Oral Health Workforce for Low Income Children

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1 Oral Health Workforce for Low Income Children National Health Policy Forum April 20, 2007 Shelly Gehshan, Senior Program Director National Academy for State Health Policy National Academy for State Health Policy

2 Dentists and physicians practice patterns differ 90% dentists are in private practice 76% dentists are solo practitioners 80% are general practice dentists Ave. net income $125K for general dentists, $192 for specialists 33.3 hours/week treating patients 50% physicians are in private practice 25% are solo practitioners 30% are primary care practitioners Ave. net income $164K for primary care, range is $120K - $205K for specialists 51.6 hours/week treating patients National Academy for State Health Policy

3 Factors Limiting Participation in Medicaid/SCHIP Average debt for graduating dentists: $119,000 in 03 Cost to lease equipment $150,000/ year; costs for space, staff $200,000/year Dental services: 57% inflation since 1997 Average debt for graduating physicians: $104,000 in 03 Most physicians practice without expensive equipment Physician services: 36% inflation since 1997 National Academy for State Health Policy

4 Dental practice Income About 45% of patient visits are for hygiene services About half from insurance, half cash Very sensitive to downturns in the economy Overhead averages about $.60-$.65 of each dollar earned National Academy for State Health Policy

5 Source: Albert Guay, Dental Practice: Prices, Production, and Profit, JADA, Vol. 136 (March 2005), 359. National Academy for State Health Policy

6 Is there a shortage? Active dentists per 100,000 population National Academy for State Health Policy

7 Dentists per 100,000 population (2000) CA 68.3 OR 67.4 WA 65.3 NV 39.2 ID 52.4 MT 55.6 WY 56.7 UT 63.7 CO 69.8 AZ 47.6 NM 45.1 ND 48.3 SD 49.2 NE 65.5 TX 48.2 KS 50.6 OK OK MN 61.1 IA 54.3 MO 49.2 AR AR LA 48.2 WI 58.7 IL 67.4 MS 39.7 IN 48.0 MI 59.7 KY 55.9 TN 53.2 AL 43.5 OH 54.2 NY 83.1 WV 46.2 PA 67.3 VA 58.1 NC 43.1 SC 45.4 GA 45.5 VT 60.1 ME 47.9 NH 57.5 MA 81.2 RI 59.5 CT 79.6 NJ 80.4 DE 46.7 MD 76.5 Less than 50 AK 72.7 FL HI National Academy for State Health Policy

8 Dental Health Professional Shortage Areas, 2004 Source: UNC at Chapel Hill, National Academy for State Health Policy

9 Is there a shortage of hygienists? Bureau of Labor Statistics reports: 158,000 hygienists in 2004 Expected to grow much faster than average (>27%) by 2014 ADHA says that, due to supervision requirements in many states, hygienists must locate where dentists are, so they are maldistributed as well National Academy for State Health Policy

10 Pediatric Providers See children 13 times before age 5 (AAP) Can do: oral health evaluation, apply fluoride varnish, educate patients and parents, dispense oral health supplies, prescribe antimicrobials, do limited cleanings, refer to dentists Can be reimbursed by Medicaid in several states National Academy for State Health Policy

11 Practice laws on medical providers 32 states allow MDs, and 4 states allow RNs, to provide preventive oral health services 13 states allow MDs to provide limited oral health services (emergency, institutions) 4 states allow registered nurse anesthetists to provide anesthesia for dental care National Academy for State Health Policy

12 Supervision of hygienists Dental hygienists may... be supervised for appropriate services by physicians perform procedures without the physical presence of the supervising dentist in CHCs, RHCs, clinics, schools, nursing homes and practices that serve large numbers of low income patients National Academy for State Health Policy

13 Supervision and Payment for Hygienists General supervision in 45 states in dental office or some settings Direct access to patients in some settings in 20 states (AZ, CA, CO, CT, IA, KS, ME, MI, MN, MO, MT, NH, NM, NV, NY, OK, OR, RI,TX, WA) Medicaid can reimburse hygienists directly in 12 states (CA, CO, CT, ME, MN, MO, MT, NM, NV, OR, WA, WI) National Academy for State Health Policy

14 Mid-levels in dentistry ADHA model Advanced dental hygiene practitioner Dental health aid therapist (Alaska), dental nurse, New Zealand model ADA model Community Dental Health Coordinator National Academy for State Health Policy

15 Dental therapists 8 practicing in Alaska on reservations Prevention: fluoride treatments, sealants Treatment: x-rays, prophylaxis, gingival scaling Restoration: simple restorations, stainless steel crowns, extractions Supervision: general supervision under standing orders, dentists review x-rays and treatment plans electronically National Academy for State Health Policy

16 Advanced Dental Hygiene Practitioner ADHA Prevention: comprehensive services Treatment: manage periodontal care, prophylaxis Restoration: simple restorations, extractions Supervision: unsupervised or general supervision, collaborative practice with dentist, physician, clinic manager National Academy for State Health Policy

17 Community Dental Health Coordinator ADA Prevention: education, fluorides, sealants Treatment: gingival scaling, polishing Restoration: none Supervision: direct or indirect for patient care, general supervision for education National Academy for State Health Policy