4. Access and Delivery Systems Flashcards
Forces influencing dentistry
- DEMAND
- ____
- changes in utilization patterns
- changes in ____
- shifts in sources of financing
- SUPPLY
- rising ____
- new delivery systems
- new ____
• Red are supply
• Green are demand
• Look at projections for pop and combine with utilization rates and limit the number of schools and number of graduates so you don’t have cycle of busy/non-busy
economy
oral health status
student debt
dental schools
Total dental spending
• In great recession > \_\_\_\_ out of dental expenditures ○ Rebound in 2012 ○ Expenditures for next few years will be flat
flattening
Dentist busyness
• Mean \_\_\_\_ is indictative of dentist busyness • Has \_\_\_\_ over the years • \_\_\_\_ of the distance between two lines ○ Another indication
dentist waiting time
declined
narrowing
Dentist net income vs. GDP/capita
• Compare dentists income to GDP over 30 years • GDP has been \_\_\_\_ steadily ○ Blue bars - periods where we suffered some form of a recession § Drops in these areas • GDP drops in those areas, some times barely registered ○ Mean real income for dentists > gone up from 2000 to prior recession , but taken a \_\_\_\_ sinc ehten
rising
dive
Supply vs. Demand “Drivers”
Supply Side
1 Train more ____?
2 Do today’s students
understand changing patient ____?
Demand Side 1\_\_\_\_ 2\_\_\_\_ 3\_\_\_\_ (M/M, ACA) 4Potential \_\_\_\_ Sources
dentists mix patient employer government referral
• Supply v demand drivers
○ Supply
§ Everyone understadn the changing patient mix
§ Patients have more ____ > has changed since the past
§ Access to care - lower ____ setting
○ Demand
§ Will patient value?
§ Will they have coverage?
□ Bc of ACA > children from medicaid have increased utilization prior to that
§ Care seeking has gone up in seniors > medicare doesn’t cover dental care
§ Employers
□ Primarily pay for medical/dental care through programs; supplement to ____ (or replacing)
□ Concerned about increased cost > places more strain on the ____
§ Govt
□ Increasing utilization in some groups; but 19-60 there has been a decline in utirlization of services
health problems
socioeconomic
salary
patient
Distribution of Adults 19-64 yrs
• Increase the demand ○ Difference of people who visited and din't visit • Those who visit dentist and visit physician but have private dental benefits but not going; better develop relationship with physicians > it'll be better for both patient and dentist if these people use their \_\_\_\_ ○ Physician is a \_\_\_\_ § Can just ask if they've been going
benefits
gatekeepers
Is the Supply Side ready to adjust?
____ and inner city areas? Medicaid, low income population?
Arrangements with FQHCs?
____ positions?
Will Dental Schools provide support?
Can the Demand Trend be reversed?
vReduce ____ of care?
vIntegrate ____ into whole body care?
vInnovative ____ models
• Adaptation is important for this presentation! • FQHC ○ Programs largely to serve those without access ○ >75% have dental care now • Salaried ○ Unlike traditional dentist - operate in two modes • Current mantra: reduce the cost of care ○ Healthcare is absorbing 18% of GDP > no \_\_\_\_ health results • Making sure mouth is part of body • Interacting with other health individuals ○ \_\_\_\_s are important
rural salaried cost dental delivery positive social workers
Model of Four General Eras of Public Expectation for Oral Health
• Compares the proportion of pop that ahs expectation for oral health ○ 18th century: \_\_\_\_ § Teeth will hurt and rot > can get rid of the pain, hopeful ○ 19th: \_\_\_\_ § Materials that can make full dentures > patients wanted the teeth out ○ 20th: \_\_\_\_ ○ 21st (now): \_\_\_\_
resignation
replacement
repair
protection/prevention
What is a “Delivery System”?
“…
means by which care is provided to patients.”
