GAO-11-96, Oral Health: Efforts Under Way to Improve Children's Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns


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to Dental Services, but Sustained Attention Needed to Address Ongoing 
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United States Government Accountability Office:
GAO: 

Report to Congressional Committees: 

November 2010: 

Oral Health: 

Efforts Under Way to Improve Children's Access to Dental Services, but 
Sustained Attention Needed to Address Ongoing Concerns: 

GAO-11-96: 

GAO Highlights: 

Highlights of GAO-11-96, a report to congressional committees. 

Why GAO Did This Study: 

The Children’s Health Insurance Program Reauthorization Act of 2009 
(CHIPRA) required GAO to study children’s access to dental care. GAO 
assessed (1) the extent to which dentists participate in Medicaid and 
the Children’s Health Insurance Program (CHIP) and federal efforts to 
help families find participating dentists; (2) data on access for 
Medicaid and CHIP children in different states and in managed care; 
(3) federal efforts to improve access in underserved areas; and (4) 
how states and other countries have used mid-level dental providers to 
improve children’s access. To do this, GAO (1) examined state reported 
dentist participation and the Department of Health and Human Services’
s (HHS) Insure Kids Now Web site for all 50 states and the District of 
Columbia and called a non-representative sample of dentists in four 
states; (2) reviewed national data on provision of Medicaid dental 
services and use of managed care; (3) interviewed HHS officials and 
assessed certain HHS dental programs; and (4) interviewed officials in 
eight states and four countries on the use of mid-level and other 
dental providers. 

What GAO Found: 

Obtaining dental care for children in Medicaid and CHIP remains a 
challenge, as many states reported that most dentists in their state 
treat few or no Medicaid or CHIP patients. And, while HHS’s Insure 
Kids Now Web site-—which provides information on dentists who serve 
children enrolled in Medicaid and CHIP—-has the potential to help 
families find dentists to treat their children, GAO found problems, 
such as incomplete and inaccurate information, that limited the Web 
site’s ability to do so. For example, to test the accuracy of the 
information posted on the Web site, GAO called 188 dentists listed on 
the Web site in low-income urban and rural areas in four states 
representing varied geographic areas and levels of dental managed care 
and with high numbers of children in Medicaid. Of these 188 contacts, 
26 had wrong or disconnected phone numbers listed, 23 were not taking 
new Medicaid or CHIP patients, and 47 were either not in practice or 
no longer performing routine exams. 

Although improved since 2001, available national data show that in 
2008, less than 37 percent of children in Medicaid received any dental 
services under that program and that several states reported rates of 
30 percent or less. Further, although some data indicate that children 
in Medicaid managed care may receive less dental care than other 
children, comprehensive and reliable data on dental services under 
managed care continue to be unavailable despite long-standing 
concerns. Although HHS has not required states to report information 
on the provision of dental services under CHIP, CHIPRA requires states 
to begin reporting this information for fiscal year 2010. 

Two programs that provide dental services to children and adults in 
underserved areas—HHS’s Health Center and National Health Service 
Corps (NHSC) programs—have reported increases in the number of 
dentists and dental hygienists practicing in underserved areas, but 
the effect of recent initiatives to increase federal support for these 
and other oral health programs is not yet known. Despite these 
increases, both health centers and the NHSC program report continued 
need for additional dentists and other dental providers to treat 
children and adults in underserved areas. 

Mid-level dental providers—providers who may perform intermediate 
restorative services, such as drilling and filling teeth, under remote 
supervision of a dentist—are in limited use in the United States. The 
only currently practicing mid-level dental providers in the United 
States serve Alaska Natives. Efforts to supplement the U.S. dental 
workforce with mid-level and other types of providers are under way. 
GAO interviewed officials from eight states with varied state laws 
related to dental providers. Some states have made efforts to increase 
children’s access by reimbursing dental hygienists and primary care 
physicians for providing certain dental services. Some countries have 
long-standing programs that use mid-level dental providers, also known 
as dental therapists, who the countries report have improved 
children’s access to dental services. 

What GAO Recommends: 

GAO recommends that HHS take steps to improve its Insure Kids Now Web 
site and ensure that states gather complete and reliable data on 
Medicaid and CHIP dental services provided under managed care. HHS 
agreed with the recommendations, citing specific actions it would take. 

View [hyperlink, http://www.gao.gov/products/GAO-11-96] or key 
components. For more information, contact Katherine Iritani at (202) 
512-7114 or iritanik@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

For Children in Medicaid and CHIP, Finding a Dentist Remains a 
Challenge, and HHS's Web Site to Help Locate Participating Dentists 
Was Not Always Complete or Accurate: 

States Report Improvement in the Provision of Dental Services to 
Children in Medicaid, but Data to Monitor Service Provision under CHIP 
or Managed Care are Limited: 

Federal Efforts to Improve Access to Dental Services for Children in 
Underserved Areas Are Under Way, but Effect Is Not Yet Known: 

Use of Mid-Level Dental Providers Is Not Widespread in the United 
States, and Other Countries Have Used Them to Improve Children's 
Access to Dental Services: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Medicaid Dental Utilization Rates for Fiscal Year 2008: 

Appendix III: NHSC and Health Center Funding in the Recovery Act, 
PPACA, and Fiscal Year 2010 Appropriation: 

Appendix IV: Additional HHS Programs That May Improve Access to Dental 
Services in Underserved Areas: 

Appendix V: Dental Health Aide Therapist Program for Alaska Natives: 

Appendix VI: Types of Dental Providers, Excluding Dentists, in Eight 
Selected States: 

Appendix VII: Summary of Four Selected Countries' Use of Dental 
Therapists: 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Appendix IX: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Categories of Dental Services and Examples of Dental 
Procedures: 

Table 2: Types of Supervision for Other Dental Providers: 

Table 3: State Reported Data on Dentists' Participation in Medicaid 
and CHIP: 

Table 4: Number of States Providing Missing or Incomplete Dentist 
Information through HHS's Insure Kids Now Web Site in November 2009 
and April 2010: 

Table 5: Errors in Dentist Listings on HHS's Insure Kids Now Web Site, 
May 2010: 

Table 6: Characteristics of Mid-Level Dental Providers in New Zealand, 
the United Kingdom, Australia, and Canada: 

Table 7: Utilization of Any Dental Service, Preventive Dental Service, 
and Dental Treatment Service by Children in Medicaid, Ranked in Order, 
Fiscal Year 2008: 

Table 8: Funding for National Health Service Corps and Health Center 
Programs Under the Recovery Act and PPACA, and the Fiscal Year 2010 
Annual Appropriation: 

Table 9: HHS Programs that May Improve Access to Dental Services in 
Underserved Areas: 

Table 10: Selected Types of Dental Providers in Alabama, June 2010: 

Table 11: Selected Types of Dental Providers in Alaska, June 2010: 

Table 12: Selected Types of Dental Providers in California, June 2010: 

Table 13: Selected Types of Dental Providers in Colorado, June 2010: 

Table 14: Selected Types of Dental Providers in Minnesota, June 2010: 

Table 15: Selected Types of Dental Providers in Mississippi, June 2010: 

Table 16: Selected Types of Dental Providers in Oregon, June 2010: 

Table 17: Selected Types of Dental Providers in Washington, June 2010: 

Figures: 

Figure 1: Comparison of Nationwide Medicaid Dental Utilization Rates 
for Dental Services for Children, Fiscal Years 2001 and 2008: 

Figure 2: Percentage of Children in Medicaid Receiving Any Dental 
Service, Fiscal Year 2008: 

Figure 3: Number of Dental Hygienists, Dentists, and Dental Patients 
at Health Centers, Calendar Years 2006 through 2009: 

Figure 4: Number of NHSC Dentists and Dental Hygienists Practicing in 
Shortage Areas, Fiscal Years 2006 through 2009: 

Figure 5: Dental Therapist Training Locations and Certification Status 
in Alaska, June 2010: 

Abbreviations: 

ASTDD: Association of State and Territorial Dental Directors: 

CHIP: Children's Health Insurance Program: 

CHIPRA: Children's Health Insurance Program Reauthorization Act of 
2009: 

CMS: Centers for Medicare & Medicaid Services: 

EPSDT: Early and Periodic Screening, Diagnostic, and Treatment: 

FTE: full-time equivalent: 

HHS: Department of Health and Human Services: 

HIV: human immunodeficiency virus: 

HPSA: health professional shortage area: 

HRSA: Health Resources and Services Administration: 

NHSC: National Health Service Corps: 

OIG: Office of Inspector General: 

PPACA: Patient Protection and Affordable Care Act: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

November 30, 2010: 

The Honorable Max Baucus: 
Chairman: 
The Honorable Charles E. Grassley: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Henry A. Waxman: 
Chairman: 
The Honorable Joe Barton: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

Since 2000, our reports as well as reports by the Surgeon General, 
congressional committees, and oral health researchers have underscored 
the high rates of dental disease and the challenges of providing 
dental services to children living in underserved areas and in low-
income families. In particular, children with health care coverage 
under two joint federal-state programs for low-income children--
Medicaid and the Children's Health Insurance Program (CHIP)--often 
have difficulty finding dental care even though dental services are a 
covered benefit.[Footnote 1] For example we reported in 2000 that low-
income and minority populations--including children in Medicaid and 
CHIP--had a disproportionately high level of dental disease. In a 
related report, we found that the major factor contributing to the low 
use of dental services among low-income persons was finding dentists 
to treat them, even in areas where dental care for the rest of the 
population was generally available.[Footnote 2] We also reported that 
dentists generally cited low payment rates, administrative 
requirements, and patient issues such as frequently missed 
appointments as reasons why they did not treat Medicaid patients. In 
2008, we reported that the situation was largely unchanged. National 
survey data showed dental disease remained a significant problem for 
children in Medicaid--we estimated that 6.5 million children had 
untreated tooth decay and rates of dental disease among children in 
Medicaid had not decreased over time.[Footnote 3] National surveys 
also showed that only one in three children in Medicaid had visited a 
dentist in the prior year, compared to more than half of privately 
insured children. In a 2009 survey of state Medicaid programs, we 
found that identifying a dentist who accepted Medicaid remained the 
most frequently reported barrier to children seeking dental services. 
We also found that, of the 21 states that provided Medicaid dental 
services under managed care arrangements, more than half reported that 
managed care organizations in their states did not meet any, or only 
met some, of the state's dental access standards.[Footnote 4] 

Since 2009, a number of actions have been taken to address these 
challenges. For example, to help families find a dentist to treat 
children covered by Medicaid and CHIP, the Children's Health Insurance 
Program Reauthorization Act of 2009 (CHIPRA) required the Department 
of Health and Human Services (HHS) to post on its Insure Kids Now Web 
site a current and accurate list of dentists participating in state 
Medicaid and CHIP programs.[Footnote 5] In April 2010, HHS launched a 
departmentwide oral health initiative to expand oral health services, 
education, and research, including promoting access to oral health 
care and the effective delivery of services to underserved populations. 

CHIPRA also required that we study and report on various aspects of 
children's access to dental services.[Footnote 6] This report 
discusses (1) the extent to which dentists participate in Medicaid and 
CHIP, and federal efforts to help families find dentists to treat 
children in these programs; (2) what is known about access for 
Medicaid and CHIP children in different states and in managed care; 
(3) federal efforts under way to improve access to dental services by 
children in underserved areas; and (4) how states and other countries 
have used mid-level dental providers to improve children's access to 
dental services. 

To examine the extent to which dentists participate in Medicaid and 
CHIP, and federal efforts to help families find dentists to treat 
children in these programs, we (1) analyzed survey responses from 
states regarding dentists' participation in Medicaid and CHIP, 
gathered by the Association of State and Territorial Dental Directors 
(ASTDD), and (2) evaluated information posted on HHS's Insure Kids Now 
Web site about the dentists participating in Medicaid and CHIP. 
Specifically, we reviewed the information on the Web site for all 50 
states and the District of Columbia to evaluate whether certain data 
elements specified as required in guidance from the Centers for 
Medicare & Medicaid Services (CMS)--the HHS agency that administers 
Medicaid at the federal level--were posted and whether the Web site 
was usable for a family seeking to identify a dentist for a child 
covered by Medicaid or CHIP. We also tested the accuracy of 
information posted to the Web site by calling a nongeneralizeable 
sample of 188 dentists' offices in low-income urban and rural areas in 
4 states.[Footnote 7] We also reviewed relevant academic and 
association research on dental services for children with special 
health care needs. 

To evaluate what is known about access for Medicaid and CHIP children 
in different states and in managed care, we reviewed documents and 
interviewed officials from CMS. We also (1) analyzed survey responses 
from states on the use of dental managed care in Medicaid, gathered by 
the American Dental Association; and (2) examined annual state reports 
on the provision of dental services under the Medicaid Early and 
Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. 
[Footnote 8] 

To identify federal efforts to improve children's access to dental 
services in underserved areas, we focused on two programs administered 
by HHS's Health Resources and Services Administration (HRSA)--the 
Health Center program and the National Health Service Corps (NHSC) 
program--designed, in part, to support the provision of dental 
services in underserved areas. We also examined information regarding 
other recent efforts to improve access to care for children in 
underserved areas, including funding made available by the American 
Recovery and Reinvestment Act of 2009 (Recovery Act) and the Patient 
Protection and Affordable Care Act (PPACA).[Footnote 9] 

To determine how states have used mid-level dental providers to 
improve access to dental services for children, we examined laws, 
regulations, and practices related to mid-level and other dental 
providers and interviewed federal officials as well as officials in 8 
selected states--Alabama, Alaska, California, Colorado, Minnesota, 
Mississippi, Oregon, and Washington--that have varying degrees of 
education, supervision, and scope-of-practice requirements for dental 
providers.[Footnote 10] We selected these states based on responses we 
obtained to a standard set of questions posed to oral health 
researchers, professional associations, and advocacy groups regarding 
states that use mid-level and other dental providers to expand access 
to dental services. We visited Alaska to interview state and tribal 
officials on efforts to expand access for Alaska Natives through the 
use of mid-level dental providers. To determine how other countries 
have used mid-level dental providers to improve access to dental 
services for children, we examined documents and interviewed officials 
from four countries--Australia, Canada, New Zealand, and the United 
Kingdom. See appendix I for additional information on our scope and 
methodology. 

We conducted this performance audit from August 2009 through November 
2010 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

High rates of dental disease and low utilization of dental services by 
children in low-income families and the challenge of finding dentists 
to treat them are long-standing concerns. In 2000, the Surgeon General 
reported that tooth decay is the most common chronic childhood disease 
and described what the report called the silent epidemic of oral 
disease affecting the nation's poor children.[Footnote 11] Left 
untreated, the pain and infections caused by tooth decay may lead to 
problems in eating, speaking, and learning. Tooth decay is almost 
completely preventable and the pain, dysfunction, or on extremely rare 
occasions, even death, resulting from dental disease can be avoided. 
The American Academy of Pediatric Dentistry recommends that each child 
see a dentist when his or her first tooth erupts and no later than the 
child's first birthday, with subsequent visits occurring at 6-month 
intervals or more frequently if recommended by a dentist. 

Recognizing the importance of good oral health, HHS established oral 
health goals as part of its Healthy People 2000 and 2010 initiatives. 
[Footnote 12] One objective of Healthy People 2010 was to increase the 
proportion of low-income children and adolescents under the age of 19 
who receive any preventive dental service in the past year--including 
examination, x-ray, fluoride application, cleaning, or sealant 
application (a plastic material placed on molars to reduce the risk of 
tooth decay)--from 20 percent in 1996 to 66 percent in 2010. 

Federal Programs That Promote Dental Services for Children: 

Medicaid, a joint federal and state program that provides health care 
coverage for certain low-income individuals and families, provided 
health coverage for over 30 million children under 21 in fiscal year 
2008.[Footnote 13] States operate their Medicaid programs within broad 
federal requirements and may contract with managed care organizations 
to provide Medicaid medical and dental benefits. Under federal law, 
state Medicaid programs must provide dental services, including 
diagnostic, preventive, and related treatment services for all 
eligible Medicaid enrollees under age 21 under the program's EPSDT 
benefit. 

Federal law also requires states to report annually on the provision 
of EPSDT services, including dental services, for children in 
Medicaid. The annual EPSDT participation report, Form CMS-416 
(hereafter called the CMS 416), is the agency's primary tool for 
gathering data on the provision of dental services to children in 
state Medicaid programs. It captures data on the number of children 
who received any dental services, a preventive dental service, or a 
dental treatment service each year. Information on the CMS 416 is used 
to calculate a state's dental utilization rate--the percentage of 
children eligible for EPSDT who received any dental service in a given 
year. 

CHIP, which is also a joint federal and state program, expanded health 
coverage to children--approximately 7.7 million children in fiscal 
year 2009--whose families have incomes that are low, but not low 
enough to qualify for Medicaid.[Footnote 14] States can administer 
their CHIP programs as (1) an expansion of their Medicaid programs, 
(2) a stand-alone program, or (3) a combination of Medicaid expansion 
and stand-alone. Although states have flexibility in establishing 
their CHIP benefit package, all states covered some dental services in 
2009, according to CMS officials, though benefits varied. Children in 
CHIP programs that are administered as expansions of Medicaid programs 
are entitled to the same dental services under the EPSDT benefit as 
children in Medicaid. 

CHIPRA expanded federal requirements for state CHIP programs to cover 
dental services. Specifically, CHIPRA required states to cover dental 
services in their CHIP programs beginning in October 2009 and gave 
states authority to use benchmark plans to define the benefit package 
or to supplement children's private health insurance with a dental 
coverage plan financed through CHIP.[Footnote 15] CHIPRA also required 
states to submit annual reports to CMS on the provision of dental and 
other services--similar to information provided by state Medicaid 
programs each year on their CMS 416 reports.[Footnote 16] States were 
previously required to submit annual CHIP reports, although these 
reports did not contain detailed information on the provision of 
dental services as required for Medicaid on the CMS 416. 

To make it easier for families to find dentists to treat children 
covered by Medicaid and CHIP, CHIPRA also required that HHS post "a 
current and accurate list of all such dentists and providers within 
each State that provide dental services to children" under Medicaid or 
CHIP on its Insure Kids Now Web site. CHIPRA required the Secretary of 
HHS to post this list on the Web site by August 4, 2009, and ensure 
that the list is updated at least quarterly.[Footnote 17] In June 
2009, CMS issued guidance specifying certain data elements required 
for each dentist listed on the Insure Kids Now Web site--including the 
dentist's name, address, telephone number, and specialty; whether the 
dentist accepts new Medicaid or CHIP patients; and whether the dentist 
can accommodate patients with special needs. HHS posts listings on the 
Insure Kids Now Web site by state and in some cases provides a link to 
such a list on an individual state's or managed care organization's 
Web site. 

To address the need for health services in underserved areas of the 
country, HHS's HRSA administers programs that support the provision of 
dental and other medical services in underserved areas. For example, 
under HRSA's Health Center program, health centers--which must be 
located in federally designated medically underserved areas or serve a 
federally designated medically underserved population--are required to 
provide pediatric dental screenings and preventive dental services, as 
well as emergency medical referrals, which may also result in the 
provision of dental services.[Footnote 18] Health centers must accept 
Medicaid and CHIP patients and treat everyone regardless of their 
ability to pay. HHS reported that in fiscal year 2009, over 1,100 
health center grantees operated over 7,900 service delivery sites in 
every state and the District of Columbia, and provided health care 
services, including dental services, to approximately 19 million 
patients, about one-third of whom were children. 

