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Dental practitioner bills could undercut care of the developmentally disabled
Sometimes even well-intentioned bills in the Legislature can have unintended impacts, and we’re concerned about two such bills that authorize mid-level dental practitioners to perform basic dental procedures in order to address under-served populations around the state.
Versions of one of the bills are being promoted in several states, including Massachusetts, by the Pew Charitable Trusts. The second bill is being promoted by the Massachusetts Dental Society.
While we appreciate the intent behind the bills, we are concerned that passage of either one as currently written could actually result in the loss of existing services to clients of the Department of Developmental Services.
If either bill is enacted, many DDS clients, who are currently served by experienced dentists, could be switched by the administration to less skilled and experienced practitioners as a money-saving measure.
Backers of the Pew Trusts bill (S. 1169) point out that large numbers of adults and children in this and other states around the country are unable to access dental care either because they live in under-served areas or because only about a third of U.S. dentists accept publicly provided health insurance.
Under S. 1169, practitioners known as “dental therapists” would work under supervisory agreements with dentists, and would be authorized to do such things as fill cavities, extract teeth, and apply crowns. While this may work well for patients in the general population, we don’t think it is workable for many people with developmental disabilities who require dentists with advanced skills and significant experience.
As such, we would not support either S. 1169 or the competing bill from the Massachusetts Dental Society (S. 142) unless either bill contained language specifying that dentists must continue to treat persons with developmental disabilities.
The primary sponsors of S. 1169, Senator Harriette Chandler and Representative Smitty Pignatelli, maintain that hundreds of thousands of children covered by Masshealth in Massachusetts do not regularly see a dentist.
However, it has apparently not been as difficult to find a dentist for people with intellectual and developmental disabilities (ID/DD). Right now, the availability of dental services to persons with ID/DD appears to be quite high in Massachusetts. The Massachusetts Developmental Disabilities Council’s (MDDC) State Plan for Fiscal 2017 states that between 90% and 97% of DDS clients have continued to receive annual dental exams.
Some 7,000 developmentally disabled persons in Massachusetts receive dental care in seven state-funded clinics run by the Tufts University School of Dental Medicine. Pediatric dentistry is offered by Franciscan Hospital for Children.
Despite that high level of service provision, we have seen in the past that administrations have proposed elimination of some of the Tufts clinics in order to save money. Strong opposition from families of DDS clients helped to preserve at least one such clinic temporarily at the now closed Fernald Developmental Center, but that clinic was ultimately closed.
Our concern is that as currently written, either S. 1169 or S. 142 might actually give the Baker administration an excuse to reduce funding for the Tufts clinics because those clients could now presumably be served by the dental therapists or hygienists, as authorized by the legislation. If that is the case, there could be an increasing impetus to close additional Tufts facilities for those clients.
Moreover, while S. 1169 requires that the dental therapists receive training in treating people with ID/DD, the therapists would certainly not have the expertise or experience of the dentists in the Tufts clinics. The bill actually doesn’t specify the amount of training the dental therapists would be required to receive.
The Tufts Dental school declined to comment on either bill. Dentists themselves in Massachusetts oppose S. 1169, arguing that it does not provide for sufficient training of the dental therapists or direct supervision of them in all cases. The dentists also fear the use of dental therapists could lead to reduced reimbursement rates from insurance companies.
The Dental Society’s bill (S. 142) would establish more stringent educational and supervisory requirements regarding mid-level practitioners than does S. 1169. The Dental Society bill would require, for instance, that mid-level practitioners, which S. 142 refers to as public health dental practitioners, be under the direct, on-site supervision of a dentist at all times.
If either bill does pass, we would urge that language be added to prohibit the dental therapists or public health dental practitioners from having authorization to treat people with ID/DD unless an individual’s guardian specifically requested it.
We think that language along those lines would potentially protect existing dental services for people with ID/DD. Allowing guardians to request the therapists or public health dental practitioners would keep those options open if full dental services were not available for a developmentally disabled individual.
We emailed a Pew Charitable Trusts dental campaign officer on February 17 to express our concerns about the S. 1169, but have not as yet received a response from him.
Last week, I also contacted a legislative aide to Senator Chandler, who defended S. 1169, contending that it would would not result in reduced services to persons with ID/DD, but would “strengthen Tufts” and allow them to provide the same services at a “slightly lower cost.”
The aide said he would convey our concerns to Senator Chandler and would try to arrange for someone from Pew to get back to us with their response to our concerns. As noted, that hasn’t happened yet.
No one from Rep. Pignatelli’s office has yet responded to an email we sent early last week.
S. 1169, which currently has 30 co-sponsors from the House and Senate, has been referred to the Legislature’s Public Health Committee. Please call the Committee at (617) 722-1206 and urge them to insert language into the legislation to prevent dental therapists from treating people with developmental disabilities unless a guardian requests that. Or you can email the co-chairs of the Committee — Senator Jason Lewis ( Jason.Lewis@masenate.gov) and Representative Kate Hogan (Kate.Hogan@mahouse.gov).
The Massachusetts Dental Society’s bill (S. 142) has been referred to the Consumer Protection and Professional Licensure Committee. That bill should also be amended to include our protective language. Please call that Committee at(617) 722-1612. Or you can email the co-chairs — Senator Barbara L’Italien (barbara.l’italien@masenate.gov) and Representative Jennifer Benson (Jennifer.Benson@mahouse.gov).
DDS providers pushing Gov. Baker to phase out state-run care
The major lobbying organizations for corporate providers to the Department of Developmental Services appear to be pushing the Baker administration and the Legislature to privatize more and more state-run care.
