Dental Workforce Trends

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
ADHP DHAT CDHC
Masters level 2-year program 12-18 months
Licensure IHS certification (like licensure) Certification
Curriculum draft on web In 53 countries Planning
Seeking partners, , legislation, pilot planned at 2 MN colleges Proven model, many studies published. Pending legis. bars use in lower 48. ADA has approved 2 M for 3 pilot projects pilot ruled illegal in MI
38
ADHP DHAT CDHC
True midlevel provider (RDH 2 yrs) Function like midlevels, but educated in less time Part dental assistant, part social worker (not a midlevel)
Post-RDH career track High school grads High school grads
Could be supported by reimbursable services Could be supported by reimbursable services Supported by grants? Few reimbursable services
39
ADHP DHAT CDHC
Pool of RDHs ready to train Recruited from underserved areas, groups Not clear, dental assistants?
Risk assessment, case management Basic preventive and restorative services Prevention, education, case-finding for dentists
Useful to expand safety net Useful to expand safety net Useful for prevention, limited use in safety net
40
Restorative Capacity of Providers
Procedures EFDA CDHC (proposed) DHAT ADHP (proposed)
Atraumatic Restorative Technique (ART) X X
Placement of temporary restorations X X X X
Simple restorations X X X
Light cure composites X
Simple extractions X X
Lab processed crowns X X
Pulpotomy X X
Pulp capping X X
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

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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

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