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Access Proposal. Phased Strategies for Reducing Barriers to Dental Care. University of California, San Francisco Dental Public Health March 13, 2012. Agenda. THE RESEARCH Mandate, topics and results. THE HISTORY CDA initiatives. THE PROPOSAL Phased strategies and opportunities.
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Access Proposal Phased Strategies for Reducing Barriers to Dental Care University of California, San Francisco Dental Public Health March 13, 2012
Agenda THE RESEARCH Mandate, topics and results THE HISTORY CDA initiatives THE PROPOSAL Phased strategies and opportunities
Reducing Barriers to Dental Care The history
The problem is real • 11 million Californians do not have any form of dental insurance • 7 million are low-income or disadvantaged • 4.5 million are children eligible for Denti-Cal • 233 dental professional shortage areas Children are the most vulnerable
California Dental Association • Mission Statement: The California Dental Association is committed to the success of our members in service to their patients and the public • Vision: The California Dental Association is the recognized leader for excellence in member service and advocacy promoting oral health and the profession of dentistry
CDA’s role is to be an expertvoice representing the best interests of the profession and the public • 2002 House of Delegates adopts resolution recognizing access issues • 2008 CDA House of Delegates authorizes research, asks for evidence-based recommendations • 2009 Two working groups created • 2010 Research conducted and analyzed • 2011 Recommendations formulated and presented
CDA Foundation • Student Loan Repayment Grants • Community Program Grants • Community Water Fluoridation • Perinatal Oral Health Guidelines • CAMBRA • Pediatric Oral Health Access Training Program
Community Water Fluoridation • 1992: 17% • 1995: AB733 • 1998: The California Endowment • 2011: 63% • Future: 70%
Caries Prevention & Treatment • Caries Management By Risk Assessment • Pediatric Oral Health Access Program • Perinatal Oral Health Guidelines
Grant Making • Student Loan Repayment Grant • Up to $105,000 over 3 years • Work in an underserved community • Application period: May 1 – August 15 • CDA Foundation Grant Program • Up to $25,000 • LOI submission: April 1 – June 30
Commitment To Knowledge-Based Decisions • A culture of science • Peer reviewed Journal • CDA Presents • Governance that is transparent about decisions • Membership that invites conversation with other associations and individuals representing specialists, ethnicities, stages of practice, practice models
Comprehensive, evidence-based approach to access • Become the expert • Consider every option except standing still • Be transparent and inclusive; communicate with membership throughout • Go beyond emotions and assumptions to data and outcomes; focus on what really works
Reducing Barriers to Dental Care CDA Research
Research began witha mandate • Assess existing research • Fill gaps with new research • Examine barriers to care • Examine workforce models • Be thorough and deliberative • Evaluate data in context, not isolation • Develop recommendations that … • respect the unique role of the dentist • are realistic yet comprehensive • focus first on where we can make the greatest difference • build one upon the next and ensure effectiveness can be maintained over time
CDA reviewed the literatureon variety of topics … • Oral health infrastructure • Medicaid reform • School-based oral health programs • Incentives for working in public health • Oral health literacy
… and commissioned newresearch where there were gaps • Oral Health in California • State oral health infrastructure • Dental Residency programs
… and commissioned newresearch where there were gaps • Efficiency and capacity of the current dental delivery system • Impact of additional dental providers in the dental labor market • Economic analysis of new dental workforce models • Comparative safety and quality of dental providers world-wide
Study Design • Benefits of state oral health infrastructure • Why does infrastructure matter? • What are the national standards? • What are the federal resources for funding and support? • Lessons learned from other states? • What is California’s opportunity?
Key Findings • Leadership, leadership, leadership • Strong support from department and policymakers • Visibility in state agency is critical • Models and infrastructure support already available • Not all work needs to be done by the state • Doing something is better than doing nothing
Recommendations • Hire a director with dental public health experience • Develop an oral health plan building on what exists • Work with existing stakeholders and programs • Seek federal and private funding • Develop new childhood prevention programs
Study Design • Analysis of Medicaid reforms in other states • National Academy for State Health Policy • U.S. General Accounting Office • Center for Medicare and Medicaid Services • Review of state litigation for Medicaid reform
Key Findings • Rate increases are necessary – but not sufficient on their own – to improve access to dental care • Rates must cover the cost of providing service, estimated at 60 to 65% of dentists’ charges • Working with families on how to use dental services is a core element of reforms • Even after substantial effort and investment – only 32 to 43 percent of children covered under Medicaid received dental care, pointing to the need to explore other solutions
Study Questions • What is required to establish a dental residency? • What are the funding opportunities? • What is the experience of dental graduates who complete residencies? • What is potential benefit to the dentist and the public? • What are the barriers?
