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Chapter 4 THE SUPPLY OF DENTAL SERVICES A major concern in recommending the inclusion of dental services in a national health insurance program is the capacity of dental care providers to meet a potential increase in the demand for services. A sufficient supply of providers is important not only for a projected comprehensive national health insurance plan but also for limited plans that offer a specified set of services to a particular popula- tion. The supply of and access to dental services are influenced by a number of factors. The committee examined the current status and trends in dental providers, their productivity and the nature of various practice settings. Accordingly, Chapter 4 discusses the number of dentists, their specialization and distribution, the number and kinds of auxiliary personnel and the range of services they can deliver, the types of practice settings in which services are delivered, and conditions that influence productivity. Three types of expanded function dental auxiliaries are described, with reflections of some of the committee's discussion and debate. Cap- sule descriptions of private dental practice, hospital dentistry, and public programs and delivery systems are provided. The committee considered this information, especially in regard to the available data on productivity and the particular attributes of different practice settings. School-based settings, which lend themselves to the delivery of a preventive service for children and adolescents, are explored specifically. Practitioners Dentists In January of 1979, there were about 119,000 active dentists in the United States, of which 88 percent were general practitioners and 78 percent practiced alone. The average dentist in solo practice saw 67.5 patients a week and spent 33.5 hours a week in direct patient contact 230-232/. 47

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As Table 17 shows, the total number of active dentists has in- creased since 1950. However, it was not until the last half of the 1960s that the rate of increase equaled the increase in population. Since then the rate of increase in the supply of dentists has exceeded growth of the population. The increase in the supply of dentists can be attributed mainly to federal policy initiatives. In the 1960s, legislation was enacted to provide funds for the construction of dental schools, whose number then grew from 47 in 1962 to 59 in 1976 233/. That increase was furthered by the Comprehensive Health Manpower Training Act of 1971, which mandated increases in the size of dental school classes as a condition for capitation grants from the federal government. Between 1960 and 1976, the number of dentist graduates increased from 3,233 to 5,336 per year 234-236/. Several different projections have been made about the future supply of dentists through 1990 237-238/. The U.S. Bureau of Health Manpower estimates that there will be enough practitioners to meet the demand in 1990 even if third party dental insurance coverage is greatly increased 239/. Most dental students in the past have been white and male. More women are entering dental school today. In 1970-71, only 2.1 percent of entering dental students were women; by 1978-79, they made up 15.9 percent of the entering class and 21 percent of the senior class. Minorities have not fared as well. In the academic year 1971- 72, about 8 percent of first year dental students were identified as minority. Blacks represented about 5 percent, Asians 2 percent, and Hispanics less than l percent. There was a negligible number of Native Americans. In 1978-79, minorities represented about 11 percent of the class, with some increase of Hispanics and Asians, but a relative decrease in representation of blacks. Geographic Distribution There is great variation in the distri- bution of dentists, both in terms of geographic regions and between metropolitan and rural areas. Although the national average ratio is about one dentist for every 1,900 persons, more than 85 percent of the counties in the United States have less than the average, and about 7 percent (218) have no dentist at all. In 1979, the ratio of dentists to population in the northeast and the west was about one and a half times that in the south. New York had 70.8 dentists per 100,000 population, the highest in the nation, while Mississippi was lowest with 30.7. 48

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Table 17. NUMBER OF ACTIVE DENTISTS AND DENTIST-TO-POPULATION RATIOS: SELECTED YEARS, 1950-79 Year Active Civilian Active Civilian Dentists Persons per Active Dentists per 100,000 Civilian Dentist Civilian Population 1950 75,310 49.8 2,008 1955 78,270 47.6 2,103 1960 84,500 47.0 2,127 1965 89,640 46.5 2,149 1970 95,680 47.1 2,123 1971 97,210 47.3 2,115 1972 98,860 47.7 2,097 1973 100,000 48.2 2,073 1974 103,030 48.9 2,044 1975 106,740 50.3 1,990 1976 110,000 51.4 1,944 1977 112,720 52.0 1,913 1978 115,450 53.1 1,883 1979* 118,330 54.0 1,851 Source: DREW, Health Resources Administration 240-242/ American Dental Association *Personal Communication with J.Ake 243/ 49

