New Mexico goes big and goes small

New Mexico is fascinating right now on the health policy front. They are going big:

New Mexico has been working towards a Medicaid buy-in program for a couple of years now. They have outlined options and weighed some of the trade-offs. Right now an off-exchange only buy-in is the simplest lift but they are thinking about other, more comprehensive and more complex, options as well.

And New Mexico is going small:

The bill passed the house. It will expand the scope of practice for dental technicians to do more. Dental therapists have started to become common on the West Coast and the Mountain West as a way to get some services out into under-served communities including American Indian reservations. Dental therapists should put some downward pressure on provider pricing. It is a step that addresses an immediate need of taking care of teeth, an intermediate need of placing downward pressure on some medical prices, and a long term objective of reducing inflammation which should reduce negative health events.

New Mexico is going big and New Mexico is going small. Successfully changing systems of care require both. And these two things don’t need to be locked together. If you live in a state that can’t or won’t go big, you still likely live in a state that can go small. Little nudges and hip checks are useful correctives.






22 replies
  1. 1
    satby says:

    Both great news. One of the reasons my former employer, the eye doctor, moved from IL (home of the AMA HQ) to IN was because in IL she was restricted from prescribing simple medications like for pink eye. As an optometrist she had been trained to identify and treat the eyes, but since the AMA kept a stranglehold on the ability to prescribe medicines, she had to refer even simple conditions to an ophthalmologist for treatment. Delays in treatment and at minimum double the time and expense for patients.

  2. 2
    rikyrah says:

    I am very interested in the Medicaid buy-in. I think other states should do it.

    Thanks for the information about the dental care, too, Mayhew.

  3. 3
    O. Felix Culpa says:

    Proud of my state. A lot of good legislation happening, after 8 years of pig-headed obstructionism by our thankfully former R governor. Once again goes to show that elections matter. And electing Dems matters A LOT.

  4. 4
    Karen says:

    What is the difference between a dental therapist and a dentist?

  5. 5
    O. Felix Culpa says:

    @Karen: I think it’s similar to the difference between an MD and a physician’s assistant.

  6. 6
    O. Felix Culpa says:

    @O. Felix Culpa: FYWP won’t let me edit: make that Physician Assistant.

  7. 7
    Yutsano says:

    I’ll do some research when I get home tonight, but if dental therapy can get listed as a benefit in the FEBHP dental plans that could help it take off hugely. The largest insurance pool in the country yet our debtal coverage is complete ass.

  8. 8
    Carol Johnson says:

    @Yutsano: It does suck ass. FEBHP in retirement. My case is textbook for these innovations. Just enough income to go over the Medicaid limit, but far from being able to pay for everything on my own. Thankfully, I have the FEBHP for some coverage, but doing that has copays, which for a diabetic, can be fairly substantial for insulin and doctor visits. A buy-in depending on how much the payment costs would at least help. Also, a buy-in would insure coverage for the people who retire early who don’t get much coverage until Medicare.

    And dental coverage sucks ass, regardless. I tried before retirement, and it’s inadequate. I’ve needed a partial for decades, and could never afford the extensive work needed. I would rather have implants now, but who covers that either? At least dental assistants would be allowed to do basic exams, teeth cleaning and referrals if they see something beyond their expertise.

    That brings me to a final point about universal care: we don’t get the numbers, either financially, or coverage-wide unless we empower para-professionals. A lot of physicians do things that are pretty routine just because of outdated laws regarding who does what. That raises the costs of service, and of course, if the physician is needed for something more major, it doesn’t get done or done later. We can improve coverage doing this.

  9. 9
    Yarrow says:

    Dental really should be part of medical. It’s becoming more clear that there’s a connection between dental health and overall health. Fix the teeth and other things can clear up. I know someone personally who had this happen. It works the other way too–dental problems cause health problems that heave to be treated.

  10. 10
    Ian R says:

    @Yarrow: Likewise vision. “We cover all of your health problems, unless they occur in your mouth or eyes” is a really weird policy that only exists by historical accident.

  11. 11
    laura says:

    Does the Medicaid buy in come with a claw back? My mom’s care facility was covered by Medi-Cal and our biggest worry was that the State would seek reimbursement after she died, wiping out every thing she and dad worked for, including their home.

  12. 12
    Kelly says:

    Since the Republicans killed most of the health insurance co-ops making the insurance companies compete with Medicaid seems an appropriate response.

  13. 13
    Yarrow says:

    @Ian R: Also, coverage for feet (podiatry) is iffy. Because feet are totally separate from the rest of you, just like teeth and eyes.

  14. 14
    Jager says:

    Dental coverage is essential, I had a couple of lower teeth knocked out in a high school hockey game. Over the years I’ve probably invested over 30k in my mouth, maybe more. Lose a couple of teeth and you’re guaranteed to lose more as the years go by. Those two teeth I lost at 16 have morphed into a 5 tooth bridge anchored by two implants.

  15. 15
    oatler. says:

    @Jager: Lack of dental coverage is a huge blight on our healthcare system.

  16. 16
    Jager says:

    @oatler.:

    A former teammate of mine, just had a full upper plate installed after his implants failed. The cost? Just under 12k! Sure you can get it done for less, but as he said, “There are no bargains in the world of dentistry.”

