Preliminary FindingsOral Health Workforce Research

The Boston Workforce WorkgroupMarch 15, 2010

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• 2002 CDA House of Delegates resolution recognizing access to care issues:

– Committed to a thorough and deliberative process for understanding access barriers and opportunities

– Committed to conducting necessary research in order to understand and apply the evidence base for future decision-making

Background

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• Collaborated with the Nicholas C. Petris Center on Health Care Markets & Consumer Welfare at the University of California, Berkeley on unmet needs:

– The demand for dental care and financial barriers among adults in California

– Oral Health Status of Adults Over 65 in California 1995-2006

• These foundational studies were important to understand the unmet dental care needs

Background

Background

• 2008/9 CDA House of Delegates affirmed concerns about access, authorized a series of activities including formation of Access Workgroup and Workforce Taskforce to study the issue– Focus on the 30% of the population that cannot access care

• Board of trustees adopted CDA basic research plan and authorized funding for additional research initiatives– Workforce related research began first because of the national

conversation about alternative workforce models

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Workforce Research Agenda• CDA’s Workforce Taskforce is committed to a

research-based review of workforce models

• Service Capacity and Provision of Care– A review of the capacity of current California dental delivery

system to address unmet needs

– A comparative matrix of workforce model duties

• Economics– An econometric model to estimate the economic impact of

workforce models on private practice dentistry

– A financial analysis of the capitalization and sustaining operating costs for proposed workforce models

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Workforce Research Agenda• Patient Safety

– International literature review and paper on comparative safety of dental workforce models

• Communications– Focus groups and quantitative surveys to determine dentists’

perceptions and knowledge of access challenges, workforce models, and their feelings about those issues

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Preliminary Findings

Service Capacity & Provision of Care

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Study Design• A review of the capacity of current California dental

delivery system to address unmet needs– This study will determine the available capacity of the current

dental delivery system to care for the underserved

– Includes private practice and safety net providers

– Utilizes data from 2003 and 2005, which is a representative time frame for average dental practice patterns

– Uses efficiency to measure productivity as defined by patient visits

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Preliminary Findings• There is little excess capacity in private practice and

safety net delivery systems to provide care to additional patients– Private practice general and specialty dentists are extremely

efficient

– Safety net clinics are also very efficient, although less so than private practice

• Current delivery systems have the capacity to provide treatment to about a quarter of Californians not now receiving care (~10 million people), so significant additional capacity will be required to fully address the unmet need for care

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Preliminary Findings• Economic recession and 2009 elimination of adult

dental Medicaid program has created temporaryunused capacity

• If adult Medicaid is not restored, this temporary excess capacity will disappear– Offices and clinics will reduce staff, hours, etc. to only meet

demand

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Study Design• A comparative matrix of workforce model duties

– Illustrates differences in various workforce models, determines the extent to which those models may be deployed, and under what circumstances procedures may be performed

– Side-by-side matrix of existing and proposed workforce categories

• Duties, Supervision, Education, Practice Setting, & Compensation

– Intended to provide a factual baseline for emerging workforce categories for Taskforce member reference

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Preliminary Findings• Matrix included the following categories:

• Dental Therapist & Advanced Therapist (Minnesota)

• Dental Therapist (Washington)

• Dental Health Aide Therapist (Alaska)

• Dental Therapist (Australia)

• Advanced Dental Hygiene Practitioner (ADHA model)

• Registered Dental Assistants Extended Function (Calif.)

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Preliminary Findings

Economics

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Study Design• A financial analysis of the capitalization and

sustaining operating costs for workforce models

– Determining the oral health financing infrastructure necessary for a new workforce model is important for determining sustainability of a provider model

– The objective is to assess the economic viability of alternative practitioner career models for providing care to the underserved

– Models include dental therapists* (DTs), dental health aide therapists (DHATs), and advanced dental hygiene practitioners (ADHPs)

*Dental therapists are modeled under the New Zealand school-based program, not the Minnesota Therapist model.

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Study Design• Research tasks include:

– Evaluating compensation levels, cost of training, cost of practice, estimated productivity, and potential revenue for each practitioner

– Developing economic projections for alternative dental workforce practitioner models

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Preliminary Findings• The costs of education and capitalization of practices

significantly impacts the viability of any workforce model– The DT and DHAT models are more economically viable

from the practitioner and system perspective

– The state/public health infrastructure must either subsidize educational programs or provide tuition grants, debt waivers, etc.

– To ensure practitioner serves intended population, licensure must limit practice location or patient population

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Study Design• Communications research to determine dentists’

knowledge and perceptions of access issues & workforce models– This study is to understand the extent to which dentists are

aware of access issues, workforce proposals and their knowledge, attitudes and perceptions about any proposed solutions

– Comprised of two components:

• Focus groups (completed)

• Quantitative surveys (in process)

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Study Design• February 2010 – Conducted focus groups

• Pediatric dentists and general practitioners who see mostly children

• General practitioners only

– Dentist participants reflected a wide array of characteristics:

• Stage of practice (recent grad, middle career, near retirement)

• Ethnicity & gender

• Place of practice (private, community clinic, etc.)

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Study Design• Discussion guide focused on key characteristics

– General orientation and attitudes

• Perceptions regarding the state of dentistry (generally and specifically)

• Attitudes about dentists’ responsibilities

• Impressions of how dentistry has/will change, and attitudes about those changes

• Opinions on how decisions regarding the delivery of dental are made

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Study Design• Discussion guide focused on key characteristics

– Workforce specific questions

• Knowledge of workforce categories/proposals nationally

• Attitudes toward unprompted workforce terminology

• Re-assessment of a attitudes based on workforce definitions

• Role of organized dentistry in workforce discussions

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Preliminary Findings• Very few dentists accept that there is an access

problem and are unaware of any workforce initiatives

• Dentists perceive there is a surplus of dentists and as a result there is no access issue

– They believe those who want care can get it

– See a surplus of young dentists who would be more than willing to meet the needs of underserved communities

– As a result, they don’t see a driving need for a workforce expansion proposal, and are skeptical when they hear one

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Preliminary Findings• Lacking awareness of the underlying problem,

dentists’ responses to various workforce proposals turn to how it would affect them, their patients, and new dental grads– Very few have an immediate association with the term “mid-

level provider.”

• Dentists’ comfort increased significantly with greater awareness of access issues and focus on children– Dentists more readily accepted access gap for children

– Resistance decreases if the workforce model is focused on serving children

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Next Steps• Remaining research to be conducted:

– An econometric model to estimate the economic impact of various workforce expansion models on private practice dentistry

– A meta analysis and paper on the safety of dental workforce models

• Completed research will inform taskforce and subsequent work and will inform the strategic communications plan for the members