Does NC need licensure reciprocity for dentists and hygienists?

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By Anne Blythe

As many states struggle with workforce shortages across the health care industry, there’s a national effort to give dentists and dental hygienists more authority to work in multiple states without going through a time-consuming licensure process in each one.

Two licensing compacts are being floated, one by the Council of State Governments — a nonprofit that helps states collaborate on complex policy issues — and the other by the American Association of Dental Boards, or AADB.

Other health care professions have similar interstate licensure compacts allowing providers to move more easily from state to state, and North Carolina participates in some of them.

The North Carolina State Board of Dental Examiners issued a position statement this month that highlights the differences between the two proposals, questions whether such an agreement is needed but ultimately comes down on the side of the AADB’s plan if state lawmakers decide to put such a compact in place.

Bobby White, CEO and chief counsel for the dental examiners board, said the decision to adopt a stance was more proactive than reactive. Though the board would like to see more details, they’ve provided an outline of what members are thinking.

“If the legislature wants to say, ‘What does our board think of this,’ they have a shell of all this together,” White told NC Health News in a recent interview.

Although both compacts have the common goal of enhancing “licensing portability for dentists and dental hygienists; especially those serving in the military and their spouses,” the NC dental board statement says, neither includes data or survey results from dentists and hygienists who want to pursue licensure in multiple states.

“It is difficult to recommend support of sweeping, long-term, and binding compact legislation without some idea of the demand for such a process,” the board statement says.

The work on the two competing proposals grew from a federal Department of Defense approval of a series of grants in March 2021 to develop interstate compacts for teaching, social work, cosmetology, massage therapy and dentistry/dental hygiene. The goal was to help military spouses who might be subject to many relocations during their partner’s time in the service.

At its roots

At the time, 14.5 percent of the military spouse population moved across state lines compared with 1.1 percent of civilian spouses. Those cross-border moves can create challenges for licensed workers, whether they are affiliated with the armed services or other professions.

Some states might require a series of tests and payment of local licensure fees, while others might honor work authorization from other states.

In North Carolina, state law allows for military personnel and their spouses to be licensed by military endorsement. That, coupled with amendments to the Servicemember Civil Relief Act, make it possible for military personnel and their spouses to practice dentistry or dental hygiene within days of their arrival at no cost.

“It is hard to imagine a compact with less cost and greater efficiency than procedures that are already in place…,” the state board said.

White elaborated on that. If someone had a military order to a university teaching appointment, the board would have to honor that, he said.

Furthermore, the General Assembly has tweaked state law to grant the NC dental board the authority to issue a license to applicants who are licensed to practice dentistry in any other state or U.S. territory based on their credentials if they produce “satisfactory evidence” that they have the “required education, training and qualifications.” They also must be “in good standing” with the jurisdiction where they are licensed and have passed satisfactory exams of their proficiency in the field.

Devil in the details

The Council of State Governments’ proposal, which has support from the American Dental Association, the American Dental Hygienists’ Association and the federal defense department, has language that’s similar to compacts created for other health care professions. In North Carolina, that includes nursing, physical therapy, audiology and speech/language pathology, occupational therapy, emergency medical services and psychology.

The American Association of Dental Boards’ proposal is similar to compacts used by the Federation of State Medical Boards.

There are significant structural differences, according to White and the state dental board. Most notably, the Council of State Governments’ proposal would create a new governing agency made up of appointed commissioners from each participating state.

That would erode the power of the General Assembly to regulate the practice of dentistry and dental hygiene through the state dental board, which is subject to legislative oversight.

The Council of State Governments commission “has the authority to pass rules with the effect of state law in each member state and is not subject to oversight by the NC General Assembly, any elected North Carolina official, the North Carolina Dental Board, or the North Carolina Courts,” according to the board NC dental board statement.

Additionally, the new commission would have taxing and fee levying authority to cover its state budget, but the proposed compact agreement does not provide projections for what its annual fiscal plan could be.

The state board “simply thinks it is fiscally irresponsible to join an organization without having some idea of the initial and ongoing costs,” according to its statement.

In contrast, the American Association of Dental Boards’ compact would not have taxing authority nor would it levy an annual assessment on member states, according to the state board.

“All costs are to be borne by fees dentists and dental hygienists pay for the privilege of obtaining a Compact License,” the state board said. “These fees are collected only from dentists and dental hygienists who voluntarily seek to obtain such a license.”

