Advancing Dental Education in the 21st Century: Phase 2 Report on Strategic Analysis and Recommendations.

In Phase 1 of the "Advancing Dental Education in the 21st Century" project, research was conducted and published on a number of serious challenges facing dental and allied dental education, both presently and projected to 2040. Those findings informed the strategic analysis and recommendations developed in Phase 2 of the project. This report provides an overview of the Phase 2 conclusions and presents recommendations to address the challenges identified. The recommendations propose ways to educate a workforce prepared to meet the oral health needs of the population; develop a sustainable economic model that allows schools to meet their education, research, and service missions; make dental and allied dental education and practice an integral part of the larger health education and delivery systems; and keep dentistry advancing as a "learned" profession. This report begins with an Executive Summary and then presents the strategic analysis of challenges facing dental schools and allied dental programs and provides a brief explanation of the rationale for each recommendation. Two appendices are included with the report: the first summarizes discussions held at the national conference to consider the recommendations; and the second provides additional documentation of calculations used to estimate the number of new dental graduates needed in 2040.

Pay-for-performance incentive program in a large dental group practice.

BACKGROUND: Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS: The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS: The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS: This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS: Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

The Oral Health Care Delivery System in 2040: Executive Summary.

This executive summary for Section 4 of the "Advancing Dental Education in the 21st Century" project examines the projected oral health care delivery system in 2040 and the likely impact of system changes on dental education. Dental care is at an early stage of major changes with the decline in solo practice and increase in large group practices. These groups are not consolidated at the state level, but further consolidation is expected as they try to increase their negotiating leverage with dental insurers. At this time, there is limited integration of medical and dental care in terms of financing, regulation, education, and delivery. This pattern may change as health maintenance organizations and integrated medical systems begin to offer dental care to their members. By 2040, it is expected that many dentists will be employed in large group practices and working with allied dental staff with expanded duties and other health professionals, and more dental graduates will seek formal postdoctoral training to obtain better positions in group practices.

How Many Dentists Are Needed in 2040: Executive Summary.

Five background articles in Section 2 of the "Advancing Dental Education in the 21st Century" project examined some of the factors likely to impact the number of dentists needed in 2040: 1) the oral health of the population, 2) changes in the utilization of dental services, 3) new technologies, 4) the growth of large capitated dental group practices, and 5) the demand for dental care. With this information, a sixth background article estimated the number of dentists needed in 2040 compared to the number expected if current trends continue. This executive summary provides an overview of findings from these six articles. The data indicate major improvements in oral health, especially in upper income groups that account for 65% of practice revenues. At the same time, per capita utilization of restorative and prosthetic services has declined dramatically. No major new technologies are likely to impact the need for dentists by 2040. In a large capitated group practice, full-time general dentists treated an average of 2,100 patients per year; solo general dentists averaged 1,350. Based on the examined factors, growth in demand for traditional forms of care may slow substantially, raising the potential for a surplus of dentists in 2040. If these trends continue, the key national policy issue then would be: should schools reduce the number of graduates before market forces require them to downsize or close, or are other alternatives available?

Trends in Financing Dental Education, 2004-05 to 2011-12.

This article examines dental school financial trends from 2004-05 to 2011-12, based on data from the American Dental Association (ADA) annual financial survey completed by all U.S. dental schools. For public schools, revenues from tuition and fees increased 68.6%, and state support declined 17.2% over the examined period. For private schools, revenues from tuition and fees increased 38.9%, and university indirect subsidies declined 77.9% over the same period. The major factors affecting dental school expenditures were the number of students and postdoctoral students, faculty practice, and research. The findings suggest that dental schools are now more dependent financially on tuition and fees than in the past. Schools have been able to pass on increases in operating costs to students and specialty postdoctoral students. Now that growth in dentists' incomes is slowing and student debt is at an all-time high, this financing strategy may not be sustainable in the long run. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Are Dental Schools Part of the Safety Net?

This article examines the current safety net activities of dental schools and reviews strategies by which schools could care for more poor and low-income patients. The primary data come from the annual Survey of Dental Education, a joint American Dental Education Association (ADEA) and American Dental Association (ADA) activity. The analyses use descriptive statistics and are intended to give ballpark estimates of patients treated under varying clinical scenarios. Some 107.4 million people are underserved in comparison to utilization rates for middle-income Americans. In 2013-14, pre- and postdoctoral students treated about 1,176,000 disadvantaged patients. This is an estimate; the actual value may be 25% above or below this number. The impact of potential strategies for schools to provide more care to poor and low-income patients are discussed; these are larger class size, more community-based education, a required one-year residency program, and schools' becoming part of publicly funded safety net clinics. While dental schools cannot solve the access problem, they could have a major impact if the payment and delivery strategies discussed were implemented. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Dental Group Practice and the Need for Dentists.

