Dental Workforce Trends Opportunities for Improving Access

1. Dental Workforce Trends�Opportunities for Improving Access Shelly Gehshan, M.P.P. National Academy for State Health Policy March, 2008

2. 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

3. Is there a Shortage in the US? Active Dentists per 100,000 Population

4. Is there a shortage? Active Dentists per 100,000 Population (2000)

5. Dentist Vacancy Rates at Health Centers (2004)

6. Age Distribution of Private Practice Dentists (2005)

7. 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

8. Number of Employed Dental Hygienists, in thousands

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 insurance�make 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/ Children: including those who qualify for Medicaid, HealthWave, free or reduced lunch program, Head Start and other early education settings, foster care, therapeutic centers, schools, community youth programs, local health departments, juvenile justice programs, and safety net clinics. Adults: those at individual and group homes, developmental disabilities centers, community subsidized housing and meal programs as well as senior centers, long-term care facilities, local health departments, and safety net clinics. Children: including those who qualify for Medicaid, HealthWave, free or reduced lunch program, Head Start and other early education settings, foster care, therapeutic centers, schools, community youth programs, local health departments, juvenile justice programs, and safety net clinics. Adults: those at individual and group homes, developmental disabilities centers, community subsidized housing and meal programs as well as senior centers, long-term care facilities, local health departments, and safety net clinics.

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 Nation�s Oral Health Needs,� HRSA�s 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 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.

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 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

28. �And, Investment in Upstream Strategies Sealant programs serve too few kids ME: programs reach about � 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

29. Progress on New Provider Models

30. 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

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

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

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 Parents not getting kids to the dentist Areas lack fluoridated water, sealant programs Too few dentists locate near, serve low income patients 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

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

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.� �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.

51. 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)

52. 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

53. 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

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 dentistry�restricts choices for dentists, and options for communities Examine dental practice act�may need safety net exemption

56. 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

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 don�t treat 1/3 of the public; won�t 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

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 est�d early on (RWJ $) Developed separately from NPs Less controversial, yet similar to NPs

68. Growth of Physician Assistants 1980-2020

69. Elements for Progress Demonstrated need Workable solutions Broad support Leadership�rural states led the way in developing nurse practitioners, physician assistants

71. Shelly Gehshan Senior Program Director National Academy for State Health Policy sgehshan@nashp.org 202-903-0101