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Access more than Geographical
Dental debate continues
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EDITOR’S NOTE: The dental debate continues. Following a previous story, “Great Bend dentists speak out: Dental crisis fact or myth”, representatives from Kansas Action for Children and the W.K. Kellogg foundation contacted the Tribune to comment about access to dental care in rural Kansas. They expressed concerns about the information about access to dental care presented in the story, which ran on Sunday, Feb. 20. We listened, and did some more digging, and this is what we found.

Just because something is within reach doesn’t mean you can reach out and grab it. Courage, skill, training, credentials, resources, networks and often money help people to move forward in the world. But the lack or one or more of these can act as an invisible barrier that keeps others stuck, spinning their wheels, or even slipping backward.  

Access is at the heart of the fight for and against the creation of a new type of dental care provider to serve Kansans, the Registered Dental Practitioner. The Kansas Dental Association testified against Kansas House Bill 2157 in January, while Kansas Action for Children testified in favor of the bill.

According to the Kansas Dental Association’s Kevin Robertson, 98 percent of Kansans live within 30 miles of a dentist, and he said with the addition of just 14 more dentists spread out to serve more remote areas, everyone in the state of Kansas would have reasonable access to dental care.

However, Kansas Action for Children’s Susan Wilke notes that in his testimony he admitted, “...for the purpose of the research, only geographic distance is taken into consideration.”

“If you can’t get in to see a dentist, then there really isn’t access,” she said.

Getting seen
In 2011, the Kansas Bureau of Oral Health produced a study, “Mapping the Rural Kansas Dental Workforce” in which the term “Dental Care Service Desert” was defined.

According to the study, “The “Dental Care Service Desert” is a new designation that describes geographic areas where there are no dental services and where the closest dental office is at least a half-hour drive from residents’ homes.”

“It’s important to look at whether existing dentists are taking new patients or participating in Medicaid and other plans (like KanCare),” Wilkes said. “Proximity does not equal access.”

The Tribune contacted dental practices listed in the Central Kansas Yellowbook, and inquired if the practice could schedule an appointment for a regular checkup for a child covered by KanCare.

Of the 40 dentists listed, 13 practiced in Barton County, two in Larned, one in Lyons, one in Ellsworth, and one in St. John. The rest are more than 30 minutes away, in Hays, Salina, Hutchinson and Wichita.

Most do not open on Fridays, with only one open for half the day. While most of the dentists in this area did not accept patients on KanCare, some were willing to take them as self-pay patients.

Two outside of Barton County accept KanCare, but are not accepting new patients. There were only two practices in Great Bend that said they accept KanCare, one of which could schedule a regular check-up within the month, the other was booked into the last week of November at the time the Tribune inquired.

Outside of Barton County, but still within a 30-minute drive, the Tribune found one practice in Larned, one in Lyons, and one in Ellsworth who could take a new patient on KanCare for an appointment within two to eight weeks.

While a 30-minute drive may be considered reasonable, other factors need to be taken into consideration. The Tribune found many practices find it difficult to schedule more than two children on the same day, so parents with three or more kids may be looking at making the drive more than once.

Secondly, business hours for dental offices within the scope of this story did not include evening or weekend hours. That means parents may need to take time off work or find a family member who can take the children to the appointment, and they may need to take their children out of school, too.

Inability to schedule
Here is where the big picture of the national economy and employment trends filters down to the local level. According to a story in the Wall Street Journal, “A Part-Time, Low-Wage Epidemic”, Nov. 5, 2012, by Mortimer Zuckerman, The highest sector of job growth has been in lower-wage jobs, accounting for 58 percent of new jobs. The majority of these jobs are in the retail, food-service, and home health fields.

The Bureau of Labor Statistics has found that a million full-time jobs in the retail and wholesale sector have been cut since 2006, and 500,000 part-time jobs have been added, according to a New York Times story, “A part-time life, as hours shrink and shift”, Oct. 27, 2012.

“The widening use of part-timers has been a bane to many workers, pushing many into poverty and forcing some onto food stamps and Medicaid. And with work schedules that change week to week, workers can find it hard to arrange child care, attend college or hold a second job.”

While some workers try to piece together more than one part-time job, new scheduling trends in these industries are making even that more difficult than ever. Many major companies reduce available hours to employees who notify managers they can’t work at certain times. According to one former assistant manager at a Walmart in Minnesota quoted in the story, if they (part time workers) said they were unavailable during certain hours, then the managers and scheduling software would reduce their hours further.

With many low-income or poor parents operating under these conditions, many without the benefits full-time workers receive, oral health care for themselves, as well as their children may be less of a priority. This may be part of the reason behind many dentist’s frustrations with taking KanCare patients.

In addition to the extra paperwork involved in being a contracting provider for KanCare, several of the dentists we interviewed complained of high percentages of no-show patients, compared to those who were covered by other mainstream insurance plans, or even the self-paid.

Dental clinics
Public dental clinics are one alternative to private practices. One such practice in Great Bend is Heart of Kansas Family Health Care. When the Tribune called to inquire about dental care services, we were told the clinic recently remodeled their dental care area and are currently searching for a dentist. In the meantime, they are referring dental patients to Prairie Star Health Center at Hutchinson (620-663-8484). According to their website, the clinic is staffed with two dentists and one Registered Dental Hygienist with Extended Care Permit 1 and 2.  These ECPs allow the hygienist to take on more responsibilities with the approval of the supervising dentist.

The clinic accepts patients on Medicaid and Kancare, and serves self-paid patients on a sliding scale based on income with savings up to 50 percent. Patients must complete paperwork before they are scheduled.

These clinics are an example of what Wilkes hopes could become more common in underserved areas if HB 2157 were to become law. While the KDA is in favor of adding a third level to the ECP, these dental hygienists would still be required to be under direct supervision of a dentist. The Registered Dental Practioner would only be under general supervision, which means more than one clinic could be served by one dentist.

According to the Bureau of Oral Health’s study, “areas of western Kansas will join the Dental Care Service Desert in the next three years because of retirement of many primary care dentists.”  Even with the current accessablity for KanCare patients in Barton County available today, the number of dentists serving the general population is likely to shrink if these statistics prove to be correct.

“There are fewer dentists serving populations in frontier and rural communities and the dentists practicing there are older and sponsor few ECPs,” the study went on to say. “In 2009, 54 percent of dentists practicing in frontier counties were planning to retire in the next three to five years and among those dentists already seeking to sell their practices, most had no interested buyers.”

While the KDA is trying to help by offering scholarships or loan repayment awards to dentists who agree to open practices in these underserved areas, it may be too little too late.

Kansas has a handful of schools that offer programs in dental hygiene, but there are none that offer a full dental program. Students who wish to become dentists must compete for a very limited number of seats at universities in neighboring states, said Great Bend dentist Marc Huslig. With many new graduates of these programs choosing to practice in more populated areas, there may not be time to train up an adequate force of new dentists to take the place of retirees in time to avoid the expansion of dental deserts in the western part of the state.