Mid-Level

Preliminary Findings

Oral Health Workforce Research The Boston Workforce Workgroup March 15, 2010

Background • 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

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Background • 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

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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

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 5

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 9

Preliminary Findings • Economic recession and 2009 elimination of adult dental Medicaid program has created temporary unused 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 “midlevel 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

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