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These data do not lead to clear conclusions about the number of dentists needed. However, some differences in dental practice asso- ciated with variation in ratios have been observed. Table 18 displays these differences by region. Dentists who practice in regions with lower ratios are more likely to have longer waiting periods for appoint- ments, to report that they are "too busy to see all people requesting appointments," and to have seen a greater number of patients. Table 19 shows utilization data by region; as expected, utiliza- tion is greater where the supply is greater. The ratio of dentists to population is greater in metropolitan areas. The national average is 56 dentists per 100,000 population for metropolitan areas. At the other extreme, there are only 26 per 100,000 in counties having a principal city of less than 5,000 people 244/. This distribution problem is reflected in data on Table 20. People wait longer for appointments in small cities than in large. Fewer dentists in large cities regard their practices as busy. The result is a difference in utilization: residents of metropolitan areas made 1.8 dental visits per person in 1977, while those who lived outside metropolitan areas (non-farm) made 1.2 visits 245/. The problem in the distribution of dentists is further exacer- bated by the growth of dentist specialization. The dental profession recognizes eight specialties beyond general dentistry: dental public health, oral pathology, oral surgery, orthodontics, pedodontics, periodontics, endodontics, and prosthodontics. In 1979, 12.6 per- cent of all practicing dentists were specialists. The number of active specialists grew from 2,584 in 1953 to 15,003 in 1979 246/. This movement toward specialization in dentistry peaked in 1974 when new enrollees in dental specialty programs reached 1, 282 or about 26 percent of their graduating class. But by 1978, new enroll- ment had dropped to the 1971 leve] of 1,217. This change represented a significant percentage drop because the 1978 graduating class was 37 percent larger 250/. It would appear that the total number of specialists (Table 21) is leveling off. The geographic distribution of specialists mirrors that of gen- eral dentists. For example, in 1976, 25 percent of all specialists were in California and New York, states that have only 18 percent of the total population 251/. Because specialists are dependent upon referrals from general practitioners, they must locate near general dentistry practices. The result is a continuation of the maldistri- bution problem, and specialty care is relatively inaccessible in many areas. 50

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Table 19. UTILIZATION RATES BY REGION, 1977* National Center for Health Statistics Region % Population Making Visit In Preceding Year Average No. Visits for Population in Preceding Year All Regions 49.7 1.6 Northeast 54~1 1.9 West 51.3 1.3 North Central 51.7 1.6 South 44.2 _ 1.3~- Source: National Center for Health Statistics, 1977 248/ * Weighted data not available Table 20. APPOINTMENT DELAY AND PRACTICE ACTIVITY, BY SIZE OF CITY, 1975 % With Average Waiting Time of 1 Month or More ~ Who Perceive ~ Who Perceive for Initial Practice to be Practice to be City Size Appointment Too Busy Not Busy All independent dentists 8.6 14.0 22.3 Under 2,500 20.1 25.0 12.9 2,500- 25,000 15.2 21.0 17.9 25,000- 100,000 6.5 12.0 23.1 100,000- 1,000,000 5.1 10.1 25.1 Over 1,000,000 3.1 8.7 27.0 Source: American Dental Association 249/ 52

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Other problems have been associated with specialization. As in medicine, the fragmentation of services has fostered uncoordinated dental care in which the responsibility for the overall dental health of the patient becomes unclear, and basic dental services may not be provided. Further, the cost of basic services provided by a specialist often is greater. Dental Auxiliaries The present dental manpower team consists of the dentist super- vising the dental assistant, the dental hygienist, and the dental laboratory technician. Most dentists employ at least a part-time auxiliary. More than 90 percent employ assistants, about 50 percent employ hygienists, and about 10 percent have technicians 252/. Table 22 shows the growth of the three auxiliary programs from 1967 through 1977. The sizes of the assistant and hygienist programs appear to be leveling off. The effects of auxiliaries on a dentist's productivity are shown in Table 23; the number of people an individual dentist can see can be greatly increased through the use of auxiliaries. Recently, however, the Bureau of Health Manpower, DHHS, predicted a decreased use of auxiliaries in private dental practices in the future. According to a simulated market analysis, there will be a relative oversupply of dentists and they will "economize" by substituting their own time for that of auxiliaries 253/. Dental Assistants The traditional duties of the assistant are assisting at the chairside in operations, preparing the patient for treatment, keeping the operating field clear, preparing filling materials, passing in- struments, and handling general office duties. The training period may be one academic year, one calendar year, or two academic years, depending on the schools' policy. A high school diploma is a prere- quisite 260/. The average monthly salary in 1976 was $558 (Table 24) There were 140,300 active dental assistants in 1977. The number of educational institutions (predominantly junior colleges) increased from 26 with 658 graduates to 284 with 6,502 graduates. Forty-eight states have at least one program. Dental Hygienists The traditional functions of the hygienist include the per- formance of prophylactic procedures, the exposure and processing of radiographs, the application of fluoride solutions, and the teaching of toothbrushing, flossing, and other preventive health measures. 54

