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Dental Workforce Trends—Opportunities for Improving Access

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Dental Workforce Trends Opportunities for Improving Access Shelly Gehshan, M.P.P. National Academy for State Health Policy March, 2008 What I ll cover Overall ... – PowerPoint PPT presentation

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Title: Dental Workforce Trends—Opportunities for Improving Access


1
Dental Workforce TrendsOpportunities for
Improving Access
  • Shelly Gehshan, M.P.P.
  • National Academy for State Health Policy
  • March, 2008

2
What Ill cover
  • Overall workforce trends
  • State strategies in rural areas
  • State action on workforce
  • Progress on new workforce models
  • Implementation Thoughts
  • FYI--Lessons learned from Medical field

3
Is there a Shortage in the US? Active Dentists
per 100,000 Population
55
54.5
54.5
54
53.3
53
52
52
51
50.7
50
49
48
2000
2005
2010
2015
2020
4
Is there a shortage? Active Dentists per
100,000 Population (2000)
Source American Dental Association, Survey
Center. US Census Bureau (2001).
5
Dentist Vacancy Rates at Health Centers (2004)
Source Roger Rosenblatt, Holly Andrilla, Thomas
Curtin, and Gary Hart. Shortage of Medical
Personnel at Community Health Centers, Journal
of the American Medical Association 295, No. 9
(2006) 1042-10491.
6
Age Distribution of Private Practice
Dentists (2005)
Source American Dental Association, 2005
7
Is There a Shortage of Hygienists?
  • 158,000 hygienists in 2004
  • Expected to grow (gt27) by 2014
  • Hygienists leave profession
  • ADHA says that, due to supervision requirements
    in many states, hygienists must locate where
    dentists are, so they are maldistributed as well

8
Number of Employed Dental Hygienists, in thousands
Source U.S. Department of Labor, Bureau of
Labor Statistics, http//www.bls.gov
9
Dental Safety Net Needs Expanding
  • No dental emergency rooms
  • Serves less than 10 of 82 million underserved
    people (Bailit, JADA, 2003)
  • Critical safety net consists of community health
    centers, hospitals, dental and hygiene schools,
    school-based health centers

10
State Strategies for Rural Areas
11
Supply, Redistribution Strategies
  • State loan repayment programs for rural DDs and
    RDHs
  • Licensing strategies
  • Foreign dentists in safety net settings
  • Licensure by credential
  • Licensure after service, residency
  • Payment incentives (higher Medicaid fees in rural
    areas, clinics, e.g. Utah)

12
Ways to Increase the Supply...
  • Exempt retired dentists from liability for
    volunteering to work in vans, CHCs, RHCs
  • Establish rural clinical training sites or
    preceptorships for dental and hygiene students
  • Work with rural schools and colleges to recruit
    dental and hygiene students
  • Establish scholarships for rural dental students

13
More Ways to Increase the Supply...
  • Help add dental capacity in clinics, CHCs
  • Start a revolving loan fund for establishing
    rural practices
  • Enhance sales of rural practices with grants for
    equipment upgrades
  • Play matchmaker to help retiring rural dentists
    sell their practices

14
More Ways to Increase the Supply...
  • Teledentistry via email or video saves trips
  • Mobile dental vans
  • expensive, waste disposal problems
  • continuity of care and follow-up problems
  • hard to staff, but sometimes the only option
  • Mobile dental units
  • rotate to locations like schools, nursing homes
  • easier to staff but smaller capacity

15
State Action on Workforce
16
Integrating Oral Health into Primary Care
  • Dentist to population ratio shrinking PCP to
    population ratio is growing
  • Prevention is cheaper, better
  • More frequent, earlier use of primary care
    services for young children and underserved
  • Patient trust and comfort (fear factor)

17
Oral Health Services Medical Professionals Can
Provide
  • Oral health evaluation (visual screening for
    decay)
  • Application of fluoride varnish
  • Patient and parent education
  • Dispensing oral health supplies
  • Toothbrushes, toothpaste, xylitol gum
  • Limited prophylaxis, antimicrobials
  • Case management, referral