Another HRSA program, NHSC, offers scholarships and educational loan 
repayment for clinicians who agree to practice in underserved areas. 
[Footnote 19] NHSC awards scholarships to students entering certain 
health professions training programs, including dentistry, who agree 
to practice in underserved areas when their training is completed. 
NHSC also provides educational loan repayment for health care 
providers, including dentists and dental hygienists, who have 
completed their training and can begin serving in a shortage area. 
HRSA designates geographic areas, population groups, and facilities as 
dental health professional shortage areas (HPSAs) for purposes of 
placing dentists and dental hygienists through the NHSC program. These 
designations are based, in part, on the number of dentists in an area 
compared to the area's population.[Footnote 20] As of July 13, 2010, 
HRSA reported that there were 4,377 dental HPSAs in the United States 
[Footnote 21] and estimated that it would take 7,008 full-time 
equivalent (FTE) dentists to remove these designations.[Footnote 22] 
To be eligible for a NHSC provider, a site must be located in a HPSA 
of greatest shortage and meet other requirements, such as accepting 
Medicaid and CHIP patients and treating everyone regardless of their 
ability to pay.[Footnote 23] Providers can then choose where they wish 
to serve from a list of eligible sites, although providers who have 
received scholarships are limited to a narrower list of higher 
priority vacancies.[Footnote 24] According to HRSA, about half of all 
NHSC providers, which include dentists and hygienists, practice in 
health centers. 

Dental Services and Dental Providers: 

Dental services cover a broad array of specialized procedures, from 
routine exams to complex restorative procedures. For this report, we 
grouped dental services into five main categories: (1) supportive, (2) 
preventive, (3) basic restorative, (4) intermediate restorative, and 
(5) advanced restorative dental procedures (see table 1). 

Table 1: Categories of Dental Services and Examples of Dental 
Procedures: 

Supportive: 
* Preparing a patient to be examined by a dentist; 
* Passing instruments to a dentist. 

Preventive: 
* Examination and assessment; 
* Counseling; 
* Cleaning above and below gum line; 
* Fluoride application; 
* Sealant placement[A]. 

Basic restorative: 
* Temporary fillings; 
* Smoothing an existing restoration; 
* Administration of local anesthetic. 

Intermediate restorative: 
* Tooth preparation (drilling); 
* Tooth restoration (filling); 
* Tooth extractions. 

Advanced restorative: 
* Periodontal treatment (gums); 
* Endodontic treatment (root canals). 

Source: GAO. 

[A] Dental sealants are plastic material that are commonly applied to 
the chewing surfaces of back teeth to reduce the risk of decay. 

[End of table] 

While a provider's specific scope of practice may vary by state, types 
of dental providers who may provide some or all of these services 
include: 

* Dentists, who may perform the full range of dental procedures. 
[Footnote 25] 

* Mid-level dental providers, often dental therapists, who may perform 
preventive, basic restorative, and intermediate restorative dental 
procedures under remote supervision of a licensed dentist. 

* Dental hygienists, who generally perform preventive procedures, such 
as tooth cleaning, oral health education, and fluoride applications, 
as well as basic restorative procedures in certain states, under 
various supervisory agreements with a dentist. 

* Dental assistants, who may provide supportive services and in some 
states certain preventive and basic restorative procedures under on- 
site supervision of a dentist. 

* Primary health care providers (such as physicians and nurse 
practitioners) who may also perform certain preventive dental 
procedures, such as applying fluoride varnish, to children in some 
states. 

Dental therapists, dental hygienists, and dental assistants work under 
various supervisory arrangements with a dentist. The type of 
supervision required for these providers may vary depending upon the 
state and the type of service provided. For this report, we 
categorized dental supervision as on-site, remote with prior knowledge 
and consent, remote with consultative agreement, or no supervision 
(see table 2). 

Table 2: Types of Supervision for Other Dental Providers: 

Supervision type: On-site supervision; 
Description: The dentist must be on-site when the dental provider 
performs services and examines the patient at any point before, 
during, or after the dental services are provided. 

Supervision type: Remote supervision with prior knowledge and consent; 
Description: The dentist may be off-site but must have prior knowledge 
of and consent to the procedures, in some cases through a treatment 
plan. 

Supervision type: Remote supervision with consultative agreement; 
Description: The dentist may be off-site but maintain a consultative 
role, for example through a signed collaborative agreement with 
another type of dental provider. 

Supervision type: No supervision; 
Description: Dental provider may perform services without dentists' 
supervision. 

Source: GAO. 

Note: This table presents examples of the type of supervisory 
arrangements that may exist between dentists and other dental 
providers, such as dental therapists and dental hygienists. 

[End of table] 

For Children in Medicaid and CHIP, Finding a Dentist Remains a 
Challenge, and HHS's Web Site to Help Locate Participating Dentists 
Was Not Always Complete or Accurate: 

States continue to report low participation by dentists in Medicaid 
and CHIP. While HHS's Insure Kids Now Web site--which provides 
information on dentists who serve children enrolled in Medicaid and 
CHIP--has potential to help families find a dentist to treat children 
in these programs, we found problems such as incomplete or inaccurate 
information that limit its ability to do so. 

States Report Low Dentist Participation in Medicaid and CHIP, and 
Children with Special Health Care Needs Face Particular Difficulties: 

While comprehensive nationwide data do not exist, available data 
suggest that problems with low dentist participation in Medicaid and 
CHIP persist. Additionally, among dentists who do participate in 
Medicaid, many may place limits on the number of Medicaid patients 
that they will treat. Most states responding to a 2009 ASTDD 
survey[Footnote 26] reported low participation among dentists, 
although not all states responded completely. Our analysis shows that 
25 of 39 states reported that fewer than half of the dentists in their 
states treated any Medicaid patients during the previous year. 
[Footnote 27] Only one of 41 states reported that more than half of 
the state's dentists saw 100 or more Medicaid patients during the 
previous year (see table 3). Fewer states responding to the 2009 ASTDD 
survey provided data on dentists' participation in CHIP separately 
from data on participation in Medicaid and CHIP expansions, but the 
data reported separately for CHIP indicates that dentists' 
participation in CHIP is also low. 

Table 3: State Reported Data on Dentists' Participation in Medicaid 
and CHIP: 

Level of Dentist Participation in Medicaid or CHIP: States reporting 
more than half of the dentists in the state treat any patients; 
State officials' responses to 2009 Association of State and 
Territorial Dental Directors (ASTDD) survey: Medicaid or CHIP 
expansion[A]: 14 of 39 states (36%); 
State officials' responses to 2009 Association of State and 
Territorial Dental Directors (ASTDD) survey: CHIP only: 4 of 11 states 
(36%). 

Level of Dentist Participation in Medicaid or CHIP: States reporting 
more than half of the dentists in the state treat 100 or more patients; 
State officials' responses to 2009 Association of State and 
Territorial Dental Directors (ASTDD) survey: Medicaid or CHIP 
expansion[A]: 1 of 41 states (2%); 
State officials' responses to 2009 Association of State and 
Territorial Dental Directors (ASTDD) survey: CHIP only: 0 of 12 states 
(0%). 

Source: GAO analysis of ASTDD survey data. 

Note: This table presents data collected by ASTDD in 2009. ASTDD sent 
its survey to dental directors in all states and the District of 
Columbia and received 45 responses. Information collected was for 
fiscal year 2008 (or the most recent available fiscal year). 

[A] States have the option of administering their CHIP programs as 
expansions of their Medicaid programs. 

[End of table] 

The results of the 2009 ASTDD survey indicating low levels of 
dentists' participation in Medicaid are consistent with findings we 
reported in 2000. We reported that 16 of 39 states responding to our 
inquiry indicated that more than half of the dentists in the state 
treated any Medicaid patients in 1999, but that none of the states 
reported that more than half of the dentists treated 100 or more 
Medicaid patients.[Footnote 28] 

One group of children particularly affected by low levels of dentists' 
participation in Medicaid and CHIP are children with special health 
care needs. On its Web site, HRSA's Maternal and Child Health Bureau 
has defined children with special health care needs as "those who have 
or are at increased risk for a chronic physical, developmental, 
behavioral, or emotional condition and who also require health and 
related services of a type or amount beyond that required by children 
generally." According to a March 2009 ASTDD evaluation of 17 state 
oral health programs, the most common barriers to dental services for 
children with special health care needs include low rates of dentists' 
participation in Medicaid and CHIP, difficulty locating dentists who 
accept children with special health care needs who have behavioral 
challenges, and the high cost of specialized care.[Footnote 29] 
Studies have also cited the lack of training for dentists to 
accommodate children who have special treatment needs.[Footnote 30] In 
response to the 2005-2006 National Survey of Children with Special 
Health Care Needs--a periodic survey sponsored by HRSA's Maternal and 
Child Health Bureau and carried out by the Centers for Disease Control 
and Prevention--parents (or guardians) of children with special health 
care needs reported that unmet dental care was the greatest health 
care need for these children and reported problems getting dental care 
at levels that exceeded those of healthy children. Unmet dental care 
for children with special heath care needs can also vary by diagnosis. 
For example, a study based on the 2005-2006 National Survey of 
Children with Special Health Care Needs found that children with 
Down's Syndrome were about twice as likely to have unmet dental needs 
as children with asthma.[Footnote 31] The study also reported that the 
odds of having unmet dental care needs were 13 times greater for low-
income children with more severe special health care needs compared 
with higher-income children without special health care needs. 
[Footnote 32] 

Information on HHS's Web Site to Help Locate Participating Dentists 
Was Not Always Complete or Accurate: 

To help families locate dentists near them to treat children in 
Medicaid or CHIP, CHIPRA required HHS to post information on 
participating dentists on its Insure Kids Now Web site. However, we 
found problems with the data available through the Web site-- 
specifically that the listings available on the Web site or through 
links available from the Web site were not always complete and 
accurate. CHIPRA required HHS to post a current and accurate list of 
dentists participating in Medicaid or CHIP on the Web site by August 
2009 and to ensure that the list is updated at least quarterly. In 
August 2010, officials from CMS--the agency within HHS responsible for 
implementation and that established the data elements that states 
should provide--described the Web site as a "work in progress" and 
reported that they are continually improving the site. Although we 
found that improvements were evident over a 6-month period, problems 
remained. Specifically, we found cases in which information posted on 
the Web site was not complete, not usable, or not accurate. 

* Completeness. Our review of dentist listings for all 50 states and 
the District of Columbia in November 2009, 3 months after CHIPRA 
required HHS to post the list of participating dentists, found a 
variety of problems, including missing or incomplete information on 
dentists' telephone numbers and addresses, whether dentists accepted 
new Medicaid or CHIP patients, and whether dentists could accommodate 
children with special needs. Our second review of dentist listings in 
April 2010 for these data found some improvements had been made, but 
that problems with missing or incomplete information continued for 
some states (see table 4). 

Table 4: Number of States Providing Missing or Incomplete Dentist 
Information through HHS's Insure Kids Now Web Site in November 2009 
and April 2010: 

Required data element missing or incomplete: Medicaid; Missing or 
incomplete contact information (i.e., name, address, telephone number) 
for some or all dentists; 
Number of states: November 2009: 10; 
Number of states: April 2010: 10. 

Required data element missing or incomplete: Medicaid; Did not 
indicate for all dentists whether dentist accepts new patients; 
Number of states: November 2009: 34; 
Number of states: April 2010: 29. 

Required data element missing or incomplete: Medicaid; Did not 
indicate for all dentists whether dentist can accommodate patients 
with special needs; 
Number of states: November 2009: CHIP: 40; 
Number of states: April 2010: CHIP: 37. 

Required data element missing or incomplete: CHIP; Missing or 
incomplete contact information (i.e., name, address, telephone number) 
for some or all dentists; 
Number of states: November 2009: 17; 
Number of states: April 2010: 14. 

Required data element missing or incomplete: CHIP; Did not indicate 
for all dentists whether dentist accepts new patients; 
Number of states: November 2009: 34; 
Number of states: April 2010: 29. 

Required data element missing or incomplete: CHIP; Did not indicate 
for all dentists whether dentist can accommodate patients with special 
needs; 
Number of states: November 2009: 38; 
Number of states: April 2010: 36. 

Source: GAO analysis of HHS's Insure Kids Now Web site for 50 states 
and the District of Columbia. 

Note: This table presents the results of our review of the information 
posted on HHS's Insure Kids Now Web site in November 2009 and April 
2010. Specifically, we examined each state's listing of dentists to 
determine if certain data elements, specified in CMS guidance as 
required, were present for all dentists in all Medicaid and CHIP 
programs operated by the state and recorded instances in which data 
were missing or incomplete for all or some dentists. 

[End of table] 

* Usability. In May 2010, we reviewed all state dentist listings on 
the Insure Kids Now Web site to determine whether families of a child 
in Medicaid or CHIP could reasonably use the site to find potential 
dentists near them and found that listings from 25 states and the 
District of Columbia had usability problems that prevented or hampered 
the search for a dentist participating in Medicaid or CHIP. For 
example, menu or search functions for 14 states did not work for a 
program or entire state--with no indication of when functions would be 
restored or how the user could obtain alternate assistance while it 
was unavailable. Other problems we encountered included broken or 
incorrect links (for example, one state link that took the user to an 
unrelated agency in another state) and confusing menus that could 
hinder the search. For example, seven states listed multiple health 
plans with similar names, some containing typographical errors and 
some that produced different provider listings, increasing the 
likelihood of selecting the wrong plan and generating an incorrect 
list of dentists. 

* Accuracy. To check the accuracy of information on dentists posted on 
the Insure Kids Now Web site, in May 2010 we called the telephone 
number listed for 188 general dentists shown on HHS's Web site as 
practicing in selected low-income urban and rural areas in four 
states[Footnote 33] and found problems in about half (96) of the 
listings we checked, including dentists who were not accepting 
children in Medicaid or CHIP and wrong or disconnected telephone 
numbers (see table 5). We also asked respondents to tell us what the 
typical wait time would be for an appointment with the dentists. Of 92 
dentists we called that reported that they accepted new Medicaid or 
CHIP patients under age 19, all but one reported that the wait time 
was the same for Medicaid or CHIP patients and privately insured 
patients.[Footnote 34] 

Table 5: Errors in Dentist Listings on HHS's Insure Kids Now Web Site, 
May 2010: 

State (number of dentists whose offices we called): California (40); 
Wrong or disconnected telephone number, percentage (number of errors): 
5% (2); 
Errors in other posted information,[A] percentage (number of errors): 
8% (3); 
Not accepting new Medicaid or CHIP children, percentage (number of 
errors): 30% (12). 

State (number of dentists whose offices we called): Georgia (45); 
Wrong or disconnected telephone number, percentage (number of errors): 
4% (2); 
Errors in other posted information,[A] percentage (number of errors): 
38% (17); 
Not accepting new Medicaid or CHIP children, percentage (number of 
errors): 11% (5). 

State (number of dentists whose offices we called): Illinois (56); 
Wrong or disconnected telephone number, percentage (number of errors): 
36% (20); 
Errors in other posted information,[A] percentage (number of errors): 
36% (20); 
Not accepting new Medicaid or CHIP children, percentage (number of 
errors): 4% (2). 

State (number of dentists whose offices we called): Vermont (47); 
Wrong or disconnected telephone number, percentage (number of errors): 
4% (2); 
Errors in other posted information,[A] percentage (number of errors): 
38% (18); 
Not accepting new Medicaid or CHIP children, percentage (number of 
errors): 9% (4). 

Source: GAO analysis. 

Note: In May 2010, we called the telephone number listed on HHS's 
Insure Kids Now Web site for 188 dentists in California, Georgia, 
Illinois, and Vermont--states we selected because they provided 
variation in geography, use of Medicaid dental managed care, and the 
number of children covered by Medicaid. Within each state we 
identified 25 urban dentists and 15 rural dentists to call in the 
areas with the largest number of children in poverty. For a dentist in 
a group practice, a single telephone call could yield additional 
dentists; thus more dentists were called in some states. We accounted 
for each dentist separately, so an error such as a wrong telephone 
number for a dental clinic with multiple dentists would account for 
multiple errors. 

[A] Other errors included incorrect addresses (11) or dentists no 
longer in practice or not providing routine examinations (47). 

[End of table] 

In addition, while CMS issued guidance requiring states to indicate on 
the Web site whether a dentist could treat children with special 
needs, as of August 2010, CMS had not defined what capabilities 
dentists who serve children with special needs should have, and we 
found some confusion among dentists' offices regarding their ability 
to treat these children. For example, several of the dentist offices 
we called indicated they were unsure whether they could serve children 
with special needs, while others indicated that they would try to 
serve them. Of the dentist offices that responded to questions about 
specific capabilities, nearly all (89 of 95) reported that their 
offices were wheelchair accessible, but few (6 of 74) reported that 
they could treat children requiring sedation--although a small number 
indicated that they would refer the patient to another dentist who 
could provide sedation. 

Finally, we identified one dentist shown on a state's Insure Kids Now 
listing of dentists treating children enrolled in Medicaid or CHIP who 
was on HHS's register of excluded providers and should not have been 
allowed to receive reimbursement from either program.[Footnote 35] We 
contacted the dentist's office on May 5, 2010 as part of our review of 
the accuracy of the information posted on the Web site and the 
dentist's office confirmed that the dentist was accepting new Medicaid 
patients. We also contacted the HHS Office of Inspector General (OIG), 
which administers the HHS exclusion program and HHS-OIG officials 
confirmed that the dentist had been excluded from participation in the 
Medicaid program and that the dentist had been reinstated effective 
May 13, 2010.[Footnote 36] 

States Report Improvement in the Provision of Dental Services to 
Children in Medicaid, but Data to Monitor Service Provision under CHIP 
or Managed Care are Limited: 

Although annual state reports on the CMS 416 indicate that the 
provision of dental services to children in Medicaid nationwide had 
improved between 2001 and 2008 (the most recent data available at the 
time of our review), overall utilization rates remained low. In 
addition, data to measure provision of dental services for some 
children, such as those in managed care programs or in CHIP, are 
limited. 

States Report Improvement in the Provision of Dental Services to 
Children in Medicaid between 2001 and 2008, but Utilization Remains 
Low: 

According to data provided by states on annual CMS 416 reports, 
utilization of dental services among children in Medicaid had 
improved, but reported utilization rates still varied among states. 
[Footnote 37] Nationwide, reported utilization of any Medicaid dental 
service increased--from 27 percent of children in federal fiscal year 
2001 to 36 percent of children in federal fiscal year 2008--but 
despite this increase, no dental service utilization was reported for 
nearly two-thirds of Medicaid-enrolled children.[Footnote 38] Overall, 
states also reported a higher proportion of children receiving 
preventive dental services than dental treatment services in both 
years (see figure 1). 

Figure 1: Comparison of Nationwide Medicaid Dental Utilization Rates 
for Dental Services for Children, Fiscal Years 2001 and 2008: 

[Refer to PDF for image: horizontal bar graph] 

Type of dental service: Any dental service; 
2001: 27%; 
2008: 36%. 

Type of dental service: Preventive dental service; 
2001: 22%; 
2008: 32%. 

Type of dental service: Dental treatment service; 
2001: 14%; 
2008: 18%. 

Source: GAO analysis of CMS 416 data. 

Note: This figure represents national dental utilization rates 
calculated from data reported by states in their CMS 416 reports 
submitted for federal fiscal years 2001 and 2008 on the number of 
EPSDT-eligible Medicaid-enrolled children who received a dental 
service during the fiscal year. Children enrolled in CHIP programs 
that are expansions of the states' Medicaid programs are entitled to 
the Medicaid EPSDT benefit package and are included in the states CMS 
416 reports, but are not identified separately as CHIP enrollees. 

[End of figure] 

Although the percentage of children nationwide in Medicaid who 
received any dental service increased, there continued to be wide 
variation among states in the percentage of children reported to have 
received any dental service, including eight states that reported 
dental utilization rates at 30 percent or less in fiscal year 2008 
(see figure 2). There was also wide variation among states in 
utilization rates for preventive and dental treatment services--see 
appendix II for a complete list of the utilization rates for any 
dental service, preventive dental services, and dental treatment 
services reported by states in their fiscal year 2008 CMS 416 reports. 