Testing hand skills

One attraction of the association of dental boards’ proposal is the national database of disciplinary actions that would be expanded to include other administrative actions, giving the public more knowledge about their providers.

Another difference between the compact proposals that White and other dentists in North Carolina highlight is that the association’s proposal would uphold long-standing state law that requires dentists and hygienists to — at some point — have passed a “hand-skills” examination conducted by “a competent third party” before the granting of a license.

“It is the Board’s belief that testing critical thinking and analytical skills is not enough for the new licensee,” its statement says. “The practice of dentistry and dental hygiene involves surgically precise movement within the narrow confines of the oral cavity often while doing so in a mirror image.”

The board adds that it isn’t enough to be able to diagnose a problem and know what must be done. A practitioner “must have the practiced and precise motor skills to heal without harm.”

“The Board believes allowing newly graduated dentists and dental hygienists to perform procedures on patients without undergoing a hand-skills test is akin to allowing the new pilot to attempt landing a fully loaded passenger plane based solely on a written examination without ever having taken a check-ride with a certified flight examiner,” the board concluded.

Allowing dentists and hygienists from other states to practice in North Carolina without having completed such skill tests would create an unequal landscape where patients might be subject to a different quality of care, depending on where their provider was licensed, the board added.

Advocates of the Council of State Governments’ proposal tout that organization’s compact as less burdensome than the plan from the association of dental boards.

“License portability has long been a challenge for the professions of dental hygiene and dentistry,” Ann Lynch, director of advocacy for the American Dental Hygienists’ Association, told ADA News last year. “The compact will offer a clear pathway for those licensed dentists and dental hygienists who wish to move across state lines or practice in multiple states. This will reduce the burden of obtaining multiple licenses, which is often expensive, cumbersome, and results in loss of income and delays in contributing to the workforce.”

Questioning the need

Stan Hardesty, a Raleigh dentist and past president of the North Carolina Dental Society, questions whether interstate mobility is at the root of workforce shortages not just in this state but across the country.

The dental society’s stance is that no compact is needed. Like the dental board, the society highlights recent changes in state law that allow military personnel and their spouses to practice in this state with an order from an officer.

“It seems like a solution in search of a problem,” Hardesty said.

In 2001, according to a report compiled by the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill, the state was ranked 47th in the country with only 4.2 dentists for every 10,000 residents. By 2022, the state was 24th in the country with 5.6 dentists per 10,000 people, slightly lower than the national average of 6.1 for every 10,000 residents.

Over the past three years — from Jan. 1, 2021 to Jan. 1, 2024 — 347 dentists have come from other states to practice in North Carolina, Hardesty said, only slightly less than the number of new graduates coming from the state’s dental schools during the same period. That shows that dentists are able to come to North Carolina and get licensed to practice, he added.

“We don’t have a mobility issue,” Hardesty said.

There are workforce shortages, though, having an impact on practices across the state, especially for many offices having difficulty hiring and keeping hygienists.

This year, according to White, the CEO of the dental board, there are 6,702 hygienists and 6,153 dentists who are licensed and actively practicing in this state. The number of licensed hygienists is 8,839, but slightly more than 2,000 are not active this year.

For many years, North Carolina hygienists have fought for more autonomy, seeking to be able to practice on their own without a dentist overseeing them on site.

They gained a bit of ground in their scope-of-practice tug-of-war in 2020 right before COVID-19 wreaked its havoc around the world.

The numbers of active hygienists started to decline during the pandemic but have not rebounded in the aftermath. The state has set up community college programs to try to educate and get more people in many health care fields licensed, not just hygienists. Even if those efforts are successful, the impact from them could still be several years away.

Meanwhile, oral health advocates are weighing the pros and cons of proposed compact agreements. So far, the state dental board and the Dental Society are of the same mind — no such agreement is needed.

Steve Cline, vice president of the North Carolina Oral Health Collaborative, said his organization hasn’t taken a stand on either of the proposals. There are many questions and no assurances at this point that either proposal would provide greater access to oral health care.

The dental society’s stance is that no compact is needed. Like the dental board, the society highlights recent changes in state law that allow military personnel and their spouses to practice in this state with an order from an officer.

“It’s still too soon to say in any absolute way what these would do,” Cline said.

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