Key Findings • History of national commissions recommending all states make dental residency a licensure requirement • Too few residency positions and large graduate debt burden are common reasons to oppose • General Practice Residencies hold potential to increase care to underserved
Study questions • How efficient are dental practices at utilizing time and resources? • How efficient are community clinics at utilizing time and resources? • How stable is this efficiency over time? • What is the capacity in the current system to treat additional patients?
Study Design • Determined the technical efficiency of the dental delivery system in California – defined by patient visits • Includes private practice and safety net providers • Utilizes data from 2003, 2005, and 2007, which is a representative time frame for typical dental practice patterns outside a recession
Key Findings • High efficiency in dental practices • Practice patterns stable over many years • Significantly increasing number of patients seen would require substantially more days and longer hours – unlikely given the physical and emotional demands of dental practice
Study Design • Model dental therapists (DTs), dental health aide therapists (DHATs), and advanced dental hygiene practitioners (ADHPs) • Evaluate compensation levels, cost of training, cost of practice, estimated productivity, and potential revenue for each practitioner • Develop economic projections for alternative dental workforce practitioner models
Key Findings • The costs of education, debt burden and compensation significantly impact the viability of all workforce models • The Advanced Dental Hygiene Practitioner (ADHP) is most costly – due to length of education and likely debt burden • DT and DHAT models are less costly, but even those costs are substantial • Dental education is very expensive and educational programs require subsidy to be economically viable
Other Findings • Advantages to drawing from local population – enhances cultural competency and longevity of practitioner; supports practice in community of origin • To ensure practitioner serves intended population, licensure must limit practice location or patient population
Study Questions • Relative economic value produced by proposed new dental providers • Potential impact on the earnings per hour of private practice dentists from the entry of additional private practice dentists into the dental labor market • Potential impact on the earnings per hour of private practice dentists from the entry of hypothetical new dental providers into the dental labor market
Key Findings • Income impact is largely a result of direct competition for patients – though small in all cases • Additional general dentists have the greatest effect on the income of other general dentists • Additional providers who care for children slightly increase earnings of others • Practice restrictions (age, payer source) diminish overlap and decrease negative impact
Study Design • Systematic literature review using PRISMA • Primary question: are the irreversible procedures performed by any non-dentist provider category safe compared to the same procedures performed by dentists? • Due to the limited number of studies available to answer the above question, added quality, productivity or cost-benefit, and patient satisfaction as secondary outcomes
Study Design • Cochrane, Medline, EMBASE, and Pub Med databases • Search strategy developed; filters included human studies and were limited to publications in English language • 20 original articles abstracted and summarized using a style similar to the one prescribed in Cochrane Handbook for Systematic Reviews of Interventions • Level of evidence within each study was graded by the lead author using the modified Strength of Recommendation Taxonomy (SORT)
Key Findings • Non-dentist providers have high level of safety, quality, productivity and patient satisfaction for reversible procedures • Insufficient high level evidence for irreversible procedures • Recommended additional high powered studies to fully answer these questions
Research confirmed some observations, created new insights • Approximately 30% of Californians face multiple barriers to accessing the current dental care delivery system • Children are the most vulnerable • California needs dental director with influence in the administration • Effective and coordinated dental public health programs essential
Significant barriers exist to dentist participation in Denti-Cal, including low reimbursement and high administrative burden • Healthcare reform is expected to extend dental benefits to more than 1 million additional children by 2014 • Capacity to provide care to these additional children does not currently exist • External pressures exist to develop systems that provide care at the lowest cost and to expand capacity by developing a new dental provider category
Implication of research • A comprehensive and multifaceted approach is necessary, employing many strategies • Build on what works, support and expand successful programs and best practices • Prevention of dental disease is essential, solutions must focus on children • The greatest benefit expansion for children is likely to occur in public programs • Children’s programs are mandated, federally supported and sustainable
Financial incentives are successful in influencing provider behavior • Practices restrictions ensure providers work in settings that are accessible to the 30% in need • Evidence indicates barriers are reduced for children when care delivered in or close to where they live, go to school • Safety and quality research on irreversible procedures still needed to make evidence-based workforce recommendations
Reducing Barriers to Dental Care Recommendations
