Need for dental access persists across state
Hutchinson ? What Hutchinson will witness when the Kansas Mission of Mercy takes place Feb. 9-10 on the Kansas State Fairgrounds will be an outpouring of charity by those providing free dental treatment.
Also visible will be the need.
People will drive for hours to arrive before the sun rises.
Kim Moore, the outgoing president of the United Methodist Health Ministry Fund in Hutchinson, worked the gate at the first Mission of Mercy in 2003 in Garden City. A snowstorm did not prevent people from lining up at 4 a.m., he said.
“And then there was the point when I shut the gate and didn’t let any more people through,” he said, because they had run out of time.
At a subsequent Mission of Mercy in Pittsburg, a high school student and scholar from a small town came with family members every day of the three-day clinic because they needed multiple treatments, Moore said. “Finally on the last day, he opened his mouth and smiled,” Moore said.
“People just don’t understand the burden of dental diseases,” he said.
These big-event clinics have treated nearly 28,000 people. To Moore, they illustrate the problem with access to dental care, The Hutchinson News reports.
“We have a market failure,” he said.
Cathleen Taylor-Osborne, a dentist and director of the Kansas Department of Health and Environment’s Bureau of Oral Health, is eager to see the results in 2018 of a demographics study of those who do not go to the dentist annually.
She said when people picked the reason out of more than a dozen choices for why they had not been to a dentist in the last 12 months, nearly 70 percent said cost. That response dwarfed the number saying it was fear or travel distance.
“Dentistry is a cash-and-carry business,” Moore said. “You don’t get services unless you pay for them, and frequently you pay on the spot.”
Some employers do not offer dental insurance, and insurance coverage can be limited. Medicare does not have a dental care benefit, and Medicaid recipients may or may not have dental coverage.
Further, some dentists do not accept dental insurance, which controls what they can charge. Many more dentists do not accept Medicaid patients or limit the number they take.
When a budget crunch in 2016 prompted Gov. Sam Brownback to cut Medicaid reimbursements by 4 percent, that affected private dental practices, Taylor-Osborne said.
Hays dentist Dr. Melinda Miner opened her testimony in November 2016 to a legislative committee:
“Almost 7,000 children in western Kansas need a new dentist, and there will likely be more in this situation. Why? After the reimbursement rate cut was announced, at least four dentists in western Kansas and two more in eastern Kansas canceled their KanCare contracts due to the lack of funding, appreciation and value put on the dental care they provide. I am one of those providers.”
The business model for a dentist is different than the physician. The latter is more likely to be part of a clinic or hospital. The former has more in common with the Main Street business or entrepreneur.
Dentists face the pressure of bringing in income from the start. A graduate leaves dental school with “a minimum of a $150,000 debt,” Taylor-Osborne said. Investing in equipment or potentially buying the practice of a retiring dentist adds to the debt.
Those factors contribute to a concentration of dentists in urban areas, rather than in more sparsely populated regions.
Dentists in Hutchinson advertise and compete for patients. It’s even more competitive in some larger cities.
But there has been no dentist in Ness County for years. The Ness County Chamber of Commerce’s Cinda Flax said she goes to Hays for dental care.
There is no dentist in Clark County, and some residents there drive to Dr. Brian Headrick’s office in Meade. Comanche and Kiowa counties don’t have dentists, either, and some people there go to Headrick, too. Oklahomans and even Texans drive to Meade for dental care.
Dentist-less Barber County has residents variously driving to dentists in Harper, Pratt, Hutchinson, Wichita and Oklahoma.
A September 2011 report, “Mapping the Rural Kansas Dental Workforce,” found that counties without a dentist were not exclusive to western Kansas, but that region had most of them.
“Our county really worked hard,” said Wichita County Economic Development Inc. Director Diana Kirk, of the concerted economic development efforts that attracted Dr. E. Joanne Brown, originally from Arkansas.
“Leoti had a whole bunch of stuff in place to entice us to get out here. They had been without a dentist for seven years before we moved in,” said Craig Sandlin, married to Brown and the office manager at the practice, Great Plains Family Dentistry.
There were too many dentists in Arkansas, and they looked at Kansas. They paid four site visits — Atwood, Medicine Lodge, Stockton, and Leoti — before choosing Leoti more than 17 years ago.
The land was donated and favorable loans enabled acquisition of equipment and construction of a building. At last count, the practice had patients in 13 counties in Colorado and in 27 counties in Kansas.
“There are not enough dentists out in western Kansas for the need,” Sandlin said.
Meade’s Headrick grew up in Dodge City and graduated from Creighton University Dental School in Nebraska. He thought about locating in a more urban area such as Tulsa, Okla., but knew he wanted to raise a family in a rural area, he wrote in an email.
Meade County was in need of a dentist because of a retirement. Headrick contacted the older dentist and ended up purchasing the practice.
