DHAT’s and Tribal SovereigntyDHAT’s and Tribal SovereigntyA Snapshot of Problems and PotentialsA Snapshot of Problems and Potentials

Northwest Portland Area Indian Health Board Northwest Portland Area Indian Health Board PresentationPresentation

Swinomish-Upper Skagit Dental Swinomish-Upper Skagit Dental Clinic-BackgroundClinic-Background

The Swinomish Indian Tribal Community is the federally The Swinomish Indian Tribal Community is the federally recognized entity comprised of the aboriginal Swinomish, recognized entity comprised of the aboriginal Swinomish, Lower Skagit, Kikialus and Samish tribes.Lower Skagit, Kikialus and Samish tribes.

The Swinomish Indian Tribal Community has a 10 The Swinomish Indian Tribal Community has a 10 square mile reservation, created as a result of the Treaty square mile reservation, created as a result of the Treaty of Point Elliot in 1855, which was signed in exchange for of Point Elliot in 1855, which was signed in exchange for giving up land title to over 500 square miles of Northwest giving up land title to over 500 square miles of Northwest Washington Washington

Location of Reservations in the State of Location of Reservations in the State of WashingtonWashington

Swinomish Canoe FamilySwinomish Canoe Family

Swinomish Dental ClinicSwinomish Dental ClinicSystems OverviewSystems Overview

Part of the Indian Health System of Dental ClinicsPart of the Indian Health System of Dental Clinics

There are 29 I/T/U Dental Clinics in the State of Washington There are 29 I/T/U Dental Clinics in the State of Washington

In 2012 Indian Health Service I/T/U’s are currently serving 106,372 Official In 2012 Indian Health Service I/T/U’s are currently serving 106,372 Official Users out of Users out of 192,114 Native Americans living in the State. Only 55% of Native Americans have access or are accessing these Clinics

Clinics are operated directly by the Indian Health Service or by the Tribes or Clinics are operated directly by the Indian Health Service or by the Tribes or Urban Indian organizations through Contracts or Self Governance Urban Indian organizations through Contracts or Self Governance CompactsCompacts

The SITC Dental Clinic is operated by the Swinomish Indian Tribal The SITC Dental Clinic is operated by the Swinomish Indian Tribal Community through a Self Governance CompactCommunity through a Self Governance Compact

Oral Health in Indian CountryOral Health in Indian Country

American Indian and Alaska Native American Indian and Alaska Native children between the ages of 2 and 4 children between the ages of 2 and 4 have the highest rate of decay in the have the highest rate of decay in the United States—five times the national United States—five times the national average…average…

-U.S. Department of Health and Human Services-U.S. Department of Health and Human Services

From the Last National Oral Health Survey in 1999From the Last National Oral Health Survey in 1999

Old I.H.S. Provided Dental TrailerOld I.H.S. Provided Dental TrailerSwinomish Indian Tribal CommunitySwinomish Indian Tribal Community

Swinomish Dental ClinicSwinomish Dental Clinicafter Self Governanceafter Self Governance

-Exercising Sovereignty-Exercising Sovereignty

Swinomish Dental ClinicSwinomish Dental Clinic

Typical small I/T/U Dental Clinic within the Portland Area Typical small I/T/U Dental Clinic within the Portland Area Office and located in northwest Washington stateOffice and located in northwest Washington state

Current Staffing consists of 1 Full time Dentist, 1 Part Current Staffing consists of 1 Full time Dentist, 1 Part time Dentist, 1 Dental Hygienist, 2 Dental Assistants, 1 time Dentist, 1 Dental Hygienist, 2 Dental Assistants, 1 Support staffSupport staff

Indian Health Service OverviewIndian Health Service Overview

General U.S. population has an average of 1,500 Patients General U.S. population has an average of 1,500 Patients per Provider/Dentistper Provider/Dentist

Typical I.H.S. Provider/Dentist availability is 2,800 Typical I.H.S. Provider/Dentist availability is 2,800 Patients per ProviderPatients per Provider

