access proposal

Access Proposal

Phased Strategies for Reducing Barriers to Dental Care

University of California, San FranciscoDental Public HealthMarch 13, 2012

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Agenda

THE HISTORY

CDA initiatives

THE RESEARCH

Mandate, topics and results

THE PROPOSAL

Phased strategies and opportunities

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THE HISTORYReducing Barriers to Dental Care

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The access problemis persistent

The problem is real

• 11 million Californians do not have any form of dental insurance

• 7 million are low-income or disadvantaged

• 4.5 million are children eligible for Denti-Cal

• 233 dental professional shortage areas

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Children are the most vulnerable

California Dental Association

• Mission Statement: The California Dental Association is committed to

the success of our members in service to their patients and the public

• Vision: The California Dental Association is the

recognized leader for excellence in member service and advocacy promoting oral health and the profession of dentistry

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CDA’s role is to be an expertvoice representing the best interests of the profession and the public

• 2002 House of Delegates adopts resolution recognizing access issues

• 2008 CDA House of Delegates authorizes research, asks for evidence-based recommendations

• 2009 Two working groups created• 2010 Research conducted and analyzed• 2011 Recommendations formulated and

presented 8

CDA Foundation• Community Water

Fluoridation• Perinatal Oral Health

Guidelines• CAMBRA• Pediatric Oral Health

Access Training Program

• Student Loan Repayment Grants

• Community Program Grants

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Community Water Fluoridation

• 1992: 17%

• 1995: AB733

• 1998: The California Endowment

• 2011: 63%

• Future: 70%

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Caries Prevention & Treatment

• Caries Management By Risk Assessment

• Pediatric Oral Health Access Program

• Perinatal Oral Health Guidelines

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Grant Making

• Student Loan Repayment Grant

– Up to $105,000 over 3 years

– Work in an underserved community

– Application period: May 1 – August 15

• CDA Foundation Grant Program

– Up to $25,000

– LOI submission: April 1 – June 30

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Commitment To Knowledge-Based Decisions•A culture of science

– Peer reviewed Journal

• CDA Presents

• Governance that is transparent about decisions

• Membership that invites conversation with other associations and individuals representing specialists, ethnicities, stages of practice, practice models

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Comprehensive, evidence-based approach to access• Become the expert

• Consider every option except standing still

• Be transparent and inclusive; communicate with membership throughout

• Go beyond emotions and assumptions to data and outcomes; focus on what really works

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CDA RESEARCHReducing Barriers to Dental Care

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Research began witha mandate• Assess existing research• Fill gaps with new research• Examine barriers to care• Examine workforce models• Be thorough and deliberative• Evaluate data in context, not isolation• Develop recommendations that …

– respect the unique role of the dentist– are realistic yet comprehensive– focus first on where we can make the greatest difference– build one upon the next and ensure effectiveness can be maintained

over time

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CDA reviewed the literatureon variety of topics …

• Oral health infrastructure

• Medicaid reform

• School-based oral health programs

• Incentives for working in public health

• Oral health literacy

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… and commissioned newresearch where there were gaps• Oral Health in California

• State oral health infrastructure

• Dental Residency programs

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… and commissioned newresearch where there were gaps• Efficiency and capacity of the current dental

delivery system

• Impact of additional dental providers in the dental labor market

• Economic analysis of new dental workforce models

• Comparative safety and quality of dental providers world-wide

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Oral Health Infrastructure

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Study Design

• Benefits of state oral health infrastructure

• Why does infrastructure matter?

• What are the national standards?

• What are the federal resources for funding and support?

• Lessons learned from other states?

• What is California’s opportunity?

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Key Findings

• Leadership, leadership, leadership

• Strong support from department and policymakers

• Visibility in state agency is critical

• Models and infrastructure support already available

• Not all work needs to be done by the state

• Doing something is better than doing nothing

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Recommendations

• Hire a director with dental public health experience

• Develop an oral health plan building on what exists

• Work with existing stakeholders and programs

• Seek federal and private funding

• Develop new childhood prevention programs

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Medicaid Reform

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Study Design

• Analysis of Medicaid reforms in other states

– National Academy for State Health Policy

– U.S. General Accounting Office

– Center for Medicare and Medicaid Services

– Review of state litigation for Medicaid reform

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Key Findings

• Rate increases are necessary – but not sufficient on their own – to improve access to dental care

• Rates must cover the cost of providing service, estimated at 60 to 65% of dentists’ charges

• Working with families on how to use dental services is a core element of reforms

• Even after substantial effort and investment – only 32 to 43 percent of children covered under Medicaid received dental care, pointing to the need to explore other solutions

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Dental Residency Programs

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Study Questions

• What is required to establish a dental residency?

