7
Challenges of the Current System

A panel of experts discussed some of the major challenges to the current system of oral health care. These challenges include education and training challenges, regulatory challenges, financial challenges, and challenges in performing quality assessment.

CREATING FUTURE LEADERS

Jack Dillenberg, D.D.S., M.P.H.

Arizona School of Dentistry & Oral Health


Many critical challenges face the dental workforce. The practice of dentistry is a privilege that includes an underlying responsibility and expectation to give back to society. To quote from the report of the American Dental Education Association President’s Commission:

Economic market forces, societal pressures, and professional self-interest must not compromise the contract of the oral health provider with society. (Haden et al., 2003)

Societal Changes

Many changes affect the way the health care workforce interacts with society. Today, the public is increasingly well-informed about their health care choices, and so professionals need to be aware of the types of information the public has access to, including incorrect information. In addition,



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7 Challenges of the Current System A panel of experts discussed some of the major challenges to the current system of oral health care. These challenges include education and training challenges, regulatory challenges, financial challenges, and challenges in performing quality assessment. CREATING FUTURE LEADERS Jack Dillenberg, D.D.S., M.P.H. Arizona School of Dentistry & Oral Health Many critical challenges face the dental workforce. The practice of den- tistry is a privilege that includes an underlying responsibility and expecta- tion to give back to society. To quote from the report of the American Dental Education Association President’s Commission: Economic market forces, societal pressures, and professional self-interest must not compromise the contract of the oral health provider with society. (Haden et al., 2003) Societal Changes Many changes affect the way the health care workforce interacts with society. Today, the public is increasingly well-informed about their health care choices, and so professionals need to be aware of the types of informa- tion the public has access to, including incorrect information. In addition, 

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4 THE U.S. ORAL HEALTH WORKFORCE today’s patients are different in that they want to have more active roles in their own health care. Therefore, everyone (e.g., health care executives, health professionals, legislators, policy makers, and the public) needs to work together to be more responsive to the demands of this well-informed and engaged society. Strong leaders who are humble, compassionate, and confident are especially needed. This nation is currently undergoing a paradigm shift from primary care to comprehensive care to interdisciplinary care. The focus needs to be on overall health, not just specific disciplines, in order to provide systemic disease prevention and management and to engage patients in healthier behaviors. In that vein, “health homes” should be considered (instead of medical homes or dental homes). Currently, the oral cavity is separated from the rest of the body in many ways, including in the insurance system. Health homes that are accessible, continuous, comprehensive, and family centered are needed. There is more to dentistry than fixing teeth; the whole person must be seen in the context of his or her family and community. The Arizona School of Dentistry & Oral Health To address all of these challenges, special consideration is warranted for the recruitment of the next generation of dental students. The Arizona School of Dentistry & Oral Health (ASDOH) focuses on training dental students to become community-based educational leaders for populations in need. In that regard, the school officials think differently about the types of students to accept, looking for students who want to make a difference and are from diverse backgrounds. For example, one of the main criteria of admission is the documented demonstration of previous community service. ASDOH also has the highest number of American Indian dental students in any dental school in the United States. The modular curriculum allows time for further community service. Grant funding secured the building of a special care clinic that has become the largest provider of special care dentistry in the Southwest. The program has other nontraditional elements. For example, in lieu of a permanent sci- ence faculty, renowned educators from around the country come to teach in 1-week modules. There are also a lot of clinics, and in their fourth year, students spend half of their time outside the school including 4 weeks work- ing in sites across the country such as community health settings and Indian Health Service clinics. One-third of the first graduating class and about one-fourth of the second class went to work in community health centers. Finally, every student graduates with a certificate in public health, which is a requirement for graduation. Students can take additional courses online to receive a full master’s of public health (MPH) degree. About one-third of the class graduating in 2010 will receive an MPH degree.

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 CHALLENGES OF THE CURRENT SYSTEM The school also has a few unique programs for recruitment of students and placement of graduates. For example, the school reserves dental school spots for students recommended by the Alabama Medical Foundation. Additionally, in an agreement with the National Association of Community Health Centers, the Hometown Project allows community health centers to identify students they want to prioritize for job interviews. Conclusions To create the leaders of tomorrow, new and creative thinking is needed when considering the types of students to recruit into dental schools and how to train them. ASDOH works hard to create scholarships so that stu- dents with commitment to communities in need can be trained to go back to those areas. All oral health professionals in the future need to be educated and trained to provide patient-centered, family-centered, comprehensive, and coordinated care. Discussion One participant raised the issue of the trend toward dental schools not being part of larger academic health centers and wondered where the future evidence will come from in an era of evidence-based dental practice. In response, Dillenberg noted that ASDOH has collaborative agreements with universities around the country and fosters research experiences for interested students. Dillenberg expressed that regionalizing dental educa- tion through collaborative agreements is especially useful with the faculty shortages seen at many dental schools. REGULATORY CHALLENGES Regulatory Challenges in Health Care Catherine Dower, J.D. Uniersity of California, San Francisco, Center for Health Professions The following discussion of the regulatory challenges is addressed to the health professions in general. Challenges In the United States, the regulation of health professions can impede the delivery of health care services because of three main challenges. First,

