The U.S. Oral Health Workforce in the Coming Decade: Workshop Summary (2009)

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5 Current Delivery Systems A panel of experts discussed some of the main ways in which oral health care services are currently delivered. Panelists paid special attention to the organization, size, capacity, workforce, financing streams, target populations, and impact of state practice acts for each system of care. pRIVATE pRACTICE Wayne R. Wendling, Ph.D. American Dental Association The private practice model of care delivery applies to the approximately 92 percent of the 165,000 professionally active dentists who are involved in the private delivery of dental services. As seen in Figure 5-1, the majority of dentists in private practice are sole proprietors. Independent dentists in private practice typically work 49 weeks a ­ nnually, and 32 of the 36 hours of weekly practice are devoted to the treatment of patients. These numbers have declined in the last 10 years due in part to the aging male component of the workforce and the greater share of females in the workforce who tend to work 2–3 hours less per week. The typical independent dentist has almost 4,000 patient visits each year, with walk-ins and emergencies accounting for about 6 percent of all visits. About 70 percent of private practice dentists provide charitable care    The source for all data in this section is attributable to ADA Survey Center, 2008. 39 

40 THE U.S. ORAL HEALTH WORKFORCE Contractors 3% Employees 6% Partners 16% Sole proprietors 75% FIGURE 5-1  Employment situation of dentists in private practice, 2005. SOURCE: ADA Survey Center, 2008. Figure 5-1 R01521 (75 percent among dentists in practice less than 10 years) at an average value of about $13,200. redrawn Most dentists (92 percent) are in single-office locations and have at Fully editable vectors least one staff member (92 percent). The typical dentist has almost five staff members on his or her team, including chair-side assistants, secretar- ies, dental hygienists, and other staff members. As seen in Figure 5-2, these dentists see patients across the age spectrum, with 14 percent of patients being over age 65 and 22 percent being under age 18. A little more than half (55 percent) of a private practice dentist’s patients are female. The majority of patients (63 percent) are covered by private insurance, and 31 percent of patients are not covered by insurance. Private practices tend to be located in areas that have the population to support them. The typical travel time to a practice is less than 10 minutes for about one-third of the population, 11–40 minutes for about half of the population, and 13 percent travel for more than 40 minutes. A 2005 survey of new dentists (i.e., dentists in practice for less than 10 years) showed about 54 percent of new dentists start off as employees, but with more years of practice, they are less likely to be employees. As they move out of employee status, they move into partnerships or become sole proprietors. New dentists earned about $86,000 annually, but those 

CURRENT DELIVERY SYSTEMS 41 Age <5 Age >65 5% 14% Age 5–17 17% Age 55–64 19% Age 18–34 18% Age 35–54 27% FIGURE 5-2  Age distribution of patients seen by independent dentists, 2006. SOURCE: ADA Survey Center, 2008. in practice for about 10 years earned about $200,000. While the majority of all new dentists go into private practice, a slightly higher percentage of Caucasian new dentists enter private practice than Hispanics, African Americans, and Asians. Among new dental graduates, 70 percent enter Figure 5-2 editable private practice while 20 percent go on to graduate studies. The remaining 10 percent go into public health, military, or other areas of the workforce. The majority of dental students (94 percent) graduate with debt, with the average debt being $158,000 in 2006. About 70 percent of graduates carry additional debt with an average of about $89,000. In conclusion, based on data from the 2000 U.S. Census, there are about 43 million economically disadvantaged individuals (persons at less than 125 percent of the federal poverty level) who make up the bulk of the populations that have difficulties with access to health care services. When considering solutions, more attention needs to be given to the flexibility, capacity, and diversity of the workforce as well as collaboration and effi­ ciency within that workforce. 