This study compared the number of patients treated per year by general dentists and dental hygienists in solo practice and by those employed by a large group practice. Information on the annual number of patient visits to solo general dental practitioners comes from the 2013 American Dental Association (ADA) Survey of Dental Practice. Patient visits were divided by 2.5 to estimate the number of patients treated annually. The data on group practices come from HealthPartners (HP) of Minnesota, a large not-for-profit medical and dental Health Maintenance Organization that accepts insurance contracts based on global budgets and is financially at risk. In 2013, solo general dentists averaged 1,350 patients, while the average HP general dentist treated 2,052 patients. HP general dentists thus treated over 700 more patients annually than did solo practitioners. This large difference has major implications for the future of the dental delivery system and dental education. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Estimating the Number of Dentists Needed in 2040.

Numerous factors that underlie the need for dentists are undergoing significant changes. Three factors are especially important: 1) improvements in oral health; 2) lower expenditures per patient per year, giving dentists the incentive to treat more patients to maintain incomes that justify their investment in dental education and practice; and 3) dental schools' producing new dentists at a faster rate than the growth in the population. If these trends continue, there is likely to be a dentist surplus of between 32% and 110% by 2040. A major challenge for dental schools is to adjust the production of dentists before 2040 and not wait for market forces to reduce the surplus. Whether there will be a painful market-based solution to the problem, as there was in the 1980s, or whether a more orderly path can be found is one of the key challenges of the project "Advancing Dental Education in the 21st Century," for which this article was written.

Introduction to "Advancing Dental Education in the 21st Century" Project.

In 1926, the Carnegie Foundation for the Advancement of Teaching published a report prepared by William J. Gies, PhD, a professor of biochemistry and founder of the Columbia University College of Dental Medicine. The Gies report examined the current status of dental education in the United States and Canada and made recommendations for a new direction. This report led to major improvements in dental education and research and was a critical factor in making dentistry a learned profession. Dental and allied dental education are now challenged by a new set of issues related to financing education, improved oral health, more effective treatment technologies, and a rapidly changing delivery system. In an effort to meet these challenges, this strategic planning project first examined the current status and future trends that are likely to impact the dental profession over the next 25 years. The project was organized into six sections, and 50 authors were invited to prepare 38 articles to address these issues. The executive summaries for each section are being published in the August and September 2017 issues of the Journal of Dental Education, and the background articles are being published in online supplements to those issues. In the next phase of the project, information from the articles will be used to make strategic recommendations to assist dental schools and allied dental education programs in preparing graduates for practice in 2040 and to meet their institutions' missions for scholarship and service. This introduction presents the project rationale, provides a list of the published articles, and acknowledges the organizations that supported this effort.

Population-centered Risk- and Evidence-based Dental Interprofessional Care Team (PREDICT): study protocol for a randomized controlled trial.

BACKGROUND: To improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health. METHODS/DESIGN: This is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records. DISCUSSION: If effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.

Federally qualified health center dental clinics: financial information.

OBJECTIVE: Federally Qualified Health Center (FQHC) dental clinics are a major component of the dental safety net system, providing care to 3.75 million patients annually. This study describes the financial and clinical operations of a sample of FQHCs. METHODS: In cooperation with the National Network for Oral Health Access, FQHC dental clinics that could provide 12 months of electronic dental record information were asked to participate in the study. RESULTS: Based on data from 28 dental clinics (14 FQHCs), 50 percent of patients were under 21 years of age. The primary payers were Medicaid (72.4 percent) and sliding-scale/self-pay patients (17.5 percent). Sites averaged 3.1 operatories, 0.66 dental hygienists, and 1.9 other staff per dentist. Annually, each FTE dentist and hygienist provided 2,801 and 2,073 patient visits, respectively. Eighty percent of services were diagnostic, preventive, and restorative. Patient care accounted for 82 percent of revenues, and personnel (64.2 percent) and central administration (13.4 percent) accounted for most expenses. CONCLUSION: Based on a small convenience sample of FQHC dental clinics, this study presents descriptive data on their clinical and financial operations. Compared with data from the UDS (Uniform Data System) report, study FQHCs were larger in terms of space, staff, and patients served. However, there was substantial variation among clinics for almost all measures. As the number and size of FQHC dental clinics increase, the Health Resources and Services Administration needs to provide them access to comparative data that they can use to benchmark their operations.

Expanded function allied dental personnel and dental practice productivity and efficiency.

This study examined the impact of expanded function allied dental personnel on the productivity and efficiency of general dental practices. Detailed practice financial and clinical data were obtained from a convenience sample of 154 general dental practices in Colorado. In this state, expanded function dental assistants can provide a wide range of reversible dental services/procedures, and dental hygienists can give local anesthesia. The survey identified practices that currently use expanded function allied dental personnel and the specific services/procedures delegated. Practice productivity was measured using patient visits, gross billings, and net income. Practice efficiency was assessed using a multivariate linear program, Data Envelopment Analysis. Sixty-four percent of the practices were found to use expanded function allied dental personnel, and on average they delegated 31.4 percent of delegatable services/procedures. Practices that used expanded function allied dental personnel treated more patients and had higher gross billings and net incomes than those practices that did not; the more services they delegated, the higher was the practice's productivity and efficiency. The effective use of expanded function allied dental personnel has the potential to substantially expand the capacity of general dental practices to treat more patients and to generate higher incomes for dental practices.