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There are 29,700 active dental hygienists in the United States. They are trained for a minimum of two academic years in 187 programs in 48 states. Some programs require other college courses and lead to baccalaureate degrees. One four year program admits stu- dents as freshmen. The trend in enrollment parallels that for dental assistants--a 250 percent increase between 1967 and 1977 261-262/. According to the 1977 Survey of Dental Practice, there is wide individual variation in the number of patients a hygienist treats 263/. The national average is 35 per week. Assuming an average fee of $15 per patient, a hygenist would produce a revenue of more than $2100 per month for a dentist, as compared with their median monthly salary of $947 in 1976 (Table 24~. Dental Technicians The dental laboratory technician constructs dentures, crowns, and other oral appliances following a dentist's prescription. There are currently 41,600 active technicians. Two-year training programs are offered in twenty-seven states. Between 1967 and 1977, the number enrolled in training increased 340 percent. Their median salary in 1976 was $996 a month. The number in training appears to be slowing in its rate of increase, but to a lesser extent than dental assistants and hygienists (Table 22~. Expanded Function Dental Auxiliaries Expanded Function Dental Auxiliaries (EFDAs) usually are certified dental assistants or dental hygienists who have received extra training of six weeks to six months duration. This enables them to perform a wider range of reversible restorative procedures, such as placing restorations, carving and finishing amalgam, fabricating temporary restorations, and taking impressions. A number of studies conducted in military, university, and public health department settings have shown that the delegation of restorative procedures to EFDAs can result in appreciable increases in dentists' productivity with no significant reduction in the quality of the services. Patient acceptance has not been a problem. 266-269/. Dentists, however, have a variety of attitudes towards EFDAs and the kinds of functions they are willing to delegate. Younger dentists tend to accept them better than older dentists. To help train dentists in the efficient management of auxiliaries and to help them clarify role relationships, the DHHS introduced a program for Training in Expanded Auxiliary Management (TEAM) in the early 57

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Inpatients are admitted and discharged by a dentist in most hospitals, and physical examinations are performed by the attending physician. Ninety percent of the hospitals in the study do oral surgery and nearly 70 percent provide operative (restorative) dentistry. The preventive maintenance services of dental hygien- ists are available to inpatients in only about 14 percent. Many of these hospitals are federal. Federal Delivery Systems The U.S. Public Health Service is responsible for the dental care of about 500,000 Native Americans, which occupies about 250 dentists in 47 hospitals, 135 ambulatory health centers, and 31 mobile units. Much of the work is contracted to private practi- tioners 286/. The Department of Defense and the Veterans Administration have separate systems of dental care. The armed forces dental services are located at military bases and employed 6,141 dentists in 1976 287/. The Veterans Administration dental services are located in 171 hospitals, 10 satellites, and six outpatient clinics and employ 777 dentists 288-289/. Federally funded Neighborhood Health Centers were developed by the Office of Economic Opportunity in the 1960s. They offer dental care as a component of comprehensive care. They operate under federal guidelines, but they are administered locally. The pro- gram was intended to serve 25 million low income people through 1,000 health centers at a projected cost of $3.35 billion. Public policy shifts in the early 1970s, however, arrested the growth of the centers. In 1976, there were about 125 centers serving 1.5 million people at a cost of $197 million 290/. Dental care accounted for 0.59 visits per enrollee as compared with 2.6 visits for medical care 291/. State and Local Programs Since 1940, many direct dental service programs have been organized and financed by state and local governments. Their services usually have been intended for children between ages five and fifteen, and their primary purpose has been to detect and treat dental caries in its early stages 292/. Of the 55 states and terri- torial health agencies or departments, 52 offered some type of den- tal care programs in 1975; two others incorporated dental services into other health programs. Table 26 shows the services provided in the various programs. Medicaid represents a partnership between the various states and the federal government for the financing of health care benefits. 62

