Mid-level Providers-Threat or Good Idea?

It’s a problem I have heard before – fear over using a mid-level provider.

What is a mid-level provider?

You probably know the answer, even if you have not heard the term. It is a health care professional who provides care under the supervision of a physician. Examples of medical mid-level providers include: 

  • Physician assistant (PA)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Nurse practitioners (NP)

The latest buzz is over mid-level providers in the dental industry – the Registered Dental Practitioner (RDP).

The Problem – Supply and Demand

As the story in Kaiser Health News explains, there is a shortage of dentists, particularly in rural areas. The shortage of providers crosses all specialties of health care.

The shortage arrives with the aging of the baby boomers when the demand for care typically increases.

The Fear

Having been a registered dental hygienist (RDH) in a former life, this story struck a chord. When I was in practice, RDHs worked under the supervision of a dentist.

  • The dentist checked our patients after the appointment
  • If the dentist did not work (e.g., vacation, sick days), we could not work

I practiced a very long time ago, but at the time. there was a great deal of resistance to dental hygienists.

  • Resistance from patients who didn’t want to be seen by an “assistant”
  • Resistance from dentists when hygienists campaigned for independence

The newest mid-level provider, the Registered Dental Practitioner (RDP), has been proposed by some states to fill the shortages of dentists. The RDP would have more training than a hygienist, but less than a dentist.

Their responsibilities primarily involve basic restorations (fillings) and extractions.

The resistance and fear is the usual one associated with mid-level providers – do they have adequate training and skills for providing quality care.

What do you think?

Are you opposed to mid-level providers?

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Notice of Disclaimer –Cathy Miller is not an attorney and cannot provide legal advice. The information provided is for your general background only, and is not intended to constitute legal advice as to your specific circumstances. We recommend you review legislation with legal counsel.




  1. says

    Good info to know. I’m shocked by the shortage number.

    I may get hate mail from NPs and other mid-level providers but I’d rather not see them. I’d rather see the physician. I’ve had bad experiences when I’ve seen a PA or NP instead of my doctor. These examples are for providers other than a dentist. I wouldn’t feel uncomfortable being seen by an RDP.
    Lisa Kanarek´s last blog post ..How to Create More Storage Space in Your Home OfficeMy Profile

  2. Cathy says

    Hi Lisa: I am sure you are not alone in your feelings. Not to put words in your mouth, but I am betting that you’re feeling okay about an RDP (dental) because you don’t see that as having the same consequences as poor care with a medical professional. Am I correct in that assumption?

    If you don’t mind sharing, what kind of problems did you encounter with the medical mid-level providers? Did it have to do with your treatment?

    Thanks for sharing your thoughts, Lisa.

  3. says

    Cathy-You’re absolutely right. The problem I encountered with a PA was that she didn’t respond to a prescription refill until several days later, which caused a setback in treatment. During my next appointment with my physician, she gave me her cell phone and told her to call or text anytime. She was less than happy to know what her PA had done.

  4. Cathy says

    Thanks for sharing your story, Lisa.

    As someone who has been a health care provider (in my dental hygiene days), I find it interesting how no matter what your specialty – health care, selling widgets, whatever – a good part of a happy patient/customer is good customer service. Be responsive to the needs of your patients/customers.

    Thanks again, Lisa.

  5. says

    PA’s have been in use for various rural facilities, for a while. I have no problems with them. Nor would I have a problem with RDP, but I am not sure I am willing to extend extractions and fillings. I could see X-rays (if so trained, probably an additional training proficiency) and cleanings. But, I am not sure they should be able to administer drugs via injection- which would be needed for fillings and extractions.
    Roy A. Ackerman, Ph.D., E.A.´s last blog post ..Not for children- REALLY?My Profile

  6. Cathy says

    Hi Roy: Thanks for weighing in with your view. If you take away the added responsibilities of the RDP and limit it to x-rays & cleanings, there is no need for an RDP as assistants and hygienists perform those functions.