Typical I.H.S. Provider is expected to service 86% Typical I.H.S. Provider is expected to service 86% more patients than the U.S. Dental averagemore patients than the U.S. Dental average

Indian Health Service User Count Indian Health Service User Count and Service Deficienciesand Service Deficiencies

Indian Health Service provides only 22% of current program funding Indian Health Service provides only 22% of current program funding from Dental Program funds –balance comes from the Tribal general from Dental Program funds –balance comes from the Tribal general fund and 3fund and 3rdrd Party billing, mainly Medicaid Party billing, mainly Medicaid

Program is dependent upon soft money from 3Program is dependent upon soft money from 3rdrd party collections, party collections, especially Medicaid reimbursementsespecially Medicaid reimbursements

Indian Health Service is a dramatically underfunded system, both in Indian Health Service is a dramatically underfunded system, both in how it counts Users and how Congress funds its operations . Rule of how it counts Users and how Congress funds its operations . Rule of thumb-Indian Health Service gets 60% of Level of Need Funding, thumb-Indian Health Service gets 60% of Level of Need Funding, actually a little lower in I.H.S.actually a little lower in I.H.S.

...BECAUSE WE’VE ALWAYS DONE IT THAT WAY!

Why no DHAT’s in the lower 48 states?Why no DHAT’s in the lower 48 states?

“Organized dentistry does agree with the proponents of DHAT on one issue: some people with significant oral health needs do not have access to dental care, and something needs to be done. . . . The ADA’s proposed solutions have been both vague and irrelevant to the access barriers, and they have not be followed up with action.”

Solution Provided by DHATSolution Provided by DHAT

Procedure review for FY 2012 and 2013 for Swinomish-Procedure review for FY 2012 and 2013 for Swinomish-Upper Skagit Dental Clinic showed that over 50% of Upper Skagit Dental Clinic showed that over 50% of procedures and services could have been provided by procedures and services could have been provided by trained Dental Health Aide Therapists under the Alaska trained Dental Health Aide Therapists under the Alaska modelmodel

DHAT Licensure Authorization would help I/T/U Clinics DHAT Licensure Authorization would help I/T/U Clinics fill a huge gap in service demand across the Indian fill a huge gap in service demand across the Indian Health Service system for Native patientsHealth Service system for Native patientsWork Force Development based in the Community Work Force Development based in the Community assures longer term benefits assures longer term benefits

Swinomish PeopleSwinomish Peoplein Regalia for in Regalia for

Canoe Journey Welcome July 2011 Canoe Journey Welcome July 2011

Dental Capacity PyramidDental Capacity PyramidSwinomish Upper Skagit Dental Clinic Swinomish Upper Skagit Dental Clinic

with Patient Flow with DHAT’s as a Vital Piecewith Patient Flow with DHAT’s as a Vital Piece`̀

Other Dental Support Staff

Dental Assistants

Dental Health Aide Therapist

Dental Hygienist

Dentist

Dental Capacity PyramidDental Capacity PyramidSwinomish Upper Skagit Dental Clinic Swinomish Upper Skagit Dental Clinic

with Patient Flow without DHAT’s as a Vital Piecewith Patient Flow without DHAT’s as a Vital Piece`̀

Other Dental Support Staff

Dental Assistants

Dental Hygienist

Dentist

Medical Care System in the Medical Care System in the 1970’s1970’s

-Imagine when Primary Care could only -Imagine when Primary Care could only be provided by an MD, ie No Physician’s be provided by an MD, ie No Physician’s

Assistants Or Nurse Practitioners- Assistants Or Nurse Practitioners-

In the 21In the 21stst Century the Primary Care Century the Primary Care System is reliant on Mid-Level ProvidersSystem is reliant on Mid-Level Providers

-Dental Practices are operating under -Dental Practices are operating under the similar model that Medical was under the similar model that Medical was under

in the 1970’sin the 1970’s

Alaska DHAT Scope of PracticeAlaska DHAT Scope of Practice

DHATDHAT

[----]--------------------------------------------------[----]--------------------------------------------------<<50 Billable Procedures50 Billable Procedures