Figure 2: Percentage of Children in Medicaid Receiving Any Dental 
Service, Fiscal Year 2008: 

[Refer to PDF for image: illustrated U.S. map] 

0-30% (8 states): 
California: 
Florida: 
Missouri: 
Montana: 
Nevada: 
North Dakota: 
Pennsylvania: 
Wisconsin: 

31-40% (26 states): 
Alaska: 
Arizona: 
Arkansas: 
Colorado: 
Connecticut: 
Delaware: 
District of Columbia: 
Illinois: 
Kansas: 
Kentucky: 
Louisiana: 
Maine: 
Maryland: 
Michigan: 
Minnesota: 
Mississippi: 
New Jersey: 
New York: 
Ohio: 
Oklahoma: 
Oregon: 
South Dakota: 
Tennessee: 
Utah: 
Virginia: 
Wyoming: 

41% or more (17 states): 
Alabama: 
Georgia: 
Hawaii: 
Idaho: 
Indiana: 
Iowa: 
Massachusetts: 
Nebraska: 
New Hampshire: 
New Mexico: 
North Carolina: 
Rhode Island: 
South Carolina: 
Texas: 
Vermont: 
Washington: 
West Virginia: 

Source: GAO analysis of CMS Form 416 data; Map Resources (map). 

Note: This figure represents dental utilization rates calculated from 
data reported by states in their fiscal year 2008 CMS 416 reports (the 
most recent available at the time of our review) on the number of 
EPSDT-eligible Medicaid-enrolled children who received any dental 
service during the fiscal year. Nationwide, 36 percent of children in 
Medicaid received any dental service in fiscal year 2008. Children 
enrolled in CHIP programs that are expansions of the states' Medicaid 
programs are entitled to the Medicaid EPSDT benefit package and are 
included in the states' CMS 416 reports, but are not identified 
separately as CHIP enrollees. Dental utilization rates are rounded to 
the nearest whole percentage. 

[End of figure] 

For Children in Managed Care and Children in CHIP, Data on the 
Provision of Dental Services Are Limited: 

Comprehensive and reliable data on dental utilization by children in 
Medicaid managed care programs and children in CHIP are not available. 
States do not distinguish between fee-for-service and managed care 
programs when reporting annual Medicaid data to CMS (using CMS 416). 
[Footnote 39] A comparison of fiscal year 2008 CMS 416 data with 
available data on the proportion of children in Medicaid managed care 
in a given state suggests that children in Medicaid managed care plans 
may have lower dental utilization rates than children in fee-for- 
service programs. Our analysis of 2008 data on Medicaid managed care 
penetration rates from the American Dental Association found that 10 
states provided dental services predominantly through dental managed 
care programs.[Footnote 40] These 10 states reported that 34 percent 
of children covered by Medicaid received any dental service, compared 
to 41 percent of children reported by the 33 states that reimbursed 
exclusively under fee-for-service. 

Questions about the provision of Medicaid dental services under 
managed care compared to fee-for-service payment arrangements are long-
standing. In 2007, we reported that CMS had taken steps to improve the 
CMS 416 data, but that concerns remained about the completeness and 
sufficiency of the data for purposes of overseeing Medicaid dental 
services.[Footnote 41] In particular, we noted that the information 
could not be used to identify problems with specific delivery methods. 
Following our report, CMS officials had considered revising the CMS 
416 to capture services delivered through managed care; however, as of 
August 2010, CMS officials did not have any plans to do so. 

In addition, national data were not available on the provision of CHIP 
dental services, although CMS will require improved reporting per 
CHIPRA in 2011 for dental services provided in 2010. Although states 
must assess the operation of their CHIP programs each federal fiscal 
year and report on the results of this assessment,[Footnote 42] CMS 
had not required states to include specific information on the 
provision of CHIP dental services, such as required for Medicaid 
dental services in the CMS 416. However, beginning in fiscal year 
2010, CHIPRA requires states to include information on CHIP dental 
services of the type contained in the CMS 416 in their annual CHIP 
reports and further requires the inclusion of information on the 
provision of CHIP dental services in managed care programs.[Footnote 
43] According to CMS officials, a CMS work group is developing 
specific reporting requirements for CHIP dental services provided by 
states in fiscal year 2010, with the first reports due to CMS in 2011. 

Federal Efforts to Improve Access to Dental Services for Children in 
Underserved Areas Are Under Way, but Effect Is Not Yet Known: 

Two HHS programs that provide dental services to children as well as 
adults in underserved areas--HRSA's Health Center and NHSC programs-- 
have reported increases in the number of dentists and dental 
hygienists practicing in underserved areas, but the effect of recent 
initiatives to increase federal support for these and other oral 
health programs is not yet known. And despite these increases, some 
gaps may remain. For example, even with recent increases, both health 
centers and the NHSC program report continued need for additional 
dentists and dental hygienists to treat children and adults in 
underserved areas. 

Health Center and NHSC Programs Report Recent Increases in the Number 
of Dentists and Dental Hygienists, but Full Effect of Federal Efforts 
Is Unknown: 

One federal effort to improve access to dental services in underserved 
areas is the Health Center program. To support the expansion of dental 
services in health centers, HRSA reported that it provided grant 
opportunities for health centers to expand oral health services, 
making 312 awards between 2002 and 2009 totaling $56.4 million. The 
number of patients, including children, that HRSA reported as 
receiving dental services in health centers, the number of FTE 
dentists, and the number of FTE dental hygienists providing those 
services all increased by more than one-third between calendar years 
2006 and 2009 (see figure 3).[Footnote 44] In addition to dental 
services required of health centers, such as pediatric dental 
screenings and preventive dental services, HRSA reported a 40 percent 
increase in the number of patients receiving restorative dental 
services over this period.[Footnote 45] Despite these increases, an 
official with the National Association of Community Health Centers 
reported continued need for additional health centers and dental 
providers to practice in them to meet the needs of underserved areas. 
[Footnote 46] 

Figure 3: Number of Dental Hygienists, Dentists, and Dental Patients 
at Health Centers, Calendar Years 2006 through 2009: 

[Refer to PDF for image: vertical bar graph] 

Year: 2006; 
Full-time equivalent (FTE) dental hygienists: 714; 
Full-time equivalent (FTE) dentists: 1,912; 
Total number of dental patients: 2.6 million. 

Year: 2007; 
Full-time equivalent (FTE) dental hygienists: 806; 
Full-time equivalent (FTE) dentists: 2.108; 
Total number of dental patients: 2.8 million. 

Year: 2008; 
Full-time equivalent (FTE) dental hygienists: 892; 
Full-time equivalent (FTE) dentists: 2,299; 
Total number of dental patients: 3.1 million. 

Year: 2009; 
Full-time equivalent (FTE) dental hygienists: 1,018; 
Full-time equivalent (FTE) dentists: 2,577; 
Total number of dental patients: 3.4 million. 

Source: GAO analysis of HRSA data. 

Note: This figure presents information HRSA reported on the number of 
FTE dental hygienists and dentists practicing in health centers for 
each calendar year and the total number of dental patients. HRSA 
reported the exact number of patients receiving dental services as 
follows: 2,577,003 in 2006, 2,808,418 in 2007, 3,071,085 in 2008, and 
3,438,340 in 2009. 

[End of figure] 

Another HHS program reporting an increase in the number of dentists 
and dental hygienists practicing in underserved areas is the NHSC. 
HRSA reported that 611 dentists and 70 dental hygienists were 
practicing in HPSAs through the NHSC scholarship and loan repayment 
programs at the end of fiscal year 2009.[Footnote 47] This was at 
least 30 percent higher than the number of NHSC dentists and dental 
hygienists HRSA reported as practicing in HPSAs through the program at 
the end of the three preceding fiscal years (see figure 4). Despite 
this increase, the NHSC reported vacancies for 673 dentists and 192 
dental hygienists to practice in dental HPSAs in August 2010. 

Figure 4: Number of NHSC Dentists and Dental Hygienists Practicing in 
Shortage Areas, Fiscal Years 2006 through 2009: 

[Refer to PDF for image: stacked vertical bar graph] 

Fiscal year: 2006; 
Dental hygienists: 48; 
Dentists: 474; 
Total: 522. 

Fiscal year: 2007; 
Dental hygienists: 44; 
Dentists: 443; 
Total: 487. 

Fiscal year: 2008; 
Dental hygienists: 36; 
Dentists: 450; 
Total: 486. 

Fiscal year: 2009; 
Dental hygienists: 70; 
Dentists: 611; 
Total: 681. 

Source: GAO analysis of HRSA data. 

Notes: This figure presents information HRSA reported on the number of 
dentists and dental hygienists practicing in shortage areas through 
the NHSC as of the end of each fiscal year. 

[End of figure] 

In 2009, the Recovery Act provided appropriations for both the Health 
Center and NHSC programs, funding activities to improve access to 
services, including dental services for children, in underserved 
areas. For example, according to HRSA, Recovery Act funds were used to 
support NHSC loan repayment awards for 96 of the dentists and 20 of 
the dental hygienists practicing in HPSAs through the NHSC at the end 
of fiscal year 2009[Footnote 48] as well as an additional 382 dentists 
and 105 dental hygienists who received NHSC loan repayment awards in 
fiscal year 2010. HHS also indicated that it used funds made available 
through the Recovery Act to award more than 1,100 grants totaling 
approximately $338 million to health centers to support efforts to 
increase the number of patients served.[Footnote 49] 

Another recent statute--PPACA--authorized and in some cases 
appropriated funding for both the Health Center and NHSC programs. For 
example, in August 2010, HHS announced the availability of $250 
million in grants--from funds made available in PPACA--for new full-
time service delivery sites that provide comprehensive primary and 
preventive health care services, including pediatric dental screenings 
and preventive dental services, for underserved and vulnerable 
populations under the Health Center program. The full effect of PPACA 
funding on children's access to dental services in underserved areas, 
however, remains to be seen. See appendix III for additional 
information on the funding made available to the NHSC and Health 
Center programs through the Recovery Act and PPACA. 

HHS's Oral Health Initiative 2010 and Other HHS Programs May Improve 
Access to Dental Services for Children in Underserved Areas: 

In an effort to increase support for and expand the department's 
emphasis on access to oral health care, including access for 
underserved populations, HHS launched a departmentwide Oral Health 
Initiative in April 2010 to improve the nation's oral health by better 
coordinating federal programs. According to HHS, the initiative is 
intended to improve the effective delivery of services to underserved 
populations by creating and financing programs to emphasize oral 
health promotion and disease prevention, increase access to care, 
enhance the oral health workforce, and eliminate oral health 
disparities.[Footnote 50] The initiative includes two new HHS efforts 
targeted at specific groups of children that, although too early to 
tell, may lead to improved access for children in underserved areas: 

* HHS's Administration for Children and Families has started the Head 
Start Dental Homes Initiative, to establish a national network of 
dental homes for children in Head Start and Early Head Start. The 
Administration for Children and Families Office of Head Start and the 
American Academy of Pediatric Dentistry define a dental home as 
comprehensive, continuously accessible, coordinated, and family- 
centered oral health care delivered to children by a licensed dentist. 

* HHS's Indian Health Service has started the Early Childhood Caries 
Initiative to promote the prevention and early intervention of dental 
caries (tooth decay) for young American Indian and Alaska Native 
children--a population that experiences dental caries at a higher rate 
than the general U.S. population.[Footnote 51] 

In addition to the NHSC and Health Center programs, HHS administers, 
or has authority to administer, a number of other oral health 
programs. Although not all of these programs are targeted specifically 
to children in underserved areas, they may improve their access to 
dental services. Examples of such programs include: (1) the School-
Based Dental Sealant Program, which was authorized by PPACA to expand 
grants for school-based dental sealant programs to all 50 states, 
territories, and Indian tribes and organizations;[Footnote 52] and (2) 
the State Oral Health Workforce Grant program which awards grants to 
states to address workforce issues, including those associated with 
dental HPSAs. See appendix IV for a list of these and other HHS 
programs that may improve access to dental services in underserved 
areas. 

Use of Mid-Level Dental Providers Is Not Widespread in the United 
States, and Other Countries Have Used Them to Improve Children's 
Access to Dental Services: 

Mid-level dental providers--providers who can perform intermediate 
restorative procedures, such as drilling and filling a tooth, under 
remote supervision of a licensed dentist--are not widely licensed or 
certified to practice in the United States. Other countries, which 
have used mid-level dental providers for many years, reported that 
these providers deliver quality care and increase children's access to 
dental services. 

Efforts Are Under Way to Use Mid-Level and Other Dental Providers to 
Improve Children's Access to Dental Services: 

Within the United States, experience with mid-level dental providers 
is limited to the Dental Health Aide Therapist program for Alaska 
Natives and the advanced dental therapy program in Minnesota.[Footnote 
53] Efforts are under way to increase access to dental services 
through the use of dental therapists, dental hygienists, physicians, 
and other new dental provider models. 

Dental Health Aide Therapist Program for Alaska Natives: 

The Dental Health Aide Therapist program in Alaska, the only mid-level 
dental provider program with providers practicing in the United States 
as of July 2010, began in 2003 in response to the extensive dental 
health needs of Alaska Natives and high dentist vacancy rates in rural 
Alaska.[Footnote 54] Dental health aide therapists (dental therapists) 
in Alaska are not licensed by the state; rather the program is 
authorized under the federal Community Health Aide Program for Alaska 
Natives. The 2-year training program is based on a long-standing 
dental therapy program in New Zealand. After completion of their 
training and preceptorship, dental therapists become certified and 
practice in their assigned villages under the remote consultative 
supervision of a dentist.[Footnote 55] Services performed by dental 
therapists may include assessments and basic and intermediate 
restorative procedures. As of June 2010, 19 dental therapists were 
serving in rural Alaska native villages or completing their 
preceptorship with a supervising dentist. 

Children are an important focus of the Dental Health Aide Therapist 
program. According to an official from the Alaska Native Tribal Health 
Consortium, about half of the patients seen by dental therapists under 
this program are children. For example, between 2006 and 2009, 
approximately 59 percent of encounters for one dental therapist were 
with children under 18 years old. Consortium officials also noted that 
Medicaid is a major payer for dental therapist services, indicating 
that dental therapists provide a substantial portion of their services 
to children under Medicaid.[Footnote 56] Although limited research 
regarding the impact of this program has been completed, a 2008 study 
examining the quality of restorative procedures performed by dental 
therapists found that procedures provided by dental therapists do not 
differ from similar procedures performed by dentists.[Footnote 57] In 
addition, in October 2010, a study of the Dental Health Aide Therapist 
program found that the five dental therapists who were included in the 
study performed well, operated safely, and were technically competent 
to perform procedures within their defined scope of practice. The 
study also noted that the patients of the dental therapists were 
generally very satisfied with the care they received from those 
therapists. The study assessed the quality of services and procedures 
provided by dental therapists using various methods including patient 
and oral health surveys, observations of clinical technical 
performance, medical chart audits, and facility evaluations.[Footnote 
58] See appendix V for more information on the Dental Health Aide 
Therapist program in Alaska. 

Minnesota's Advanced Dental Therapist Program: 

In 2009, Minnesota authorized the certification of the advanced dental 
therapist and dental therapist positions to provide dental services to 
low-income, uninsured, and underserved patients.[Footnote 59] Advanced 
dental therapists are licensed dental therapists who, upon completion 
of additional education and experience, may become certified to 
perform a range of preventive, and basic and intermediate restorative 
procedures--including drilling and filling and non-surgical 
extractions of permanent teeth--under the remote consultative 
supervision of a dentist. They may also develop patient treatment 
plans with authorization by a consulting dentist.[Footnote 60] 

Advanced dental therapy training is offered by Metropolitan State 
University as a master's degree program which prepares students with 
an existing dental hygiene license for licensure as a dental therapist 
and certification as an advanced dental therapist upon completion of 
2,000 hours of dental therapy practice.[Footnote 61] As of June 2010, 
certification requirements for advanced dental therapists had not yet 
been finalized, and there were no practicing advanced dental 
therapists. State officials anticipated that the first advanced dental 
therapists will graduate in 2011. Once licensed, advanced dental 
therapists are required to enter into consultative agreements--which 
outline any restrictions to their scope of practice--with licensed 
dentists to whom they will refer patients for services beyond their 
scope of practice.[Footnote 62] Minnesota health officials anticipated 
that advanced dental therapists will be eligible to receive direct 
Medicaid and CHIP reimbursement, but payment arrangements had not been 
finalized as of June 2010. 

Use of Dental Hygienists and Physicians in Selected States: 

Certain states have made efforts to increase children's access to 
dental services by allowing dental hygienists and primary care 
physicians to provide certain dental services without the on-site 
supervision of a dentist. In seven of the eight states we examined-- 
Alaska, California, Colorado, Minnesota, Mississippi, Oregon, and 
Washington--dental hygienists may perform certain procedures, such as 
fluoride application, under remote or no supervision of a dentist; in 
some cases specifically to increase access for underserved 
populations.[Footnote 63] For example, dental hygienists in 
California, Minnesota, Mississippi, Oregon, and Washington may 
practice in limited settings outside the private dental office under 
remote or no supervision of a dentist, increasing access to dental 
services for underserved populations, including children. Such 
practices are generally limited to settings such as schools or 
residential facilities and, in most cases, allow hygienists to provide 
only preventive services upon completion of additional training or 
clinical experience. Dental hygienists in these states increase the 
available locations for individuals to access certain preventive 
dental procedures. In addition, five of the eight states we studied--
California, Colorado, Minnesota, Oregon, and Washington--reported that 
they allow direct Medicaid and in some cases CHIP reimbursement to 
certain dental hygienists for providing some preventive dental 
services.[Footnote 64] See appendix VI for additional information on 
the scope of practice and requirements for dental therapists, dental 
hygienists, and dental assistants in the eight states we examined. 

In addition, many states have also engaged primary care medical 
providers--such as physicians--in the provision of children's dental 
services. A survey conducted in 2009 indicated that 34 state Medicaid 
programs reimburse primary care medical providers for providing 
preventive dental procedures, such as fluoride application, and this 
represents an increase of nine states from a similar study conducted 
in 2008.[Footnote 65] To track the provision of dental services by 
physicians and dental hygienists to children covered by Medicaid, CMS 
officials reported that they are in the process of revising the CMS 
416 to collect information on the number of children receiving dental 
services--such as sealants and oral assessments--from these providers 
and expect states will use the revised forms in 2011. 

Efforts to Train or Employ New Dental Providers: 

In addition to state initiatives, PPACA authorized demonstration 
projects to train or employ certain dental providers. In March 2010, 
PPACA authorized $60 million to fund 15 demonstration projects to 
train or to employ "alternative dental health care providers" to 
increase access to dental services in rural and other underserved 
communities. PPACA defines alternative dental health care providers to 
include dental therapists, independent dental hygienists, advanced 
practice dental hygienists, primary care physicians, and any other 
health professionals that HHS determines appropriate.[Footnote 66] 
Entities eligible to apply for the demonstration grants include 
colleges, public-private partnerships, federally qualified health 
centers, Indian Health Service facilities, state or county public 
health clinics, and public hospital or health systems. 

Two professional organizations have also proposed new dental provider 
models to increase children's access to dental services. 

* The American Dental Association developed the position of a 
community dental health coordinator as a new type of dental provider 
who may provide oral health education as well as some preventive 
services (depending on the state dental practice laws) under the 
supervision of a dentist in communities with little access to dental 
care. The association has begun a community dental health coordinator 
pilot training program, and as of July 2010, there were 27 students in 
three locations in California, Oklahoma, and Pennsylvania. The 
training includes a 12-month online training program through Rio 
Salado College and a 6-month clinical internship.[Footnote 67] 
Officials from the American Dental Association told us they plan to 
train 18 additional community dental health coordinators by September 
2012, and they anticipated all of these providers will serve in their 
home communities after the training program. The American Dental 
Association is currently designing an evaluation of the program to be 
completed in 2013, one year after the pilot training program ends in 
2012. 

