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 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 (>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 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 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/

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 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

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

40. Restorative Capacity of Providers 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

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. 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 Problems lead to Solutions

49. 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 Consider Attitudes in Building Support for Solutions

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.