Dental Workforce TrendsOpportunities for Rural Leadership

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Dental Workforce TrendsOpportunities for Rural
Leadership

• Shelly Gehshan, M.P.P.
• National Academy for State Health Policy
• January, 2008

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What Ill cover

• Overall workforce trends
• Whats happening in states
• integrating oral and general health
• Changes in scope, supervision
• Progress on new midlevel models

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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
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Is there a shortage? Active Dentists per
100,000 Population (2000)
Source American Dental Association, Survey
Center. US Census Bureau (2001).
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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.
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Age Distribution of Private Practice
Dentists (2005)
Source American Dental Association, 2005
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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

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Number of Employed Dental Hygienists, in thousands
Source U.S. Department of Labor, Bureau of
Labor Statistics, http//www.bls.gov
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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

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Whats Happening in States
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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)

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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)

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Target Populations for Integrating Oral Health
into Primary Care

• Children 0-5
• Adolescents
• Pregnant women
• Special needs children and adults
• Elderly, nursing home residents
• People with chronic diseases, diabetes

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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

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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 (NC about 9 others)
• Joint initiatives for screening and referral (SC)

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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

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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)

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What isnt happening, 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

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Progress on New Provider Models
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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

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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)

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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

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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

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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

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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 dental
  emergencies
• Dental therapists make dentists visits more
  productive, triage patients, take x-rays, arrange
  for medications before dentist arrives Source
  Dr. Todd Hartsfield

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Newtok Clinic, Yukon-Kuskokwim
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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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• How do we move forward on new workforce models?

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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

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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

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Ideas for groundwork

• Study impact of midlevels on private dental
  practice, safety net clinics
• Establish manpower pilot authority (CA)
• Consider new regulatory structure for auxiliaries
  (WA, NM, IA, CT)
• Target new providers to safety net settings
• Data collection to monitor supply, demand
• Establish multi-state collaboratives

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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

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Dental Economics

• About 45 of patient visits are for hygiene
  services
• 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

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

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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.

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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, fluoride,
  Title VII, dental issues in IHS, CMS)

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Lessons Learned from theMedical Field
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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 )

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Nurse Practitioner Workforce Growth
Source Unpublished data from the National
Organization of Nurse Practitioner Faculties
Analysis by the Center for Health Professions,
UCSF, 2004.
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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

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Elements for Progress

• Demonstrated need
• Workable solutions
• Broad support
• Leadership

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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

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Growth of Physician Assistants 1980-2020
Source Bureau of Labor Statistics and American
Academy of Physician Assistants Analysis by The
Robert Graham Center, 2004.
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• Shelly Gehshan
• Senior Program Director
• National Academy for State Health Policy
• sgehshan_at_nashp.org
• 202-903-0101