“I’ve been here for 33 years and never regretted a minute of it,” Headrick wrote. He had a satellite office in Cimarron for 22 years and closed it after his children graduated from high school. That gives Headrick and his wife more time to travel.
His practice is busy but he is not overwhelmed with patients. He plans to continue work as long as his health is good.
“We must look for people who will appreciate the rural quality of life to replace us,” he said.
There are 22 safety net clinics in Kansas — including Hutchinson’s federally qualified health center PrairieStar Health Center — that provide medical and dental services to the uninsured or underinsured.
“We want to take care of these patients who don’t have anywhere else to go,” said Bryan Brady, the chief executive officer of First Care Clinic, Hays, and board president of the Kansas Association for the Medically Underserved.
First Care Clinic is fully staffed when it has two dentists on board, but when Brady was in Topeka Feb. 14, 2017, for a House Health and Human Services Committee hearing, he testified the Hays clinic had only one dentist.
The News talked to Brady in November and the outlook had worsened.
“We’ve actually seen a reduction in Medicaid providers in Ellis County,” he said, and the clinic, which accepts Medicaid patients, still had only one dentist.
PrairieStar has two dentists: Dentist Director Dr. Scott Rohr and Dr. Emily Knee.
Rohr was in the U.S. Air Force and now is in the Air Force Reserves.
“I think it was a natural transition,” he said, from the Air Force to public health and “taking care of our underserved and people in need.”
PrairieStar serves eight counties and a sliding scale for fees takes into account a patient’s income. The services available range from teeth cleaning to root canals and crowns.
“It’s definitely possible to make more in private practice,” Rohr said, but PrairieStar provides a guaranteed salary and assisting staff and equipment. A partial college loan repayment program also can be an incentive at clinics.
Before the addition of Knee, patients were being scheduled two to three months out to see Rohr. Now the wait is a few weeks.
Ideas for improving Kansans’ access to dental care include raising Medicaid reimbursement rates, creating the licensure of midlevel dental care providers, and establishing a dental school in Kansas.
“We are advocating to get a comprehensive adult dental Medicaid component and higher rates,” said Tanya Dorf Brunner, executive director of Oral Health Kansas Inc. There are no restorative services, such as fillings, for adults under Medicaid, she said. Although Medicaid coverage is available for preventative services for adults, if rates are not higher to cover a dentist’s costs, dentists won’t take Medicaid patients.
The state could raise reimbursement rates, if there was money to do it, Dorf Brunner said.
Telemedicine is one method of connecting rural Kansans to distant physicians, but there is not a counterpart in dentistry.
“One of the things we’re starting to think of is tele-dental services,” Dorf Brunner said. It is found in some other states, but not in Kansas, she said.
The economic development approach used by Wichita County to entice a dentist may not be an option for cities where population and resources have declined, Moore said.
Moore is an advocate for licensure of dental therapists. Such therapists would work under the supervision of a dentist but the dentist would not be required to be on site. A dental therapist would have more training and would be able to perform more procedures than a hygienist, under House Bill 2139. Alaska and Minnesota have dental therapists, and the push to add this in Kansas has been a years-long effort.
At a Feb. 14 hearing before the House Health and Human Services Committee, proponents for the dental therapist legislation outnumbered opponents and included Moore, Brady and Miner, as well as the Kansas Association of Counties, AARP-Kansas, and the free-market Americans for Prosperity-Kansas.
“We have a shortage of dentists in many parts of Kansas, and a severe shortage of dentists willing to accept Medicaid. At the same time, we have untapped talent in our pool of Kansas dental assistants and hygienists who are willing to step up to help,” wrote Americans for Prosperity’s Jeff Glendening in his testimony.
Opponents to the bill included the Kansas Dental Board and the Kansas Dental Association. The KDHE was neutral.
“If the Legislature pursues funding of the new dental school, which would become the first dental school in the history of Kansas, the board stands ready to collaborate with interested parties in the accreditation process,” was the testimony of Lane Hemsley, executive director of the Kansas Dental Board.
The committee did not act on the bill. “We’ve been fighting, but we can’t get it to the floor,” Moore said.
Funding for a dental school has not been authorized but Taylor-Osborne thinks the school would make a difference. Kansas has limited spots at in-state tuition rates in the University of Missouri-Kansas City Dental School. Paying out-of-state tuition at other institutions exacerbates a dental student’s debt.
Meanwhile, Taylor-Osborne said one of the things KDHE is doing is working with a lot of extended-care permit hygienists to provide preventative care to schoolchildren. During 2016-17, nearly 170,000 children received a dental screening, she said. Those children identified as having urgent problems requiring a dental visit within 24 hours were less than 3 percent but that was still about 3,600 children, she said.
Taylor-Osborne shares Moore’s mixed feelings about Mission of Mercy.
“It’s an amazing program,” Taylor-Osborne said, “but I wish that we had another way of providing services other than that.”