18
State Action
  • Curricula or training for primary care providers
    (AL, AR, CA, KY,ME, NH, NV, NY, OR, SD, WA, WI)
  • Medicaid payment for MDs to provide fluoride
    varnish (13 states)
  • Joint initiatives for screening and referral (SC)
  • Source Survey of Medicaid/SCHIP Directors of
    Administration conducted by NASHP, 2008

19
Challenges in Integration
  • Involve dentists in training MDs, RNs, NPs
  • Link medical and dental homes
  • Reimbursement through public and private
    insurancemake it universal
  • Differences in fee-for-service and managed care
  • Diffusion of idea change practice patterns

20
Trends in dental hygiene
  • Gradual loosening of supervision, expansions in
    scope
  • Movement towards providing services in public
    health settings
  • Bulk of hygienists still practice in traditional
    settings maldistributed as are dentists

21
Supervision and Payment for Hygienists
  • General supervision in 45 states in dental office
    or some settings
  • Direct access to patients in some settings in 22
    states (AZ, CA, CO, CT, IA, KS, ME, MI, MN, MO,
    MT, NE, NH, NM, NV, NY, OK, OR, PA, RI,TX, WA)
  • Medicaid can reimburse hygienists directly in 12
    states (CA, CO, CT, ME, MN, MO, MT, NM, NV, OR,
    WA, WI)
  • Source American Dental Hygienists
    Association, Direct Access States, Available at
    www.adha.org
  • Source American Dental Hygienists
    Association, States Which Directly Reimburse
    Dental
  • Hygienists for Services under the Medicaid
    Program, Available at www.adha.org.

22
Current Workforce Proposals
  • Proposals to expand scope or loosen supervision
    of hygienists
  • 7 states have proposals far along or completed in
    the legislative process (MA, WI, MN, MT, CA, OH,
    KS)
  • Proposals to develop new dental practitioners
  • 3 states have proposals far along in the
    legislative process (MN, MI, MA)
  • 11 states are discussing proposals (CO, ME, NM,
    CA, FL, TX, OH, OR, KS, CT, PA)
  • Survey of State Oral Health Coalition Leaders,
    NASHP 2008

23
Kansas Extended Care Permit (ECP) Hygienists
  • RDH-ECP are hygienists in community settings
    (Head Start, schools, health depts, safety net
    clinics, and long-term care facilities)
  • Hub and spoke system--general supervision
  • 55 hygienists have ECPs 25 working in community
    settings.
  • In 2007, settings changed
  • ECP I hygienists can serve wider range of
    children
  • ECP II hygienists can serve a wider range of
    elders and adults with special health care needs
  • Hygienists can apply fluoride varnish in
    community settings
  • Source Kansas Dental Hygienists Association,
    http//www.kdha.org/

24
California Registered Dental Hygienists in
Alternative Practice (RDHAP)
  • Work independently in underserved settings
    (HPSAs, FQHCs, schools, nursing homes, public
    health)
  • 2 education programs in CA
  • Requirements 150 CE units, BA or equivalent,
    2,000 hours in last 36 months as licensed RDH
  • Licensure via standard testing process, plus
    referral agreement with DDS required.
  • Need proof of dental visit and prescription for
    hygiene services within 18 months of seeing a
    patient
  • Source Beth Mertz, Presentation on Meeting the
    Nations Oral Health Needs, HRSAs BHPs 2008 All
    Programs Meeting

25
The Business of RDHAP Practice
  • Business plans--education program needed on how
    to do these
  • Developing payment structures and charting
    systemwho will be charged and for what?
  • Start up loans--mobile equipment runs 25K
  • Building the business
  • Strategies vary by setting and community
  • Diversification helps mitigate risks
  • Outreach to consumers and health care systems
  • Overcoming resistance
  • Building relationships
  • Source Beth Mertz, Advancing Oral Health of
    Underserved Populations through Innovative Oral
    Health Care Delivery Models Registered Dental
    Hygienists in Alternative Practice,
    Presentation for Center for the Health
    Professions Seminar Series, 2008.