* The American Dental Hygienists' Association developed and proposed 
the advanced dental hygiene practitioner as a mid-level dental 
provider to work independently in a variety of settings to provide 
preventive and certain basic and intermediate restorative services--
including procedures such as drilling and filling a tooth--to 
underserved populations. The model is similar to the advanced dental 
therapist position in Minnesota and proposes a master's degree 
curriculum that builds upon existing dental hygiene education 
programs.[Footnote 68] 

Other Countries Have Used Mid-Level Dental Providers to Improve Access 
to Dental Services: 

Mid-level dental providers--dental therapists--have been used by many 
countries to improve access to preventive and restorative dental 
services. In particular, New Zealand, the United Kingdom, Australia, 
and Canada have long-standing dental therapist programs.[Footnote 69] 
These countries have used dental therapists to staff school-and 
community-based dental programs aimed at improving access to dental 
services for children and other underserved populations, such as those 
in rural areas (see table 6).[Footnote 70] Since the mid-1990s, three 
of the four countries--New Zealand, the United Kingdom, and Australia--
have combined their dental therapy and dental hygiene training 
programs.[Footnote 71] 

Table 6: Characteristics of Mid-Level Dental Providers in New Zealand, 
the United Kingdom, Australia, and Canada: 

Country (year program started): Type of mid-level dental provider[A]: 
New Zealand (1921); Dental therapist/Oral health therapist; 
Scope of practice: 
* Preventive; 
* Restorative (basic and intermediate); 
Supervision: Remote: consultative; 
Years of post secondary education[A]: 3; 
Number licensed or practicing (year): 730 (2009). 

Country (year program started): Type of mid-level dental provider[A]: 
United Kingdom (1959); Dental therapist/Oral health therapist; 
Scope of practice: 
* Preventive; 
* Restorative (basic and intermediate); 
Supervision: Remote: prior knowledge and consent; 
Years of post secondary education[A]: 3; 
Number licensed or practicing (year): 1,480 (2010). 

Country (year program started): Type of mid-level dental provider[A]: 
Australia[B] (1966); Dental therapist/Oral health therapist; 
Scope of practice: 
* Preventive; 
* Restorative (basic and intermediate); 
Supervision: Remote: consultative; 
Years of post secondary education[A]: 3; 
Number licensed or practicing (year): 1,760 (2005). 

Country (year program started): Type of mid-level dental provider[A]: 
Canada (1972); Dental therapist; 
Scope of practice: 
* Preventive; 
* Restorative (basic and intermediate); 
Supervision: Remote: prior knowledge and consent; 
Years of post secondary education[A]: 2; 
Number licensed or practicing (year): 310[C](2010). 

Source: GAO analysis. 

Note: In these countries, most dental therapists are paid through the 
government as salaried employees. However, some work in private 
practice and are then paid by their employers. The information in this 
table was obtained from interviews with health officials in the four 
countries, professional organizations, government reports, and 
published research. We did not conduct an independent review of the 
legal authorities for this information. 

[A] Since the mid-1990s, Australia, the United Kingdom, and New 
Zealand have combined their dental therapy and dental hygiene programs 
with many offered as a bachelor's degree. The required education for 
the combined degree is between 2 and 3 years and graduates are trained 
in both scopes of practice. 

[B] Until July 2010, dental therapy registration differed among 
Australia's states with three states allowing dental therapists to 
provide services to adults. Australia implemented a national 
registration scheme in July 2010 that will require all states to have 
the same scope of practice. 

[C] Approximately three-quarters of dental therapists (230 of 310) in 
Canada practice in Saskatchewan, the only province where they are 
registered providers and able to work in private practice. 

[End of table] 

Dental therapists in the four countries, including those trained in 
combined oral health therapy programs, can perform preventive and 
basic and intermediate restorative procedures for children and adults 
without the on-site supervision of a dentist in both the public and 
private sectors. New Zealand, Australia, and Canada also permit dental 
therapists to determine patient treatment plans providing they 
maintain a relationship with a dentist where they can refer patients 
for services beyond their scope of practice. See appendix VII for more 
information on the use of dental therapists in these countries. 

Health officials from the four countries expressed no reservations 
about the quality of care provided by dental therapists. Although 
recent data on the quality of services provided by dental therapists 
in these countries are limited, a study published in 2009 on 
Australian dental therapists reported that the standard of restorative 
procedures performed by dental therapists was comparable to the 
standard expected of newly graduated dentists in that country. 
[Footnote 72] 

Health officials from New Zealand, Australia, and Canada reported that 
the majority of dental therapists' patients are children and available 
research found that dental therapists providing care in school-or 
community-based programs were an important part of improving dental 
outcomes for children.[Footnote 73] For example, a health official 
from New Zealand--where dental therapists provide dental services in 
school-based clinics--told us that nearly all children aged 5 to 12 
(96 percent) were enrolled in the nation's publicly funded school-
based dental program in 2009. The program aims to see all enrolled 
children annually (or more frequently in high-risk cases) and the 
official told us that available data indicated that decay rates are 
reduced for these children. A New Zealand national oral health survey, 
planned for publication in December 2010, was expected to provide a 
clearer picture of children's oral health status across the 
population. In addition, one academic dental therapy official told us 
that in 2010 between 40 and 70 percent of Australian children, 
depending on the state, obtained dental services through publicly 
funded school-based dental programs primarily staffed by dental 
therapists. A 2008 study in Australia found that, from 1977 to 2002, 
the number of decayed, missing, and filled teeth declined 37 percent 
for primary teeth in 6-year old children and 79 percent for permanent 
teeth in 12-year old children enrolled in school-based programs. 
[Footnote 74] A Canadian health official reported that dental 
therapists serving aboriginal children in rural provinces and 
territories since the 1970s have often been the only reliable source 
of dental care for those children, in part because dentists are 
difficult to retain in rural areas. In the Canadian province of 
Saskatchewan, research on the impact of the province's school-based 
dental program estimated that the program served over 80 percent of 
non-aboriginal children in the province from 1976 to 1980 and that 
lower incidence of dental caries could be demonstrated with increased 
exposure to the program.[Footnote 75] An official from the 
Saskatchewan Dental Therapists Association--the dental therapy 
regulating authority in the province--also reported that dental 
therapists working in private practice in the province increase 
children's access to dental services because they can provide 
restorative services and free time for dentists to see more patients. 
Since 2004, Canada has piloted and expanded the use of dental 
therapists to provide preventive and restorative services to 
aboriginal children in a community-based dental program. As of May 
2010, Canadian health officials were completing an evaluation of the 
program, which they expected to show improved dental outcomes. 

Conclusions: 

In the decade that has passed since the Surgeon General described the 
silent epidemic of oral disease affecting children in low-income 
families, dental disease and access to dental services have remained a 
significant problem for these children--including those in Medicaid 
and CHIP. States report that nationwide, only 36 percent of children 
in Medicaid received any dental service in fiscal year 2008, far below 
HHS's Healthy People 2010 target of 66 percent for low-income 
children. States also continue to report low participation by dentists 
in Medicaid and CHIP. Recognizing this challenge, HHS has taken a 
number of steps to strengthen its dental programs, including its HHS 
Oral Health Initiative 2010, and recent legislation has authorized and 
in some cases appropriated funding specifically for programs that may 
help increase access to dental services in underserved areas; but 
results of these efforts are yet to be seen. And while states report 
some improvement in the provision of Medicaid dental services between 
2001 and 2008, CMS has not yet collected comprehensive data on 
utilization of dental services for children in Medicaid managed care 
programs and covered by CHIP. We have reported in the past that such 
gaps limit CMS's oversight of the provision of dental services for 
children, such as its ability to identify problems with specific 
service delivery methods. 

Providing complete and accurate information to help families with 
children in the Medicaid and CHIP programs find dental care is an 
important tool in improving access. The information that HHS is 
required to post on its Insure Kids Now Web site could provide a 
useful tool for connecting these children and their families with 
dentists who will treat them. However, we found problems that limit 
its ability to do so, such as incorrect, outdated, or incomplete 
information; links to state Web sites that were not working; and even 
a dentist taking Medicaid patients who had been excluded by HHS from 
participation in the program. Addressing these problems--such as 
providing alternative sources of information to assist users when the 
Web site is not functioning or taken offline for maintenance, or 
providing additional guidance on dentists' ability to serve children 
with special needs--could help make the site more useful to 
beneficiaries. 

Recommendations for Executive Action: 

We are making several recommendations to enhance the provision of 
dental care to children covered by Medicaid and CHIP. 

First, to help ensure that HHS's Insure Kids Now Web site is a useful 
tool to help connect children covered by Medicaid and CHIP with 
participating dentists who will treat them, we recommend that the 
Secretary of HHS take the following actions: 

* Establish a process to periodically verify that the dentist lists 
posted by states on the Insure Kids Now Web site are complete, usable, 
and accurate, and ensure that states and participating dentists have a 
common understanding of what it means for a dentist to indicate he or 
she can treat children with special needs. 

* Provide alternate sources of information, such as HHS's toll-free 1- 
877-KIDS-NOW telephone number, on the Insure Kids Now Web site when a 
page or link from the Web site is not functioning or taken offline for 
maintenance. 

* Require states to verify that dentists listed on the Insure Kids Now 
Web site have not been excluded from Medicaid and CHIP by the HHS-OIG, 
and periodically verify that excluded providers are not included on 
the lists posted by the states. 

Second, to strengthen CMS oversight of Medicaid and CHIP dental 
services provided by dental managed care programs, we recommend that 
the Administrator of CMS take steps to ensure that states gather 
comprehensive and reliable data on the provision of Medicaid and CHIP 
dental services by managed care programs. 

Agency Comments: 

We provided a draft of this report for comment to HHS. HHS agreed with 
our recommendations and provided written comments, which we summarize 
below. The text of HHS's letter--which included comments from CMS, 
HRSA, and CDC--is reprinted in appendix VIII. HHS also provided 
technical comments, which we incorporated as appropriate. 

In commenting on our recommendation that steps should be taken to 
improve the Insure Kids Now Web site, CMS and HRSA concurred that more 
attention needs to be devoted to improve the accuracy of information 
submitted by the states. To that end, CMS and HRSA commented that they 
will undertake several actions: 

* To address errors on the site, CMS stated that the agency will 
increase the type and frequency of checks performed and work with 
states to ensure that they submit data that are free of the types of 
problems we identified. HRSA commented that it will work with CMS to 
develop a plan to periodically analyze a sample of data provided by 
states to assess its accuracy. 

* To ensure that providers that HHS has excluded from Medicaid and 
CHIP are not listed on the site, CMS commented that it will ensure 
states are aware that such providers must not be included in the data, 
and HRSA reported that it plans to cross-check listed providers 
against the HHS-OIG's database of excluded parties. 

* CMS commented that it will ensure that there is a consistent 
understanding of what it means to be identified on the site as a 
dentist serving children with special needs. 

CMS agreed with our recommendation that the agency take steps to 
ensure that states gather comprehensive and reliable data on the 
provision of Medicaid and CHIP dental services by managed care 
programs, noting that the agency is in the process of revising the CMS 
416 to include more information about dental services provided to 
children in state Medicaid programs, including under managed care 
payment arrangements. CMS's comments do not specify whether the agency 
will require states to separately report utilization under managed 
care for children in Medicaid or CHIP, a step that we believe is 
necessary for effective oversight. 

In addition, CDC commented that a statement in the introduction of our 
report regarding the prevalence of tooth decay and dental disease in 
children may be misleading. Although our statement accurately reflects 
information that we previously reported, we revised the language to 
clarify that the results of our analysis specifically refer to 
children enrolled in Medicaid. 

We are sending copies of this report to the Secretary of Health and 
Human Services and other interested parties. In addition, the report 
will be available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions regarding this report, please 
contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix IX. 

Signed by: 

Katherine Iritani: 
Acting Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

To address the objectives in our review--to examine (1) the extent to 
which dentists participate in Medicaid and the Children's Health 
Insurance Program (CHIP) and federal efforts to help families find 
dentists to treat children in these programs, (2) what is known about 
access for Medicaid and CHIP children in different states and in 
managed care, (3) federal efforts under way to improve access to 
dental services by children in underserved areas, and (4) how states 
and other countries have used mid-level dental providers to improve 
children's access to dental services--we interviewed appropriate 
officials from the Department of Health and Human Services (HHS), 
academic institutions, professional associations, states, and dental 
and children's advocacy groups; reviewed federal and state laws and 
regulations; obtained, reviewed, and determined the reliability of 
data; and reviewed relevant literature. 

Specifically, to determine the extent to which dentists participate in 
Medicaid and CHIP and federal efforts to help families find dentists 
to treat children in these programs, we: 

* Analyzed state reported data on the number of dentists in a state 
treating Medicaid and CHIP patients, including data from the 2009 
Association of State and Territorial Dental Directors (ASTDD) 
survey[Footnote 76] and one of our prior reports.[Footnote 77] 

* Reviewed articles in peer-reviewed journals and reports on access to 
dental services by children with special health care needs. 

* Examined states' dentist listings on HHS's Insure Kids Now Web site, 
including whether listings were complete, usable, and accurate: 

Completeness: To examine the completeness of the information on the 
Web site, we conducted two reviews--in November 2009 and in April 
2010--to determine whether information CMS guidance had identified as 
required elements were present. We examined each state's listing of 
dentists to determine if certain elements listed as required in the 
Centers for Medicare & Medicaid Services' (CMS) June 2009 guidance 
were present for all dentists in all Medicaid and CHIP programs 
operated by the state (states can have multiple dental plans within 
Medicaid and CHIP) and recorded instances in which data were missing 
or incomplete for all or some dentists. Specifically, we examined each 
state's listing for the presence of dentists' names, addresses, phone 
numbers, and specialties; whether they accepted new Medicaid or CHIP 
patients; and whether they could accommodate children with special 
needs.[Footnote 78] 

Usability: In May 2010, we conducted a review of the information 
available on the Insure Kids Now Web site for each of the 50 states 
and the District of Columbia. The purpose of this review was to 
determine whether families seeking a dentist to treat a child covered 
by Medicaid or CHIP could reasonably complete the task and, if not, 
what types of errors prevented the site from being usable, such as 
whether hyperlinks functioned as expected and linked pages contained 
appropriate information. We tested the drop-down menus on the Web site 
for the Medicaid and CHIP programs in each state, conducted a general 
search of dentists for each program, and searched for dentists in each 
state's capital city and in the District of Columbia. 

Accuracy: To check the accuracy of information on dentists posted on 
the Insure Kids Now Web site, we selected a nongeneralizable sample of 
dentists listed on the Web site for four states (California, Georgia, 
Illinois, and Vermont) that provided variation in geography, managed 
care penetration for Medicaid (as reported by the American Dental 
Association), and number of children covered by Medicaid. We selected 
25 urban dentists and 15 rural dentists listed on the Insure Kids Now 
Web site in each state. For urban dentists, we identified the urban 
county with the most children in poverty, the largest city in that 
county, and then the zip code within that city with the most children 
in poverty. We then searched for general dentists nearest to the 
selected zip code.[Footnote 79] For rural dentists, we selected 
general dentists in the rural counties with the most children in 
poverty, excluding rural counties adjacent to major metropolitan 
areas. We limited our searches to dentists listed as accepting new 
Medicaid and CHIP patients. We used U.S. Census data and an 
urban/rural classification system developed by the U.S. Department of 
Agriculture (called Rural-Urban Continuum Codes) to identify the areas 
from which we selected dentists. In May 2010, we called the telephone 
number listed for the selected dentists and asked the person 
scheduling appointments if the listed dentist currently accepted new 
patients, including new patients enrolled in the state's Medicaid and 
CHIP programs. We also asked whether the dentist accommodated children 
with special health care needs--generally, and specifically with 
regard to wheelchair access and ability to treat children requiring 
sedation. Finally, we asked if the listed address was accurate and 
inquired about the next available appointment time. In the course of 
making calls we contacted more than 40 dentists in some states because 
some offices had multiple dentists listed on the Web site, resulting 
in a total of 188 dentists included in our calls. 

* Reviewed the literature, including our past reports and peer-
reviewed journals, on factors that impact dentists' decisions to 
participate in Medicaid and states' efforts to address barriers to 
dentists' participation. 

To examine what is known about access for children in Medicaid and 
CHIP in different states, including for children in managed care, we 
examined dental utilization data on children covered by Medicaid, 
including those covered under Medicaid expansion programs, reported by 
states to CMS through the annual CMS 416 form. For each state and 
nationally, we calculated utilization rates reported for any dental 
service, preventive dental services, and dental treatment services. We 
calculated utilization rates for federal fiscal year 2001, the year 
after our first report on oral health, and federal fiscal year 2008, 
the most recent year for which data were available. In addition, we 
compared children's utilization of any dental service to data reported 
by the American Dental Association on the proportion of children in 
each state who receive their Medicaid dental benefits through managed 
care. 

To identify federal efforts under way to improve access to dental 
services by children in underserved areas we interviewed cognizant HHS 
officials, including those from CMS and the Health Resources and 
Services Administration (HRSA), and obtained written responses from 
agency officials to specific questions about relevant programs. We 
obtained data on health center and National Health Service Corps 
(NHSC) dental provider numbers and HHS program funding levels from HHS 
officials and documents such as annual HRSA budget justifications. We 
also reviewed provisions in the Recovery Act and the Patient 
Protection and Affordable Care Act (PPACA) legislation and interviewed 
HHS officials to discuss legislative changes and funding authorized 
and in some cases appropriated for programs that promote dental 
services in underserved areas. 

To determine how states and other countries have used mid-level dental 
providers to improve dental access for children, we examined laws, 
regulations, and practices in eight states and interviewed or obtained 
written responses from relevant officials in those eight states and 
four countries. To select those eight states for review, we used a 
standard set of questions posed to relevant officials from academic 
institutions, professional associations, and advocacy groups regarding 
states' dental practice laws, including practice of mid-level dental 
providers. Using the standard set of questions, we obtained responses 
on those states considered "expansive" and those considered 
"restrictive" in their laws governing the practice of dental 
providers. We assessed the responses and, to demonstrate the variation 
in state laws, selected eight states--Alabama, Alaska, California, 
Colorado, Minnesota, Mississippi, Oregon, and Washington. To obtain 
information on the selected states' use of dental providers other than 
dentists, we conducted interviews and obtained information from 
Medicaid and CHIP officials and dental boards in the selected states. 
Our interviews with officials revealed that there is no commonly 
recognized definition of mid-level dental providers, therefore we 
defined mid-level dental providers as providers who may perform 
intermediate restorative procedures, such as drilling and filling a 
tooth, under the remote supervision of a dentist. In addition, we 
defined scope of practice for the purposes of this report based on 
interviews and review of literature and state laws. To gather 
information on the only practicing mid-level dental providers in the 
United States, we conducted a site visit to Alaska. We interviewed 
state and tribal officials on the Alaska Dental Health Aide Therapist 
program administered by the Alaska Native Tribal Health Consortium and 
visited two clinics where dental therapists were training and 
practicing. To identify efforts related to new dental provider models, 
we reviewed policies and proposals by professional associations and 
interviewed officials from academic institutions, professional 
associations, HHS, and our selected states. To select countries for 
further review, we identified four countries that use mid-level 
providers, specifically dental therapists, and are comparable to the 
United States (identified as developed countries by the CIA World 
Factbook[Footnote 80] and with a similar percentage of children living 
in households with incomes below: 

50 percent of their country's median income). The four countries 
examined were Australia, Canada, New Zealand, and the United Kingdom. 
To obtain information on the selected countries' use of mid-level 
dental providers, we conducted a literature review and interviewed 
oral health experts and government health officials in each country. 
[Footnote 81] 

To verify the reliability of the data we used for all four objectives, 
including HRSA's health center data, ASTDD survey data, the American 
Dental Association's Medicaid managed care data, U.S. Census data, the 
U.S. Department of Agriculture's Rural-Urban Continuum Codes, the CMS 
416 annual reports, and Alaska Dental Health Aide Therapist encounter 
data, we interviewed knowledgeable officials, reviewed relevant 
documentation, and compared the results of our analysis to published 
data, as appropriate. We determined that the data were sufficiently 
reliable for the purposes of our engagement. 