DDSDDS

[------------------------------------------------------][------------------------------------------------------]

>500 Billable Procedures>500 Billable Procedures

Source: Dr. Louis Fiset, BA-DDS- University of WashingtonSource: Dr. Louis Fiset, BA-DDS- University of Washington

Alaska Native Oral Health SolutionAlaska Native Oral Health Solution::DHATSDHATS

• Providers with cultural awareness and understanding of community needs

• Provide routine care – overburdened Dentists can now prioritize complex cases

• Saving health systems money • Creating a new educational/employment field for AI AN students• Improved pediatric care• Alleviate burden IHS faces

Alaskan DHAT’s in 10 years are the Most studied health professional in the history of oral medicine!

Why a 2 Year DHAT Program Why a 2 Year DHAT Program

Competency reached with 2 years for the <50 Billable Competency reached with 2 years for the <50 Billable ProceduresProcedures

Curriculum fits a 2 Year structureCurriculum fits a 2 Year structure

Training Costs lowerTraining Costs lower

Graduates return to their Communities soonerGraduates return to their Communities sooner

Cost of social commitments for trainees lowerCost of social commitments for trainees lower

Decay of Tribal Decay of Tribal Sovereignty under the ACASovereignty under the ACA

• Worcester v. Georgia (1832)Worcester v. Georgia (1832)-Indian Nations are distinct -Indian Nations are distinct political communities with inherent sovereign rights political communities with inherent sovereign rights free from free from interference from statesinterference from states

• Indian reservations borders are Indian reservations borders are protective barriersprotective barriers from from states and their citizensstates and their citizens

• Clearly established that state law and jurisprudence did Clearly established that state law and jurisprudence did notnot reach into the confines of a reservationreach into the confines of a reservation

The Affordable Care Act has allowed the legitimacy of Indian The Affordable Care Act has allowed the legitimacy of Indian Nations as self-determining governments to be chipped awayNations as self-determining governments to be chipped away

With Thanks to Dr. Terry BatlinerWith Thanks to Dr. Terry Batliner

DHATS: A Legal and Political Health IssueDHATS: A Legal and Political Health Issue

Swinomish Dental ClinicSwinomish Dental Clinic

Our analysis shows that over 50% of procedures could Our analysis shows that over 50% of procedures could have been provided by DHAT’s rather than a Dentisthave been provided by DHAT’s rather than a Dentist

Analysis shows that the same procedures could have Analysis shows that the same procedures could have been covered with 50% Personnel cost savings-replace been covered with 50% Personnel cost savings-replace Dentist time with DHAT timeDentist time with DHAT time

Analysis shows that Dentist time could have been Analysis shows that Dentist time could have been significantly re-oriented to more complex Dentist only significantly re-oriented to more complex Dentist only procedures, ie such as prosthodontic, advanced procedures, ie such as prosthodontic, advanced restorative and surgical procedures, etc.. restorative and surgical procedures, etc..

Our Current Political Solution Our Current Political Solution

Swinomish Tribal Community worked with Swinomish Tribal Community worked with the Northwest Portland Area Indian Health the Northwest Portland Area Indian Health Board and the Washington State House and Board and the Washington State House and Senate to craft a Senate to craft a Tribal Specific DHAT Tribal Specific DHAT Authorization Bill-HB 2466 Authorization Bill-HB 2466 consistent with consistent with the limitations under the ACAthe limitations under the ACA

http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bill%20Reports/http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bill%20Reports/House/2466%20HBA%20CDHT%2014.pdfHouse/2466%20HBA%20CDHT%2014.pdf

Thanks for Listening and Thanks for Listening and Appreciate your TimeAppreciate your Time

John StephensJohn Stephens

Programs AdministratorPrograms Administrator

Swinomish Indian Tribal CommunitySwinomish Indian Tribal Community

jstephens@swinomish.nsn.us

360-466-7216360-466-7216