The Oregon Dental Market A Case Study.

This case study examines changes taking place in the Oregon dental care system. Data were obtained from interviews with senior executives from several delivery organizations. Conducted by the senior author (HB), the summarized interviews were reviewed by informants. Oregon Medicaid enrollees now receive medical! dental care in capitated managed care organizations. Several dental group practices that provide care to privately and publicly insured patients are growing rapidly.The largest local dental insurer has diversified into other health products, including management services for affiliated dental practices. The Oregon dental market is undergoing a major reorganization: (a) large dental group practices are expanding and solo practices are declining; (b) all Medicaid patients receive their care in state-regulated Coordinated Care Organizations and their contracted Dental Care Organizations; and (c) more dental graduates are seeking employment in group practices. Longer term, the dental group practice companies are expected to undergo some consolidation.Two key features of the Oregon dental market are the growth of large dental group practices and the reorganization of the dental Medicaid system.

Federally qualified health center dental program finances: a case study.

OBJECTIVES: We analyzed the operation of one Connecticut federally qualified health center (FOHC) dental program with seven delivery sites. We assessed the financial operation of the different delivery sites and contrasted the overall performance of the FOHC with private practices. METHODS: We obtained data from a pretested financial survey instrument, electronic patient visit records, and site visits. To assess clinic productivity, we used two output measures: patient visits and market value of services. For the latter, we estimated the implicit fee of each service provided in patient visits. RESULTS: On average, these clinics were running a modest deficit, mainly due to startup costs of two new clinics. The primary factor that impacted net revenues was low reimbursement rates, including privately insured patients. When FOHC dental revenues were adjusted to market rates, revenues were close to expenses. CONCLUSIONS: FOHC dental clinics are major components of the dental safety net system. This case study suggests that the established clinics use resources as effectively as private practices.

Financial feasibility of a model school-based dental program in different states.

OBJECTIVES: This article describes a model for a school-based program designed to reduce dental access disparities and examines its financial feasibility in states with different Medicaid reimbursement rates. METHODS: Using state and national data, the expected revenues and expenses for operating the program in different states were estimated. Hygienists with support staff provided screening and preventive services in schools using portable equipment and generated surplus funds that were used to supplement payments to community clinics and private practices for treating children. RESULTS: The program is financially feasible in states when the ratio of Medicaid fees is 60.5% of mean national fees. Of the 13 states examined, one-third have adequate Medicaid fees to support the program. CONCLUSION: The model program has considerable promise for reducing access disparities at a lower cost per child than current Medicaid programs.

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program.

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices.

Financing dental care: trends in public and private expenditures for dental services.

This article examines the financing of dental care in the United States. The major issues addressed include the amount and sources of funds, the reasons for increased dental care expenditures, the comparison of dental care with other medical care expenditures, the policy implications of current trends, and some cautious predictions about the financing of dental care in the next 10 to 20 years. The supply of dental services is expected to increase substantially in the next 10 to 20 years with more dental school graduates, a new midlevel practitioner, and greater use of allied dental health personnel. Whether the supply of services will grow faster than the demand for care is unknown.

Assessing the cultural competency of dental students and residents.

This article presents a literature review of cultural competency education in the health professions (dentistry, dental hygiene, medicine, and nursing) with specific reference to methods of evaluating student and resident knowledge of cultural competency concepts and practices and clinical performance. Some important barriers to developing evaluation instruments are the following: 1) little consensus on core competency knowledge; 2) erroneous notions of race; and 3) stereotyping the behavior of racial groups. The relative advantages of the different examination methods now used to evaluate students and residents (qualitative, quantitative, practical, and self-evaluation) are reviewed, and recommendations are made regarding three instruments that schools can use to assess student knowledge and clinical performance.

Financing clinical dental education.

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.

U.S. state-supported dental schools: financial projections and implications.

This article examines the impact of financial trends in state-supported dental schools on full-time clinical faculty; the diversity of dental students and their career choices; investments in physical facilities; and the place of dentistry in research universities. The findings of our study are the following: the number of students per full-time clinical faculty member increased; the three schools with the lowest revenue increases lost a third of their full-time clinical faculty; more students are from wealthier families; most schools are not able to adequately invest in their physical plant; and more than half of schools have substantial NIH-funded research programs. If current trends continue, the term "crisis" will describe the situation faced by most dental schools. Now is the time to build the political consensus needed to develop new and more effective strategies to educate the next generation of American dentists and to keep dental education primarily based in research universities. The future of the dental profession and the oral health of the American people depend on it.

Evolution of dental school clinics as patient care delivery centers.

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.

Dental schools and access disparities: what roles can schools play?

Dental schools can address access disparities in several ways: the direct delivery of dental care to underserved population; the recruitment of students more likely to provide care to underserved population; clinical experiences that will influence student and resident career decisions, and basic and clinical research. Currently, schools are having a modest impact on the access problem, and there are several promising new efforts underway. These include establishment of dental school clinics in underserved areas that are run as real delivery systems rather than as teaching laboratories; the recruitment of more underrepresented minority and low-income students; the assignment of senior students and residents to community clinics; and basic and clinical research.

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.

Economic impact of regulating the use of amalgam restorations.

OBJECTIVE: This article estimates the financial impact of a ban on amalgam restorations for selected population groups: the entire population, children, and children and women of childbearing age. METHODS: Using claim and enrollment data from Delta Dental of Michigan, Ohio, and Indiana and the American Dental Association Survey of Dental Services Rendered, we estimated the per capita use and annual rate of change in amalgam restorations for each age, gender, and socioeconomic subgroup. We used population projections to obtain national estimates of amalgam use, and the dental component of the Consumer Price Index to estimate the annual rate of change in fees. We then calculated the number of dental amalgams affected by the regulation, and the fees for each of the years 2005 to 2020. RESULTS: If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion. CONCLUSIONS: An amalgam ban would have a substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease. Based on the available evidence, we believe that state legislatures should seriously consider these effects when contemplating possible restrictions on the use of amalgam restorations.

Financing clinical dental education.

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.

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?

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."

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.

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.

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."

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."