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Dental services are allowed but not required by federal guidelines, therefore dental benefits vary from state to state, and many offer none 293/ . Table 26. NUMBER OF STATES AND TERRITORIES PROVIDING DENTAL SERVICES BY TYPE OF SERVICE, FISCAL YEAR 1978 Type of Service Number of States and Territories Reporting Services Dental Services Preventive Restorative Emergency Screening Prosthetic Orthodontic Dental Health Education Nutrition Education Hypertension Screening 52 52 40 38 39 20 19 41 19 Source: Association of State and Territorial Health Officials 294/ Other Practice Modes Most dental care in the United States is delivered in the settings that have been described. However, there are other models in this country and elsewhere that suggest options for the development of a dental health strategy in the U.S. Maricopa County, Arizona provides an example of a locally funded program. Its Bureau of Dental Health was established in 1966 to provide preventive, restorative, and educational services to poor children through age eight. Since that time its client group has been expanded to include poor children to age 14; its goal also has been broadened to the improvement of the oral health of all citizens. Restorative services are available in neighborhood pri- mary health centers administered, funded, and staffed by the health department. Educational and preventive programs are offered to school children and through special education programs. Dental services are also available for high risk Maternity and Infant Care (M.I.C.) projects 295/. 63

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Several demonstration programs have been conducted in U.S. schools. In the late 1940s and early 1950s, the U.S. Public Health Service and the state health departments cooperated on programs in Woonsocket, Rhode Island, and Richmond, Indiana. Four series of treatments were given to children from kindergarten through the ninth grade. Each series included an examination, prophylaxis, topical flouridation, and the treatment of all dental defects except those requiring orthodontics. Dentists, dental assistants, dental hygienists and, in one case, a health educator were involved. More than 80 percent of eligible children received all four treatment series in both demonstrations. Oral health as reflected in the DMF was markedly improved, and the dentist time required to complete the fourth treatment was 55 to 75 percent less than the first 296-297/. One of the major objectives of the Richmond-Woonsocket pro- grams was to encourage good oral health habits in the children and their parents. Dental health education was directed both to participants and non-participants in the schools through infor- mation media. A five year follow-up examination showed that both participants and non-participants received more dental care during those five years than they had previously. All had considerably better DMF scores than they had at the start of the program 298/. In Chattanooga, Tennessee, school children were treated in mobile dental clinics that went to the schools. During the years 1971 to 1975, approximately 2,250 children were treated twice a year. Average total costs per patient per year were $55.60 over the entire five-year period. There was an average annual decline in cost per patient of $7. More than three-quarters of this decline was due to changes in mix and amount of services needed. The remainder was due to increased efficiency associated with increased utilization. In this demonstration, mobile clinics were an effective and low cost method of providing dental care to school children 299/. School-based dental treatment programs have been instituted in many countries, some as a part of a more comprehensive national health program and others independently. Such programs in New Zealand, Australia, Sweden and Canada have recently been described 300-301/. In New Zealand, 98 percent of children receive services; in Sweden, 95 percent. Australia is moving rapidly toward a similar utilization rate. In the New Zealand and Australian programs, much of the routine treatment is performed by dental auxiliaries, including dental nurses. A dentist conducts the initial examination and follow-up examinations every two years. Services in the intervening years are provided by a therapist who performs a wide range of procedures, including routine operative dentistry with off-site supervision. 64