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 THE U.S. ORAL HEALTH WORKFORCE while the education, training, and testing of most health care professionals and the accreditation of educational programs have national standards, the establishment of scope of practice laws are state-based and politically driven processes that result in wide variability and unnecessary limitations on professional practice. One example of the mismatch between what pro- fessionals are trained to do and what they are legally permitted to do is the variability in state laws regarding nurse practitioners. State laws vary tre- mendously regarding whether nurse practitioners can work independently despite the fact that there is no evidence indicating that nurse practitioners do better with physician supervision. There is a similar divergence of prac- tice laws and lack of evidence about patient outcomes when it comes to nurse practitioners’ prescription authority. In fact, research now shows that expanded and overlapping scopes of practice are correlated with increased access without compromised quality or safety. A second challenge in the regulation of health professions is that there are inherent conflicts of interest both with the regulatory oversight of one profession by another profession (as with dentistry and dental hygiene) as well as when a profession self-regulates—that is, when the state regulatory boards are composed primarily of the members of the profession that they are regulating. The state has a legitimate interest in protecting the public, which is the only reason you can interfere with an individual’s ability to practice his or her profession. There is self-interest when a profession is regulating itself, and every year state boards are accused of serving their professions rather than serving the public. However, when two professions are at odds with each other over scope of practice, the issues become more complex. The inherent conflict of interest between protecting self-interests of a profession and protecting the public is exacerbated when one profes- sion regulates another. In these cases, the dominant profession may likely have an additional conflict of interest in trying to protect its own scope of practice, putting itself at odds with both the other profession and the public. While society may choose for now to live with the unavoidable conflict within self-regulating professions, it can avoid the additional con- flicts of one profession regulating another by permitting each profession to regulate only itself. A third challenge in the regulation in health care professionals is that health workforce data collection is limited or nonexistent in most states. For example, little is known about how many professionals are practic- ing or where they are located. While state boards collect some data on licensees, they are quite limited. Short surveys could be tied to the events of initial licensure or relicensure and would provide useful comparison and trend data, such as practice status (e.g., in clinical practice, adminis- tration, academia), location of practice, and specialty. These data would help to inform many key workforce decisions (such as the need for new

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 CHALLENGES OF THE CURRENT SYSTEM professional schools) and to better identify true health professional short- age areas. Promising Directions While these challenges are serious, some promising advances show an increased reliance on evidence and data for regulatory decisions. For exam- ple, new state-based models for deciding scope of practice laws have arisen whereby separate advisory committees review all the submitted evidence (both by the profession proposing an extension of scope and the profession opposing that expansion). These committees then submit their recommen- dations to the state legislatures, which still hold ultimate authority regard- ing practice acts. These new types of review committees have several factors that contribute to their success including having an advisory-only status, credibility, a patient-focused approach, efficiency, and evidence-based deci- sion making. For example, Figure 7-1 shows an evidence-based pyramid being developed by the University of California, San Francisco, that could be used to prioritize different types of evidence submitted to these com- mittees. As one moves up the pyramid, the evidence has a higher degree of filtering (i.e., it is reviewed by more people) and the quality of the evidence Meta - analyses Controlled De e trials nc g ide re Demonstrations e Ev of Research studies of Fi Government data, lte lity Office of Inspector General reports rin a Qu g State laws and regulations Educational curricula, accreditation standards Survey articles, state studies Expert opinion, opinion pieces, anecdotes FIGURE 7-1 Pyramid to prioritize evidence. SOURCE: Reprinted, with permission, from Catherine Dower, 2009. Copyright 2008 by University of California, San Francisco Center for the Health Professions.

