In an effort to serve more low-income and uninsured families, Minnesota’s dental industry is returning to a high-tech solution known as teledentistry, which allows dental hygienists to provide preventive care at low cost while supervised electronically by dentists at a different location.
For the 25 percent of Minnesotans without dental insurance, even basic preventive care may be too expensive, and among the 1.1 million enrolled in the state’s Medicaid program, many cannot find a dentist who takes government insurance.
Hoping to address these gaps, a private dental practice called mylife Dental recently launched a low-cost preventive clinic in Eagan, pairing teledentistry with a new payment model that does not rely on insurance.
“I feel like we are innovators in this market,” said Dr. Joseph Trowbridge, one of the clinic owners. “This is helping a segment of the population that has been vastly ignored.”
Safety-net providers, too, are making wider use of teledentistry, including the nonprofit Apple Tree Dental, which has seven clinics across the state and mobile operations that serve nursing homes and other sites.
Minnesota was a pioneer of teledentistry, as far back as 2001, when Apple Tree adopted technology that allowed dentists to remotely supervise preventive care provided by hygienists to children at Head Start locations.
Those efforts came to a halt in 2010, when the state’s Medical Assistance program cut all reimbursements for teledentistry during a state budget crunch. Then, in 2016, the Legislature directed the state’s health insurance programs to resume reimbursing clinics for the service.
“Minnesota has been at the forefront in this whole area of teledentistry nationally,” said Dr. Michael Helgeson, chief executive at Apple Tree.
“We are still ramping it all back up,” Helgeson said, adding that several thousand patients have benefited already.
The trend comes as dental hygienists are taking on a greater share of preventive care, such as cleaning teeth, taking X-rays and applying fluoride treatments. Minnesota has 4,800 dental hygienists, compared to just 3,400 dentists. And the efficiencies can be substantial: government data show that a Minnesota dental hygienist earns about $73,000, or roughly one-third the average dentist salary.
Even when hygienists provide more of the care, dentists still must supervise the work and determine a patient’s treatment plan. And for the most part, dentists do the more advanced work of filling cavities, performing root canals and other procedures.
Until now, most of this division of labor has occurred within the confines of the dental clinic, with the dentist popping in to examine a patient after the hygienist finishes the preparatory and preventive work. But with advances in technology, the dentist can supervise from afar, with the hygienist in a satellite location or even providing care in the field to patients in schools, nursing homes and other institutions.
“If the dentist is going to take their time to do every single one of these procedures, it is just a huge money loser under the old model,” said Helgeson.
Most of Apple Tree’s patients are either uninsured or covered by state programs such as Medicaid, known in Minnesota as Medical Assistance, which pays among the lowest rates in the country for dental work. A recent survey found that 62 percent of enrollees said they were turned away by dental clinics that were not taking new Medical Assistance patients.
In addition, only 37 percent of children on the program got preventive dental care in 2015, prompting federal health officials to warn the state earlier this year that it was in danger of losing federal funding if it did not improve access.
As part of its strategy to increase access, Minnesota became one of the first states to certify a class of midlevel professionals known as dental therapists, who can do some of the same work as a dentist but, like hygienists, work under supervision of a dentist. The state’s first dental therapist was licensed in 2011 and today there are 89, according to the Minnesota Board of Dentistry.
Apple Tree has a dental therapist working at a nonprofit pediatric clinic in Coon Rapids connected to Apple Tree dentists through data stored in the cloud.
“Our staff can see all imaging and clinical notes live,” said Helgeson. “So a supervising dentist can be on the phone and be on the computer to see everything live if they need to.”
Mostly, though, dentists review care records and images after the visit is over, then follow up with the patient if more treatment or diagnosis is required.
At mylife Dental, patients who need follow-up care would visit Trowbridge in his downtown St. Paul clinic or at the Plymouth office of another owner. Patients at mylife pay a monthly subscription fee of $12.95, or $32.95 for a family, and get two teeth cleanings a year, X-rays and an exam. Appointments are not necessary or can be scheduled through a smartphone app.
The Eagan clinic is staffed by two hygienists. Because patients pay a subscription fee, insurance is not accepted, which also cuts costs.
“It allows me to extend my reach without building a new clinic with a dentist on staff and a business manager on staff to deal with insurance,” said Trowbridge.
“Now that the technology is available, this is where things are moving,” he said.