We conducted this performance audit from August 2009 through November 
2010 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Medicaid Dental Utilization Rates for Fiscal Year 2008: 

States report annually to the Centers for Medicare & Medicaid Services 
(CMS) on the provision of certain covered services, including dental 
services. Specifically, services covered under Medicaid's Early and 
Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit are 
reported by states on an annual participation report, CMS 416. It 
captures data on the number of children who received any dental 
service, preventive dental service, or dental treatment service each 
year. We used this information to calculate state and national dental 
utilization rates--that is, the percentage of children eligible for 
EPSDT that received services in a given year (see table 7). 

Table 7: Utilization of Any Dental Service, Preventive Dental Service, 
and Dental Treatment Service by Children in Medicaid, Ranked in Order, 
Fiscal Year 2008: 

Any dental service utilization, by state: 
Idaho: 56.1%; 
Vermont: 51.1%; 
Texas 48.5%; 
New Hampshire: 46.6%; 
Nebraska: 45.9%; 
Rhode Island: 45.8%; 
Iowa: 45.8%; 
South Carolina: 45.0%; 
Washington: 45.0%; 
Massachusetts: 44.0%; 
North Carolina: 43.8%; 
New Mexico: 42.9%; 
Hawaii: 42.1%; 
West Virginia: 41.7%; 
Georgia: 41.7%; 
Alabama: 41.6%; 
Indiana: 40.8%; 
Oklahoma 39.2%; 
Kansas: 38.9%; 
Arizona: 38.8%; 
Colorado: 38.5%; 
Mississippi: 38.5%; 
Virginia: 38.4%; 
South Dakota: 38.4%; 
Illinois: 38.4%; 
Kentucky: 38.1%; 
Alaska: 38.0%; 
Tennessee: 37.6%; 
Maryland: 37.2%; 
Connecticut: 36.7%; 
Minnesota: 36.7%; 
Wyoming: 36.5%; 
Ohio: 36.4%; 
Maine: 36.2%; 
Utah: 35.0%; 
District of Columbia: 34.0%; 
Arkansas: 33.6%; 
Delaware: 33.4%; 
New Jersey: 32.9%; 
Oregon: 32.8%; 
Louisiana: 32.5%; 
Michigan: 32.4%; 
New York: 32.1%; 
California: 30.2%; 
Nevada: 29.8%; 
North Dakota: 29.1%; 
Pennsylvania: 26.9%; 
Montana: 25.6%; 
Missouri: 24.7%; 
Wisconsin: 24.1%; 
Florida: 20.9%; 
Nationwide: 36.2%. 

Preventive dental services utilization: 
Vermont: 49.9%; 
Idaho: 46.0%; 
Rhode Island: 43.1%; 
New Hampshire: 42.5%; 
South Carolina: 42.4%; 
Nebraska: 41.6%; 
Texas: 41.6%; 
Washington: 41.4%; 
Massachusetts: 40.3%; 
North Carolina: 39.9%; 
Iowa: 39.4%; 
Georgia: 38.5%; 
Alabama: 38.4%; 
New Mexico: 38.2%; 
Indiana: 37.1%; 
Hawaii: 36.9%; 
Oklahoma: 36.5%; 
West Virginia: 36.0%; 
Kansas: 35.9%; 
Illinois: 35.4%; 
Virginia: 35.2%; 
South Dakota: 34.6%; 
Utah: 34.1%; 
Maine: 33.9%; 
Tennessee: 33.7%; 
Colorado: 33.5%; 
Arizona: 33.5%; 
Minnesota: 32.7%; 
Wyoming: 32.0%; 
Ohio: 31.7%; 
Mississippi: 31.7%; 
Kentucky: 31.6%; 
Michigan: 31.6%; 
Maryland: 31.6%; 
Arkansas: 31.4%; 
Alaska: 31.4%; 
Connecticut: 30.3%; 
Delaware: 30.1%; 
District of Columbia: 29.0%; 
Louisiana: 28.0%; 
New Jersey: 27.8%; 
New York: 27.6%; 
Oregon: 27.6%; 
Nevada: 25.0%; 
California: 24.5%; 
North Dakota: 23.8%; 
Pennsylvania: 22.3%; 
Montana: 22.1%; 
Missouri: 21.9%; 
Wisconsin: 21.0%; 
Florida: 13.8%; 
Nationwide: 31.5%; 

Dental treatment services utilization: 

New Mexico: 42.1%; 
West Virginia: 41.5%; 
Idaho: 30.4%; 
Arkansas: 29.9%; 
Hawaii: 26.1%; 
Massachusetts: 25.1%; 
Maine: 25.1%; 
Texas: 25.0%; 
South Carolina: 22.1%; 
Nebraska: 21.8%; 
Vermont: 21.5%; 
Kentucky: 21.2%; 
New Hampshire: 21.1%; 
Rhode Island: 20.7%; 
Virginia: 20.5%; 
Arizona: 20.4%; 
Washington: 20.4%; 
Alaska: 20.2%; 
Indiana: 20.0%; 
Georgia: 19.6%; 
North Carolina: 19.2%; 
Colorado: 19.1%; 
Tennessee: 19.0%; 
Iowa: 19.0%; 
Wyoming: 18.9%; 
Oklahoma: 18.4%v
New Jersey: 18.0%; 
Kansas: 17.9%; 
Utah: 17.7%; 
Alabama: 17.7%; 
Louisiana: 17.2%; 
Minnesota: 17.0%; 
Mississippi: 16.6%; 
Maryland: 16.4%; 
Ohio: 16.1%; 
Delaware: 16.1%; 
California: 16.0%; 
Oregon: 15.8%; 
Connecticut: 15.4%; 
New York: 15.1%; 
South Dakota: 14.8%; 
Illinois: 14.7%; 
Michigan: 13.6%; 
District of Columbia: 13.6%; 
Montana: 13.3%; 
Missouri: 13.3%; 
Pennsylvania: 12.9%; 
Nevada: 11.7%; 
North Dakota: 11.7%; 
Wisconsin: 10.4%; 
Florida: 7.8%; 
Nationwide: 18.0%. 

Source: CMS Form 416 data for fiscal year 2008. 

Note: This table represents dental utilization rates calculated from 
data reported by states in their fiscal year 2008 CMS 416 reports (the 
most recent available at the time of our review) on the number of 
EPSDT-eligible Medicaid-enrolled children who received any dental 
service during the fiscal year. Children enrolled in CHIP programs 
that are expansions of the states' Medicaid programs are entitled to 
the Medicaid EPSDT benefit package and are included in the states' CMS 
416 reports, but are not identified separately as CHIP enrollees. 

[End of table] 

[End of section] 

Appendix III: NHSC and Health Center Funding in the Recovery Act, 
PPACA, and Fiscal Year 2010 Appropriation: 

The Recovery Act appropriated $500 million to address health 
professions workforce shortages through means such as scholarships and 
loan repayment awards, of which the Conference Committee directed $300 
million be provided to NHSC for recruitment and field activities. 
[Footnote 82] HRSA plans to use these funds in fiscal years 2009 
through 2011.[Footnote 83] For the Health Center program, the Recovery 
Act appropriated $2 billion for grants to benefit health centers--$500 
million for grants to support the delivery of patient services and 
$1.5 billion for grants to support and improve health center 
infrastructure. According to HRSA, as of December 31, 2009, Recovery 
Act funds for health centers had provided support to over 550 full-
time equivalent dental positions, including dentists, dental 
hygienists, and dental assistants, as well as dental aides, and dental 
technicians. HRSA reported that these positions have led to more than 
575,000 dental visits to over 264,000 patients, including children, in 
underserved areas. 

PPACA authorized and appropriated a total of $1.5 billion for NHSC for 
fiscal years 2011 through 2015. According to HRSA, this funding will 
increase the number of dentists and dental hygienists participating in 
NHSC. However, the agency reported that the exact number of 
scholarship and loan repayment awards made using these funds will 
depend on the number of qualified applications the program receives. 
[Footnote 84] Additionally, PPACA authorized and appropriated $9.5 
billion for health centers through the Community Health Center Fund 
established by the Act as well as $1.5 billion for construction and 
renovation of community health centers for fiscal years 2011 through 
2015.[Footnote 85] 

Funds specifically provided for these programs in the Recovery Act and 
PPACA are in addition to the funds that may be specifically or 
generally available for the NHSC and Health Center programs through 
HHS's annual appropriations (see table 8). 

Table 8: Funding for National Health Service Corps and Health Center 
Programs Under the Recovery Act and PPACA, and the Fiscal Year 2010 
Annual Appropriation: 

Legislation/Program: Recovery Act: National Health Service Corps; 
Funding (appropriated) (in millions): $300[A]; 
Funding time frame (fiscal years): 2009-2011. 

Legislation/Program: Recovery Act: Health Center; 
Funding (appropriated) (in millions): $2,000; 
Funding time frame (fiscal years): 2009. 

Legislation/Program: PPACA: National Health Service Corps; 
Funding (appropriated) (in millions): $1,500; 
Funding time frame (fiscal years): 2011-2015. 

Legislation/Program: PPACA: Health Center; 
Funding (appropriated) (in millions): $11,000[B]; 
Funding time frame (fiscal years): 2011-2015. 

Legislation/Program: Fiscal Year 2010 Program Funding: National Health 
Service Corps; 
Funding (appropriated) (in millions): $142[C]; 
Funding time frame (fiscal years): 2010. 

Legislation/Program: Fiscal Year 2010 Program Funding: Health Center; 
Funding (appropriated) (in millions): $2,190[C]; 
Funding time frame (fiscal years): 2010. 

Source: GAO analysis. 

Note: This table presents data from the American Recovery and 
Reinvestment Act of 2009, Pub. L. No. 111-5, 123 Stat. 115 and H.R. 
Rep. No. 111-16 (2009) (Conf. Rep.); the Consolidated Appropriations 
Act, 2010, Pub. L. No. 111-117, Division D., Title II, 123 Stat. 3034 
and H. R. Rep. No. 111-220 (2009) and S. Rep. No. 111-66 (2009); the 
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 
Stat. 119 (2010); and the Health Care and Education Reconciliation Act 
of 2010, Pub. L. No. 111-152, 124 Stat. 1029. Funding time frames 
represent the fiscal years during which funding detailed in the 
"Funding (appropriated)" column will be available for obligation. All 
amounts rounded to the nearest million. 

[A] Based on direction provided by the Conference Committee for the 
Recovery Act for specific use of the Act's appropriation to the 
Department of Health and Human Services. H.R. Rep. No. 111-16, at 451 
(2009). 

[B] As amended by the Health Care and Education Reconciliation Act of 
2010. Pub. L. No 111-152, § 2303, 111 Stat.1029, 1083. 

[C] Based on direction provided by the House and Senate Committees on 
Appropriations for specific use of the 2010 HRSA appropriation. H. R. 
Rep. No. 111-220, at 46, 49 (2009); S. Rep. No. 111-66, at 38, 40-41 
(2009) (providing direction for HRSA appropriation contained in 
Consolidated Appropriations Act 2010, Pub. L. No. 111-117, Division D, 
Title II, 123 Stat. 3034, 3239 (2009)). 

[End of table] 

[End of section] 

Appendix IV: Additional HHS Programs That May Improve Access to Dental 
Services in Underserved Areas: 

In addition to the NHSC and Health Center programs, HHS administers a 
number of programs that, while not targeted specifically to children 
in underserved areas, may nevertheless improve their access to dental 
services in underserved areas. These include programs that target the 
provision of oral health services to specific populations such as 
schoolchildren, as well as programs that support training of oral 
health providers or prioritize the training of dentists and dental 
hygienists that could serve in underserved areas (see table 9). 

Table 9: HHS Programs that May Improve Access to Dental Services in 
Underserved Areas: 

Program (Authority) HHS Agency: Children's Hospitals Graduate Medical 
Education (42 U.S.C. § 256e) HRSA; 
Program Type: Supports the Provision of Dental Services: [Empty]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Provides support to freestanding children's hospitals to 
train medical residents, including dental residents and fellows.[A] 

Program (Authority) HHS Agency: Grants for Training in General, 
Pediatric, and Public Health Dentistry (42 U.S.C. § 293k-2) HRSA; 
Program Type: Supports the Provision of Dental Services: [Empty]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards grants to schools, hospitals, and other entities 
that plan, develop, operate, or participate in an approved 
professional training program that emphasizes training in general, 
pediatric, and public health dentistry.[B] 

Program (Authority) HHS Agency: Health Professionals Student Loan 
Program (42 U.S.C. § 292q) HRSA; 
Program Type: Supports the Provision of Dental Services: [Empty]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards loans to financially needy health professions 
students, including dental students. 

Program (Authority) HHS Agency: Loans for Disadvantaged Students (42 
U.S.C. § 292t) HRSA; 
Program Type: Supports the Provision of Dental Services: [Empty]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards loans to health professions students from 
disadvantaged backgrounds, including dental students. 

Program (Authority) HHS Agency: Ryan White Community-Based Dental 
Partnership and Ryan White Dental Reimbursement Programs[C[(42 U.S.C. 
§] § 300ff-111) HRSA; 
Program Type: Supports the Provision of Dental Services: [Check]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards grants to accredited dental education programs to 
increase access to oral health services for people with human 
immunodeficiency virus (HIV) in underserved areas by: (1) increasing 
the number of dentists and dental hygienists with the capability of 
managing the oral health needs of HIV positive patients; and (2) 
defraying their unreimbursed costs associated with providing oral 
health care to people with HIV (applicable to the Dental Reimbursement 
program only). 

Program (Authority) HHS Agency: Scholarships for Disadvantaged 
Students (42 U.S.C. § 293a) HRSA; 
Program Type: Supports the Provision of Dental Services: [Empty]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards scholarships to health professions students from 
disadvantaged backgrounds, including dental and dental hygiene 
students. 

Program (Authority) HHS Agency: School-Based Dental Sealant Program 
(42 U.S.C. § 247b-14(c)) Centers for Disease Control and Prevention; 
Program Type: Supports the Provision of Dental Services: [Check]; 
Oral Health Workforce Training and Support: [Empty]; 
Description: Expands grants for school-based dental sealant programs 
to provide dental sealants to target populations of children.[D] 

Program (Authority) HHS Agency: School-Based Health Centers (42 U.S.C. 
§§ 280h-4, 280h-5) HRSA; 
Program Type: Supports the Provision of Dental Services: [Check]; 
Oral Health Workforce Training and Support: [Empty]; 
Description: Authorizes HHS to award grants for the establishment of 
or for the operation of school-based health centers. Requires or 
authorizes HHS to give preference to applicants that serve a large 
population of Medicaid and CHIP children or that serve communities 
with high numbers of children and adolescents who are uninsured, 
underinsured, or enrolled in public health insurance programs.[E] 

Program (Authority) HHS Agency: State Oral Health Workforce Grants (42 
U.S.C. § 256g) HRSA; 
Program Type: Supports the Provision of Dental Services: [Check]; 
Oral Health Workforce Training and Support: [Check]; 
Description: Awards grants to states to address primarily workforce 
issues associated with dental HPSAs.[F] 

Source: GAO analysis of statutes and HHS information, including grant 
guidance, summary information from HRSA and CDC Web sites, and 
information provided by agency officials. 

Note: This table presents selected HHS programs that may improve 
access to dental services in underserved areas. While not targeted 
specifically to children in underserved areas, these programs may 
improve their access through support of the provision of dental 
services to specific populations or through support for oral health 
workforce training. 

[A] HRSA reports that, in fiscal year 2009, 56 hospitals were funded 
through the Children's Hospitals Graduate Medical Education payment 
program. According to HRSA, the program enables the hospitals to 
support graduate medical education, enhance research, and provide care 
for underserved children. 

[B] Statutory priority for awarding grants includes giving priority to 
applicants that establish formal relationships with health centers as 
well as applicants that have a high rate of placing residents in 
underserved areas. 

[C] While the Ryan White Act authorizes support for institutions that 
may provide oral health services, these two grant programs--the Ryan 
White Community-Based Dental Partnership Program and the Ryan White 
Dental Reimbursement Program--are specifically focused on funding for 
dental services. 

[D] As of May 2010, 16 states had grants to operate school-based or 
linked dental sealant programs, which generally target schools with 
large populations of low-income children using the percentage of 
children eligible for federal free and reduced-cost lunch programs. 
The Patient Protection and Affordable Care Act (PPACA) authorized an 
expansion of the program to all 50 states, territories, and Indian 
tribes and organizations. Dental sealants are a plastic material 
applied to the chewing surfaces of back teeth that have been shown to 
prevent tooth decay. 

[E] PPACA provided for the establishment of this program and 
appropriated $200 million over 4 years for the establishment of school-
based health centers. PPACA also authorized such sums as may be 
necessary for grants for program operations over 5 years, although 
HRSA officials reported no funding had been appropriated specifically 
for this purpose as of October 2010. 

[F] HRSA reported that, as of October 2010, a total of 30 states had 
34 grants, with California, Florida, Kansas and Ohio having two grants 
each. Twenty-five of these 34 active, three-year, grants were awarded 
in fiscal year 2009 and nine more were awarded in fiscal year 2010. 
All 30 states may only use the funds received under these grants for 
the 13 legislatively-authorized activities including, but not limited 
to, loan forgiveness and repayment programs for dentists who agree to 
practice in dental HPSAs, programs to expand or establish oral health 
services and facilities in dental HPSAs, and community-based 
prevention services--see Social Security Act 340G(b) (codified at 42 
U.S.C. 256g(b)). HRSA reported that it awarded $10 million in grants 
in fiscal year 2009 and $17.5 million in fiscal year 2010. 

[End of table] 

[End of section] 

Appendix V: Dental Health Aide Therapist Program for Alaska Natives: 

Based on a 1999 oral health survey, the Indian Health Service issued a 
report detailing the extensive dental health needs and increasing 
dental vacancy rates within the Alaska Native population.[Footnote 86] 
In order to meet the extensive dental health needs of the Alaska 
Native population, the Alaska Native Tribal Health Consortium 
(Consortium), a tribal organization managed by Alaska Native tribes 
through their respective regional health organizations, in 
collaboration with others, developed the Dental Health Aide Therapist 
program in 2003. This program selects individuals from rural Alaska 
communities to be trained and certified to practice under remote 
consultative supervision of dentists in the Alaska Tribal Health 
System. Dental health aide therapists (dental therapists) in this 
program in Alaska are not licensed by the state; rather the program is 
authorized under the federal Community Health Aide Program for Alaska 
Natives. 

Under standards and procedures developed for this program, dental 
therapists must complete a 2-year training program, a 400-hour 
preceptorship under a dentist's supervision, and apply for 
certification in order to practice. Alaska's first dental therapists 
received their training from New Zealand's National School of 
Dentistry in Otago with the first dental therapists graduating in 
2004. In 2007, the Consortium in partnership with the University of 
Washington opened the DENTEX training center and, in 2008, opened the 
Yuut Elitnaurivat Dental Training Clinic in partnership with the Yuut 
Elitnaurviat--People's Learning Center. These are the first Dental 
Health Aide Therapist training centers in the United States. As of 
March 2010, there were 13 dental therapy students enrolled in the 
training program. 

Since 2005, dental therapists have practiced throughout Alaska. As of 
June 2010, 19 dental therapists had completed the 2-year training 
program. Of those 19, 10 dental therapists were trained in New Zealand 
and were certified and practicing in rural Alaska. Another five 
completed their preceptorships and were certified to begin practice. 
The remaining four dental therapists were completing their 
preceptorships. Figure 5 shows the areas and villages where the dental 
therapists were practicing or were scheduled to practice upon 
completion of their preceptorships. According to Consortium officials, 
the population of the communities where dental therapists were 
practicing varies from under 100 to nearly 9,000 individuals. 

Figure 5: Dental Therapist Training Locations and Certification Status 
in Alaska, June 2010: 

[Refer to PDF for image: illustrated map of Alaska] 

Training Location and Status (number of persons): 

New Zealand trained, certified and in practice (10): 
Kiana; 
Kotzebue; 
Metlakatia; 
Savoonga; 
Shishmaref; 
Sitka; 
Stebbins; 
Togiak; 
Unalakleet. 

