populations with minimal supervision. This program is administered through Michigan’s public health oral health program. Our state has 54 mobile community-based programs treating Medicaid populations where they are, including provision of preventive oral health care.
There are limitations on the types of providers that can offer care independently or with supervision. To overcome this, we are looking at ways to embed dental hygienists into clinical practices beyond traditional dentist offices. For example, we have a program in the Upper Peninsula that embeds dental hygienists into a pediatric office. During these visits, the hygienists provide preventive care, patient education, and schedule follow-up visits. Additionally, before the pandemic, we embedded six dental hygienists into different OB-GYN clinics in federally qualified health centers (FQHCs). States interested in embedding oral health care into broader health care settings, like primary care, should start by examining their scope of practice definitions.
Michigan Medicaid also reimburses community health workers (CHWs) for services related to care coordination, health education and promotion, healthy system navigation, and screenings and assessments, and we hope to receive a grant to expand their training to include oral health specifications. If we are successful, CHWs working in pediatric and OB-GYN clinics will be able to connect their patients to necessary oral health care.
It would be great to see similar efforts in doula care, where an additional oral health module is added to their certification. This could also be valuable in other home-based models of care, where, for instance, a hygienist could be part of the infant well-visit check at home.
Q. What are challenges in using the oral health workforce to its full potential to serve Medicaid-covered populations?
A. The biggest challenge is the shortage of workers, including both clinical and non-clinical dental professionals. Tele-dentistry can help mitigate this shortage; however, many of these models work asynchronously, where the patient and provider are not speaking live, which can be ineffective. If the Centers for Medicare & Medicaid Services (CMS) could require asynchronous options, this could make tele-dentistry more effective in rural areas. It would provide time for dental providers to review x-rays, notes, and make recommendations. This would also help with referral processes, helping dentists connect virtually with specialist providers, like orthodontists.
From the public health side, it is challenging to compete with private sector salaries. A philanthropic partner put together a workgroup to look at how we can solve this problem in Michigan. Our FQHC partners expressed frustration with the high churn rates of their dental assistants. After training their dental assistants, they lose them to private practices that offer double the salary. As a state, we are looking for innovative ways to train and maintain dental assistants.
Additionally, dentists cite reimbursement rates as one of the biggest challenges for covering Medicaid populations. In Michigan, even though we have raised the Medicaid rates to match commercial reimbursements, I think it’s going to take a long time for the dental community to feel comfortable working with Medicaid.
Q. How is Michigan leveraging the oral health workforce to support underserved communities in non-traditional ways?
A. There are 58 of 83 counties in Michigan that are considered Dental Health Provider Shortage Areas. The majority of the counties are rural and encompass the Upper Peninsula and the northern Lower Peninsula of Michigan. Access to oral health care is an issue due to lack of providers and travel distances. We have established a rural oral health consultant who is building a rural oral health plan with the input of a wide range of partners in developing an asset map. In addition, the rural oral health consultant is working with a Veterans group to assess veterans and their oral health needs. Working with local and regional partners help guide the recommendations and determine the needs of the community.
Q. Do you see opportunities for states to work with their managed care organizations (MCOs) to address the oral health care worker shortage?
A. States can collaborate with MCOs to explore ways to expand their provider network. MCOs could hire CHWs if their contract with the state permits. They might also evaluate their provider network to identify opportunities for integrating hygienists as independent providers. Although Michigan Medicaid permits hygienists to enroll directly, some MCOs do not recognize them as billable providers. States can consider requiring MCOs to acknowledge dental hygienists as providers, particularly if public health hygienists are allowed to enroll in Medicaid. From a cost reduction perspective, there can be a compelling argument for getting hygienists recognized as providers. Arizona achieved this by successfully advocating that hygienists can reduce the number of readmissions for hospital-acquired pneumonia by providing oral health services to critically ill patients on ventilators.
Q. What are other considerations for states seeking to expand access to oral health services?
A. Other health care professionals, such as behavioral health and social workers, provide essential supports that can help connect individuals to oral health care. In Michigan, peer support workers are reimbursed through the behavioral health system, and they assist individuals in navigating oral health services. To truly address the workforce shortage, we need to explore creative ways of expanding oral health care services, particularly on the prevention side, to reduce the strain of traditional dental care. For example, policymakers can consider the role that pharmacists play, including through oral health assessments or screenings, applying fluoride varnish for children, and providing oral health education. Another example can be in addressing the side effects of comorbidities. Hygienists can be embedded in outpatient diabetes management programs, given the impact of oral health on blood glucose levels. By incorporating different types of providers and settings into oral health care, we can expand the workforce without overextending our public health resources.