26
Structure of RDHAP Practice
  • Laws/Regulations
  • Allow practice, but also limit it
  • Title 22/OBRA vague construct creates confusion
  • Care systems
  • RN, LTC homes, Schools, Clinics, etc.
  • Payment systems
  • Denti-Cal, self pay, insurance companies
  • Anti-competitive practices of dentists
  • Lawsuits, exclusion from institutions, slanderous
    marketing fear-mongering, betrayal of trust,
    exclusion of suppliers or dentists who
    collaborate
  • Source Beth Mertz, Advancing Oral Health of
    Underserved Populations through Innovative Oral
    Health Care Delivery Models Registered Dental
    Hygienists in Alternative Practice,
    Presentation for Center for the Health
    Professions Seminar Series, 2008.

27
What isnt Happening in States, but Needs to
  • Disease management approach for dental caries
  • Caries is infectious, recurs
  • Change to primary care model in dentistry
  • Private practice model organized around surgery,
    restorations, maximizing income
  • Primary dental care would involve screening, risk
    assessment, case management, referrals

28
And, Investment in Upstream Strategies
  • Sealant programs serve too few kids
  • ME programs reach about ½ the schools (better
    than many states)
  • Water fluoridation, in some areas its stalled or
    retreating, despite sound science, low cost
  • Education and outreach for at-risk families

29
Progress on New Provider Models
30
Existing Models
  • Dental therapistNew Zealand model
  • Called dental health aid therapist in AK in use
    in 53 countries
  • Oral health therapistnewer 3-yr program combines
    dental therapy and hygiene
  • Expanded Function Dental Assistants
  • Underutilized can expand productivity and
    profitability of dental practices
  • For state licensing, scope info, check
    http//www.danb.org/main/statespecificinfo.asp

31
EFDAs are Underused
  • Only 16 states train and license Expanded
    Function Dental Auxiliaries
  • EFDAs are dental extenders that make practices
    more profitable
  • Increase efficiency in large practices, clinics
  • Most dentists not trained to use them
  • RWJ grant to PA may help other states replicate
    training and practice models

32
Evidence on EFDAs
  • Lotzkar et al, JADA. 82(1971)
  • Dental teams with 4 EFDAs and 1 dentist increase
    productivity over base-line performance by 110
    to 133 compared to 3 EFDAS and 1 dentist with
    productivity increase over base-line performance
    of 62 to 84
  • Abramowitz et al, JADA. 87(1973)
  • As more auxiliaries added to dental team,
    relative costs per unit of time worked decreased
    from 2.54 to 2.26 and net income for the
    dentist increased from 28,030 to 39,147
  • Lobene et al, The Forsyth Experiment An
    Alternative System for Dental Care (Cambridge,
    MA Harvard University Press, 1979)
  • Optimal setting of 1 dentist supervising 2
    hygienist-assistant teams provided calculated
    annual net of the gross income to practice of
    35.3 and 47.0 by welfare and usual fees,
    compared to practice with 1 dentist and 1 team
    that had calculated expenses of 28.7 and 42.9
    annual net of gross income to the practice

33
New Models for Dental Providers
  • ADA model Community Dental Health Coordinator
    (similar to Primary Dental Health Aides in
    Alaska)
  • ADHA model Advanced Dental Hygiene Practitioner
  • Pediatric Oral Health Therapist (a dental
    therapist specializing in kids)

34
Community Dental Health Coordinator
  • Prevention education, fluorides, sealants
  • Treatment gingival scaling, polishing
  • Restoration atraumatic restorative therapy
  • Supervision direct or indirect for services,
    general supervision for patient education

35
Advanced Dental Hygiene Practitioner
  • Prevention comprehensive services
  • Treatment manage periodontal care, prophylaxis,
    prescriptions
  • Restoration simple restorations, extractions
  • Supervision general supervision or unsupervised
    in collaborative practice, or private dental
    offices

36
Dental therapists
  • Prevention fluoride treatments, sealants
  • Treatment x-rays, prophylaxis, gingival scaling
  • Restoration simple restorations, stainless steel
    crowns, extractions
  • Supervision general supervision under standing
    orders