Alaska trained, certified and in practice (5): 
Atka; 
Hooper Bay; 
Klawock; 
St. Mary's; 
Yakutat. 

Alaska trained and in preceptorship (4): 
Chistochina; 
Fairbanks (2); 
New Stuyahok; 

Dental therapy training centers: 
Anchorage; 
Bethel. 

Source: Alaska Native Tribal Health Consortium; MapInfo (map). 

[End of figure] 

In general, dental therapists are based in a sub-regional clinic in an 
Alaska Native village and travel to surrounding villages to provide 
services.[Footnote 87] For example, one dental therapist who has been 
practicing at a sub-regional clinic since 2006 estimated that he 
travels approximately two weeks per month to the surrounding villages 
to provide dental services. Travel for the dental therapists, 
particularly in the winter, is a challenge as there are limited roads 
to and from the villages and in many cases air travel is the only 
possible mode of transport. When traveling, dental therapists often 
bring their own supplies into the villages and in some cases have to 
pack a portable dental chair. 

Dental therapists treat patients primarily in rural Alaska Native 
communities. Although these patients are typically Alaska Native or 
American Indian, services may be provided to other patients, for 
example when the program has capacity to provide the services to 
others without denying or diminishing care to Alaska Native or 
American Indian beneficiaries or there are limited health care 
resources in the area. Consortium officials stated that all the tribal 
organizations for regions employing dental therapists generally make 
services available to non-Native patients, except in larger 
communities, such as Anchorage, Fairbanks, Juneau, and Sitka. 

According to Consortium officials, dental therapists often have an 
agreement with the schools in their communities to allow for students 
to receive services during school hours. Dental therapists are trained 
to focus on expectant mothers and pre-school and school-aged children. 
Consortium officials estimate that about half of patients treated by 
dental therapists are children. For example, encounter data for 2006 
through 2009 for two practicing dental therapists suggest that, on 
average, 64 percent and 59 percent of their encounters were children, 
respectively.[Footnote 88] 

[End of section] 

Appendix VI: Types of Dental Providers, Excluding Dentists, in Eight 
Selected States: 

In the states we examined--Alabama, Alaska, California, Colorado, 
Minnesota, Mississippi, Oregon, and Washington--a variety of dental 
providers other than dentists, such as dental therapists and 
hygienists, may provide certain services with varying degrees of 
supervision. Supervision of other dental providers by a dentist may 
take many forms. For the purposes of this report, we categorized 
dental supervision as: (1) the dentist must be on-site during the 
procedure; (2) the dentist may be off-site (remote) but must have 
prior knowledge of and consent to the procedures, in some cases 
through a treatment plan; (3) the dentist may be off-site (remote) but 
maintain a consultative role, for example through a signed 
collaborative agreement; or (4) the dentist provides no supervision 
(none). In addition, within each state, there is a basic level of 
required education and experience for each category of provider, which 
may increase depending on the scope of practice authorized. For 
example, dental hygienists in Alaska may perform preventive and basic 
restorative procedures under a collaborative agreement if--in addition 
to graduating from dental hygiene school--they have completed 4,000 
hours of clinical experience. All required education and experience is 
listed for each type of provider. 

In the eight states we examined scope of practice, required 
supervision, education and experience, and reimbursement varied by 
state. Tables 10 through 17 present information on dental providers-- 
other than dentists--authorized to practice in those eight states. 

Table 10: Selected Types of Dental Providers in Alabama, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* Approved dental hygiene school, college or state program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* None; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[End of table] 

Table 11: Selected Types of Dental Providers in Alaska, June 2010: 

Type of dental provider: Dental health aide therapist for Alaska 
Natives[B]; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
* Intermediate restorative; 
Supervision required: Remote: consultative; 
Required education and experience: 
* Two years post-secondary training program[C]; 
* Specified clinical experience; 
Licensed or certified: Yes[D]; 
Direct Medicaid/CHIP reimbursement: Yes. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: Remote: consultative; 
Required education and experience: 
* Dental hygiene program; 
* Specified clinical experience; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant: 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
* Intermediate restorative[E]; 
Supervision required: On-site; 
Required education and experience: 
* Specific instructional program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant: 
Scope of practice[A]: 
* Supportive; 
* Preventive[F]; 
Supervision required: On-site; 
Required education and experience: None; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state and tribal officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] The Dental Health Aide Therapist program is authorized under the 
federal Community Health Aide Program for Alaska Natives, not the 
state. 

[C] Dental health aide therapists are recruited from Alaska 
communities. 

[D] Dental health aide therapists are not licensed by the state; 
rather they are certified by the Alaska Native Tribal Health 
Consortium as part of the federal Community Health Aide Program for 
Alaska Natives. 

[E] State regulations establishing specific restorative function 
requirements have not yet been established. 

[F] Dental assistants may perform certain preventive procedures such 
as coronal polishing, with appropriate certification which would 
require the completion of a specific instructional program. They may 
perform other preventive procedures such as the application of 
sealants with no additional training. 

[End of table] 

Table 12: Selected Types of Dental Providers in California, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive [limited settings][B]; 
Supervision required: Remote: consultative; 
Required education and experience: 
* Dental hygiene program/bachelor's degree; 
* Specified clinical experience; 
* Approved post-licensure training; 
Licensed or certified: Yes[C]; 
Direct Medicaid/CHIP reimbursement: Yes[D]. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* Dental hygiene program; 
* Approved post-licensure training; 
Licensed or certified: Yes[E]; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* Dental hygiene program; 
* Specific instructional program; 
Licensed or certified: Yes[F]; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* Specific instructional program; 
* Specified clinical experience; 
* Specified post-licensure training; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
Supervision required: On-site; 
Required education and experience: 
* Specific instructional program; 
* Specified clinical experience; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
Supervision required: On-site; 
Required education and experience: None; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] Certain dental hygienists may provide preventive services in 
specific settings, such as schools, homebound residences, and 
residential facilities under remote consultative dentist's supervision. 

[C] Dental hygienists with this type of license are known as 
registered dental hygienists in alternative practice. 

[D] California CHIP does not contract with providers directly; the 
managed care plans reimburse providers. California Medicaid does 
reimburse certain licensed dental hygienists. 

[E] Dental hygienists with this type of license are known as 
registered dental hygienists in extended function. 

[F] Dental hygienists with this type of license are known as 
registered dental hygienists. 

[End of table] 

Table 13: Selected Types of Dental Providers in Colorado, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
Supervision required: None; 
Required education and experience: 
* Dental hygiene program; 
Licensed or certified: Yes[B]; 
Direct Medicaid/CHIP reimbursement: Yes[C]. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: Remote: prior knowledge and consent; 
Required education and experience: 
* Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: Yes[C]. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site[D]; 
Required education and experience: None; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] Unsupervised dental hygienists are known as independent dental 
hygienists and operate under the same license as other hygienists in 
the state. 

[C] Dental hygienists may be paid directly for dental services under 
Medicaid. Under CHIP, only dental hygienists enrolled in a specific 
state program are paid directly for their services. 

[D] Performance of some procedures may require prior knowledge and 
consent of a dentist, but not on-site supervision. 

[End of table] 

Table 14: Selected Types of Dental Providers in Minnesota, June 2010: 

Type of dental provider: Advanced dental therapist [limited 
setting][B]; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
* Intermediate restorative; 
Supervision required: Remote: prior knowledge and consent[C]; 
Required education and experience: 
* Master's level program; 
* Specified clinical experience; 
Licensed or certified: Yes[D]; 
Direct Medicaid/CHIP reimbursement: Not yet determined. 

Type of dental provider: Dental therapist [limited setting][B]; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
* Intermediate restorative; 
Supervision required: On-site[E]; 
Required education and experience: Bachelor's or Master's level 
program; 
Licensed or certified: Yes[D];
Direct Medicaid/CHIP reimbursement: Not yet determined. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative [limited setting]; 
Supervision required: Remote: consultative[F]; 
Required education and experience: 
* Dental hygiene program; 
* Specified clinical experience; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: Yes[F]. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: On-site[G]; 
Required education and experience: 
* Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site[H]; 
Required education and experience: 
* Specific instructional program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: Supportive; 
Supervision required: On-site; 
Required education and experience: None; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] Advanced dental therapists and dental therapists are limited to 
practicing in settings that serve low-income, uninsured, and 
underserved populations or in a dental health professional shortage 
area. 

[C] Pursuant to a collaborative agreement with a dentist, advanced 
dental therapists may perform all the procedures of a dental 
therapist--including restorative drilling and filling--under remote 
supervision of a dentist, as well as develop treatment plans and 
nonsurgical extractions of permanent teeth under remote supervision. 

[D] Licensure for dental therapists and advanced dental therapists is 
the same. Advanced dental therapists require special certification 
which includes additional education, but specific requirements had not 
been finalized as of June 2010. As of June 2010, students were 
enrolled in advanced dental therapy and dental therapy training 
programs, but none were yet practicing. 

[E] Pursuant to a collaborative agreement with a dentist, dental 
therapists may perform some preventive and basic restorative 
procedures off-site with prior knowledge and consent of a dentist, 
other procedures require on-site supervision. 

[F] Pursuant to a collaborative agreement with a dentist, dental 
hygienists may be authorized to provide services in a health care 
facility, program, or nonprofit organization. These services may 
result in direct-to-provider Medicaid reimbursement. 

[G] Dental hygienists may perform certain preventive and basic 
restorative procedures without the dentist being present in the dental 
office if the procedures being performed are with prior knowledge and 
consent of a dentist; other procedures require on-site supervision. 

[H] Registered dental assistants may perform certain preventive and 
basic restorative procedures without the dentist being present in the 
dental office if the procedures being performed are with prior 
knowledge and consent of a dentist; other procedures require on-site 
supervision. 

[End of table] 

Table 15: Selected Types of Dental Providers in Mississippi, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: Preventive; 
Supervision required: On-site[B]; 
Required education and experience: Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive[C]; 
Supervision required: On-site; 
Required education and experience: None[C]; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] Dental hygienists may provide preventive services outside a dental 
office under remote supervision through a consultative arrangement 
with a dentist when employed by the State Board of Health or public 
school boards. In addition, dental hygienists employed by the State 
Board of Health may apply fluoride in this context. 

[C] Dental assistants must acquire a permit through the state board of 
dental examiners in order to take radiographs. 

[End of table] 

Table 16: Selected Types of Dental Providers in Oregon, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive [limited setting][B]; 
Supervision required: None; 
Required education and experience: 
* Dental hygiene program; 
* Specified clinical experience and coursework or approved course of 
study including clinical experience; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: Yes. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: Remote: prior knowledge and consent; 
Required education and experience: 
* Dental hygiene program; 
* Specific instructional program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience: 
* Dental hygiene program; 
* Specific instructional program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
Supervision required: Remote: prior knowledge and consent; 
Required education and experience:
* Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site[C]; 
Required education and experience: 
* Specific instructional programs[D]; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
Supervision required: On-site; 
Required education and experience: None; 
Licensed or certified: No; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] Dental hygienists can obtain permits to provide preventive 
services, including fluoride application, in limited settings such as 
schools and nursing homes without the supervision of a dentist. These 
services may result in direct-to-provider Medicaid reimbursement. 

[C] Dental assistants may perform certain basic restorative procedures 
without the dentist being present in the dental office if the 
procedures being performed are with prior knowledge and consent of a 
dentist. 

[D] Dental assistants in Oregon can obtain certification to perform 
various preventive and restorative services upon completion of 
specific instructional programs. 

[End of table] 

Table 17: Selected Types of Dental Providers in Washington, June 2010: 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive [limited setting][C]; 
Supervision required: None; 
Required education and experience[B]: 
* Dental hygiene program; 
* Specific instructional program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: Yes. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive [limited setting][D]; 
Supervision required: Remote: consultative; 
Required education and experience[B]: 
* Dental hygiene program; 
* Specified clinical experience; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
Supervision required: Remote: prior knowledge and consent; 
Required education and experience[B]: 
* Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental hygienist; 
Scope of practice[A]: 
* Preventive; 
* Basic restorative; 
* Intermediate restorative[E]; 
Supervision required: On-site; 
Required education and experience[B]: 
* Dental hygiene program; 
Licensed or certified: Yes; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive [limited setting][F]; 
Supervision required: Remote: prior knowledge and consent; 
Required education and experience[B]: 
* Program-specific instructional program; 
* Specified clinical experience; 
Licensed or certified: Yes[G]; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site[H]; 
Required education and experience[B]: 
* Specific instructional program or comparable credential; 
Licensed or certified: Yes[G]; 
Direct Medicaid/CHIP reimbursement: No. 

Type of dental provider: Dental assistant; 
Scope of practice[A]: 
* Supportive; 
* Preventive; 
* Basic restorative; 
Supervision required: On-site; 
Required education and experience[B]: None; 
Licensed or certified: Yes[G]; 
Direct Medicaid/CHIP reimbursement: No. 

Source: GAO analysis of information from state dental practice acts, 
state dental boards, and state officials. 

[A] Each scope of practice category contains a variety of specified 
procedures. A provider may not be authorized to perform all procedures 
in a particular category. 

[B] All dental hygienists and dental assistants in Washington must 
complete AIDS education and training. 

[C] Dental hygienists can become endorsed to administer sealants and 
fluoride varnishes and remove deposits and stains from the surfaces of 
teeth in school-based settings by completing a specified instructional 
program (hygienists licensed on or before April 19, 2001 were 
automatically endorsed). These services may result in direct-to- 
provider Medicaid reimbursement. 

[D] Dental hygienists with at least two years clinical experience may 
provide preventive services in certain health-care facilities or 
senior centers under remote dentist's supervision. A consultative 
agreement with a dentist is required to provide these services in 
senior centers. 

[E] Dental hygienists may place a restoration (filling) in a cavity 
prepared by a dentist. 

[F] Dental assistants can become endorsed to administer sealants and 
fluoride varnishes in school-based settings by completing a program- 
specific training program and 200 hours of clinical experience 
(assistants employed by a licensed Washington dentist on or before 
April 19, 2001 were not required to obtain an endorsement). 

[G] All dental assistants in Washington must be registered or licensed 
to practice in the state. Dental assistants must meet limited 
requirements to become registered. Dental assistants must meet 
additional educational requirements to become licensed or endorsed to 
perform additional or preventive procedures under remote supervision. 

[H] Licensed dental assistants may perform certain preventive 
procedures without a dentist being present and with prior knowledge 
and consent of a dentist. 

[End of table] 

[End of section] 

Appendix VII: Summary of Four Selected Countries' Use of Dental 
Therapists: 

Dental therapists practice in many countries around the world. 
[Footnote 89] In particular, New Zealand, the United Kingdom, 
Australia, and Canada have long-standing dental therapy training 
programs originally aimed at improving access to dental services for 
children and other underserved populations. Below are brief 
descriptions of the dental therapist programs in these four countries. 
[Footnote 90] 

New Zealand: 

New Zealand began training dental therapists in 1921 to provide dental 
care to children through school-based clinics--known as the school 
dental service--in response to high rates of dental decay and a 
shortage of dentists.[Footnote 91] Since 2006, dental therapy and 
dental hygiene training have been combined into a single 3-year 
bachelor's degree granting program offered through two 
universities.[Footnote 92] Graduates of the combined programs can 
register as both a dental therapist and a dental hygienist.[Footnote 
93] Registered dental therapists can work throughout the country to 
determine treatment plans and provide preventive and basic and 
intermediate restorative services--including procedures such as 
drilling and filling a tooth--for children and, in some cases, adults, 
under remote consultative supervision of a dentist.[Footnote 94] 
Dental therapists in New Zealand maintain a consultative relationship 
with a dentist and refer patients to a dentist for services beyond 
their scope of practice. Although dental therapists have been able to 
work in private practice since 2004, according to a 2007 study, the 
majority of dental therapists in the country work as salaried 
employees for District Health Boards to provide dental services to 
children through the school dental service in school-and community-
based dental clinics.[Footnote 95] An official from the New Zealand 
Ministry of Health estimated that in 2009, 96 percent of children aged 
five to 12 in the country were enrolled in the school dental service 
and therefore received dental care from dental therapists. 

The United Kingdom: 

The United Kingdom established its first dental therapy training 
program in 1959 to meet a growing need for dental providers to staff 
school-and community-based dental programs.[Footnote 96] Students were 
selected from across the United Kingdom and were expected to return to 
their home areas after training. The number of dental therapy training 
programs has expanded in recent years, and most are offered as 3-year 
combined dental therapy and dental hygiene programs.[Footnote 97] 
Dental therapists in the United Kingdom must be registered with the 
General Dental Council to practice and registered dental therapists 
may provide preventive and basic and intermediate restorative 
services--including procedures such as drilling and filling a tooth--
for children and adults under a treatment plan developed by a dentist. 
[Footnote 98] Until 2002, dental therapists were restricted to 
salaried employment in the public sector. Since then, they have been 
able to work in independent practice, and since 2006, dental 
therapists have been permitted to own their own practice and employ 
other dental professionals. According to a 2007 survey of registered 
dental therapists; 50 percent worked in private practice, 31 percent 
worked in public dental services, and 10 percent worked in both. 
[Footnote 99] Overall, 39 percent of dental therapists reported 
spending most of their time treating children.[Footnote 100] 

Australia: 

Dental therapy training programs began in certain Australian states in 
1966 and 1967 and expanded to all states and territories to train 
dental therapists to provide dental services to children through 
school-based dental programs--known as the school dental service. 
[Footnote 101] In 2010, there were nine dental therapy training 
programs in Australia, eight of which offered a combined 3-year dental 
therapy and dental hygiene bachelor's degree.[Footnote 102] In the 
past, Australia's eight states and territories were responsible for 
dental therapy registration, but as of July 1, 2010, Australia 
implemented a national registration and accreditation scheme requiring 
standard qualification for all dental therapists and oral health 
therapists registering after that date. Australian health officials 
reported that prior to national registration, dental therapists could 
generally provide primary oral health care including treatment 
planning, preventive and basic and intermediate restorative services-- 
including procedures such as drilling and filling teeth for children 
under the remote consultative supervision of a dentist. Three 
Australian states--the Northern Territory, Victoria, and Western 
Australia--also allowed dental therapists to provide services to 
adults according to an Australian expert. Until recently, the majority 
of states and territories restricted employment of dental therapists 
to the public sector, however according to a 2005 national survey, 78 
percent of dental therapists worked in the public sector--mostly as 
salaried employees of school-and community-based dental programs. 
[Footnote 103] In Western Australia, however, which has always 
permitted dental therapists to work in private practice, about 55 
percent of dental therapists worked in the public sector in 2005. 

Canada: 

The first Canadian dental therapy training programs were established 
in the Northwest Territories and Saskatchewan in 1972 to increase 
access to dental services for rural and aboriginal populations with a 
focus on children.[Footnote 104] Dental therapy practice differs 
across Canadian provinces and territories.[Footnote 105] Dental 
therapy training is offered as a government funded 2-year program 
through the National School of Dental Therapy at the First Nations 
University, whose charter is to train dental therapists to treat 
aboriginal populations. Although the National School of Dental Therapy 
program is not accredited, graduates either become licensed by and 
practice in Saskatchewan or work for the federal government or 
aboriginal tribes. Canadian dental therapists may provide preventive 
and basic and intermediate restorative services--including procedures 
such as drilling and filling a tooth--for children and adults under a 
treatment plan provided by a dentist. As of May 2010, the majority of 
Canadian dental therapists worked in Saskatchewan where they must be 
licensed by the Saskatchewan Dental Therapists Association according 
to an association official.[Footnote 106] Most of the dental 
therapists in Saskatchewan work in private dental practices, although 
some are directly employed by the federal or provincial government or 
aboriginal tribes.[Footnote 107] In all other Canadian provinces and 
territories except Ontario and Quebec, dental therapists are generally 
restricted to employment through the federal or territorial government 
or tribes to provide care to aboriginal populations living on 
reservations.[Footnote 108] 

[End of section] 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 4, 2010: 

Katherine Iritani: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Iritani: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) correspondence entitled: "Oral Health: Efforts Underway to 
Improve Children's Access to Dental Services, but Sustained Attention 
Needed to Address Ongoing Concerns" (GAO 11-96). 