42 THE U.S. ORAL HEALTH WORKFORCE mEDICAID-fOCUSED pRACTICES Burton L. Edelstein, D.D.S., M.P.H. Columbia University Beneficiaries in the Medicaid program have little access to the primary sources of dental care in the United States. Medicaid-focused practices include private practices, exclusive Medicaid management companies, or public and private safety net programs (other than federally qualified health centers). These practices serve poor children via the Medicaid program and the children of working poor families via the Children’s Health Insurance Program (CHIP). Notably, states are not required by either program to pro- vide adult dental coverage. Medicaid and CHIP are publicly funded sources of health insurance and cover 20 percent of the U.S. population, usually the children with the greatest oral health needs, but only account for 5 percent of total U.S. dental financing. In addition, payments from these sources often fall below dentists’ overhead rates. To accommodate these challenges, Medicaid-focused practices strive to lower operational costs, increase effi- ciency, find additional sources of funding (or hybridize their practices with patients with higher-reimbursing payments), and negotiate fees. Medicaid- focused practices often engage staff members who are committed to serving vulnerable populations and maximize the role of each staff member. Private Practice The majority of dentists in private practice do not participate actively in the Medicaid program (i.e., bill more than $10,000 annually). Therefore, in the setting of private practice, a small subset of dentists provides the overwhelming majority of care to Medicaid patients. A major challenge to increasing the willingness of dentists to provide these services may be inadequate education and training in the needs of the Medicaid population. Some of the reasons that dentists choose to serve Medicaid populations include their strong sense of social responsibility, their confidence in their clinical abilities, the income opportunity, and a favorable attitude toward the Medicaid program. These practitioners are also willing to stretch social norms—that is, they are willing to redefine what a “successful” practice is, to relocate to areas that are accessible to these populations, to have more flexible schedules, and to lower their income expectations. Medicaid Management Companies Medicaid management companies are for-profit practices that are grow- ing rapidly in number. The presence of these practices can lead to dramatic increases in utilization and increase the number of children who receive 

CURRENT DELIVERY SYSTEMS 43 care. These practices are able to succeed because they have strong control over expenses by locating the practice in areas of low rent (which are often areas more accessible to these populations), by ordering equipment and supplies in large volume, and by having lower staff salaries. Since these practices are typically much larger than the traditional private practice, they can have increased flexibility in scheduling appointments, hire a larger staff, and use each staff member to his or her highest level of ability. Safety Net Providers Safety net providers comprise a disparate and numerous group that range widely in their stability and productivity. These providers tend to meet the critical needs of much smaller groups of populations in need. Safety net providers may deliver services through school-based programs, such as sealant programs, prevention programs, and screening and surveil- lance programs. Other safety net providers deliver services through mobile dental programs, the clinics of dental schools, and voluntary programs. Conclusions To expand care to Medicaid populations, new and existing dentists need more experience working with these populations. Increased access may also be facilitated by thinking about what types of students are accepted into schools and how they are trained. Pediatric dentists especially need to become more engaged, as they are the best trained to provide the most sophisticated treatment to the children with the greatest need. Other considerations include the provision of incentives to caring for this population and expanding the roles of dental assistants to allow for increased efficiency. Dental hygienists may also be critical to providing oral health services to this population by continuing to expand the out-stationing of dental hygienists in public health- affiliated sites and the ability to pay for their services directly. Finally, more primary medical care providers need to be engaged in oral health care, and true disease management approaches need to be embraced. COMMUNITY hEALTH cENTERS Donald L. Weaver, M.D. Health Resources and Services Administration Federally supported community health centers (referred to here as “health centers”) include a range of settings including community health    Data for the following section are based on internal Health Resources and Services Admin- istration (HRSA) data (personal communication, D. Weaver, HRSA, February 9, 2009). 

44 THE U.S. ORAL HEALTH WORKFORCE centers, migrant health centers, programs that care for homeless persons, and programs that provide primary care in public housing. The mission of these centers is to improve the health of the nation’s underserved and vulnerable populations by assuring access to care that is comprehensive, culturally competent, and of the highest quality. Health centers must be located in or serve a medically underserved area or medically underserved population. Health centers are governed by community boards that have fiduciary responsibility for the health centers. More than half of the com- munity board’s members must be actual patients of that health center and must be representative of the population served. Health centers must pro- vide comprehensive primary health care services as well as supportive ser- vices, such as education and transportation. Health care centers need to be tailored to overcome each community’s barriers such as geography, personal finances, and cultural and language differences. For example, health centers must see patients regardless of their ability to pay for those services and have sliding scales of payment according to income. Finally, health centers are subject to other requirements related to their administration, financing, and clinical operations. Over 7,000 health centers exist and are located in every state, the Common­wealth of Puerto Rico, the Virgin Islands, the Pacific basin, and the District of Columbia. Only slightly more than half of health centers are in rural areas. Health centers serve just over 16 million people with 63 million patient encounters. Overall, one in 19 people in the United States receives care at a health center, but this ratio is higher for those who live below the poverty level and uninsured individuals. Annually, health centers see about 1 million homeless individuals, more than 825,000 m ­ igrant and seasonal farmworkers, and about 133,000 residents of public housing. While health centers evolved from caring for mothers and chil- dren, an increasing number of older patients are being treated at health centers. Medicaid provides 35 percent of the revenue for health centers. Health centers have over 100,000 staff including almost 6,900 oral health professionals (i.e., dentists, dental hygienists, and dental assistants). The numbers of oral health professionals has been growing consistently in recent years. However, there continue to be a significant number of staff vacancies at health departments, and health centers work with the National Health Service Corps to identify practitioners for these communities. In addi­tion, many centers are becoming more involved with residency pro- grams in general medicine, pediatrics, and dentistry to expose residents to working in health centers. While health center legislation does not require the provision of com- prehensive dental services, many health centers do provide these services, and the number of unduplicated dental visits has been on the rise con- sistently since 2002. Legislation does, however, require dental screenings 