____
supply of ____
means of ____
structure
personnel
payment
• Private and public side to structure
○ And ____ that address the system
QA
Private Practice (~90% of dentists)
+ Aspects
- ____
- ____
- no tax ____ required
- freedom of choice?
negative Aspects
- fixed ____
- dentist ____
- cost of care
- chronically ____
- developmental disabilities
- ____ children• Largest
• Positive
○ Don’t need to buy more equipment to get more money. Of it
○ Flexible
§ Can open more offices
• Negative
○ Dentists are not always where patients need them to be
○ Cost
§ Trying to include dental care as package of Clinton reform, frustrated bc couldn’t get admin to get feedback
§ “Costs too much to include dental care”; but didn’t have to be this way > got into the bill but not via government
○ Pre-school
§ GD don’t feel comfortable treating
flexible
efficient
$$
overhead
distribution
ill
pre-school
Distribution of Private Practice Dentists
* Majorly \_\_\_\_ * Shrinkly rapidly * Indep non solo - \_\_\_\_practice
solo
group
Other Private Practice
Franchised
- rapid growth in 1980s
- named ____
- bulk purchasing
- ____ clinic design
- rapid decline in late 80s
- lack of ____
- poor management/unprofessional image
- ____
- high costs
branded
standard
capital
overexpansion
Other private practice
Hospital-based
- 1,000 dental depts
- ____/academic
- 40,000 dentists w/ hospital privileges
- ____ children
- maxillo-facial surgery
- ____ patients
- GPR programs
federal
young
high risk
Other private practice
• Hospital-based ○ Less common in \_\_\_\_ hospitals ○ Largely set up to take care of young children, OMFS, high-risk and GPR programs • Franchised ○ Grew rapidly but flamed out ○ Rapid decline due to the reasons listed
private
Dental Management Companies
Potential Benefits:
____ support (bookkeeping, billing, payroll, supplies) Human resources
____
Training
____, purchasing power, marketing, access to capital
New ____
Team players
Possible Disadvantages:
Lack of ____ Practice decisions
* Not directly paying for these things * Better for team players - traditionally been solo-oriented
admin insurance QA programs technology ownership/control
Corporate Dental Practice
What is it?
“… frightening … no one knows exactly what
we are dealing with.” (
Separation of treatment and management
Most states ____ corporate ownership
States that allow include: ____, MS, ____, ND, ____, and Utah
prohibit
AZ
NM
OH
Dental Practice Management/Service Companies
Increasing percentage of dentists are in DPMCs Student \_\_\_\_ Two career families (flexibility/mobility) \_\_\_\_ opportunities Practice management experience More \_\_\_\_ time
● Heartland Dental: 250 practices in 14 states
● Pacific Dental Services 195 in 5 states
● Aspen Dental > 300
● Dental Care Alliance 250 in 15 states
debt
CE
family
• Buy dental practices, string them together, or build their own clinics and hire clinics as salaried employees
• Take care of the management side
• Reasons
○ Usually younger dentists
○ More flexible than a private practice if you’re moving often
• Why are DMOs growing? ○ \_\_\_\_ available ○ Increased supply of labor, and supply of practices for sale § Due to the recession and dentists hanging onto their practices \_\_\_\_ ○ Increased revenue from captured specialty svcs § Can now be provided in house ○ More efficient use of facil and staff ○ Lower facil cost ○ Higher \_\_\_\_ from mgd care plans § Result of \_\_\_\_ power - better rates ○ Aggressive marketing ○ Economies of scale for equip & supplies
venture capital
longer
reimbursement
bargaining
- Size of dental orgs
- ____% of dentals particiapate in DMO
- Greater percentage are ____, and are younger
- Many specialties involved > ____ is high
- ____ states have none involved with DMOs
- ____ have the largest % (17.5%)
- Upenn is 6.2% - below average (the national)
- Under age of ____ - a lot of dentists participate in DMO
- Compare to those not in DMO that participate in medicaid - a larger % of dentists in DSOs have ____ services
7.4 female pediatrics 6 Arizona 30 medicaid
- In a year > now ____%
- Better than franchising of the 80’s
- Now only ____ states that don’t participate
- All specialty groups have gone up by a %
- Same is for gender, and the age categories
8.3
3
Kaiser Permanente
Successful since 1960s Integrated \_\_\_\_ and payer 17 dental offices serving 250,000 \_\_\_\_ care (ACO like) HMO model but some \_\_\_\_ 142 dentists (100 are shareholders) Owned and governed by \_\_\_\_ 70% of associates eventually \_\_\_\_
• Another type of practice - started on west coast • Integrates provider and payer ○ Deal is now with Kaiser and the physician (not Aetna) • Coordinated care (ACO-like) ○ System where health and dental system are integrated - healthcare not dental system • Most dentists are shareholders
provider coordinated PPO shareholders buy-in
Non- profit model: Sarrell Dental Alabama, KY, TX Cardiologist and successful corp exec \_\_\_\_ dentists and RDHs Staff training opportunities Intensive patient \_\_\_\_ Call centers 100% chair utilization \_\_\_\_
• Non-profit model ○ Medicaid patients needed dental care ○ Intensive patient mgt and call centers § People who man phones, and make sure no slots are unutilitized in any day ○ Bonuses for 100% chair utilization
salaried
management
bonuses
• Blue - reimbusrsment per visit
○ $330/visit, and take medicare/caid and chip > starting falling immediately > now flat > $____/visit
§ Recall > the patient won’t have as much need once it’s all taken care of > not as much ____ needed
§ Remained viable bc keeps chair ____ > visits are shorter once the patients are healthy
• Get paid for medicaid patients to do preventative procedures now ____ times a year (up from 2!)