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Saskatchewan, Canada's central prairie province, started training dental auxiliaries to treat children in 1972, after a survey had shown that their dental health was poor. The two- year training program is similar to the New Zealand School Dental Nurse Program. Under the supervision of dentists, the nurses pro- vide dental health education, prophylaxis, topical flouridation, restorative services using local anesthesia, and some surgical services including the extraction of primary teeth. More than 350 clinics have been established in elementary schools throughout the province. Each nurse can treat more than five hundred children a year. In 1976, the third year of the program, the costs were $83 per child, a 48 percent decrease from the first year. 302/ Dental Practice Productivity The productivity of dental practice is important to this study because it indicates the efficiency of a practice in provid- ing dental services. Comparisons among different types of dental practices enable the identification of factors that can increase productivity and thus increase the supply of dental services without increasing the supply of dentists. Dental practice productivity often is measured as patient visits per dentist hour and gross revenue per firm. Other measures for comparing dentists working in different settings include visits per hour and net income per year. These measures of productivity assume that dental visits are homogeneous, an assumption that will be discussed later. Many factors have contributed to an increased productivity of dentists over the past 25 years. Changes that have occurred in dental practice include improvements in instruments (such as high speed drills, evacuators, and ultrasonic cleaners), more efficiently designed facilities, standardization of procedures and instrument storage, more carefully planned scheduling systems, and the greater use of auxiliaries. Contemporary analyses of dental practice show that the factors most closely associated with productivity are dentist hours worked, size of practice, use of auxiliaries, use of capital, type of services rendered (casemix), dentist-population ratio in vicinity of practice, consumer demand in practice market area, and personal characteristics and preferences of dentists. Dentist Hours Worked and Size of Practice Statistically significant relationships have been shown between dentist hours worked and productivity 303-304/. Also the 65

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average number of weekly hours worked by the dentist decreases as the size of the practice increases (Table 27~. Time at the chair in practice also decreases with the size of practice but at a slower rate. Correspondingly, the weekly average of visits per dentist was 16 percent less for solo dentists than for offices with five or more dentists. However, the number of visits per hour declines only five percent between solo practice and multiple dentists. The negligible differences in productivity suggested by visits per dentist hour are not borne out by figures on dental incomes, which reflect the amount of services rendered. Table 28 shows that the gross revenue minus expenses per dentist increases as the size of the practice increases. Dentists in a practice with five or more dentists generated about $26,000 more in revenue per dentist than did solo dentists. This difference may be bigger than it seems, because the average age of the dentist (and thus experience and in- come) is less as the size of practice is greater. Part of the ex- planation may be that average billings per dental visit are directly related to practice size; gross billings per visit were 30 percent higher for practices with five or more dentists than for solo practi- tioners. These higher billings may be the result of higher dental fees or differences in the nature of the services provided. However, data on a weighted average price index of dental services show that fees for dental service do not vary substantially by size of prac- tice; prices of group practices are only about two to three percent higher than those of solo dentists 307/. Therefore, it would seem that some shifts in services provided are taking place. Table 29 shows that as the size of practice increases, the dentists deliver relatively more fixed prosthodontics, periodontics, endodontics, and orthodontic services. These services are more complex and bespeak a qualitative difference from services delivered by solo dentists. Productivity comparisons between solo and group den- tists must adjust for this difference. One recent study of dental productivity that makes such adjust- ments for the complexity of the service produced found economies of scale in the dental practices studied. Practices with three to four dentists were found to be about 14 percent more productive than solo dentists. Those with five or more dentists were about 10 percent more productive than the three to four dentist practice 308/. Other studies have also found economies of scale in dental practice 309/. Use of Auxiliaries Perhaps the most frequently discussed, widely advocated, and thoroughly studied alternative for increasing the supply of dental services is the greater use of auxiliary personnel. The concept 66

