By Phil Cauthon
October 03, 2013

Advocates for licensing a new class of dental provider in Kansas for years have been pushing for passage of legislation that would allow advanced hygienists to do things such as temporary fillings, tooth extractions, and filing sharp edges off teeth.

They say approval of a new type of dental practitioner would help address Kansas’ large and growing shortage of dentists by letting hygienists with additional training perform common, routine procedures.

But the state’s leading dentist association has opposed the move, saying only those with the advanced training of a dentist can do the work safely.

The gridlock has entered a new phase. The two sides have entered formal mediation with the goal of finding a compromise they can take to the Legislature for consideration.

The Kansas Dental Association and the Kansas Dental Project — which represents various interests pushing for the licensing of mid-level dental providers — agreed to share the cost of a professional mediator.

As part of the negotiation ground rules, each side agreed to avoid publicly discussing the mediation process or what it might produce.

“Sorry, I cannot comment on any discussions we may be having,” Kevin Robertson, the dental association chief executive, wrote in an email to KHI News Service.

“The process we’re engaged in is confidential and privileged and I’m not at liberty to talk about it,” said Shannon Cotsoradis, chief executive of Kansas Action for Children, a group that is part of the Kansas Dental Project.

Mediation typically involves a neutral third party, often a lawyer with advanced training in negotiating compromises. The mediator works with the disputing parties to find legally binding middle ground. Mediation is most commonly used in an effort to avoid the costs of a lawsuit.

The process generally requires that both parties abstain from public comment to avoid upsetting the discussion or the perception that one side is jockeying for a stronger public relations position.

While common in the private sector, it rarely results from legislative stalemate — at least in Kansas — said Larry Rute, partner and co-founder of Associates in Dispute Resolution, a Topeka mediation firm.

“It’s not very common. It should be more common, and in some states it’s very common. But not in Kansas,” Rute said.

Rute said he helped mediate a similar impasse about 15 years ago.

“The Legislature was at war over some provision in the Protection From Abuse Act,” Rute said. “The committee working on it was under a lot of pressure.”

A group of mostly fathers was arguing they were too often subject to frivolous lawsuits under the law. A group of mostly mothers said the law was not strong enough.

“The committee — facing public outcry on both sides of this issue — sent it off to a mediation to reach a compromise on what the legislation was going to look like,” Rute said.

“Sometimes the parties need a private meeting to discuss these things, outside the light of the press, the spotlight. So, often these meetings are held at a location not to be disclosed — just get everybody in there and talk,” he said.

In the case of the dental dispute, the mediator’s brokered resolution — should there be one — is not expected to be made public until proposed legislation is introduced, if then.

In private mediations it is not unusual for there to be no public disclosure of the resolution.

But in public policy mediations, Rute said, “the end result is often not confidential. The end result is normally out there: Here’s what we’ve agreed to.”<a name=”dentists-not-opposed”></a>

Rute said mediations generally boil down to one party deciding it has more to gain from compromise than from risking an outcome it cannot control.

“What has to be considered by the dental association is ‘if we don’t agree, what’s the worst thing that’s going to happen to us?’ They have to look at what that’s going to be in terms of reputation and actual dollars.”

Among the association’s considerations, Rute said, could be the cost of lobbying to prevent changes in dental laws, the cost of existing relationships with lawmakers, and the reputation of dentists statewide.

Dr. Daniel Minnis of Pittsburg — who is among a handful of dentists who support licensing middle-level providers — said it is clear to him what is at stake in the negotiations.

“If the Legislature sees that the Kansas Dental Association is not looking out for the best interests of the general public…that is, if they stonewall this, then the Legislature is liable to accept a dental mid-level provider proposal,” said Minnis, who helped write the latest proposal, put before the Legislature last session.

“If you refuse to put providers out in areas where we have dental shortage areas, who suffers? It’s the children, the vulnerable populations, the frail elderly and handicapped,” he said.

Minnis said he was glad to see the parties sit down but skeptical that a meaningful compromise would be struck.<a name=”medicaid”></a>

“I think it’s just one of those things where, until the Legislature does something, we’re not going to get any closer to it,” he said.

That has been the case in most of the 15 or so states actively pushing their legislatures to license mid-level dental providers. So far, only Alaska and Minnesota have approved the licensing.

In Nebraska, “the dentists have won,” said Dr. Jim Cossaart, who lives in Narka, which is north of Salina, but practices in Hebron, Neb.

“It’s a lot of push and shove and the dentists are going to have to give something up,” he said. “There’s no way that the number of dentists that are out there can serve the population, particularly the low-income population.”

Cossaart said he only accepts Medicaid patients from Nebraska — not Kansas.

“The Kansas compensation rate for Medicaid is so poor, you’re not even covering your costs for what you do. The Nebraska rate is better and covers more things,” he said.

“Kansas has one of the worst rates I’ve ever seen. They just flat out neglect their people. The state of Kansas has its funding priorities all wrong. From a health care perspective, low-income people aren’t getting enough help,” Cossaart said.

Mid-level training ‘simply not adequate’

Robertson, the dental association’s chief executive, also has urged the Legislature to raise Medicaid reimbursements as a way to improve access to oral health care.

The association has also launched its own initiatives to improve access, including a scholarship program for dental school graduates who agree to locate in an underserved area.

But one thing most dentists simply will not support, Robertson has said in earlier phases of the dispute, is allowing non-dentists to drill and fill teeth.

“A maximum 18-month training is simply not adequate for a dental hygienist to learn restorative dental surgical procedures, science, anatomy and emergency treatments,” Robertson said in an April 2012 interview.

He has said the proposals to license mid-level providers in Kansas would lower the standard of care to all patients.

“Why should the U.S. (or) Kansas lower the standard of care for oral care that is the gold standard for the world?” he said.

Read more from the Kansas Health Institute.