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Mid-Level Providers: Friend or Foe?

Mid-Level Providers: Friend or Foe?
Matt Giulianelli

Since Alaska adopted the idea of the dental therapist as a solution to access to care, other states have been considering this as an option. The “mid-level provider” practitioner, as they’ve come to be called, can perform certain procedures, even irreversible procedures, to populations that otherwise have absolutely no licensed, qualified dentist in their geographic area.


The idea of the mid-level provider has now morphed somewhat to become the favored solution by some to bring care to people in underserved areas throughout the U.S., not just geographically isolated parts of much larger states such as Alaska. So now the question becomes, is adding another level of dental practitioner the best answer to the access to care question?


Honestly, I think many dentists are asking “Is this safe for patients and could this model eventually compete with the traditional practice model?”


Let’s consider the first question briefly. I practice in Vermont, and we currently have a bill in the legislature to make mid-level providers (called Licensed Dental Practitioners) reality here. I have talked with at least a half-dozen state senators and representatives in person and via email. We’ve had some very good conversations surrounding this issue. All politics aside, some see this as the answer, some do not think it solves anything, and a few liken this idea to physician’s assistants. What I heard from the strongest supporters however is that this model will save people money and make dental care more affordable.

What I found is that not one of them realized the cost of education for today’s dental school graduate or the cost of running a dental practice. The perception was that dentists set fees arbitrarily and those fees have zero correlation with the overhead to run a practice.


The other disturbing realization when looking at a draft of the bill was the real issue of providing care in geographically remote or underserved areas was not a mandatory requirement for a LDP. They could choose to practice in areas already congested with dentists. Also, they would be billing procedures at the same fee as a dentist under the state’s Medicaid system. Does this offer any financial relief to patients or to the the state?


Two other things I find confusing or otherwise challenging:

  1. A licensed dentist must directly supervise an LDP.
  2. Who provides the malpractice insurance for an LDP? If the solution is for an LDP to practice in an area that has no dentist, who is going to supervise them? Is it feasible to ask dentists to incorporate them into their practices, having to undertake expensive expansions along with adding support staff. So now we are asking a dentist (who will most likely not be practicing in the areas that need them anyway), to add to their existing overhead and liability coverage to allow and LDP to practice all while charging fees at the same level as the dentist. Am I missing something here?


My other two concerns:

  1. Is this safe for the public?
  2. Will this model compete with the current model for rendering dental care? To the first, I personally say maybe. To the other, I say absolutely not. Right now the bill states LDP’s will have a scope of practice that includes medically necessary and irreversible procedures. Yet an LDP only needs to have training as a hygienist and have an additional 12 months of education and 400 clinical hours. There is also no accredited institution for LDP’s. Again, in remote areas of Alaska where people have absolutely no options and need urgent care, this may be the best way to proceed. However, if we are to unleash this model to help lower costs, then I think it does put the public at risk and creates more issues that it is supposed to solve. With proper training and accredited licensing standards, I’m sure an LDP can do a great job within their scope of practice and would not require direct supervision from a dentist. Politicians should not be asking more of an LDP than they can handle just to serve an agenda. It is not fair to them or to their patients. I do not think LDP’s are a threat at all. I think we as a profession should encourage the model of LDP’s as it was originally devised to care for people in remote and underserved areas. If people want another level of care and it fills a need, then I’m all for it as long as it makes economic sense for everyone and puts no one in harm’s way.


Are mid-level providers a consideration in your state’s policies? What do you think could be a better solution?

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