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of increased productivity through the use of a trained dental assistant was discussed as early as 1925 310/. However, it was not until 1943 that a correlation was established between numbers of chairs and assistants, and the number of patients who could be treated per week 311/. first to resort acts A publication in the middle 1950s was the ~ a-- procedures performed by the assistant 311a/. The five-year Richmond-Woonsocket study performed on a population of school children showed that an increase in productivity of 52 percent could be expected using one assistant, and 70 percent using two assistants. The annual percentage increase in productivity per dentist over the 1950-1970 period has been calculated at 1.6 percent per year, with productivity measured in terms of patient visits 312/. This analysis led to a further conclusion that increased auxiliary use was the main contribution to these gains in dentist productiv- ity. Another analysis of the same data shows that the mean number of visits per week increases by 12.5 visits with the addition of each auxiliary 313/. Dental practices with no auxiliaries average about 45 patients per week, whereas practices with 4 or more auxil- iaries (including 1 dental hygienist) see 95 or more patients per week. Also, dental practices with two or more auxiliaries work six more hours delivering direct patient care each week, while spending only four more hours in the office than dentists with no auxiliaries 314/. A different measure of the productivity increases associated with dental auxiliaries is provided by the 1975 ADA Survey of Dental Practice 315/. As the number of full and part-time auxil- iaries increases from none to five or more, both the median and mean gross and net incomes of the practice rise in almost direct proportion. The relationship between productivity in the dental office and use of auxiliaries has also been extensively studied using mathematical methods 316-321/. Taken together, the national data on dental practice, the experiments in actual clinical settings and the computer-assisted productivity analyses provide consistent results. The conclusion in all cases has been that the assistant, EFDA, and/or hygienist contributes substantially to practice output. However, it appears that there is no consensus on the optimal number of auxiliaries for a practice of a given size facing a given set of input prices and serving a given patient population. Also there is little docu- mentation regarding the magnitude of the productivity of dental laboratory technicians, denturists, and dental nurses in the United States. 68

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Capital With respect to the role of non-labor inputs in augmenting the productivity of a dental practice, if capital is defined as the number of chairs in the practice, plus twice the number of operatory units, it has been estimated that a 10 percent increase in capital would be associated with a 2 percent increase in visits 322/. These results are consistent with an earlier finding'323/. Thus, the more providers generating patient visits (i.e. dentists, dental hygienists, preventive therapists, EFDA's, etc.) the more capital investment in operatories is needed. Casemix While there is little doubt that the mix of services offered by a practice affects both the volume of visits and the income generated, relatively few empirical studies of this have been made. This is primarily due to the lack of good casemix data in large sample. An activity analysis investigation of the productivity impact of expanded function auxiliaries used actual time per ser- vice data that were generated in a private practice. The study developed three alternative casemix specifications for this model dental practice: (1) a "general practice" mix basically reflecting the type of care rendered by a small suburban dental practice, (2) a "primary care" mix dominated by extractive and restorative care, and (3) a "cosmetic care" mix of services dominated by more elective procedures, such as bridges and endodontics 324/. Con- trolling for all other factors, the study found a sizable difference in the productivity potential of such a model practice across these three case mixes, regardless of the number of dentists assumed to be employed. Primary care had the least productivity potential while the cosmetic care practice had the greatest. The inability to adjust for casemix changes can clearly con- found efforts to measure productivity change over time. If dental visits are becoming relatively more complex and time-consuming, observed visit rates may serve to understate gains in practice efficiency over time 325/. One report 326/ indicates that the casemix does shift somewhat as practice size increases. Table 29 shows that relatively more time is spent providing fixed prosthe- dontics as practice size increases. The amount of endodontics also increases substantially. In contrast, relatively less time is spent providing routine operative and preventive services. This shift in the relative mix of services does not necessarily mean, however, that patients in larger practices are not receiving preventive services; it could be simply a large increase in en- dodontic and fixed prosthetics services. 69