○ Not for everybody - based on risk assessment; some patients need to come more often than others
120
reimbursement
full
4
Public Dental Delivery Programs Demand beyond private practice
Military personnel Veterans Affairs
US Public Health Service
Community Health Centers Indian Health Service National Health Service Corps
State, County, Cit
• Military personnel ○ Difficult for dental visits when \_\_\_\_, large base of operations ○ Have own core • VA ○ Generally have disabilities • CHC ○ Wave of future > \_\_\_\_ political support ○ Places where integrate dental and medical easily ○ Philly has city dental clinics
mobile
bipartisan
Quality Assurance Public Goal: best possible health care
Appraisal and corrective action as needed
Structure, Process, Outcome
Structure (facilities, equipment, personnel)
Process (records, management, diagnosis, treatment plan, treatment)
Outcome (patient satisfaction, completed treatment, oral health status, recall)
* Donobedian's terms > came up with this way of looking at oulook of care * If structure, process and outcome are in order then patient is \_\_\_\_ * \_\_\_\_ comes later in terms of QA
benefitting
outcome
QA Activities in Dentistry
Testing of \_\_\_\_, devices (ADA, FDA) Selection of \_\_\_\_ Dental school \_\_\_\_ National Boards, Licensure exams Continuing \_\_\_\_ Review of the dental practice Peer review (state dental boards) \_\_\_\_ action
* CE to maintain the license * Weakness of state dental boards: \_\_\_\_ oriented (not prospective or proactive)
materials students accrediation education legal complaint
Review of the dental practice
• On-site \_\_\_\_ not used anymore • Quality of \_\_\_\_ not used anymore ○ Not related much to patient outcome • Consumer \_\_\_\_ ○ Used! ○ \_\_\_\_s care about this the most • Record \_\_\_\_ ○ Used! • Apropriateness of care ○ Used \_\_\_\_ • Provider profiling ○ Looking at indivdual providers or aggregates and seeing whether certain procedures are out of lines of the norm with the procedure • Oral health status ○ NO \_\_\_\_
evaluation care satisfaction employers audit sparingly gold standard
Overtreatment
Unnecessary services provided knowingly by
dentists
Services provided that dentists believe improve patient oral health but are actually ____
• \_\_\_\_ indicator • One of the things that led to \_\_\_\_; knowing that what we do is related to care • Twice a year recall > there's no \_\_\_\_ basis at all; adopted by the profession, and it works for most patients ○ But is it necessary? Would they be worse off, better?
valueless
AOC
EBD
research
Dentist
- professional education in acc. institution
- proven ____
- personal qualities
- Dx/Tx patients
- Rx ____
- employ auxiliaries
Dental auxiliaries
- assist dentist
- ____
- hygienists
- ____
- lab technicians
- ____ (AK, MN)
- receptionists, clerks, secretaries• EFDAs
○ Not legal in most states; but they are in ____
• Therapists
○ More states now
• Increase in clerks bc of complexity of billing
competence drugs assistants EFDAs therapists PA
Levels of Dentist Supervision of Auxiliaries (American Dental Assoc. 2002)
- ____
- ____ (authorizes, in office & evaluates)
- ____ (will evaluate)
- general (not in office)
- – not ____ to the ADA… fails to protect the health of the public
• Direct ○ Dentist personally oversees • Indirect ○ The patient wille valaute at a later time • General is not acceptable to the ADA ○ Research shows that it's not \_\_\_\_
personal direct indirect acceptable true
Supply of Dentists
186,000 active dentists 75% are general practitioners 22% are female Students: 48% female; 25% nonwhite Foreign-trained dentists PASS Accreditation of foreign schools
* Females are \_\_\_\_ * Takes a long time to change that when pushing out 6k grads into a pop of 186k
increasing
Distribution of specialists
* \_\_\_\_ is the biggest one * \_\_\_\_, path and \_\_\_\_ are smallest * Others evenly distributed * A lot of demand for \_\_\_\_
ortho
PH
radio
peds
White dentists to Pop: 1: ____
• African-American dentists to AA pop: 1: 8,500
AA dentists to AA Pop: 1: 7,307
* Hasn't changed much over the years * Range has been \_\_\_\_
1700
small
dentists per 100k pop
____: 143
usa: 60
india: 3
ethiopia: <1
HIGHEST USA: ____, NY, MA, ____, CT
LOWEST USA: ____, NC, ____, MS, NV
1 dentist per ____ (20 per ____) is a shortage
sweden HI NJ AL MS 5000 100k
dentist supply changes
dental schools
- 1982-2000
- 7 schools ____
- class sizes decreased
- 2000-now
- 6 ____ schools
- 7 being planned
dental grads 1977- 6300 1989- 3979 2008- 4700 2015- \_\_\_\_
• Institute of medicine suggest no more than \_\_\_\_, now we're at over 6k
closed
new
5300-6000
4k
Distribution of dentists
dental health professional shortage areas
- in 2000: 1,275 HPSAs
- in 2016: ____
age of dentists
- 65% >= 45 years
- mean age ~ ____ years
dentists per 100k pop
- 1979 - 50
- 1994 - 60
- 2020 - ____• Shortage areas has increased since 2000
○ Need was always there, but now gone through ____ process!