And the administration and Legislature have so far appeared to be more than willing to accommodate the providers.
Governor Baker’s Fiscal Year 2018 budget, which he submitted to the Legislature last month, further widens a spending gap between privatized and state-run programs within the Department of Developmental Services. In doing so, it appears largely to satisfy budget requests from both the Arc of Massachusetts and the Association of Developmental Disabilities Providers (ADDP).
In fact, the increase proposed by the governor in funding for privatized group homes is $26 million more than the $20.7 million increase the Arc had sought. The ADDP may be a little disappointed only because that organization had asked for a $176 million increase in that account!
The chart below shows the widening gap in funding for key privatized and state-run DDS services over the past several years, adjusted for inflation. Under this trend, funding for corporate-run, residential group homes, in particular, has risen steeply while funding for state-operated group homes and developmental centers continues to be stagnant or cut.
For Fiscal 2018, the Arc requested a $20.7 million increase in funding for privatized group homes (line item 5920-2000), and the governor obliged with an even higher $59.9 million, or 5.4 percent, increase, as noted.* The ADDP, as noted, wanted a $176 million increase in that line item.
In the privatized community day line item (5920-2025, not shown on the chart), both the Arc and ADDP asked for a $40.2 million increase, and the governor responded with a proposed $13.6 million increase.
At the same time, both the Arc budget request for Fiscal 2018 and the ADDP request effectively asked for zero increases in funding for the state-run DDS accounts. Those include accounts funding state-operated group homes, developmental centers, and departmental service coordinators. (The column labeled “Request” in the linked Arc budget document is left blank for those state-run program line items. The ADDP budget request simply doesn’t include those line items.)
The governor appears to have more than obliged the provider organizations regarding those state-run accounts as well. His Fiscal 2018 budget proposes a $1.8 million cut in the state-operated group home account (5920-2010). This amounts to a $6.9 million cut when adjusted for inflation.
In addition, the governor is proposing a $2.4 million, or 2.2%, cut in the state-run developmental centers line item. (5930-1000). That’s a $4.9 million cut when adjusted for inflation.
And the governor is proposing a cut of $96,000 in the DDS administration account (5911-1003). That is a $1.7 million cut when adjusted for inflation, and means a likely cut in funding for critically important DDS service coordinators, whose salaries are funded under the administrative account.
It’s well known that the Arc and the ADDP oppose developmental centers because those two organizations oppose congregate care for the developmentally disabled and support only care in group homes or smaller settings. What may not be as well known is that the Arc and ADDP appear to have no interest in more funding for service coordinators or state-run group homes, in particular.
Late last month, Baker submitted his proposed Fiscal 2018 budget to the Legislature’s House Ways and Means Committee. In a letter to Representative Brian Dempsey, the chair of the budget panel, COFAR requested that, at the very least, the committee approve a plan to redirect some of the governor’s proposed increase in the corporate residential account to the state-operated group home, facilities, and service coordinator accounts.
(We would note that we have been urging this kind of redirection of funding for the past two years, and neither the governor’s office nor the Legislature are listening.)
Service coordinators
Service coordinators are DDS employees who help ensure that clients throughout the DDS system receive the services to which they are entitled under their care plans. In recent years, funding for service coordinator salaries has failed to keep up with their growing caseloads.
A reason for the Arc’s apparent disinterest in service coordinators may be that the organization has long promoted privatized “support brokers,” in which the Arc is financially invested.
The job descriptions of the Arc support brokers and the DDS service coordinators appear to be quite similar. The Arc notes on its website that “consumers or families hire a support broker to help them find appropriate services and supports to thrive in their community.”
The job description of DDS service coordinators states that they are responsible for “arranging and organizing DDS-funded and generic support services in response to individual’s needs.”
COFAR Executive Director Colleen M. Lutkevich terms the DDS service coordinators “the eyes and ears that make sure that the providers who report to DDS are doing their best for the residents in a large, confusing system. Without them, the provider agencies have total control, and families do not even have a phone number or a name to call outside the provider they are dealing with.”
Underfunding of state-operated group homes
In addition to provider-run group homes, DDS maintains a network of state-run group homes that are staffed by departmental employees. State workers receive better training on average than do workers in corporate provider-run residences, and have lower turnover and higher pay and benefits.
State-operated group homes provide a critically important alternative to the largely privatized residential care system that DDS oversees. But we have found that DDS routinely fails to offer state-operated homes as an option for people waiting for residential care, and instead directs those people only to openings in the privatized residences.
To be clear, we do not object to a highlight of Governor Baker’s budget — his proposed $16.7 million increase in the DDS Turning 22 account, which would amount to a 222% increase in that account over the current year appropriation. Turning 22 funds services for a growing number of developmentally disabled persons who leave special education programs at the age of 22 and become eligible for adult services from DDS. This account has been historically underfunded.
But our concern is that as they enter the DDS system, those 22-year-olds will be placed almost exclusively in privatized programs. An important choice is being taken away from them and their families.
As we noted in our letter to the House Ways and Means chair, the pattern of privatization in Massachusetts state government has become almost permanently established even though the benefits of privatization are highly debatable. Many questions have been raised about the privatization of prisons and the privatization of education in Massachusetts and elsewhere around the country.
The privatization of human services may be the biggest prize of all for government-funded contractors. We need to preserve what’s left of state-run services.
(*The $59.9 million figure for the governor’s proposed increase in the corporate provider line item is based on numbers provided by the nonpartisan Massachusetts Budget and Policy Center. The Arc’s budget document claims the governor’s requested increase was $46.7 million.)
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