Missouri Lacks Dentists In Rural Areas

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TIPTON - Dr. Ron Schuler is one of the four dentists in Moniteau County, and one of the two dentists in the small town of Tipton.

At 78 years old, Dr. Schuler said he sees about 15 to 20 patients a day, working four days a week. In addition to Tipton residents, he has patients from surrounding cities such as Columbia, Boonville, Lake of the Ozarks, Versailles, Sedalia, etc.

Shortage/Distribution Problem of Dentists

Missouri has a patient-to-dentist ratio of 2,168-to-1 compared with the national average of 1,516-to-1. Missouri is in worse shape than 90 percent of the nation, according to the 2011-2012 data used by the County Health Rankings & Roadmaps of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

Among all the Missouri counties ranked from high to low based on the ratio of population to dentists, the data of some mid-Missouri counties is listed as below:

  • Boone: 94 dentists (1,832:1)
  • Callaway: 9 dentists (5,367:1)
  • Cole: 39 dentists (2,079:1)
  • Moniteau: 4 dentists (4,234:1)
  • Cooper: 5 dentists (3,838:1)
  • Howard: 4 dentists (2,710:1)
  • Audrain: 6 dentists (4,598:1)
  • Randolph: 9 dentists (3,098:1)

The president-elect of the Missouri Dental Association, Dr. Merle Nunemaker said he cannot comment directly on any specific survey or number because there are different parameters and guidelines that people come up with to do their surveys.

"I know these numbers can vary across the country. Some states may have more auxiliary they can use so they can see more patients with fewer dentists. Every state has different law. So there are a lot of variables there. But one thing I do know for sure that was, there definitely is a gap between the people with good dental health care and those that are not able to receive good care," Dr. Nunemaker said.

In addition, he said he doesn't think the number of dentists in the state is an issue. The real problem, Dr. Nunemaker said, is the distribution of dentists in rural areas.

"That is kind of a common misconception that there aren't enough dentists," Dr. Nunemaker said. "The American Dental Association and the American Dental Education Association have done studies and found that may not necessarily be true in most cases. I know in Missouri for a fact it is a matter of distribution. It's not one of lack of providers, it's just where they are located."

Dr. Nunemaker pointed out there are also a number of issues relevant as to why dentists may be more centered in the city as opposed to the rural areas. 

"One of the biggest reasons behind that is that a vast majority or a great number of people in the rural areas are on Medicaid, and the way it is now there is no adult dental coverage for Medicaid within Missouri," Dr. Nunemaker said. "The care for the children is what we might term as underfunded as well. So if you have a dentist in a rural area that is mainly seeing Medicaid patients that don't have insurance or can't afford dental care, it makes a lot tougher from the economic standpoint for dentists simply to make them go over there."

The Pew Charitable Trust published research "In Search of Dental Care" in 2013, saying the severity of the shortage of dentists serving Medicaid patients is reflected by statistics. According to the research, in the state of Missouri, 63 percent of Medicaid-enrolled children did not receive any dental care in 2011.

Some dentists, like Dr. Schuler, would sometimes provides free dental services such as fillings to people who struggle to find or afford care, or establish finance plan to help them.

"You have to have different avenues to be able to serve the people, not just to be a dentist." Dr. Schuler said.

Low Medicaid Reimbursement 

To give a general idea on how the Medicaid system works, Dr. Nunemaker explained that as a rule, dentists get reimbursed 41 cents for every dollar of service they bill. Most private practices and dental offices run up about 70 cents on a dollar for an overhead.

"So if it's costing you 70 cents to break even, and you are only getting paid for 41 cents, it doesn't take much of economic genius to figure out that those numbers just don't add up. If you can't afford to break even on something, it just doesn't make any sense to be able to take Medicaid," Dr. Nunemaker said.

Dr. Nunemaker also said a lot of dental care providers do take Medicaid, but they have to limit it because they are small businesses. 

"We have to make it go all the way up, we have to pay our staff and supplies, etc. So there is a few patients you lose money on, and we all do our part to absorb some of that, but you just can't do very much and to make it go as a business," He said. "If you don't have enough patients in your practice, and cannot generate sufficient income to pay your expenses, then you don't have an economic incentive to set up a practice there."

In his nine years in Tipton, Dr. Schuler has found the best way to maintain a practice and get new patients is to keep his current patients happy.

"It's not uncommon to have 75 to 100 new patients a month in my practice," Dr. Schuler said. 

For him, having his own practice in rural area means having a closer relationship with patients and less competition compared with working in bigger cities.

"I love it here. I had a practice as a consultant in Kansas City with twelve chairs. We had eight assistants and two hygienists and we did a fabulous business. But I wouldn't trade this practice for that practice because I like the small town atmosphere. I'm working for myself. I don't work for somebody else," he said.

Dentist Retirement

The state loses 70 dentists annually to retirement. According to a 2012 Missouri Oral Health report, only 45 to 50 new graduates begin practice in Missouri every year.

The study also showed in 28 counties, at least 50 percent of dentists plan to retire within the next 10 years. 

A new dental school opened in Kirksville in October aims to address the problem by graduating new dentists. A.T. Still University's Missouri School of Dentistry & Oral Health became the state's second dental school, joining the University of Missouri-Kansas City's School of Dentistry.

The school's inaugural class has 42 students selected from 954 applicants. Only nine of those students were from Missouri. Students will spend their first two years in Kirksville on campus. In the third year, students will work at Grace Hill Health Centers, Inc., in St. Louis and start seeing patients. During the fourth year of the program, students will work in community health centers around the U.S., including in rural areas.

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