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Table 29 ~ PERCENT OF DENTIST TIME SPENT IN RENDERING SERVICES, BY TYPE OF SERVICE AND SIZE OF PRACTICE, 1977 Practice Size (number of Dentists) Type of Services 1 2 3~4 5+ - A. Diagnostic 13e5 10~3 809 11~0 B. Preventive 9 ~ 6 6 ~ 3 6 ~ 7 2 ~ 9 C. Operative 38 ~ 8 37 ~ 7 31 ~ 2 36 ~ 4 D. Removable Prosthodontics 6 ~ 9 6 ~ 3 7.1 6 ~ 5 E. Fixed Prosthodontics 18e 2 23 ~ 8 30.5 25.5 F. Oral Srugery 5 ~ 9 4 ~ 4 3 ~ 7 3.5 G. Periodontics 1.9 2 ~ 0 1 ~ 7 2 ~ 5 H. Endodontics 4 ~ 6 7 ~ 7 8.3 9e 7 I. Orthodontics 0 ~ 6 1 ~ 6 1 ~ 8 2.1 Source: Nash, et al. 327/ _ _ . Dentist/Population Ratio The current evidence appears to indicate that the observed productivity of the dental firm is inversely related to the dentist/ population ratio in its market area 328-329/. A recent study of the market for dental services found that the average number of visits per dentist increased as the number of dentists/population in an area decreased, controlling for a number of other factors that would affect this productivity measure 330/. Only one study sug- gested a positive relationship between productivity and the density of dentists in a market area 331/. An author of that study ex- plained elsewhere that "greater demand apparently allows more efficient scheduling of patients from the producer's viewpoint and some substitution of patient waiting time for idle time of dentists, auxiliaries, and capital equipment 332/. Consumer Demand Considerations Many studies of the utilization of dental services discussed in Chapter 2 indicate that consumer demand is positively related to per capita income and educational attainment. Although these factors do not bear directly upon the ability of an individual dentist or practice to be efficient, they do influence the demand for services by the population, and, therefore, the rate of ob- served productivity. Numerous dental studies have documented the impact of fluori- dated water on reducing the prevalence of caries over time. first attempt by economists to assess the marginal impact of fluoridation on demand found that fluoridation had a negative effect on demand for care in several midwestern communities 333/. 70

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Fluoridation reduces the decay experience of the first half of life. Consequently more teeth are present, and, therefore, susceptible to periodontal disease. There also are more teeth available as abutment teeth for fixed prosthetic appliances and endodontic therapy. It would seem, therefore, that with a change in the kinds of services needed, there may be little reason to expect that the overall demand for services across an entire poplation would decrease. Dentist Characteristics Dentists' ages are the principle confounding characteristic that probably captures a number of influences. From a human capital standpoint, one might expect a dentist's technical efficiency to be inversely related to his age. On the other hand, to the extent that productivity increases with experience, one would expect older dentists to be relatively more efficient. From the perspective of work-effort decisions across the life cycle, one would expect younger dentists to work relatively longer hours in order to build up their practice size; likewise, one would expect dentist's demand for leisure to increase after some point, as income goals become realized. Recent empirical findings are consistent with these hypotheses 334-336/. A statistically significant and strikingly similar relationship was found between the age of the dentist and practice productivity: productivity rose with age until about the midpoint of the dentist's career, then dropped as retirement neared. Summary and Conclusions There has been a substantial increase in the supply of dentists in the United States in recent years because of federal policy decisions. Although there now are some inequities in the geographic distribution of dentists, the current number and growth trend in the training of dentists strongly suggest that their supply will be adequate to meet the demand in 1990, even if third party dental insurance increases greatly. Productivity of private dental practice was emphasized because recommendations to cover treatment services for the entire population will, at least in the short term, necessarily be delivered largely in the settings in which dentists currently practice. Many factors affect dental practice productivity and thus the supply of services. Changes that have occurred in dental practice over the past 25 years include instrument improvements, more efficient facilities, standardization of procedures and instrument storage, more carefully planned scheduling systems, and increased use of

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auxiliaries. Because the supply of dental services can be more rapid- ly increased by adding various types of dental auxiliaries, the com- mittee concluded that the supply of these auxiliaries can provide the flexibility needed for increases in the demand for services and that the supply of dentists, dental hygienists, dental assistants, and dental laboratory technicians seems adequate to meet any increase in demand for dental care that might result from the implementation of a properly designed health insurance program covering dental care services. Most dental care in the United States is currently provided in the offices of independent solo practitioners. There are many other practice settings and differing organizational arrangements. In- cluded are solo and group practices, hospital dentistry, government programs, neighborhood primary health centers, and school-based programs. Demonstration projects with school-based dental care pro- grams clearly show the potential of the school as a practice setting for the delivery of dental care to children. On the basis of the experience with the uses of dental hygienists and expanded function dental auxiliaries in providing preventive services in school-based preventive programs for children and adolescents, the committee recommends such auxiliaries be used to provide such care in the recommended school-based system. 72