37
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38
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39
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40
Restorative Capacity of Providers
Source NASHP, Clinical Capacity of Current and
Proposed Providers, Table developed by NASHP,
February 2008
41
Cost Effectiveness of Dental Therapists in Canada
  • Dental therapists reduced the number of medical
    evacuations
  • Transportation costs dropped dramatically
  • Dental therapists can deal with most emergencies
  • Dental therapists make dentists visits more
    productive, triage patients, take x-rays, arrange
    for medications before dentist arrives
  • Quality of care studies determined that the
    procedures performed by dental therapists are of
    equal or greater quality than those performed by
    dentists
  • Source Dr. Todd Hartsfield, former director
    of Saskatchewan Health Center

42
Evidence of Dental Therapists Quality of Care
  • P.E. Hammons, H.C. Jamison, L.L. Wilson. Quality
    of service provided by dental therapists in an
    experimental program at the University of
    Alabama. Journal of the American Dental
    Association. 82 (1971)1060-1066
  • L.J. Brearley, FN Rosenblum. Two-year evaluation
    of auxiliaries trained in expanded duties.
    Journal of the American Dental Association. 84
    (1972) 600-610.
  • E.R. Abrose, A.B. Hord, W.J. Simpson, A Quality
    Evaluation of Specific Dental Services Provided
    by the Saskatchewan Dental Plan. (Regina, Canada
    Province of Saskatchewan Department of Health,
    1976).
  • Gordon Trueblood, A Quality Evaluation of
    Specific Dental Services Provided by Canadian
    Dental Therapists (Ottawa, Ontario, Canada
    Epidemiology and Community Health Specialties,
    Health and Welfare Canada, 1992).

43
Newtok Clinic, Yukon-Kuskokwim
44
AFHCAN CartAlaska Federal Health Care Access
Network
  • Wireless Networking
  • Touchscreen
  • ECG / Video Dental Camera and Otoscope / Scanner
    / Digital Camera
  • Mobile Customized
  • Patient safe
  • WWW. AFHCAN.ORG

45
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46
  • How do We Move Forward on New Workforce Models?

47
3 Requirements for Policy Change
  • Shared perception of the problem
  • Public agreement communication frames issue,
    raises priority
  • Political support
  • Broad-based support, all powerful groups or
    actors involved
  • Viable policy solution
  • Workable, timely, affordable, proven

48
Problems lead to Solutions
  • Provide education to parents, incentives,
    fines
  • Fluoridate water, fund sealant programs, school
    based care
  • Recruit dentists, pay more to treat low income
    patients, fix hassles
  • Parents not getting kids to the dentist
  • Areas lack fluoridated water, sealant programs
  • Too few dentists locate near, serve low income
    patients

49
Consider Attitudes in Building Support for
Solutions
  • Low income parents are irresponsible No
    incentives!
  • Some oppose fluoride, more services to the poor
    (equity issues)
  • Dentists are rich already, wont come, dont
    care
  • Provide education to parents, incentives, fines
  • Fluoridate water, fund sealants, school-based
    services
  • Recruit dentists to underserved areas, pay more,
    fix hassles

50
Attitudes about Dentists
  • They feel no obligation to the community.
  • Uncooperative, greedy, lacking in empathy.
  • The most territorial mammals on the face of the
    earth, except maybe dogs.
  • Dont want to care for poor people but they
    dont want us to either.
  • Source S. Gehshan, T. Straw, Access to Oral
    Health Services for Low Income People, National
    Conference of State Legislatures, 2002.