5493
50
55
designation
Factors Affecting Distribution
Personal preference
____ location Market response
____/ Licensure
• Live near dental school > CE, some time on faculty, place to refer patients; comfort zone • Market response ○ Patients in each area ○ Are salaries good? • Boards/licensure
dental school
boards
• Percentage practicing in same state of state, vs those in rural areas
• 20% of Penn grads stay in area, and that’s no unusual
○ Private
○ Public schools keep more of their own students in the ____
• Iowa has a lot in rural areas
○ Half of their students stay in the state as well
○ The dean visits every county in the state and asks what they can do for the school
• Public schools go into ____ more
state
rural
Expanded Practice for Auxiliaries
Dental Hygiene
EFDAs
DAU, TEAM
Indian Health, USPHS studies Evidence base is clear
ADA pre and post 1975
Dental therapists (NZ) Lab Technicians (#s \_\_\_\_, overseas outsourcing) Denturists (AZ, Idaho, Maine, MT, OR, WA)
• DAU > TEAM ○ Well trained EFDAs in the peds clinic ○ Made it much easier for dentists ○ Supported strongly before 1975, around that time perception that there were too many dentists > so they axed them ○ Can provide care that's just as good as the dentist § \_\_\_\_ functions, just the restorations • Dental therapist ○ The dentist in the school > diagnose the patient § Mostly caries; can do \_\_\_\_ and restoration • Lab techs are \_\_\_\_ • Denturists ○ Can provide full dentures on their own without a \_\_\_\_ from the dentist
decreasing non-invasive extractions decreasing prescription
Who will provide the additional dental care?
supply of dentists
1940s > 1960s estimated ____
mid 70s > 1990 perceived ____
1980: 2k per dentist “not enough patients”
2000: 1.8k per dentist “plenty of patients”
2020: projected ____ of dentists (HRSA)
2020: ADA/HPI - ____ # dentists
projections should be considered ____
• After WWII > shortage > a lot of recruits didn't have enough teeth to eat > more people needed to go to dentists or will have shortage of soldiers ○ In 60's provided per capita funding based on students > enrollment increased • Then an oversupply in 70s-90s • In 1980 > oversupply of dentists • 2000 > plenty of patients; ratio is smaller > population hadn't \_\_\_\_ as fast as dentist at school that's been putting out • HRSA > 2020 projected shortage of dentists; but the ADA/HPI has said we have enough • Useful to make projections > shouldn't get treating them as the gospel
shortage oversupply shortage adequate tentative grown
Factors facilitating dentist surplus or shortage
surplus
- economy (____)
- disease rates (____)
- dental insurance (decrease)
- lower ____
- increase durties for ____
- shortage
- economy (____)
- high ____ expectations
- decreased ____
- increased ____ coverage• No central control - nobody that tells how many graduates are coming from schools
○ Own needs within ____ dictate that (over national/state basis)
• If economy, disease rates, dental insurance and birth rates go down > decreased surplus of dentist
○ If auxiliaries increases
• If economy booms > shorter of dentists
○ Higher OH expectation > expecting a lot > need more dentists
○ Fewer edentulism > more teeth > more dentists to take care of them
○ Increase government coverage > more people eligible > boost for care
decrease
decrease
birth rates
auxiliaries
increase
OH
edentulism
goevenrment
university
Strategies to improve access
- safety net
- ____ funding
- tx of special pop.