    The proposed RDP position does all the services of a hygienist and with the added schooling, fillings, simple extractions.

    So, I guess I would take it as an “Opposed” for the dental mid-level provider. Thanks again for sharing your opinion, Roy.

    • Cathy says

      Hi Roy: You are right. My understanding (although I haven’t totally reviewed their scope) is that the added training is 2 years beyond that of a hygienist and that they can only administer local anesthetic. Although now that I think about it, it probably includes nitrous oxide as registered dental assistants & hygienists can administer it (at least in some, if not all, states).

  7. says

    Interesting post. There are these types of discussions in virtually every area of health care. I had no idea that it applied to the dental field as well. I personally think that it is driven by what the type of professional can be trained to handle. In my non-blogging job, I study patient navigation, which is an intervention that helps people overcome barriers to health care. There are a lot of types of patient navigators. They can be nurses, social workers, other types of professionals or just community members trained to help people get care. What we have found is that there are times when each model works best, but it depends on what skill set you need for the particular problem (or health care gap) at hand… Thanks for opening my eyes to this issue in dental care!
    Kristen´s last blog post ..The Holidays Are Coming and I Am Not Ready: Coping with Holiday StressMy Profile

  8. Cathy says

    Hi Kristen-thanks for sharing that information. I work with quite a few healthcare providers as clients and agree it depends on the needs and skill sets.

    What an interesting job you have. I love the idea of anything that removes barriers to care. A former employer (now client) bases its consulting services on managing health instead of disease and removing barriers to care is what it’s all about. It makes a whole lot of sense to me.

    Thanks again for sharing some interesting observations, Kristen.

  9. says

    Aloha Cathy, interesting topic and I not surprised with the shortage of professionals. I am sure due to the price increases in school tuition and plus legal actions and probably long hours required.

    Changes are drastically occurring and we don’t what to expect next. Glad I came by and thanks for sharing. Mahalo, Lani :)
    Lani – Aloha´s last blog post ..Success Is For AllMy Profile

  10. Cathy says

    Aloha, Lani. You are right – there are severe shortages of providers across all lines of specialties.

    I appreciate you visiting. Mahalo.

  11. says

    But why the shortage? Money, conditions or just the number of people? There is a problem world wide not just the USA and much of it is due to cost of training and then the expectation of the trained but…when money is tight, people do not afford the dentist unless there is pain and then it may be too late. The intermediaries may be a good solution to help prevent problems. And who knows one day we may even come up with a much better and less painful way of restoring teeth and gums than the dentist – now that is a solution I would like to see
    Roberta Budvietas´s last blog post ..Legal or Moral – the differenceMy Profile

  12. Cathy says

    Hi Roberta: It’s probably a combination of all those things. The key to dental care is like all health care – focus on the preventive to prevent disease or more serious problems. Total well-being is something we all would like to strive for,

    Thanks for sharing your thoughts, Roberta.

  13. says

    I really like seeing Nurse Practitioners–they don’t have the attitude of even the best doctors, and they have 95% or more of the knowledge docs have.

    I was so sorry that my former provider got rid of them “to save money.”

    Howard Katz

  14. Cathy says

    Hi Howard: That is a different way of looking at it. For me, I have no problem with seeing a mid-level provider. Thanks for sharing your experience, Howard.

  15. Eric says

    Dentist have to refer many of their extractions to oral surgeons because of the invasiveness and intense understanding of anatomical structures. Dentists usually only provide simple extractions, and that’s after intensely studying head and neck anatomy. I’m not sure I would be comfortable, nor do I think it is safe, to have midlevel providers carry out extractions.

  16. Cathy says

    Hi Eric: Thanks for sharing your view. It is certainly understandable. I imagine it’s like any profession. There are dentists skilled at simple extractions and others who are not. I’m not always comfortable with dentists performing extractions so I understand your concern.

    Thanks again for stopping by.

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