51
Organized Dentistry Does Care
  • voluntary programs to deliver free careare no
    substitute for fixing the Medicaid program.
  • We need to get more private dentists
    participating in Medicaid. (Roth, 3/27/07)
  • Active on many issues (SCHIP dental,
    fluoridation, Title VII, dental issues in IHS,
    CMS, HRSA programs)

52
Important Steps
  • State and local policy communities come to
    consensus, not national groups
  • Focus on the underserved, not providers
  • Communicate solutions, dont assume people
    understand
  • Seek investments from foundations, governments

53
Important Partners
  • PayorsMedicaid, SCHIP, private insurers,
    business
  • CoalitionsProvider associations, dental/ medical
    leaders
  • Legislators, local and state agency leaders
  • Universities, training programs
  • Safety net clinics, rural providers
  • Foundations

54
Ideas for groundwork
  • Estimate impact of new providers on private
    dental practice, safety net clinics
  • Develop financing options to support them,
    dentist supervisors, and facilities where they
    practice
  • Target new providers to specific settings
  • Data collection to monitor supply, demand
  • Establish multi-state collaboratives

55
Legal and Regulatory Groundwork
  • Establish manpower pilot authority (CA)
  • Consider new regulatory structure for auxiliaries
    (WA, NM, IA, CT)
  • Examine ban on corporate practice of
    dentistryrestricts choices for dentists, and
    options for communities
  • Examine dental practice actmay need safety net
    exemption

56
Why Dentists Oppose Midlevels
  • Would create a two-tier system of care
  • Theres no shortage of dentists
  • Its illegal for non-dentists to do dentistry
  • They would jeopardize patient safety
  • Inefficient if they practice independently
  • They would take patients away from private
    dentists

57
Answering Those Concerns
  • We have 3 tiers now (private, public, none)
  • Documented shortages in many areas
  • States regulate all health professionals,
    including dentists, to protect public safety
  • Efficient business models can be developed
  • Private dentists dont treat 1/3 of the public
    wont lose business

58
What dentists see
59
Dental Economics
  • About 55 from insurance, 45 cash
  • Very sensitive to downturns in the economy
    experience with oversupply
  • Overhead averages about .60-.65 of each dollar
    earned
  • Dentists have more to gain than lose from new
    providers
  • About 45 of patient visits are for hygiene
    services

60
  • Source Albert Guay, Dental Practice Prices,
    Production, and Profit, JADA, Vol. 136 (March
    2005), 359.

61
Concurrent Steps to Create New Providers
  • Curriculum development, faculty training,
    recruiting students
  • Accreditation
  • Legislation establishing new providers issue
    enabling regulations
  • Licensing or credentialing process

62
System Questions
  • How to limit opposition and ensure new providers
    improve access?
  • License them only in dental HPSAs?
  • License in safety net settings only?
  • Enlist physicians, hospitals
  • How to involve and benefit dentists?
  • Develop referral networks, placement sites
  • Legal responsibility, and payment, for
    supervising, collaborating with, new providers

63
Lessons Learned from theMedical Field
64
Nurse Practitioners
  • Models created by leaders in 1960s (Commonwealth
    )
  • Nurses opposed them (too medical)
  • Studies done on quality, cost effectiveness
  • Needed professional home educational program,
    faculty leaders (RWJ )

65
Nurse Practitioner Workforce Growth
Source Unpublished data from the National
Organization of Nurse Practitioner Faculties
Analysis by the Center for Health Professions,
UCSF, 2004.
66
Demonstration programs were mostly rural (RWJ )
  • UC Davis, rural physicians in home towns were
    clinical preceptors
  • Utah Valley Hospital, rural clinics, back-up by
    ER docs
  • Tuskegee Institute, mobile vans, fax/ phone to
    supervising physicians
  • Frontier Nursing Service, KY, rural maternity
    care, physician back-up

67
Physician Assistants
  • Leader at Duke envisioned PAs as primary care
    providers, from roots in military medical corps
  • National assoc. and accrediting body estd early
    on (RWJ )
  • Developed separately from NPs
  • Less controversial, yet similar to NPs

68
Growth of Physician Assistants 1980-2020
Source Bureau of Labor Statistics and American
Academy of Physician Assistants Analysis by The
Robert Graham Center, 2004.
69
Elements for Progress
  • Demonstrated need
  • Workable solutions
  • Broad support
  • Leadershiprural states led the way in developing
    nurse practitioners, physician assistants

70
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71
  • Shelly Gehshan
  • Senior Program Director
  • National Academy for State Health Policy
  • sgehshan_at_nashp.org
  • 202-903-0101
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