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8 THE U.S. ORAL HEALTH WORKFORCE increases. However, there is a lesser amount of this type of high-quality, highly-filtered evidence. There are also trends toward more independent regulatory boards (i.e., less of one profession regulating another profession), increased standardiza- tion of administrative functions among the boards, and more coordinated oversight of regulatory boards within each state. To address the lack of health workforce data, three promising directions for data collection are important to note: short surveys can be tied to relicensure; online data collection and management makes most economic and research sense; and standards across professions and across states would be most valuable and provide the most useful comparison and trend data. Competition and Consumer Protection Gusta P. Chiarello, J.D., M.P.P. Federal Trade Commission The Federal Trade Commission (FTC) is charged with preventing unfair methods of competition and unfair and deceptive acts or practices in or affecting commerce (15 U.S.C. §45) including the enforcement of antitrust laws and other basic consumer protection laws. As a general concept, com- petition in any industry spurs innovation, lower prices, and higher quality, but competition should not create an unequal balance of power or occur through improper means. In the United States, professions are subject to laws and regulations, such as who may enter a profession, what types of minimal competency requirements must be satisfied for licensure, and what services they may provide. State legislators and professional boards often ask the FTC to consider these and other regulations (e.g., rules on advertis- ing for professions). Aside from these issues, the FTC also does a significant amount of work for consumer protection related to fraud in advertising, especially false claims of the health benefit of products. Both the FTC and the Department of Justice advocate against the acts of professions that limit or prevent competition for the delivery of health care services by another profession (e.g., scope of practice laws or licen- sure restrictions) without providing countervailing consumer benefit. That is, if the provision of simpler services is restricted to more highly trained professions, demand will increase, prices will rise, and access will decrease. Therefore, a good reason must exist as to why competition is constrained in a particular area of practice. 1 Mr. Chiarello noted that his comments were his own and did not reflect the views of the Federal Trade Commission or any individual commissioner.

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 CHALLENGES OF THE CURRENT SYSTEM As the FTC often does not have institutional expertise in specific profes- sions, it provides guidance but leaves ultimate decision making to legisla- tors and others to determine proper constraints on competition. The FTC suggests a four-part test for legislators to use in assessing their regulations. First is whether the regulation restricts competition. In the case of scopes of practice, this will likely be true since there will always be individuals just outside a specific scope of practice. Second is whether the restriction benefits consumers in a way that would not exist if not for the regulation. This often relates to consumer safety in that the restriction might prevent incompetent individuals from providing services. Third is consideration of the costs versus benefit to the consumer. That is, would the consumer gain more if restrictions were removed, such as through increased provider access. Finally, is the consideration of whether there is a less restrictive way to achieve the same goal. For example, is foreclosing competition to a certain group of professionals less or more restrictive than changing the competency requirements of that profession? These decisions should be based on evidence, including the opinions of the consumers themselves. Recently, the FTC has been involved in advocacy for such areas as limited-service clinics and the requirement to hire attorneys for real estate closings. In both cases, the FTC argued to find alternative solutions to proposed or existing regulations so competition would not be hindered. Between the 1980s and the early 2000s, the FTC was involved in advocacy directly related to oral health. These cases related to scope of practice and advertising issues. For example, the South Carolina legislature expanded the scope of practice of hygienists to allow cleanings to be provided in school settings without the direct presence of a dentist. The state board of dentistry passed an emergency regulation in opposition to this, and the FTC subsequently brought an antitrust action against the board for reasons of unfair competition that would lead to the loss of preventive services for thousands of children. FINANCING CHALLENGES Craig W. Amundson, D.D.S. HealthPartners Multiple challenges exist in the financing of oral health care in the United States. One such challenge is the budget crisis at the state level. Many states struggle to meet their budgets, and dental benefits are in- creasingly becoming optional for many people. A second major challenge relates to the cost of dental care. Dental care is very expensive, and if ar- rayed against specialty areas of medical care it would be one of the most expensive areas of care. At the same time, compared to some other medical

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0 THE U.S. ORAL HEALTH WORKFORCE specialties, very little has been done to decrease these costs by targeting ef- fective preventive and disease management measures that might mitigate the need for high-cost services. In the commercial world of health care, large amounts of money are at risk if patients have complications; for example, if diabetic patients do not control their disease well, they will likely incur large costs due to hospitalization and other services. However, in dentistry, most employers have a very limited benefit, so they don’t have as much vested interest to become engaged in oral health disease management. An- other challenge is that the dental inflation rate exceeds the inflation rate for most other aspects of society, which can make negotiation difficult. In fact, in 2008, dentistry was identified as the industry with the highest profit margin (almost 17 percent) (Triangle Business Journal, 2009). Strategies The health care system can be envisioned as having four components: health promotion, care delivery, administration, and financing. The key to success is how well we integrate across those four areas. In the dental eco- nomic model, there is no association between the health care strategies and financing strategies. The first step to overcoming financing challenges is to craft a care strategy that is supported by the financing system, rather than just adjusting the financing system in a piecemeal manner. For example, one strategy is to think about population health and the health continuum, including the range of risk status and level of clinical intervention needed at each stage (see Figure 7-2). The dental benefit industry and dental professionals tend to focus on clinical procedures, namely, treatment and salvage interventions, rather than focusing on identification of risk or prevention. In addition, the dental office system is often poorly equipped to efficiently deliver the advice and lifestyle-changing education needed to reduce patient risk for oral health disease. More collaboration is needed with individuals who are more expe- rienced with changing health behaviors. Within the world of finance, several strategies are worthy of explora- tion to address these challenges. First is to think broadly about care model design and redesign instead of focusing strictly on access to the current system that often fails to meet patient’s needs. Second is to understand the importance of allocating resources to public health disease management and disease risk-reduction strategies as a financing activity independent of invasive dental care. Another strategy is to look for alternative activity- based financing systems for specific dental care that gets away from the perverse incentives that are built into the current fee-for-service payment system. Finally, the integration of medical and dental funding is critical in