The Department appreciates the opportunity to review this 
correspondence before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled: 
"Oral Health: Efforts Underway To Improve Children's Access To Dental 
Services, But Sustained Attention Needed To Address Ongoing Concerns" 
(GAO-11-961): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

CDC agrees in general with the report. However, based on data from the 
National Health and Nutrition Examination Survey (NHANES) and citing a 
previous report, the GAO "estimated that 6.5 million children had 
untreated tooth decay, and rates of dental disease among younger 
children in Medicaid had increased." This statement may be misleading 
in light of more recent analysis of NHANES data by CDC's National 
Center for Health Statistics. 

This 2010 analysis reported that among poor young children (age 2-5 
years) there has been no change in rates of dental disease between 
1988-94 and 1999-2004. Among poor children age 6-8 years, there has 
been an increase in caries experience. Among children age 2-5 years, 
however, the actual increase in caries seems to be significant only 
among the non-poor boys. Regarding untreated tooth decay, only non-
poor boys have shown an increase in untreated caries among all 2-8 
year-old children between NHANES 1988-94 and 1999-2004. Rates of 
untreated tooth decay for poor children age 2-8 years has remained 
unchanged. 

These findings and others are published in: Dye BA, Arevalo 0, Vargas 
CM. Trends in pediatric dental caries by poverty status in the United 
States, 1988-1994 and 1999-2004. International Journal of Pediatric 
Dentistry 2010; 20: 132-143. 

It should also be noted that when reporting on caries experience or 
"dental disease" in young children, these constructs include both 
treated and untreated caries. An increase in caries experience could 
be driven by an increase in the dental fillings/restorations component 
while the untreated disease component remained unchanged. An increase 
in the dental restoration component could indicate an increase in 
dental utilization, hence improvements in access to dental care, 
especially for low income children. Healthy People 2010 has shown an 
increase in utilization of preventive services among low income 
children age 2-19 years. 

CDC appreciates the efforts that went into this report and looks 
forward to working with GAO on this and other reports. 

The GAO issued two recommendations for executive action. CMS concurs 
with each recommendation with the following comments: 

GAO Recommendation: 

The Department of Health and Human Services should take steps to 
improve its Insure Kids Now Web site. 

CMS Response: 

We agree with this recommendation and that improvement undertaken by 
States and the Federal government, such as those identified in this 
report, is much needed. Under the current process, States submit the 
information on their participating dental providers to the IKN website 
through a download tool that was developed for this purpose or through 
another acceptable method. A contractor (working under a Health 
Resources and Services Administration (HRSA) contract but in 
collaboration with CMS) then includes the information in a database 
that links to the dental provider search engine. The data is subject 
to a screening process in which addresses are matched against public 
records. However, evaluating the quality of those records has not been 
part of the scope of the contractor's responsibilities. 

The CMS will undertake the following approaches to address this 
concern: 

First, to address the errors found on the Web site, the Department 
will increase the frequency and type of quality checks performed on 
State-reported dental provider information, and work with States to 
ensure they submit data that is complete, accurate and current. 
Specifically, we will follow up with States identified in the GAO 
report to ensure that they correct existing information on the Web 
site. We will also continue the process of requiring States to submit 
data on providers directly instead of providing links to State Web 
sites. We will also ensure States are aware of their responsibility to 
not list providers who have been excluded from participation under 
section 1128B of the Social Security Act; explore Federal options for 
cross checking lists of providers with the disenrolled provider 
database; and create a consistent understanding of what it means to be 
identified as a dental provider able to serve a child with special 
needs. 

We will consider additional ways, including regulatory guidance, to 
assure better information in implementing the provisions of CHIPRA, 
which may include specific requirements, parameters and timeframes for 
public listings of eligible, enrolled providers who are providing care 
to Medicaid and CHIP children, including those with special needs. 

GAO Recommendation: 

The Administrator of CMS take steps to ensure that States gather 
comprehensive and reliable data on the provision of Medicaid and CHIP 
dental services by managed care programs. 

CMS Response: 

We agree with this recommendation. CMS is in the process of 
implementing major changes that will improve collection of data 
related to dental services for children delivered through fee-for-
service or managed care payment arrangements. A revised CMS-416 form, 
which is CMS's primary tool for gathering data on the provision of 
services to children in State Medicaid programs, is in the final 
stages of the clearance process and will be released to States, along 
with written guidance, in the near future. This revised form has been 
expanded to include dental data elements as required by CHIPRA. The 
instructions for completing the CMS-416 specify that additional data 
reported on the form must include data for services delivered to 
individuals in both fee-for-service or managed care arrangements. 
Several provisions of CHIPRA also establish the foundation for CMS to 
build an infrastructure for a quality measures program in which data 
are collected and reported in a uniform way for children in Medicaid 
and CHIP. The collection of data on dental services will benefit from 
CMS-wide efforts underway to improve the collection and reporting of 
data on quality of care measures more broadly. 

The CMS is also establishing a workgroup consisting of national and 
local stakeholders in the field of child health that will focus on 
improving access to the benefits required under Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT) and will ask the 
workgroup to identify, among other things, ways to obtain more 
reliable data on dental services provided for children in managed care 
plans. This workgroup will be established by early 2011. 

Other CMS Activities: 

The CMS has also undertaken a number of efforts to improve children's 
access to oral health services. To accelerate our efforts to improve 
access to oral health services and to provide focus and visibility to 
our efforts, CMS announced in April 2010 at the National Oral Health 
conference two national oral health goals. The goals are: 1) to 
increase the national rate of children and adolescents enrolled in 
Medicaid or CHIP who receive any preventive dental service by 10 
percentage points over 5 years; and 2) to increase the rate of 
children ages 6-9 enrolled in Medicaid or CHIP who receive a dental 
sealant on a permanent molar tooth by 10 percentage points over 5 
years. The dental sealant goal will be phased in during the next two 
to three years. Data for monitoring ongoing progress on this goal will 
be collected through the CMS-416 report and the CHIP State Annual 
Reports. Data collected for Federal fiscal year 2011 will serve as 
baseline data for this goal. 

The CMS is collaborating with States on how to achieve these goals and 
we have developed an oral health strategy that identifies the 
principal barriers to children receiving dental care as well as some 
recommended approaches to overcoming these barriers. Much of the 
strategy was developed based on information learned during State 
dental reviews undertaken by CMS. In 2008, CMS examined the policies 
and practices of 16 States that had low dental utilization rates. In 
2009, CMS began reviews of eight States that had higher than average 
dental utilization rates or were recommended to CMS as having an 
innovative practice for increasing dental access. Each State review 
and a summary of the State reviews will be available on the CMS Web 
site (http://www.cms.gov/MedicaidDentalCoverage) by the end of 
December 2010. The results of these State reviews can help other 
States improve access to dental services. 

To support States in improving access to dental care, CMS will provide 
technical assistance to States to help improve access to children's 
dental care and to make progress toward achieving these goals, 
including: 

* Identifying promising practices that States have used to increase 
children's access to oral health care; 

* Annual meetings with States and national experts to share 
experiences; 

* Assessing progress toward the goals; 

* Identifying barriers to access; and; 

• Support opportunities for dental providers to receive incentive 
payments for meaningful use of electronic health record technology. 

CMS is holding two technical assistance workshops for States to 
discuss CMS' dental goals and strategy. The first workshop, held on 
October 7, 2010 in conjunction with the National Academy for State 
Health Policy conference in New Orleans, Louisiana, was attended by 20 
officials from CHIP or Medicaid programs, including several oral 
health directors. The second workshop will be held on November 10, 
2010 in Arlington, Virginia following the annual conference of the 
National Association of State Medicaid Directors. CMS will hold a 
meeting with external stakeholders this year to identify areas where 
they may wish to support our efforts in improving access to oral 
health services. CMS will take feedback from all of these meetings 
into consideration as we finalize our oral health strategy. 

The CMS' goals and dental strategy support the larger HHS Oral Health 
Initiative 2010 and the Department's comprehensive commitment to 
improved oral health. CMS is coordinating with other components of the 
Department on this important initiative as a member of the HHS 
Assistant Secretary for Health's Oral Health Coordinating Committee, 
which brings together fourteen agencies to direct the Department's 
oral health activities. In order to further the collaborative efforts 
on oral health, CMS has entered into a Memorandum of Understanding 
with HRSA and the Centers for Disease Control and Prevention.
Improving access to children's dental services in Medicaid and CHIP is 
one of our key priorities. We appreciate the efforts that went into 
this report and look forward to working with the GAO on this and other 
issues. 

HRSA has offered the following recommendations: 

Under the Children's Health Insurance Program Reauthorization Act 
(CHIPRA), the Department of Health and Human Services (HHS) is 
required to post a list of oral health providers who provide services 
to eligible Medicaid and Children's Health Insurance Program (CHIP) 
children on the Insure Kids Now (IKN) web site. This list is to be 
updated on a quarterly basis. This initiative was a huge undertaking 
given that this is the first national list of any type of Medicaid and 
CHIP health care providers. Despite the challenges, HRSA, under an 
Interagency Agreement (IAA) with the Centers for Medicare and Medicaid 
Services (CMS), met all statutory deadlines outlined under CHIPRA and 
have developed an Oral Health Locator (Locator). This Locator provides 
information to Medicaid and CHIP enrollees on how to find dentists and 
other oral health providers that accept Medicaid and CHIP. 

HRSA concurs with many of the findings and recommendations from the 
GAO report. HRSA has spent much effort in the past year working with 
states to improve the Locators capacity to accept and post data from 
states. It should be noted that while the law requires that the data 
on the IKN web site be updated on a quarterly basis, the system allows 
data to be updated on a daily basis ensuring that the most up-to-date 
information is available to enrollees. 

HRSA has specific comments regarding the following aspects of the 
report found under Section titled "Information on HHS's Web Site to 
Help Locate Participating Dentists is Not Always Complete" beginning 
on page 14, first paragraph: 

HRSA concurs that more attention needs to be devoted to improving the 
accuracy of information submitted by states. Much attention in the 
past year has been devoted to developing the system to allow for data 
submissions from states. It should be noted that data are submitted 
from states that utilize fee-for-service programs, and from health 
plans that utilize capitated or managed care programs. Given that data 
are received from multiple sources for one state, it is difficult to 
ensure the accuracy of all information. 

A sampling of the data could be done on a periodic basis. It should be 
noted that data files are reviewed systematically to ensure that all 
data fields have acceptable data (e.g., a field that requires a zip 
code has a 5 or 9 digit numerical value). Data files that do not 
adhere to the business rules outlined in our technical guidance to the 
states are returned and not posted. 

Completeness: The GAO outlines through their review, cases of missing 
or incomplete information including "...telephone numbers and 
addresses, whether dentists accepted new Medicaid or CHIP patients, 
and whether dentists could accommodate children with special needs." 
It should be noted that information concerning whether a provider is 
accepting new patients or accommodates children with special needs is 
not required under CHIPRA. This is information that CMS and HRSA 
thought would be important to enrollees trying to identify an oral 
health provider. We will continue to work with states to improve the 
quality of this information. 

Usability: GAO noted that they found "...7 states listed multiple 
health plans with similar names, some containing typographical errors 
and some that produced different provider listings, increasing the 
likelihood of selecting the wrong plan and generating an incorrect 
list of dentists." HRSA will continue to work with the Assistant 
Secretary for Public Affairs (ASPA) to improve the usability of the 
IKN web site. It should be noted that a widget is currently being 
developed to make it easier for enrollees to search for an oral health 
provider. HRSA will also work with ASPA to ensure that all the web 
links are working. The system was developed bearing in mind that many 
enrollees may not know if they are in Medicaid or CHIP but rather may 
more easily associate with the health plan. HRSA has instructed states 
to utilize the program names identified on their Medicaid or CHIP 
enrollee cards. 

Accuracy: HRSA will work with CMS to develop a plan for periodically 
analyzing a sampling of the data provided by states. 

First paragraph — page 18: In the first paragraph GAO reported 
concerns with providers being listed on the IKN web site that were 
excluded from participating in Medicaid by the HHS Office of Inspector 
General (OIG). HRSA will cross check the excluded parties list 
independently and check with CMS on the currency of the data provided, 
as the system was not developed to cross check data with OIG. 

[End of section] 

Appendix IX: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Katherine Iritani, (202) 512-7114 or iritanik@gao.gov: 

Staff Acknowledgments: 

In addition to the individual named above, Kim Yamane, Assistant 
Director; Rebecca Abela; Susannah Bloch; George Bogart; Alison 
Goetsch; Mollie Hertel; Anne Hopewell; Martha Kelly; Perry Parsons; 
Terry Saiki; Pauline Seretakis; and Suzanne Worth made key 
contributions to this report. 

[End of section] 

Related GAO Products: 

Medicaid Managed Care: CMS's Oversight of States' Rate Setting Needs 
Improvement. [hyperlink, http://www.gao.gov/products/GAO-10-810]. 
Washington, D.C.: August 4, 2010. 

Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but More Can Be Done. 
[hyperlink, http://www.gao.gov/products/GAO-10-112T]. Washington, 
D.C.: October 7, 2009. 

Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but Gaps Remain. [hyperlink, 
http://www.gao.gov/products/GAO-09-723]. Washington, D.C.: September 
30, 2009. 

Medicaid: Extent of Dental Disease in Children Has Not Decreased, and 
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink, 
http://www.gao.gov/products/GAO-08-1121]. Washington, D.C.: September 
23, 2008. 

Health Resources and Services Administration: Many Underserved Areas 
Lack a Health Center Site, and the Health Center Program Needs More 
Oversight. [hyperlink, http://www.gao.gov/products/GAO-08-723]. 
Washington, D.C.: August 8, 2008. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 
Children's Dental Services. [hyperlink, 
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2, 
2007. 

Medicaid Managed Care: Access and Quality Requirements Specific to Low-
Income and Other Special Needs Enrollees. [hyperlink, 
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.: December 8, 
2004. 

Medicaid and SCHIP: States Use Varying Approaches to Monitor 
Children's Access to Care. [hyperlink, 
http://www.gao.gov/products/GAO-03-222]. Washington, D.C.: January 14, 
2003. 

Medicaid: Stronger Efforts Needed to Ensure Children's Access to 
Health Screening Services. [hyperlink, 
http://www.gao.gov/products/GAO-01-749]. Washington, D.C.: July 13, 
2001. 

Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-149]. Washington, D.C.: 
September 11, 2000. 

Oral Health: Dental Disease Is a Chronic Problem Among Low-Income 
Populations. [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-72]. 
Washington, D.C.: April 12, 2000. 

[End of section] 

Footnotes: 

[1] Children in Medicaid are generally entitled to comprehensive 
dental services under the program's Early and Periodic Screening, 
Diagnostic, and Treatment (EPSDT) benefit. And, beginning in October 
2009, states were required to offer a package of dental benefits under 
their CHIP programs. 

[2] See GAO, Oral Health: Dental Disease Is a Chronic Problem Among 
Low-Income Populations, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-72] (Washington, D.C.: Apr. 
12, 2000), GAO, Oral Health: Factors Contributing to Low Use of Dental 
Services by Low-Income Populations, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-149] (Washington, D.C.: Sept. 
11, 2000), and Related GAO Products at the end of this report. 

[3] We used national survey data from 1999 through 2004 to estimate 
the number of Medicaid-enrolled children with untreated tooth decay. 
We also examined survey data for the 1988 through 1994 and 1999 
through 2004 time periods and found that rates of dental disease had 
not decreased, although the data suggested the trends varied somewhat 
among different age groups. See GAO, Medicaid: Extent of Dental 
Disease in Children Has Not Decreased, and Millions Are Estimated to 
Have Untreated Tooth Decay, [hyperlink, 
http://www.gao.gov/products/GAO-08-1121] (Washington, D.C.: Sept. 23, 
2008). 

[4] GAO, Medicaid: State and Federal Actions Have Been Taken to 
Improve Children's Access to Dental Services, but Gaps Remain, 
[hyperlink, http://www.gao.gov/products/GAO-09-723] (Washington, D.C.: 
Sept. 30, 2009). 

[5] Children's Health Insurance Program Reauthorization Act of 2009, 
Pub. L. No. 111-3, § 501(f), 123 Stat. 8, 88. 

[6] Pub. L. No. 111-3, § 501(f), 123 Stat. 88. 

[7] We selected 4 states that represented a variation in geography, 
use of managed care, and the number of children covered by Medicaid. 
Within each state we called the offices for at least 25 urban and 15 
rural dentists in the areas with the largest number of children in 
poverty. 

[8] Annual EPSDT reports contain information on children who are (1) 
in Medicaid and received EPSDT benefits and (2) in CHIP and received 
EPSDT benefits because they are part of a Medicaid expansion program. 

[9] American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, 
123 Stat. 115; Patient Protection and Affordable Care Act, Pub. L. No. 
111-148, 124 Stat. 119 (2010). References to the Patient Protection 
and Affordable Care Act (PPACA) in this report refer to Pub. L. No. 
111-148, as amended by the Health Care and Education Reconciliation 
Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029. 

[10] Our interviews with officials from HHS, states, academic 
institutions, professional associations, and advocacy groups found 
that there is no commonly-recognized definition of mid-level dental 
providers. 

[11] U.S. Department of Health and Human Services, National Institute 
of Dental and Craniofacial Research, National Institutes of Health, 
Oral Health in America: A Report of the Surgeon General (Rockville, 
Md.: 2000). 

[12] HHS established Healthy People 2010 as a statement of national 
health objectives designed to identify the most significant 
preventable threats to health and to establish national goals to 
reduce these threats. See [hyperlink, 
http://www.healthypeople.gov/About/] (accessed Aug. 3, 2010). 

[13] The 30 million children represent the fiscal year 2008 
unduplicated annual enrollment (the total number of children, each 
child counted once, who were enrolled in Medicaid at any point in 
federal fiscal year 2008) reported by CMS. 

[14] In February 2009, the Children's Health Insurance Program 
Reauthorization Act of 2009 renamed the State Children's Health 
Insurance Program (SCHIP) to the Children's Health Insurance Program 
(CHIP). 

[15] Pub. L. No. 111-3, § 501, 123 Stat. 84. CHIPRA allowed states to 
provide dental coverage for children in the CHIP income range who have 
health insurance through an employer, but who lack dental coverage. 

[16] Pub. L. No. 111-3, § 501(e), 123 Stat. 87. 

[17] Pub. L. No. 111-3, § 501(f), 123 Stat. 88. HHS's Insure Kids Now 
Web site was established in 1999 to help parents and guardians find 
state Medicaid and CHIP program eligibility information. To improve 
access to information on dental providers participating in Medicaid 
and CHIP, in February 2009, CHIPRA required HHS to post a list of 
participating dentists within each state on the Insure Kids Now Web 
site and also provide such information through its toll-free hotline 
(1-877-KIDS-NOW). 

[18] 42 U.S.C. § 254b. Health centers are funded in part through 
grants under the Health Center program--administered by HRSA--and 
provide comprehensive primary care services for the medically 
underserved. 

[19] 42 U.S.C. § 254d. The NHSC scholarship program provides tuition, 
fees, and living stipends for students in primary care, including 
dentistry, in exchange for at least 2 years of service. 42 U.S.C. § 
254l. The NHSC loan repayment program provides up to $50,000 toward 
repayment of student loans for providers, including dentists and 
dental hygienists, in exchange for at least 2 years of service. 42 
U.S.C. § 254l-1. HRSA also administers the State Loan Repayment 
program that provides matching grants to states to run their own loan 
repayment programs for health providers who agree to practice in 
underserved areas, which in some states includes awards for dentists 
and dental hygienists. 42 U.S.C. § 254 q-1. 

[20] 42 C.F.R. pt. 5, app. B (2009); 42 U.S.C. § 254e(a)(1). 