- cultural ____
- dental leadership
- optimal use of allied personnel
- ____-educated dentists
- expanded ____ DAs
- ____hygienists
- dental ____• Can make VISA requirements, and partial stipends for the education
• Inefficient > independent/unsupervised hygienists
○ Better to be in teams
- dental ____• Can make VISA requirements, and partial stipends for the education
adequate competence foreign function independent/unsupervised therapists
dental therapists provide cost-efficient care in Veterans’ nursing homes
- ____ delivery using ADT
- eliminates need to transport patients
- daily billing $____ vs $3,600 for dentist
- saved $52,000 annually vs. dentist
- ____% of charges w/in scope of DT/ADT
- 60% of care was ____• Revenue was less
• 70-90% of services that needed to be provided were within the scope of the DT/ADT was capable of providing
○ Weren’t doing things that shouldn’t have been doing
onsite
3000
70-90
restorative
Utilization by Communities with Dental Therapists
Compared communities with most days vs. those with none
Most therapist-days associated with:
More ____ services
Fewer ____
Fewer cases treated under ____
preventive
extractions
gen’l anesthesia
Dental Therapy in 2017
- Educational Programs implemented in Alaska and Minnesota.
- Legislation passed in Maine and Vermont (started educational program in August 2017).
- Legislation pending/being discussed in Arizona, Massachusetts, Connecticut, South Carolina, Florida, Michigan, North Dakota, Oregon, Washington, New Mexico, North Dakota, Texas, Ohio and New Hampshire.
- Organized dentistry is still fighting this but this is ____ for patients and dentists.
- Easier than to ____ individuals at the auxillary levels
- Win for everyone
good
retrain
Dental Therapy is one of Our Challenges as a Professional
Balancing our individual needs, desires and values
versus
Our collective ____ to treat patients in their best interests
responsibility
Do we have an adequate dental care delivery system?
varies by ____
public-private not ____
• \_\_\_\_ !
state
coordinated
no
Access Issues
- 12% of US population below poverty line
- 16% has no ____
- 45% has no ____
- Cultural barriers, individualism
- Efficiency of private practice: healthy, employed, upper/ middle class, compliant
- Perceived as ____
- Distribution of dentists
- Inadequately funded ____ health systems
- Dental “Tourism”
- “Charity” clinics (episodic)• Dental tourism
○ Deciding you will get care and go on vacation at same time
○ Mexico > ____ of price you would get in the US
• ER visits
○ ____ nationally over several years
medical insurance dental insurance expensive public 1/3 doubled
Answer(s)?
Do Nothing
Expand FQHCs and those with Dental ACA modification
Medicare with Dental
Medicare for All
• Could expand ACA dental component to \_\_\_\_ (not just children) • Medicare is biggest driver of health service receipt > every \_\_\_\_ will follow ○ So including dental would be huge ○ Medicare is for everyone ○ People in higher class are better advocates for \_\_\_\_ than those of lower classes
adults
commercial provider
themselves
Levels of Care \_\_\_\_* \_\_\_\_ * \_\_\_\_** \_\_\_\_**
- Medicare pays
- Private Insurance or Out-of-Pocket• Break care into levels of care
• Medicare pays for emergency care and preventative/restorative
• Complex restorative and rehabilitive is private or OOP
• Would reduce ER care > doesn’t address problem, and csots a lot
○ ____ to government
○ Potential to improve someone’s health - will have a basic level of care
- Private Insurance or Out-of-Pocket• Break care into levels of care
emergency care preventive/basic restorative complex restorative rehabilitative savings
Improving oral health delivery in US
- structure of practice
- -FQHCs, group prac., multiple sites, evening hours, DMOs
- MDs, RNs, MSWs et al, focus on ages 0-5, Fl varnish, SDF
- financing
- ____ for all
- -payment for ____
- appropriatness of care reviews
- incentives for tx ____ patients and/or using DTs in DHPSAs
- workforce
- mandatory GPR
- DTs, MSWs
- dental ____ ladder
- increase loan repayment
- dental school: target recruitment, expand ____ expereicne
medicare value medicaid career community
A matter of economic balance
Dentist
- ____
- profit
- ____
Patient
- reasonable ____
- available services
- cultural ____
overhead
salary
cost
sensitivity
