Transcript Slide 1

Dental Workforce Trends—
Opportunities for Improving
Access
Shelly Gehshan, M.P.P.
National Academy for State Health
Policy
March, 2008
1
What I’ll 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
2
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
3
Is there a shortage?
Active Dentists per 100,000 Population (2000)
4
Source: American Dental Association, Survey Center. US Census Bureau (2001).
Dentist Vacancy Rates at Health
Centers (2004)
5
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.
Age Distribution of Private Practice
Dentists (2005)
35
30
25
20
15
10
5
0
<35
35-44
45-54
55-64
65+
6
Source: American Dental Association, 2005
Is There a Shortage of Hygienists?
•
•
•
•
158,000 hygienists in 2004
Expected to grow (>27%) 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
7
Number of Employed Dental
Hygienists, in thousands
250
212
226
200
152
150
158
150 149
161 166
145
100
50
20
14
20
12
20
10
20
08
20
06
20
04
20
02
20
00
0
8
Source: U.S. Department of Labor, Bureau of Labor Statistics, http://www.bls.gov
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
9
State Strategies for Rural Areas
10
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)
11
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
12
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
13
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
14
State Action on Workforce
15
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)
16
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
17
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
18
Challenges in Integration
• Involve dentists in training MDs, RNs, NPs
• Link medical and dental homes
• Reimbursement through public and private
insurance—make it universal
• Differences in fee-for-service and
managed care
• Diffusion of idea; change practice patterns
19
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
20
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.
21
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
22
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/
23
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 Nation’s Oral Health Needs,” HRSA’s BHPs 2008 All Programs
Meeting
24
The Business of RDHAP Practice
•
•
Business plans--education program needed on how to do these
Developing payment structures and charting system—who 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.
25
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.
26
What isn’t 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
27
…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 it’s
stalled or retreating, despite sound
science, low cost
• Education and outreach for at-risk families
28
Progress on New Provider
Models
29
Existing Models
• Dental therapist—New Zealand model
– Called dental health aid therapist in AK; in use in 53
countries
• Oral health therapist—newer 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
30
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
31
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
32
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)
33
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
34
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
35
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
36
ADHP
DHAT
CDHC
Masters level 2-year program 12-18 months
Licensure
Curriculum
draft on web
Seeking
partners, $,
legislation, pilot
planned at 2
MN colleges
IHS certification Certification
(like licensure)
In 53 countries Planning
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
37
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
Could be
supported by
reimbursable
services
High school
grads
Could be
supported by
reimbursable
services
High school
grads
Supported by
grants? Few
reimbursable
services
38
ADHP
DHAT
CDHC
Pool of
RDHs ready
to train
Recruited from
underserved
areas, groups
Not clear, dental
assistants?
Risk
assessment,
case
management
Useful to
expand
safety net
Basic
preventive and
restorative
services
Useful to
expand safety
net
Prevention,
education, casefinding for
dentists
Useful for
prevention,
limited use in
safety net
39
Restorative Capacity of Providers
Procedures
EFDA
CDHC
DHAT
(proposed)
Atraumatic Restorative
Technique (ART)
Placement of
temporary restorations
X
Simple restorations
X
Light cure composites
X
Simple extractions
Lab processed crowns
X
ADHP
(proposed)
X
X
X
X
X
X
X
X
X
X
Pulpotomy
X
X
Pulp capping
X
X
Source: NASHP, “Clinical Capacity of Current and Proposed Providers,” Table developed by
NASHP, February 2008
40
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
41
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).
42
Newtok Clinic, YukonKuskokwim
43
AFHCAN Cart
Alaska Federal Health Care Access Network
• Wireless Networking
• Touchscreen
• ECG / Video Dental Camera
and Otoscope / Scanner /
Digital Camera
• Mobile – Customized
• Patient safe
• WWW. AFHCAN.ORG
44
45
How do We Move Forward on
New Workforce Models?
46
3 Requirements for Policy
Change
1. Shared perception of the problem
– Public agreement; communication frames
issue, raises priority
2. Political support
– Broad-based support, all powerful groups or
actors involved
3. Viable policy solution
– Workable, timely, affordable, proven
47
Problems lead to Solutions
• Parents not getting kids
to the dentist
Provide education to
parents, incentives, fines
• Areas lack fluoridated
water, sealant programs
Fluoridate water, fund
sealant programs,
school based care
• Too few dentists locate
near, serve low income
patients
Recruit dentists, pay
more to treat low income
patients, fix hassles
48
Consider Attitudes in Building
Support for Solutions
Provide education to
parents, incentives,
fines
Low income parents are
irresponsible; No
incentives!
Fluoridate water, fund
sealants, schoolbased services
Some oppose fluoride,
more services to the poor
(equity issues)
Recruit dentists to
underserved areas,
pay more, fix hassles
Dentists are rich already,
won’t come, don’t care
49
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.”
• “Don’t want to care for poor people but
they don’t want us to either.”
Source: S. Gehshan, T. Straw, “Access to Oral Health Services for Low Income People,”
National Conference of State Legislatures, 2002.
50
Organized Dentistry Does Care
• “voluntary programs to deliver free
care…are 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)
51
Important Steps
• State and local policy communities come
to consensus, not national groups
• Focus on the underserved, not providers
• Communicate solutions, don’t assume
people understand
• Seek investments from foundations,
governments
52
Important Partners
• Payors—Medicaid, SCHIP, private
insurers, business
• Coalitions—Provider associations, dental/
medical leaders
• Legislators, local and state agency leaders
• Universities, training programs
• Safety net clinics, rural providers
• Foundations
53
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
54
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
dentistry—restricts choices for dentists,
and options for communities
• Examine dental practice act—may need
safety net exemption
55
Why Dentists Oppose Midlevels
•
•
•
•
•
•
Would create a two-tier system of care
There’s no shortage of dentists
It’s 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
56
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 don’t treat 1/3 of the
public; won’t lose business
57
What dentists see…
58
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
59
Source: Albert Guay, “Dental Practice: Prices, Production, and Profit,” JADA,
Vol. 136 (March 2005), 359.
60
Concurrent Steps to Create
New Providers
• Curriculum development, faculty
training, recruiting students
• Accreditation
• Legislation establishing new providers;
issue enabling regulations
• Licensing or credentialing process
61
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
62
Lessons Learned from the
Medical Field
63
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 $)
64
Nurse Practitioner
Workforce Growth
65
Source: Unpublished data from the National Organization of Nurse Practitioner Faculties; Analysis by the Center
for Health Professions, UCSF, 2004.
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
66
Physician Assistants
• Leader at Duke envisioned PAs as primary
care providers, from roots in military
medical corps
• National assoc. and accrediting body est’d
early on (RWJ $)
• Developed separately from NPs
• Less controversial, yet similar to NPs
67
Growth of Physician Assistants 1980-2020
68
Source: Bureau of Labor Statistics and American Academy of Physician Assistants; Analysis by The Robert
Graham Center, 2004.
Elements for Progress
•
•
•
•
Demonstrated need
Workable solutions
Broad support
Leadership—rural states led the way in
developing nurse practitioners, physician
assistants
69
70
Shelly Gehshan
Senior Program Director
National Academy for State Health Policy
[email protected]
202-903-0101
71