  17. 17
    StringOnAStick says:

    I’m a dental hygienist, and this move to create dental therapists has been going for awhile now but with a lot of push back from dentists, especially the corporate chains that make their money by offering a $29 first visit and then finding tons of need for fillings, often excessively diagnosed for greater profits or to fill the dentist’s monthly treatment quotas. Obviously people with no dental insurance or inadequate plans tend to end up at these big chains, and then end up paying even more since they are often very, very aggressive about what actually constitutes a “cavity” that needs to be filled or upcoded into a crown, root canal treatment, etc. It’s a real problem but they are the money bags in the dental profession now so they exert a lot of control over the state licensing boards plus over the wording of the Dental Practice Acts each state has that govern the practice of dentistry. Only a Registered Dental Hygienist can legally clean below the gumline; an assistant can clean children’s teeth above the gumline but that’s it, no adults, no below the gumline. As an RDH I can diagnose periodontal disease but I have to practice under the supervision of a dentist and I legally can not read X-rays with regard to finding decay (I do read them for looking for periodontal disease indicators as that is legally within the scope of practice for RDH’s).

    Dental therapists in my state (CO) are Registered Dental Hygienist like I am but have had extra education and certification, and can do simple fillings in addition to their RDH duties. They can’t do complex fillings, root canals, or anything other than a simple extractions; I think I recall that they can do “out of the box” crowns, meanings ones that aren’t made at a lab to match your tooth, just prefab ones that look good enough and come pre-made in a range of sizes. The way the rules are written here, the only place these Dental Therapists can practice is in underserved communities like small towns that have no local dentist, so they aren’t going to suddenly open an office in the middle of Denver and start charging less than a dentist. No way in hell are the state dental association going to allow that to change because the dentists and the corporations will fight that with fire and to the death.

    You want the Dental Therapist to be an RDH with advanced training, not a dental assistant. I love the dental assistants I work with but there is a HUGE difference in our education and licensing because we perform very different jobs. As an RDH I had to obtain a degree at an accredited institution, sit for a board exam (written and practical), carry liability insurance, and maintain a license that also requires continuing education efforts. A dental assistant may or may not have taken a 6 week vocational program or have just been trained by the dentist who hired them, they have no license, no liability insurance requirements, no continuing education requirements other than having to pass a short class about radiation and X-rays once in their career. An RDH in most states can give nerve blocks (numbing injections); in no state is a dental assistant allowed to do that.

    One solution if you need expensive dental work and can’t afford it is to go to Yuma, AZ and get the work done by walking across the border into Mexico. I don’t remember the name of the city in Mexico, but it’s basic reason for being there is for dental care to US and Canadian residents who can’t afford the work in their home countries. The size of the parking lot for this purpose on the US side is huge (and you have to pay to use it of course). Some friends of mine just did this after doing a lot of research into which dentist to go to there, and he got what would have been $9,000 of work here done for about half that.

    I agree the cost of dentistry sucks, and then I go look in our supplies catalog and see how outrageous the prices are that we pay for our specialized materials and supplies. All the disposable things I use in my work are at least $1 each. I sometimes use a single drop of a desensitizing agent for a patient with hypersensitive teeth; the tiny, tiny bottle it comes in is just over $100. Sometimes I use a gel numbing agent for people with touchy gums; we don’t charge to use it but it’s about $20 because it is packaged for single use. The sterilization equipment, sterilization bags, required testing of the autoclave, etc, is about 1/3 of an office’s overhead costs, and we haven’t even talked about how expensive the white resin filling materials are, or the cost of custom crowns (some places are having their custom crowns made in India or Mexico now and Fed Ex’d back). Yes, a dentist makes a good living; the new ones coming out of school average about $500,000 in student loan debt so they have a big nut to cover to start their professional careers (just one more place where we make medical and dental too expensive is the education costs). I volunteer for charity dental work though what they really need more of are dentists helping in that effort; getting a cleaning done when what you need is the same work every 3 months or acres of decay addressed is like putting lipstick on a pig. I still do it though because the need is so great. People will start lining up at 2 am in order to not miss the daily cut off of who can be seen that day. It’s heart breaking.

  18. 18
    good2go says:

    @Carol Johnson: Amen. Read Dean Baker’s “Beat the Press” blog. He rails at the fact that the US has forced most workers to compete in a global marketplace, but not doctors, pharma, software producers, and other professionals (who happen to make large political contributions). They yak yak yak about capitalism, but what they DO is monopoly.

  19. 19
    rikyrah says:

    @StringOnAStick:

    thanks for all the info.

  20. 20
    laura says:

    @StringOnAStick: the downside is most American dentists will refuse to treat after work is done outside the US. There’s also a good deal to be had in Brookings Oregon. Assembly style oral surgery/implants, and no sales tax if that’s an option.
    Our friends and family are losing teeth at a pretty good clip. I got the bad news that 2 back teeth have to be pulled with only one having a bridge or implant option.
    The phrase “death comes through the gums” has worked its way into the conversation when we gather. :(

  21. 21
    AM in NC says:

    Thank you, David, and thank you StringOnAStick for the great information. Excluding certain parts of the body from medical insurance coverage is for the benefit of the insurers. I am more than ready for a system that is for the benefit of the patient.

  22. 22
    Paula says:

    @StringOnAStick: And of course the deep pockets of the payers (health plans, employers) make these excessive costs possible, not just for dental but for prescription drugs too.

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