• What are the funding opportunities?

• What is the experience of dental graduates who complete residencies?

• What is potential benefit to the dentist and the public?

• What are the barriers?

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Key Findings

• History of national commissions recommending all states make dental residency a licensure requirement

• Too few residency positions and large graduate debt burden are common reasons to oppose

• General Practice Residencies hold potential to increase care to underserved

Current Dental Delivery System

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Study questions

• How efficient are dental practices at utilizing time and resources?

• How efficient are community clinics at utilizing time and resources?

• How stable is this efficiency over time?

• What is the capacity in the current system to treat additional patients?

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Study Design

• Determined the technical efficiency of the dental delivery system in California – defined by patient visits

• Includes private practice and safety net providers

• Utilizes data from 2003, 2005, and 2007, which is a representative time frame for typical dental practice patterns outside a recession

Key Findings

• High efficiency in dental practices

• Practice patterns stable over many years

• Significantly increasing number of patients seen would require substantially more days and longer hours – unlikely given the physical and emotional demands of dental practice

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Economic Modeling

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Study Design

• Model dental therapists (DTs), dental health aide therapists (DHATs), and advanced dental hygiene practitioners (ADHPs)

• Evaluate compensation levels, cost of training, cost of practice, estimated productivity, and potential revenue for each practitioner

• Develop economic projections for alternative dental workforce practitioner models

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Key Findings

• The costs of education, debt burden and compensation significantly impact the viability of all workforce models

– The Advanced Dental Hygiene Practitioner (ADHP) is most costly – due to length of education and likely debt burden

– DT and DHAT models are less costly, but even those costs are substantial

– Dental education is very expensive and educational programs require subsidy to be economically viable

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Other Findings

• Advantages to drawing from local population – enhances cultural competency and longevity of practitioner; supports practice in community of origin

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

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Income Impact of Additional Dental

Providers

Study Questions

• Relative economic value produced by proposed new dental providers

• Potential impact on the earnings per hour of private practice dentists from the entry of additional private practice dentists into the dental labor market

• Potential impact on the earnings per hour of private practice dentists from the entry of hypothetical new dental providers into the dental labor market

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Key Findings

• Income impact is largely a result of direct competition for patients – though small in all cases

• Additional general dentists have the greatest effect on the income of other general dentists

• Additional providers who care for children slightly increase earnings of others

• Practice restrictions (age, payer source) diminish overlap and decrease negative impact

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Safety and Quality

Study Design

• Systematic literature review using PRISMA

• Primary question: are the irreversible procedures performed by any non-dentist provider category safe compared to the same procedures performed by dentists?

• Due to the limited number of studies available to answer the above question, added quality, productivity or cost-benefit, and patient satisfaction as secondary outcomes

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Study Design

• Cochrane, Medline, EMBASE, and Pub Med databases

• Search strategy developed; filters included human studies and were limited to publications in English language

• 20 original articles abstracted and summarized using a style similar to the one prescribed in Cochrane Handbook for Systematic Reviews of Interventions

• Level of evidence within each study was graded by the lead author using the modified Strength of Recommendation Taxonomy (SORT)

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Key Findings

• Non-dentist providers have high level of safety, quality, productivity and patient satisfaction for reversible procedures

• Insufficient high level evidence for irreversible procedures

• Recommended additional high powered studies to fully answer these questions

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Research confirmed some observations, created new insights• Approximately 30% of Californians face multiple

barriers to accessing the current dental care delivery system

• Children are the most vulnerable

• California needs dental director with influence in the administration

• Effective and coordinated dental public health programs essential

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• Significant barriers exist to dentist participation in Denti-Cal, including low reimbursement and high administrative burden

• Healthcare reform is expected to extend dental benefits to more than 1 million additional children by 2014

• Capacity to provide care to these additional children does not currently exist

• External pressures exist to develop systems that provide care at the lowest cost and to expand capacity by developing a new dental provider category

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Implication of research

• A comprehensive and multifaceted approach is necessary, employing many strategies

• Build on what works, support and expand successful programs and best practices

• Prevention of dental disease is essential, solutions must focus on children

• The greatest benefit expansion for children is likely to occur in public programs

• Children’s programs are mandated, federally supported and sustainable

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• Financial incentives are successful in influencing provider behavior

• Practices restrictions ensure providers work in settings that are accessible to the 30% in need

• Evidence indicates barriers are reduced for children when care delivered in or close to where they live, go to school

• Safety and quality research on irreversible procedures still needed to make evidence-based workforce recommendations

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As there is no one causeThere will be no one solution

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RECOMMENDATIONSReducing Barriers to Dental Care

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This proposal was conceived in the context of an association whose members are part of a healing profession and bound by a public covenant, and as a collective association tasked with advancing the oral health of the public as well as the profession of dentistry.