Impact of dental therapists on productivity and finances: I. Literature review.

This study examined the financial impact of dental therapists on Federally Qualified Health Center dental clinics (treating children) and on private general dental practices (treating children and adults). This article, the first of four on this subject, reviews the dental therapy literature and the dental access problem for low-income children. Dental therapists now practice in many developed countries, tribal areas of Alaska, and Minnesota. These allied dental professionals vary in their training and required dentist supervision, but all provide routine restorative and other related services to children and adults. The limited literature on the impact of dental therapists suggests that they work mainly in school and community clinics and some private practices, are well accepted by patients, provide restorations that are comparable in quality to those of dentists, expand the supply of services, do not increase private practices' net revenues, and in school programs decrease the number of untreated decayed teeth. Of the approximately 33.8 million children enrolled in Medicaid and the Children's Health Insurance Program (CHIP), some 40 percent now receive at least one annual dental visit. To increase utilization for all children to 60 percent--the rate seen in children from upper-income families--another 6.7 million children need to receive care; dental therapists may help to accomplish that objective.

Impact of dental therapists on productivity and finances: II. Federally Qualified Health Centers.

This article estimates the impact of dental therapists treating children on Federally Qualified Health Center (FQHC) dental clinic finances and productivity. The analysis is based on twelve months of patient visit and financial data from large FQHC dental clinics (multiple delivery sites) in Connecticut and Wisconsin. Assuming dental therapists provide restorative, extraction, and pulpal services and dental hygienists continue to deliver all hygiene services, the maximum reduction in costs is about 6 percent. The limited impact of dental therapists on FQHC dental clinic finances is because 1) dental therapists only account for 17 percent of children services and 2) dentists are responsible for only 25 percent of clinic expenses and cost reductions are related to the difference between dental therapist and dentist wage rates.

Impact of dental therapists on productivity and finances: III. FQHC-run, school-based dental care programs in Connecticut.

In many developed countries, the primary role of dental therapists is to care for children in school clinics. This article describes Federally Qualified Health Center (FQHC)-run, school-based dental programs in Connecticut and explores the theoretical financial impact of substituting dental therapists for dentists in these programs. In schools, dental hygienists screen children and provide preventive services, using portable equipment and temporary space. Children needing dentist services are referred to FQHC clinics or to FQHC-employed dentists who provide care in schools. The primary findings of this study are that school-based programs have considerable potential to reduce access disparities and the estimated reduction in per patient costs approaches 50 percent versus providing care in FQHC dental clinics. In terms of substituting dental therapists for dentists, the estimated additional financial savings was found to be about 5 percent. Nationally, FQHC-operated, school-based dental programs have the potential to increase Medicaid/CHIP utilization from the current 40 percent to 60 percent for a relatively modest increase in total expenditures.

Dental therapists in general dental practices: an economic evaluation.

Dental access disparities are well documented and have been recognized as a national problem. Their major cause is the lack of reasonable Medicaid reimbursement rates for the underserved. Specifically, Medicaid reimbursement rates for children average 40 percent below market rates. In addition, most state Medicaid programs do not cover adults. To address these issues, advocates of better oral health for the underserved are considering support for a new allied provider--a dental therapist--capable of providing services at a lower cost per service and in low-income and rural areas. Using a standard economic analysis, this study estimated the potential cost, price, utilization, and dentist's income effects of dental therapists employed in general dental practices. The analysis is based on national general dental practice data and the broadest scope of responsibility for dental therapists that their advocates have advanced, including the ability to provide restorations and extractions to adults and children, training for three years, and minimum supervision. Assuming dental therapists provide restorative, extraction, and pulpal services to patients of all ages and dental hygienists continue to deliver all hygiene services, the mean reduction in a general practice costs ranges between 1.57 and 2.36 percent. For dental therapists treating children only, the range is 0.31 to 0.47 percent. The effects on price and utilization are even smaller. In addition, the effects on most dentists' gross income, hours of work, and net income are negative. The estimated economic impact of dental therapists in the United States on private dental practice is very limited; therefore, the demand for dental therapists by private practices also would probably be very limited.

Community-based dental education: history, current status, and future.

This article examines the history, current status, and future direction of community-based dental education (CBDE). The key issues addressed include the reasons that dentistry developed a different clinical education model than the other health professions; how government programs, private medical foundations, and early adopter schools influenced the development of CBDE; the societal and financial factors that are leading more schools to increase the time that senior dental students spend in community programs; the impact of CBDE on school finances and faculty and student perceptions; and the reasons that CBDE is likely to become a core part of the clinical education of all dental graduates.

Dental school and community clinic financial arrangements.

In community-based dental education programs, student-provided services can be an important source of community clinic and practice revenues. The University of Michigan School of Dentistry has developed a revenue-sharing arrangement with multiple community clinics and practices. During their ten-week externship, senior students produce at least $800 a day in patient care revenues, and the school receives an average of $165 per student per day from community sites. These funds are used to cover program costs and enrich the curriculum. Revenue-sharing with community clinics and practices helps to ensure program longevity and is an increasingly significant source of school revenues.