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 CHALLENGES OF THE CURRENT SYSTEM Public health Clinical care FIGURE 7-2 Risk status and range of clinical interventions along the health care continuum. SOURCE: Amundson, 2009. the context of shared risk, and more improvements are needed for efficiency e 7-2 imagend effectiveness in thearrows isof oral health care services. a and text between delivery fixed Discussion In response to a question about HealthPartners’ ability to get medicine and dentistry to work together in clinics, Amundson responded that the programs have been various and variable. He noted that there have been successful projects to identify high-risk children in the pediatrics depart- ment. Amundson added the presence of both medical and dental electronic health records has been of great benefit to patients, but the current eco- nomic environment of health care makes it difficult to get attention on integrating across areas of practice.

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 THE U.S. ORAL HEALTH WORKFORCE CHALLENGES IN QUALITY ASSESSMENT IN PRIVATE PRACTICE James D. Bader, D.D.S., M.P.H. Uniersity of North Carolina Quality assessment in dental care may be defined as the evaluation of patient care provided by a dental care plan or delivery system for the purposes of comparing one plan or system to another. Understanding the challenges in quality assessment in dental care requires examining the limited scope of quality assessment measures in general use for dentistry today, exploration of why quality assessment is limited in dentistry, and consideration of possible solutions. Quality Assessment Measures in General Use2 No general standards exist for the quality assessment of dental care. Today, four types of measures are generally available. First are measures of technical excellence in individual restorations, which are applied soon after the service is performed and are not strongly associated with long-term outcomes. The collection of data for these measures is labor intensive and expensive. In addition, the criteria for judgment of technical excellence tend to be subjective and therefore make standardization and comparison dif- ficult. A second set of measures are measures of patient satisfaction. While many patient satisfaction instruments exist, most are psychometrically weak, tend to be applied to biased samples (i.e., long-term patients), and are difficult to compare. These survey instruments also tend to be very short and are imprecise at determining the source of expressed dissatisfaction. A third type of available measures is measures of service use (i.e., pro- cedures). These measures may be used to answer specific access questions, such as the proportion of a population that receives a dental service or to determine individual styles of practice for purposes of comparison. These measures may also be used to evaluate adherence to evidence-based treat- ment guidelines; however, few guidelines exist. Service use measures may be used to determine outliers of service providers, but since diagnostic infor- mation is not inherent in service use measures, effectiveness of treatment cannot be evaluated. Even the comparison of two practitioners is difficult because the service use measures need to be risk adjusted for the possible differences in the patient populations being compared, but there are no well-accepted case mix adjustors in dentistry. 2 A variety of specialized delivery systems have superior administrative data systems and can do more assessment than the typical private practice. However, this section focuses on the private practice system of dentistry.

