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11 End-of-Day Discussion: Day 2 Moderator: David N. Sundwall, M.D. Utah Department of Health Sundwall remarked that the presentations of the second workshop day showed extraordinary creativity, an incredible number of models and potential members of an oral health team, much energy and altruism, and interest in service and community collaboration. In this session, members of the planning committee were invited to reflect on the themes they perceived during the second day of the workshop. Discussantsâ panel Len Finocchio, Dr.P.H. California HealthCare Foundation The future vision of the delivery of oral health care services has many characteristics. One characteristic of this vision is the community orientation of optimizing oral health by managing limited private and public resources to purchase a range of affordable, evidence-based, high-quality oral health services that focus on prevention from interdisciplinary teams in accessible community settings. This vision includes financing and payment incentives that prioritize education and prevention, at-risk populations, coordinated care, and disease management. It also includes integration between sectors using information technology (e.g., the virtual dental home), interdisciplin- ary collaboration and co-location (e.g., the health commons), and reliance 97
98 THE U.S. ORAL HEALTH WORKFORCE on scientific method and performance in outcomes measurement. Finally, there should be some rationality to the regulation of professions. Another consideration for the future is what defines success for new workforce models. All models should be tested and compared based on evidence of success. The success of these models could include cost- e Â ffectiveness and contribution to addressing challenges in oral health care. Another element of success includes leadership accountability, integrity, and collaboration. Success also means improved public knowledge and practices for oral health. Finally, other successes may include caries-free children and youth, the elimination of oral health disparities, and harmony within and among the members of the oral health workforce. Elizabeth Mertz, M.A. Center for the Health Professions, University of California, San Francisco The many challenges in the oral health care system also provide many opportunities to improve oral health. One opportunity relates to evidence- based practice and design. More scientific evidence is necessary to support the rationale behind many basic oral health procedures and approaches in order to determine the effectiveness of these services as well as define which practitioners are able to provide those services. Also, as a better oral health care system is designed, alignment with the financial system needs to be ensured. For example, a fee-for-service system may actually create incentives for continued focus on salvage procedures instead of encouraging prevention, education, and coordination of care. Another opportunity is the use of information technology to enhance collaboration. When considering community-based care delivery systems, information technology may be especially useful to support the necessary collaboration as well as to expand the definition of an oral health system. Electronic medical records are an obvious key element for improving care coordination. Regulatory and licensing reforms also provide opportunities for improv- ing the delivery of oral health services. This is a basic issue of competition and the ability to test potentially improved models of care. Current licensing and regulatory systems are not based on competency and may prevent some practitioners from providing the services they have demonstrated they are able to provide safely and effectively. International models are especially good examples of how services can be provided effectively and rationally. Finally, the concept of a health system approach to oral health care is needed to improve the delivery of oral health services. In this approach, the patient is placed at the center of the care system and collaboration o Â ccurs in a systemic fashion, instead of focusing on individual disease data.
END-OF-DAY DISCUSSION: DAY 2 99 To make this happen, redesign is needed for regulatory models, business models, education models, and care delivery models. These changes are occurring on a number of fronts in very interesting and exciting ways and are at various stages of development. Taking a systems perspective allows one to identify the institutional constraints that prevent creative system redesign rather than focusing on conflicts between the professions. Many new models map out the routes to change. However, as system redesign begins, consideration is needed to ensure that such reforms enable future innovations to occur as well. Shelly Gehshan, M.P.P. Pew Center on the States The challenges of improving access to oral health services reflect a shared responsibility among all stakeholders and are not caused by the a Â ctions of any single profession. One challenge is the financing of care. There is a real tension between dentistry as a business and dentistry as a healing profession, including issues of money, control, and respect. How- ever, as opportunities for national health care reform become possible, the diversity of the oral health community will only help to ensure oral health care is included in those discussions. Oral health needs to be included in this reform, especially for adult care, as many workforce models rely heavily on Medicaid. In the Medicaid program, adult dental benefits are slowly disÂ appearing and therefore some workforce experiments may become unsus- tainable. Much more research and policy work is needed on the economics of dental practices and safety net practices to ensure better understanding of how to use providers, what their efficiencies are, and how they would be most effective with different populations. Another challenge is the need for more planning and evaluation. Legis- lators and purchasers often have to make decisions with very little support- ive data. Today, very few states have explicit workforce planning efforts, and more effort is needed to translate this data into effective information for use by policy makers. Finally, this research should also consider the needs and preferences of the patients themselves. Finally, oral health access is confounded by regulatory barriers. Every provider group has unique challenges since they have different regulatory requirements, often varying by state. As consideration of new practitioner types moves forward, national standards (such as for certification or edu- cational programs) should be created to eliminate confusing and conflicting requirements by state. More consideration is also needed for competency- based licensing and regulation in order to make the decision-making pro- cess more evidence based.
100 THE U.S. ORAL HEALTH WORKFORCE Daniel Derksen, M.D. University of New Mexico Discussions of improving access to oral health care services may fit into a framework of metanoia, meaning that change needs to come from within. The professions need to come together, for when groups are in unison, it is easier for policy makers to act. More attention is needed on the areas where the professions have shared interest and values. The oral health workforce is currently at a crossroads, and the time for action has come. reaction and discussion Moderator: David N. Sundwall, M.D. Utah Department of Health An open discussion followed the discussantsâ presentations. Audience members were able to give comments and ask questions of the discussants. The following sections summarize the discussion session. Engaging Legislators A participant commented on the need to include oral health in the larger health care reform debates, stating that oral health represents only a very small percentage of health care costs and that legislative staff needs to be continuously educated. The participant asserted that Medicaid participa- tion should be a requirement of licensure in dentistry. Another participant stated that universal dental care should be a part of any movement toward universal health care. Another participant commented on the need for den- tal schools to put together plans and procedures, particularly in the area of workforce diversification, so that state legislators have a sense of the value of their investments in these schools. Evidence Base One participant commented on the need to have more standardized evaluations of new workforce models so that common factors would be captured as each model is assessed individually. Some of the outcomes to assess might include outcomes, reimbursement, or policy changes. In this vein, the participant also lauded the theme of thinking on a systems level and encouraged including more people in these discussions, such as engi- neers who have more experience with systems research. Another participant stated that a barrier to improving access to oral health services includes the inability to include the average practitioner in national discussions. More
END-OF-DAY DISCUSSION: DAY 2 101 effort, he said, is needed to disseminate the findings and discussions at n Â ational conferences. He added that because the average practitioner is not involved in these discussions, decisions regarding issues such as scope of practice continue to be based on emotion rather than based on evidence. Oral Health Careers Another participant commented that many students see the different oral health professions as âstepping stonesâ to higher levels of responsibil- ity and are accustomed to the idea of having more than one career in a lifetime. However, the participant also noted that this perspective demands consideration of workforce retention issuesâthat is, what would make these professionals stay in oral health careers when they have opportunities to change direction. The participant noted that competency-based training could encourage practitioners to stay within oral health but perhaps chang- ing careers to a profession with higher levels of responsibility. Another participant commented on the discussions of job delegation and profes- sional pride. The participant asserted that dentists may sense they have limited opportunities for career growth and may therefore be reluctant to relinquish duties, and so more thinking is needed on how to expand the roles and career opportunities for dentists. Public Health Several participants commented on the need for more inclusion of p Â ublic health dentistry in discussions of oral health access. One participant also indicated the need to infuse oral health more broadly into schools of public health. Another participant commented on the number of nonÂ clinicians Âinvolved in public health who are eager to help address issues of oral health but are not being approached.