By: Sheryl Smolkin
Read this article at ebn.benefitnews.com
The increasing number of dental hygienists poised to take advantage of legislative amendments permitting them to operate independent of supervising dentists could enhance access to preventative oral health care for both employees and retirees.
The Canadian Dental Hygienists Association Web site cites research linking gum and bone disease to conditions such as heart disease and stroke; pneumonia and other respiratory diseases; diabetes; and premature and low-birth-weight deliveries.
Fran Richardson, Registrar of the College of Dental Hygienists of Ontario, says, “Seeking the right to ‘self-initiate’ was not about setting up practices that look like mini-dentists’ offices. Our members also wanted to be able to reach out to people in places like nursing homes and long-term-care facilities who cannot physically walk into a dentist’s office.”
A current snapshot
British Columbia has permitted independent practice since 1994, with Alberta (2005) and Ontario (2007) subsequently enacting similar changes. Nova Scotia’s legislation is not yet in effect, and Saskatchewan requires hygienists to have an employment relationship with a dentist or an institution that hires a dentist.
In order to self-initiate, Richardson says Ontario dental hygienists must either have quite a bit of experience working with a “standing order” from a dentist or take an additional course. “In addition, new graduates have to both take the course and be mentored by a self-initiating hygienist for six months.”
The Canadian Dental Hygienist Association reports there are over 14,000 dental hygienists across the country. To date, approximately 30 dental hygienists in B.C., 30 in Alberta and 75 in Ontario have set up shop on their own.
But Richardson thinks the Ontario number could grow very quickly. “Over 2,000 of the 10,000 hygienists we regulate now have self-initiation certificates. Most are currently still happy to work with a dentist, but it’s all about choice. They now have the option to provide mobile services or open their own office.”
Group insurers on board
Executive Director of the B.C. Dental Hygienists Association Cindy Fletcher says there are several reasons why, to date, so few B.C. dental hygienists have opted to go solo.
“Restrictions in our statute requiring that the patient be examined by a dentist within 365 days are a tough barrier to overcome. We are lobbying to have this restriction removed. The other barrier has been that, until Alberta and Ontario came on board, insurance companies have not recognized hygienists as service providers,” she says.
Abbotsford, B.C. dental hygienist Paula McAleese has practiced independently since 1997 – both from her own office and in long-term-care facilities. She agrees that until recently, rejection of group insurance claims for her services has been one of her biggest headaches.
However, she acknowledges that within the last year national insurers such as Manulife, Sun Life, Great-West Life, Desjardins and Equitable Life have relented in most cases.
For example, a June 2008 Manulife client information update says that although many benefits contracts still require the supervision of a dentist, based on plan sponsor requests, “We will change our administrative practices for claims originating in [B.C., Alberta, Saskatchewan, Manitoba and Ontario].”
Green Shield Canada is taking a different approach. “We will cover services provided by independent dental hygienists providing the employer specifically requests this coverage
to be included in their policy,” says Green Shield VP of Sales and Marketing Steve Moffat.
Nevertheless, McAleese says, “Some local providers are still a problem. Pacific Blue Cross has not come online yet. There are also a number of self-administered union plans that still haven’t gotten the message.”
Another outstanding issue is that independent dental hygienists have specific codes for billing their services , but they cannot submit claims electronically. “This is something the national association is working on,” says Fletcher.
Undoubtedly, claims for services by independent dental hygienists represent a very small number of the annual dental claims submitted nationally, but Moffat says Green Shield has seen a steady increase from 20 claims in 2006, to 50 claims in 2007 to over 400 in 2008.
In Ontario, the fee schedule for services performed by dental hygienists is roughly 30% below the cost of the same services provided by a dentist, but, McAleese says, “In B.C., our fees are pretty much the same as in a dentist’s office because we are the lowest in the country. The only way an employer would save is on the exam fee, but not on the hygiene fee.”
Yet she still believes the playing field should be leveled for independent dental hygienists in B.C., and employers across the country should review their dental coverage to ensure such services are paid for.
“If I was an employer I’d want to get the costs to insure my employees down to the best level for the best treatment. Some people just want to have their teeth cleaned without committing to dentistry. But if I tell them they have a problem, then they are happy to go to the dentist.”
Services typically provided by dental hygienists
- Assessment of teeth and gums.
- Evaluation of the client’s overall oral health.
- A checkup for oral cancer.
- Debridement (scaling).
- Stain removal.
- Teeth whitening.
- Education and home care recommendations.
Overcoming the dental fear factor
If dentists Brian Price and Howard Rocket have their way, 27% of the 445 survey respondents in the Greater Toronto area aged 18 years and over who reported they are not getting their teeth professionally cleaned by a dental hygienist twice yearly will soon have something to smile about.
Price and Rocket are partners in the Independent Dental Hygiene Centre Inc. They are also the entrepreneurs behind the Tridont Dental Centres that opened 107 locations across Canada in the 1980s.
Their first Toronto dental hygiene centre opened at Yonge and Eglinton in July 2008, and a second branch at Yonge and Sheppard began accepting clients in October. They plan to eventually establish a network of independent dental hygiene clinics across the city.
“Seventy percent of our patients are not insured. Thirty percent do have coverage,” says Price. “People we cater to either can’t afford up to $200 for a cleaning or they absolutely won’t go to a dentist at all because they are afraid of what else goes on there.”
In other cases, he says people come in to have their teeth cleaned before a special event or even before they go to their own dentist. “I guess the rationale is they want to show their dentist they have been keeping their teeth clean.”
Lower Costs, Better Health
From the perspective of a dental plan sponsors, Price thinks the availability of independent dental hygienists can help. “My understanding is that there are three different fee schedules: the fee schedule a dentist will charge when a hygienist is employed; the fee schedule when a hygienist operates independently; and our fee schedule, which is even lower,” he says.
When there is a squeeze on benefits in this new economy, he says some companies may be willing only to pay for two visits a year to a hygienist. “Another alternative is to say, ‘You have a maximum of $1,000 to spend on dental treatment each year,’ and if the employees use our services, this amount will go a lot further.”
He also sees potential for better health outcomes, particularly among those individuals who do not regularly see a dentist. “If you do nothing but come to one of our offices once a year for a cleaning, there are three major advantages. You get your teeth cleaned twice and you find out what else is going on in your mouth. If you have oral cancer, for example, or some other serious condition, at least you will be told what to do.”
After the partners are sure all the kinks have been worked out, Independent Dental Hygiene Centre Inc. plans to open other locations and sell franchise According to Price, there have already been 54 enquiries about franchising opportunities.
IDHC employs receptionists and licensed dental hygienists who perform only two procedures – cleaning and tooth whitening. Price says, “We could do X-rays but we won’t. Once we start increasing our overhead costs by buying equipment etc. the margin that makes us attractive starts to dissipate.
And because hygienists cannot give a diagnosis, it makes more sense to leave radiographs to dentists.”
He also points out that a hygienist can tell an awful lot without X-rays and subsequently advise the client to see a dentist or other medical professional for follow-up. “If they do not have a dentist, we will give them the number of the Royal College of Dental Surgeons. We do not give referrals to individual dentists.”