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 CHALLENGES OF THE CURRENT SYSTEM The last group of measures in general use in private practice today includes structure and process measures (aside from service use measures). These measures are generally determined in the context of accreditation of a plan or practice. Structural measures include evaluations of facilities, equip- ment, and personnel administration. While these are considered to reflect good practice and may have some basis in regulation (e.g., shielding around X-ray equipment), very little evidence supports their relative importance to specific treatment outcomes other than protection of patient health. Process measures include assessment of such functions as infection control, imaging, diagnosis, and treatment planning. Again, very little evidence supports the importance of these measures to the outcomes of care, but they are assumed to reflect good practice. Overall, quality assessment in dentistry today is relatively weak, and does not assess either the appropriateness or effectiveness of care. The only clinical outcome measure is technical excellence, which is not related to long-term outcomes. The only patient-oriented outcome measured is patient satisfaction, which is inherently flawed and unable to effectively compare delivery systems. Reasons for Limited Performance of Quality Assessment In part, quality assessment for dentistry is limited due to some of the typical characteristics of traditional dental practice. First is the absence of diagnosis codes. The introduction of coding systems in and of itself would be challenging due to the existing technological infrastructure and propri- etary concerns, yet only with these codes can outcomes of treatments for specific conditions be accurately determined. Second, the dental profession sprang from an apprentice-based movement and in the past has been con- cerned almost exclusively with extremely short-term outcomes such as pain relief and technical excellence, at the expense of concern over longer-term outcomes. In addition, dentists have traditionally practiced in professional isolation, which leads to a stronger sense of autonomy, together with lim- ited opportunities for comparison to the outcomes of other practitioners and alternative treatments. Quality assessment in dentistry is also limited due to the absence of a strong evidence base for most dental treatments and therefore, a lack of evidence-based guidelines. Dental research is challenged in part by the lack of the financial resources needed to perform expensive clinical trials. In addition, because of the typical practice design, it can be difficult to obtain outcomes data due to the need to gather data from multiple prac- tices through chart extraction. In fact, the majority of systematic reviews reported to date have been unable to provide unequivocal answers to the research questions. These challenges combined with organizational resis-

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4 THE U.S. ORAL HEALTH WORKFORCE tance lends to a vicious cycle as the lack of evidence-based guidelines causes dentists to rely on expert opinion, reinforcing the tradition of autonomy. However, many dental specialty societies have embraced the development of evidence-based guidelines. Potential New Measures To consider new measures of quality, one needs to redefine quality assessment as the evaluation of the outcomes of patient care provided by a dental plan or dental care delivery system. Under this definition, three sets of measures could be rapidly introduced to improve quality assessment in dentistry: patient experience measures, oral health-related quality-of-life measures, and effectiveness of care measures. First, under patient experi- ence measures, the Agency for Healthcare Research and Quality developed Consumer Assessment of Healthcare Provider Systems (CAHPS) measures, a standardized set of survey instruments that includes a dental plan survey. This survey asks the patient about his or her regular dentist (e.g., does the dentist provide explanations for the care, listen to the patient, show respect), about the care received (e.g., waiting time, presence of emergency access), and about the dental plan itself (e.g., customer service, comprehen- siveness of coverage, breadth of choice). The CAHPS plan survey is ready to be used immediately in dentistry. Second, there are a few well-developed sets of measures that can be used to evaluate oral-health related quality of life, such as the Oral Health Quality of Life and the Oral Health Impact Profile. These measure sets have been validated with reasonably good associations between score levels and other clinical indicators of oral health. These instruments have also been specifically adapted for special populations including young children and geriatric patients. Therefore, entire populations may be examined longitu- dinally to see the effect dental care plans have on outcomes. Finally, for several years, measures have been available to look at the effectiveness of care. These measures are risk adjustable, population-based, patient-centered, and modeled after accepted Healthcare Effectiveness Data Information Set measures. Four basic outcomes measures examine out- comes associated with dental caries and periodontal disease for a reporting year, including the percent of enrollees in a plan or practice that experience new caries or the loss of one or more teeth and the percent of enrollees experiencing improvement or deterioration in periodontal health. In addi- tion, three evidence-based process measures address the practice’s or care plan’s emphasis on prevention and maintenance of oral health by examin- ing the percentage of enrollees receiving a disease assessment (for caries and periodontal disease), the proportion of those who are at risk for car- ies receiving appropriate preventive therapy, and the proportion of those

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 CHALLENGES OF THE CURRENT SYSTEM who have periodontal disease receiving appropriate maintenance therapy. These measures may be applied to separate groups and stratified by level of disease in order to perform risk-adjusted comparisons. Several elements are needed in order to use all these measures, including an administrative data system, diagnostic codes, and periodontal probing information (or surrogate measures that can be approximated via chart audits). Conclusions True quality assessment will not happen until the dental professions fully adopt diagnostic codes. As the value of dental care is becoming an increasingly important concept, purchasers need to demand proof of value and design care benefit plans around existing practice guidelines. More outcomes research is needed because without evidence, practice guidelines cannot be established. Discussion In response to questions about the value of an electronic dental record in quality assessment, Bader said a properly designed electronic patient record that records diagnoses could automatically generate practitioner or plan-level performance measures. The record, he said, would provide information on outcomes and appropriateness since the diagnosis could be compared to the chosen treatment. Bader noted that firms are starting to recruit dental offices to submit the entire contents of their electronic record systems each evening in return for practice analysis feedback. This will eventually enable a large-scale assessment of the quality of practice, he said, but the growth toward electronic records has been very slow.

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