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Access Proposal: Phased Strategies for Reducing the Barriers to Dental Care in California

1. Access Proposal – 3-Phased Approach2. The Process3. Analysis4. Workforce Taskforce Report5. Appendices6. Research & Presentations

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Three-Phased Approach

1. Establish State Oral Health Leadership and Optimize Existing Resources

2. Focus on Prevention and Early Intervention for Children

3. Innovate the Dental Delivery System to Expand Capacity

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Phase 1 (Years 1–3)

Establish State Oral Health Leadership and Optimize Existing Resources

• Creates strong foundation for future success

• Builds on things that have already been proven to be effective

• Includes key Workforce Taskforce recommendation to fill remaining gaps in research on dental provider safety, quality, cost-effectiveness, and patient satisfaction so that future workforce decisions can be data-driven

• Focuses on eight objectives

OBJECTIVES

1. Build state oral health infrastructure

2. Expand capacity within dental public health

3. Expand FQHC dental services

4. Support coordinated volunteer-based provision of care

5. Promote fluoridation

6. Expand capacity to provide children’s care, especially to young children

7. Align CDA Foundation strategies with phased approach

8. Continue workforce exploration

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• Assist the state in hiring a state dental director and staff

• Dental Director will be responsible for:

– Developing a state oral health action plan

– Securing funds to support infrastructure and programs

– Advancing/protecting oral health within the Administration

– Encouraging private and public collaboration

– Surveillance and oral health reporting

– Promoting oral health literacy

OBJECTIVES







7. Align CDA Foundation with the proposal’s goals


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• Promote and remove any perceived or real barriers to FQHCs providing dental care beyond their “4 walls” including contracting with private dental providers

OBJECTIVES









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• Increase the ability of general dentists to provide care to children, especially children ages 0-5

• Increase utilization of best practices in caries management by dentists and dental hygienists

OBJECTIVES









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Phase 1 (Years 1-3)

• Promote initiatives that utilize community health workers to support improved oral health and oral health literacy

• Answer questions regarding safety, quality, cost effectiveness, and patient satisfaction of irreversible dental procedures performed by traditional and non-traditional providers

• Research parameters should include:– Public health setting

– Multiple models of dentist supervision

– Pathways of education and training

– Dental providers, including dentists and non-dentists

OBJECTIVES









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Focus on Prevention and Early Intervention for Children

• Builds on Phase 1 to create sustainable programs

• Removes barriers by optimizing early disease prevention and reducing the need for treatment

• Focuses on four objectives

OBJECTIVES

1. Reach children in school-based/linked programs, WIC, Head Start, and other public health settings

2. Utilize proven technology

3. Expand early prevention through reimbursement incentives


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• Support the re-establishment and expansion of school-based/linked programs

• Focusing first on prevention and oral health literacy, with a long-term goal of comprehensive care

OBJECTIVES





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• Evaluate and support the expansion of quality and cost-effective technology solutions for providing services to those who face difficulties reaching the dental office

OBJECTIVES





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• Advocate for the augmentation of Medicaid rates for select services provided by dentists certified through an Access to Baby and Child Dentistry (ABCD) type program

OBJECTIVES





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Delivery System Innovation

• Makes substantial changes to the delivery system

• Allows for learnings from Phases 1 and 2 to shape the most time-intensive initiatives

• Focuses on three objectives

OBJECTIVES

1. Focus on adult dental care

2. Build hospital-based treatment

3. Optimize workforce capacity

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Opportunities

• Oral health leadership and rebuilding infrastructure

• CDA Cares

• FQHC contracts with private practice dentists

• Community water fluoridation projects

• CMS Innovation grant

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Summary

30%of Californians

experience barriers to accessing

dental care

2Yearsof steady

research and analysis have

yielded evidence-base

3Phasesof strategic,

practical, comprehensive and data-driven

initiatives to reduce the gap

and improve oral health

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Questions?

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