[21] Of the 4,377 dental HPSAs, 790 were for geographic areas, 1,526 
were for population groups, and 2,061 were facilities such as health 
centers that were designated as HPSAs. See [hyperlink, 
http://bhpr.hrsa.gov/shortage/] (accessed July 14, 2010). 

[22] HRSA estimates the number of full-time equivalent dentists needed 
to remove HPSA designations by taking into account the actual level of 
service provided by a given dentist. For example, a HPSA needing a 
dentist working half-time to remove its HPSA designation would be 
estimated to need 0.5 FTE, although adjustments are made for a variety 
of factors, such as the number of dental hygienists and dental 
assistants. 

[23] To identify HPSAs of greatest shortage, HRSA scores each HPSA 
based on relative need. Only HPSAs meeting a certain threshold score 
are considered HPSAs of greatest need. This threshold may differ for 
scholarship recipients and loan repayment recipients in a given year. 

[24] The number of choices available to scholarship recipients is 
provided for in statute: no more than twice the number of scholarship 
recipients who will be available for assignment during the year. For 
example, if there were 25 dentists who received NHSC scholarships 
available for service, NHSC would provide a list of no more than 50 
vacancies for them. See 42 U.S.C. § 254f-1(d)(2). 

[25] In the United States, dentists are licensed to practice by the 
states and states are generally responsible for establishing education 
requirements and determining scope of practice of dental providers. 
They can obtain additional training in a dental specialty, such as 
pediatric dentistry or orthodontics. 

[26] ASTDD's annual survey, called the Synopses of State and 
Territorial Dental Public Health Programs, is conducted under a 
cooperative agreement with HHS's Centers for Disease Control and 
Prevention. 

[27] ASTDD sent the survey to dental directors in all states and the 
District of Columbia. However, not all states provided responses to 
the questions on the number of dentists treating children in Medicaid 
and CHIP. For example, 39 states reported how many dentists treated 
children in Medicaid (including children in CHIP programs that are 
Medicaid expansions) and 11 reported the number of dentists who 
treated children in a CHIP program separate from Medicaid. See 
[hyperlink, http://apps.nccd.cdc.gov/synopses/] (accessed July 21, 
2010). 

[28] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149]. 

[29] Association of State and Territorial Dental Directors, ASTDD 
Support for State CSHCN Oral Health Forums, Action Plans And Follow-Up 
Activities; Interim Evaluation Summary (March 2009). 

[30] Burton L. Edelstein, "Conceptual Frameworks for Understanding 
System Capacity in the Care of People with Special Health Care Needs," 
Pediatric Dentistry, Vol. 29, No. 2 (March/April 2007). 

[31] The study found that overall, 8.9 percent of children with 
special health care needs who needed any dental care were unable to 
obtain it. Children with Down's Syndrome had the highest proportion of 
unmet dental care needs at 17.4 percent, and children with asthma the 
lowest at 8.6 percent. C.W. Lewis, "Dental Care and Children with 
Special Health Care Needs: A Population-Based Perspective," Academic 
Pediatrics. Vol. 9, No. 6: 420-426 (2009). 

[32] Specifically, the study noted that the adjusted odds of unmet 
dental care needs for severely affected, poor/low-income children with 
special health care needs were 13.4 times that of unaffected, higher- 
income children. 

[33] The dentists were listed on the Insure Kids Now Web site as 
practicing in California, Georgia, Illinois, and Vermont. Our case 
study approach did not yield results that could be projected to entire 
states or managed care organizations. 

[34] One dentist reported that the wait time for a new Medicaid or 
CHIP child was 6 months, compared to 2 months for other new patients 
with private insurance. Twenty-three of the dentists we called who 
were otherwise treating children were not accepting any new Medicaid 
or CHIP patients. 

[35] HHS may exclude providers from receiving payment from federally 
funded health care programs, including Medicare and Medicaid, for 
incidents such as conviction for program-related fraud and patient 
abuse, license revocation or suspension, and default on Health 
Education Assistance Loans. See [hyperlink, 
http://oig.hhs.gov/fraud/exclusions.asp] (accessed July 20, 2010). 

[36] HHS-OIG officials told us that the dentist has been excluded from 
Medicaid in 1986 after pleading guilty to Medicaid fraud. 

[37] Children enrolled in CHIP programs that are expansions of the 
states' Medicaid programs are entitled to the Medicaid EPSDT benefit 
package and are included in the states CMS 416 reports, but are not 
identified separately as CHIP enrollees in the CMS 416. 

[38] We calculated and report the nationwide Medicaid dental 
utilization rate--that is, the percentage of total EPSDT-eligible 
Medicaid enrollees in the nation who received any dental service. CMS 
reports a national average of 37.7 percent in 2008 that is calculated 
by averaging the 51 state-utilization rates. We report the national 
utilization rate rather than the average rate because it accounts for 
differences in the number of enrollees in each state. 

[39] In prior work, we found concerns that data on the provision of 
Medicaid services by managed care programs reported by states on their 
CMS 416s were not complete or reliable. See GAO, Medicaid: Stronger 
Efforts Needed to Ensure Children's Access to Health Screening 
Services, [hyperlink, http://www.gao.gov/products/GAO-01-749] 
(Washington, D.C.: July 13, 2001). According to CMS officials, states 
have improved the quality of data gathered and reported on their CMS 
416 reports. 

[40] See American Dental Association's Medicaid Compendium Update 
[hyperlink, http://www.ada.org/2123.aspx] (accessed Feb. 12, 2010). We 
considered states with 75 percent or more Medicaid-enrolled children 
in dental managed care as predominantly dental managed care states. 

[41] GAO, Medicaid: Concerns Remain about Sufficiency of Data for 
Oversight of Children's Dental Services, [hyperlink, 
http://www.gao.gov/products/GAO-07-826T] (Washington, D.C.: May 2, 
2007). 

[42] Social Security Act § 2108(a) (codified at 42 U.S.C. § 1397hh(a)). 

[43] Pub. L. No. 111-3, § 501(e), 123 Stat. 87. 

[44] In addition to dentists, health centers employed 1,018 dental 
hygienist FTEs and over 4,800 FTEs for dental assistants, aides, and 
technicians in calendar year 2009. 

[45] HRSA reported that 942 health center grantees offered restorative 
dental services--either directly, through contracts, or through formal 
referral arrangements--as of June 2010. 

[46] We previously reported that 43 percent of medically underserved 
areas lacked a health center as of 2007. GAO, Health Resources and 
Services Administration: Many Underserved Areas Lack a Health Center 
Site, and the Health Center Program Needs More Oversight, GAO-08-723 
(Washington, D.C.: Aug. 8, 2008). In August 2010, an official with the 
National Association of Community Health Centers told us that, 
although the number of underserved areas with a health center site 
increased since 2007, the change has not been significant and many 
underserved areas still lacked a health center to provide dental and 
other medical services. 

[47] Of the 611 dentists and 70 dental hygienists in NHSC at the end 
of fiscal year 2009, 112 dentists and 13 hygienists were funded 
through the State Loan Repayment Program. 

[48] These loan repayment awards made in fiscal year 2009 represent 16 
percent of the 611 dentists and 29 percent of the 70 dental hygienists 
practicing in HPSAs through the NHSC at the end of fiscal year 2009. 

[49] These grants for increased demand for services from health 
centers were awarded to fund activities such as adding new providers, 
expanding hours, or expanding existing health center services. 

[50] See Promoting and Enhancing the Oral Health of the Public: HHS 
Oral Health Initiative 2010 for a description of the agency's efforts 
under this initiative: [hyperlink, 
http://www.hrsa.gov/publichealth/clinical/oralhealth/hhsinitiative.pdf] 
(accessed June 16, 2010). 

[51] The Early Childhood Caries Initiative activities include early 
oral health assessment by community partners such as Head Start, 
nurses, and physicians; fluoride varnish application by these 
community partners and dental teams; and the application of dental 
sealants on primary teeth for young children. 

[52] See Pub. L. No. 111-148, § 4102(b), 124 Stat. 551. 

[53] For the purposes of this report, in the United States, mid-level 
providers are known as dental therapists in Alaska under the Dental 
Health Aide Therapist program and advanced dental therapists in 
Minnesota. 

[54] Alaska Native children had rates of dental caries (cavities) that 
were 2.5 times the U.S. average and Alaska tribes experienced dentist 
vacancy rates of 25 percent. 

[55] Under standards of the Community Health Aide Program 
Certification Board, prior to certification, each dental therapist is 
required to complete a clinical preceptorship under the direct 
supervision of a dentist for a minimum of three months or 400 hours, 
whichever is longer. 

[56] Alaska Medicaid reimburses dental therapist services at the same 
encounter rate as services provided by a dentist. 

[57] K.A. Bolin, "Assessment of treatment provided by dental health 
aide therapists in Alaska; a pilot study," Journal of the American 
Dental Association, Vol. 139 (2008). 

[58] Scott Wetterhall MD, et al., Evaluation of the Dental Health Aide 
Therapist Workforce Model in Alaska (Research Triangle Park, N.C.: RTI 
International, October 2010). 

[59] 2009 Minn. Laws Ch. 95, Art. 3. 

[60] In Minnesota, a dental therapist may perform a range of 
preventive and basic restorative procedures under remote consultative 
supervision of a dentist and intermediate restorative procedures under 
the on-site supervision of a dentist. Because of the on-site 
supervision requirement for intermediate restorative procedures, we do 
not consider Minnesota dental therapists as mid-level providers in 
this report. 

[61] The University of Minnesota School of Dentistry also offers a 
bachelor of science and a master's degree program which prepare 
students for licensure as dental therapists, but does not include the 
training required for advanced dental therapist certification. 

[62] Licensed dental therapists are also required to enter into 
consultative agreements. 

[63] Dental hygienists in Alabama may only perform dental procedures 
under the on-site supervision of a dentist. In addition to dental 
hygienists, dental assistants may provide a variety of services-- 
depending on the state--including preventive and basic restorative 
procedures, however in general they require on-site supervision by a 
dentist. 

[64] In the remaining three states--Alabama, Alaska, and Mississippi-- 
Medicaid covered services provided by dental hygienists are reimbursed 
through their supervising dentist. 

[65] Chris Cantrell, Engaging Primary Care Medical Providers in 
Children's Oral Health (Portland, Me.: National Academy for State 
Health Policy, September 2009). This study did not include a separate 
review of state CHIP reimbursement. According to officials from the 
Pew Center on the States, Children's Dental Campaign--the organization 
that funded the 2009 survey and monitors state Medicaid reimbursement 
policies--as of November 2010, 40 state Medicaid programs reimburse 
primary care medical providers for providing preventive dental 
procedures. Seven of the eight states we examined provided such 
reimbursement. 

[66] Pub. L. No. 111-148, § 5304, 124 Stat. 621. According to HRSA 
officials, as of June 2010, no funds had been appropriated 
specifically for these demonstration projects. 

[67] Rio Salado College is based in Tempe, Arizona. 

[68] The model proposed by the American Dental Hygienists' Association 
describes the supervisory arrangement for the advanced dental hygiene 
practitioner as a collaborative partnership with dentists for referral 
and consultations. 

[69] The countries are presented in chronological order by the date 
that their dental therapy programs started; New Zealand has the oldest 
dental therapy program. The United Kingdom consists of the countries 
of England, Northern Ireland, Scotland, and Wales. 

[70] These countries have other types of dental providers; however 
dental therapists are the only providers practicing in these countries 
who provide preventive, basic restorative and intermediate restorative 
dental procedures under remote supervision of a dentist. For example, 
Australia has a provider called a dental prosthesist who diagnoses and 
creates denture prosthesis, but does not provide primary (preventive 
and restorative) dental services. 

[71] Graduates of the combined programs are generally known as oral 
health therapists and are trained to provide dental hygiene services 
such as preventive teeth cleaning in addition to dental therapy 
services such as intermediate restorative tooth drilling. 

[72] The study examined 258 restorations on 80 adult patients six 
months after treatment. H. Calache, et. al, "The capacity of dental 
therapists to provide direct restorative care to adults," Australian 
and New Zealand Journal of Public Health, Vol. 33 (2009). An 
Australian official noted that the use of dental therapists is widely 
accepted and that because the programs are long-standing, few recent 
studies have been conducted. However, available research on the dental 
therapists in New Zealand (1951) and Canada (1974) showed that they 
provided restorative procedures that were similar in quality to 
restorative procedures provided by dentists. 

[73] Health officials from the United Kingdom reported that dental 
therapists have not had a major impact on children's access in the 
United Kingdom because patients must first see a dentist before being 
referred to a dental therapist. 

[74] The number of decayed, missing, or filled teeth calculated for 
both primary (baby) and permanent (adult) teeth is a common measure 
for dental disease experience. See J.M. Armfield and A.J. Spencer, 
"Quarter of a century of change: caries experience in Australian 
children, 1977-2002," Australian Dental Journal, Vol. 53 (2008). 

[75] The Saskatchewan school-based dental program was staffed by 
dental therapists and in existence from 1974 to 1993. D.W. Lewis, 
Performance of the Saskatchewan Health Dental Plan, 1974-1980, 
(University of Toronto, Toronto, Ontario, 1981). Although enrollment 
in the program by aboriginal children was much lower, enrollment of 
and access for these children increased over the period of study. 

[76] ASTDD surveyed dental directors in all states and the District of 
Columbia. Respondents were asked to provide the most recent data 
available or data for the most recently completed fiscal year-- 
generally 2008 data for the 2009 survey. See [hyperlink, 
http://apps.nccd.cdc.gov/synopses/AboutV.asp] (accessed July 21, 2010). 

[77] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149]. 

[78] CHIPRA required that HHS post a complete and accurate list of 
dentists participating in state Medicaid and CHIP programs on the 
Insure Kids Now Web site by August 4, 2009. In June 2009, CMS issued 
guidance specifying certain data elements required for each dentist 
listed on the Insure Kids Now Web site, including the dentists' name, 
address, telephone number, and specialty; whether the dentist accepts 
new Medicaid or CHIP patients; and whether the dentist can accommodate 
patients with special needs. 

[79] For all 4 states, HHS's Insure Kids Now Web site allowed the user 
to enter a zip code to identify dentists nearest to the selected zip 
code. 

[80] The World Factbook 2009. Washington, D.C.: Central Intelligence 
Agency (2009). See [hyperlink, 
https://www.cia.gov/library/publications/the-world-
factbook/appendix/appendix-b.html#D] (accessed Nov. 20, 2009). 

[81] We did not perform an independent review of laws and regulations 
of foreign jurisdictions, but relied on information provided by 
officials, government reports, and peer-reviewed research. 

[82] H. R. Rep. No. 111-16, at 451 (2009) (Conf. Rep.). 

[83] Seventy-five-million dollars of the amount appropriated for NHSC 
is to remain available through September 30, 2011. 

[84] PPACA also authorized a total of approximately $31 billion for 
health centers for fiscal years 2011 through 2015, with authorization 
for funding in subsequent years to reflect the growth in costs and the 
number of patients served. However, these amounts remain unavailable 
for expenditure until appropriated. 

[85] PPACA established and authorized and appropriated funding to the 
Community Health Center Fund and directed amounts from this fund to be 
transferred to HHS to provide $9.5 billion in enhanced funding for 
health centers and $1.5 billion in enhanced funding for NHSC. It also 
authorized and appropriated $1.5 billion for construction and 
renovation of community health centers. Pub. L. No. 111-148, § 10503, 
124 Stat. 1004, as amended by Pub. L. No. 111-152, § 2303, 134 Stat. 
1083. 

[86] U.S. Department of Health and Human Services, Indian Health 
Service, An Oral Health Survey of American Indian and Alaska Native 
Patients: Findings, Regional Differences and National Comparisons 
(Rockville, Md.). 

[87] The Alaska Tribal Health System operates using a four-tiered 
approach: (1) statewide services are provided in Anchorage, (2) 
regional services are provided at hubs within the various regions, (3) 
sub-regional clinics operate in some villages, and (4) small village 
clinics are where individuals obtain their primary health care. 

[88] The 2009 encounter data for one dental therapist was only for a 
portion of that year. 

[89] D.A. Nash, J.W. Friedman, T.B. Kardos, et al. "Dental Therapists: 
a global perspective," International Dental Journal, Vol. 58 (2008). 

[90] The countries are presented in chronological order by the date 
their dental therapist program started. 

[91] New Zealand pays for dental services for all children up to age 
13, with most of the services provided by dental therapists in the 
school dental service. 

[92] Historically, dental therapists were trained in a 2-year non- 
degree granting program. 

[93] Dental therapists must be registered with the Dental Council of 
New Zealand--a self-regulating body for oral health professionals. 

[94] Dental therapists register for general dental therapy scope 
practice which allows practice for children up to age 18. Dental 
therapists can register for additional scopes of practice including 
adult care, radiology, and crowns. 

[95] K.M.S. Ayers, A. Meldrum, W.M. Thomson, J.T. Newton. "The working 
practices and career satisfaction of dental therapists in New 
Zealand," Community Dental Health, Vol. 24 (2007). 

[96] The United Kingdom consists of the countries of England, Northern 
Ireland, Scotland, and Wales. Each country has a National Health 
Service administered by Departments of Health that are responsible for 
administering health care. Countries in the United Kingdom have had 
subsidized dental services since the 1920s--known as the salaried 
dental service or community dental service--for which dental 
therapists were originally trained to serve. 

[97] Graduates of the combined programs can register as both a dental 
therapist and a dental hygienist. Historically, dental therapists were 
trained in 2-year hospital-based diploma programs, but since the 1990s 
programs have been offered through bachelor's degree granting programs. 

[98] The General Dental Council is the regulating body for oral health 
professionals. 

[99] The remaining dental therapists worked in hospitals, were 
teaching, or in a combination of positions. The National Health 
Service in each country contracts with independent dental practices--
known as the general dental service--to provide services. Independent 
practices can be reimbursed by the National Health Service for dental 
services to children up to age 18. 

[100] J.H. Godson, J.S. Rowbotham, S.A. Williams, J.L. Csikar, S. 
Bradley, "Dental therapy in the United Kingdom: Part 2. a survey of 
reported working practices," British Dental Journal, Vol. 207 (2009). 

[101] All eight Australian states and territories subsidize dental 
care for children age 5-12, with certain states also paying for care 
to younger or older children. 

[102] Graduates of the combined programs are known as oral health 
therapists and can register as both a dental therapist and a dental 
hygienist. Historically, dental therapists were trained in 2-year non- 
bachelor degree granting programs. 

[103] Australian Institute of Health and Welfare, Dental Statistics 
and Research Unit, Dental Therapist Labour Force in Australia 2005 
(Adelaide: Australia, July 2008). 

[104] Aboriginal populations in Canada are known as First Nations and 
Inuit. Health Canada--the government department responsible for 
administering health care--pays for dental services to all aboriginal 
populations. Private practices and tribes can be reimbursed by Health 
Canada for services rendered to those populations. 

[105] In the 1970s two provinces, Saskatchewan and later Manitoba, 
established school-based dental programs that utilized dental 
therapists to provide preventive and restorative dental services for 
children. The Saskatchewan program had high rates of enrollment and 
successfully reduced the rates of dental caries in children, and was 
privatized in 1987 and eliminated in 1993. Dental therapists that 
previously provided dental services in rural areas either moved to 
urban areas to work in private practice or lost their jobs according 
to a Canadian expert. D.W. Lewis, Performance of the Saskatchewan 
Health Dental Plan, 1974-1980. (Toronto: University of Toronto: 1981). 
The Manitoba program has also since been eliminated. 

[106] The Saskatchewan Dental Therapists Association is the self 
regulating body for dental therapists constituted under Saskatchewan 
law. 

[107] According to a Canadian health official, 52 dental therapists 
were employed directly by Health Canada and 30 were employed by First 
Nations tribes which are funded by Health Canada. 

[108] Dental therapists are not permitted to practice in Ontario or 
Quebec. In Manitoba, a number of dental therapists work in the private 
sector. 

[End of section] 

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