CURRENT DELIVERY SYSTEMS 45 in pediatric populations. Since 2002, the percentage of health centers with onsite preventive dental services has remained stable (ranging from a ­ pproximately 71 percent to 74 percent of all health centers). As funding becomes available, health centers may have the opportunity to expand their services, and the interest level in expansion to include dental services is high. In conclusion, health centers should be considered a health home that includes medical health, oral health, and behavioral health care. Health centers strive to provide care in a manner that is patient centered, culturally competent, and provided by an interdisciplinary team. reaction and DISCUSSION Moderator: Marcia Brand, Ph.D. Health Resources and Services Administration An open discussion followed the panelists’ presentations. For this ses- sion, workshop participants were asked to submit cards with comments and questions for the panelists. The following sections summarize the discussion session. (See Appendix E for a broader sampling of the submitted questions and comments.) Quality of Care Several participants asked about models to assess the quality of care provided instead of focusing on the person delivering the care or the mode of financing. Edelstein said there is very little information on either quality of care or even on what should be measured to establish quality of care. He noted that the new CHIP legislation does establish a commission to a ­ ddress quality of care and explicitly calls for the development of measures for oral health services. In response to a question about the quality of care provided by ­Medicaid management companies, Edelstein said he did not have a basis to evaluate this. He said that quality reviews by state Medicaid authorities and the Medicaid/SCHIP Dental Association do not reveal problems leading to issues around payment for services. Edelstein noted these companies have been subject to a fair amount of controversy but also states that there are some public misapprehensions and misunderstandings about the nature of surgical dental services for children. He said that despite rigorous effort, the companies have often failed to find pediatric dental specialists. He also recognized that some of them have worked hard to develop quality supervi- sion and quality improvement methods. Edelstein said that the wide variety of individual providers and companies does not allow for a conclusion to 

46 THE U.S. ORAL HEALTH WORKFORCE be drawn about the quality of care provided by Medicaid management companies in general. Structure of Health Centers In response to a question about the relative lack of dental hygienists working in health centers, Weaver replied that many centers are look- ing for them, but may be challenged by more competitive salaries in the private sector. He added that health centers have been encouraged to link with dental hygiene programs just as they do with residencies in dentistry. Weaver noted that several centers have successfully done this, and it seems to improve recruitment. In response to a question about regulation, Weaver said that dental clinics in federally funded health centers still operate under state practice acts. Another participant commented that the Health Resources and Services Administration (HRSA) used to have regional dental consultants provide technical assistance to health centers and asked what HRSA is currently do- ing to assist health centers. Weaver stated HRSA has a variety of resources through its support of the National Oral Health Access Group as well as consultants who are available on an as-needed basis to health centers that request technical assistance. Weaver also noted that HRSA is actively work- ing with state primary care associations to ensure they have core abilities to assist people. He also commented that in the last few years, HRSA has been striving to coordinate technical assistance efforts so that if a health center has a particular question, there will be a best practice as to how to answer that question. Finally, Weaver said that they still try to tap into the resources of employees in regional offices. Financing One participant asked about the effect of the economic downturn on practice setting (i.e., will dentists favor salaried positions over private prac- tice). Wendling noted that the economic downturn will likely have several effects, including a change in retirement patterns of existing dentists (e.g., they will stay in practice longer) as well as fewer opportunities to work as an employee or independent contractor in private practice. He said, there- fore, more opportunities may actually arise in other areas.