KIRKSVILLE — Only 13 of 114 counties in Missouri have enough dentists, but a new dental school in Kirksville hopes to raise that number by graduating dentists with a public health mission.
When it opened Tuesday, A.T. Still University’s Missouri School of Dentistry & Oral Health became the state’s second dental school, joining the University of Missouri-Kansas City’s School of Dentistry.
A closely related issue to Missouri’s poor dental health is the low reimbursement rate on dental services. Missouri reimburses 42 cents on the dollar for every hour of service. Missouri Dental Association Legislative Director Patrick Baker said increasing the reimbursement rate would help dentists.
“If we only got paid 42 cents for every dollar of our work, we wouldn’t want to do our jobs,” Baker said.
Due to this low reimbursement rate, Shuler's practice does not accept Medicaid. Shuler said the reimbursement rate is so low that it doesn't even cover his expenses.
In 2011, 824,400 Missouri residents were enrolled in the Missouri Medicaid program, almost 14 percent of the state’s population, according to the “2013 AARP Survey of 45+ Missouri Resident on Medicaid Expansion.” Currently in Missouri, different counties have different networks for providers and billing. This results in a complicated tangle of overlapping red tape. Baker said having only one set of rules would alleviate some of the problem.
“Either the state would create a provider networks or the state would contract with one managed care entity,” Baker said. “A streamlined system would increase a utilization of the program.”
The bill, Senate Bill 127, passed legislature this year, and the Missouri Dental Association will continue to lobby for the executive branch to implement the bill as legislature passed it. Baker said the bill would incentivize dentists to participate as Medicaid providers.
The Kirksville-based school’s inaugural class of 42 students was selected from a pool of 954 applicants. Although the class of 42 includes only nine Missouri residents, the school hopes its health center placement program will persuade many of its graduates to remain in the state.
Elements of a shortage
Missouri ranks 41 out of 50 states in adult oral health based on the percentage of adults who regularly visit the dentist. But the low number of dentists is not the only factor holding down the ranking. The state's dentists are retiring more quickly than dental schools can graduate new professionals.
Missouri’s dentist age distribution shows that the average age of dentists in the state is higher than the rest of the country, according to a survey called “Missouri’s Oral Health: Understanding and Overcoming Barriers to Oral Health Access.” Missouri’s population of dentists over the age of 45 is 6.5 percent above the national average, and its population of dentists over 55 comes in 8.4 percent higher.
Gary Harbison, executive director for the Missouri Coalition for Oral Health, acknowledged the aging population of the state's dentists. He said there are programs in place to introduce oral health professions to young students, including one through Missouri’s Area Health Education Centers and another at the federal level through the Department of Health and Senior Services.
Meanwhile, Missouri dentists are retiring faster than new dentists are getting degrees. In 28 counties, at least 50 percent of dentists plan to retire within the next 10 years, according to an analysis conducted for the Department of Health and Senior Services, giving a sense of urgency to efforts to train more dentists.
With a patient-to-dentist ratio of 2,168-to-1, Missouri is in worse shape than 90 percent of the nation. The national average is 1,516-to-1, according to county rankings from the Robert Wood Johnson Foundation.
Boone County has a patient-dentist ratio of 1,832-to-1, making it one of only 16 counties in Missouri with a ratio better than the state average. Some counties are much further from the mid-line; 11 counties have more than 10,000 patients per dentist, and seven have no dentists.
The concentration of dentists is highest in Columbia, Kansas City, St. Louis and Springfield.
“They’re few and far between in rural areas,” said Joseph Pierle, CEO of Missouri Primary Care Association.
The scarcity has affected Missouri's adult population. Less than 64 percent of Missouri adults saw a dentist during a 12-month period studied in the 2010 Behavioral Risk Factor Surveillance System survey. That's the statistic that has earned Missouri its low ranking.
“The fact is that we have a large segment of the population that does not have access to oral healthcare services,” Christopher Halliday, dean of A.T. Still University, said.
Dentists with a public health focus
The new dental school in Kirksville aims to increase awareness of underserved populations and provide on-the-job clinical training.
It began when representatives from A.T. Still University met with Missouri's network of health centers two or three years ago to discuss access for the underserved. Missouri Primary Care Association, a public health advocacy organization, was called in for the conversation.
“There are shortages that face most counties, especially rural Missouri,” Pierle said. “That’s when we had the idea of creating a dental school with home base in Kirksville.”
During their first two years, students will learn through simulations and classroom lectures. In their third year, they'll work at Grace Hill Health Centers, Inc., a community health organization in the St. Louis area. The center has six locations offering services such as pediatrics, public housing, OB/GYN, mental health services and transportation services. One of the centers will operate as a dental clinic for the school.
“There is an insufficient number of (dental) training programs in the Midwest,” said Alan Freeman, CEO and president of Grace Hill Health Centers. “This collaboration with A.T. Still is the most expansive yet.”
The school's collaboration with Grace Hill will connect students to an underserved urban population. Its dentistry services include preventative care and routine care, as well as community outreach like a mobile dental service for the homeless.
To put in perspective how much the students are needed, Grace Hill provided health services to more than 41,000 individual patients in 2009, according to the most recent data. Nearly 60 percent of patients had no health insurance, and more than 90 percent were under the federal poverty level.
During the fourth year of the program, students will work in community health centers across the state, including in rural areas. Students may also work at Veteran’s Administration clinics or Indian Health Service clinics, where Halliday once served as director and chief dental officer, according to the school’s website.
The public-health-centered rotations are not without their agenda.
“It’s a better opportunity to recruit,” Pierle said. “We are working aggressively to secure loan repayment at either the state level or through federal programs to incentivize [students] to serve in rural communities.”
Upon completion of the four-year program, every student will receive a certificate in public health, with the option of pursuing a master’s degree in public health, Halliday said. He defined public health as providing "the greatest amount of health services to the greatest possible number of people.”
Not having adequate dental health is no small matter. Halliday talked about the impact poor oral health can have on overall health, pointing to a direct correlation with diabetes, cardiovascular disease and pulmonary disease.
'Go where you're needed'
With so many counties in the state down to their last dentist, the school's graduates will have their pick of places to practice, if they can afford to start their own practice and pay off their student loans.
Ronald Shuler is one of five dentists in Moniteau County, which has a patient-dentist ratio of 4,234-to-1. He's been a dentist for 50 years and doesn't plan to retire, even though he's 78. He has two chairs in his practice in Tipton and says he sees 18 to 20 patients a day.
"I have an important position in this little town of 3,000," Shuler said.
Shuler said he serves patients from surrounding cities in mid-Missouri in addition to Tipton residents. He said that's because he's affordable. Shuler's practice accepts all dental plans and insurance except Medicaid, and he offers a zero percent interest financial plan to patients.
What Shuler calls the "financial problem" of dental care affects not only the cost to patients, but the cost to dentists as well. He said that "astronomical" student loans cause many students to end up in debt before they've even had a chance to buy or open their own practice. That means most dentists end up working as associates under another dentist rather than running their own practice, he said.
His solution: Go somewhere people need you.
"Go to a rural area where you're needed," Shuler said. "Buy your own practice and don't work for somebody else."
Supervising editor is Katherine Reed.
In Mercer, Chariton and Shannon counties, there are no practicing dentists. More than a dozen Missouri counties have one or fewer dentists per 10,000 residents. Graphic by Joey Fening
Missouri’s shortage of dentists could get worse soon. Missouri has a higher percentage of dentists older than 55 than the U.S. overall, which means a large number of dentists here may soon be headed for retirement. Graphic by Graciela Aguilarleon