bootleggers and baptists: there’s got to be a better way
TRANSCRIPT
1
Bootleggers and Baptists:There’s Got to be a Better Way
Shelly Gehshan, M.P.P.Senior Program Director
National Academy for State HealthPolicy
2
What I’ll cover
• State power and responsibility for healthcare workforce
• Theories of regulation• Long term trends• New provider models• How to move forward on new providers
3
Key State Government Roles inHealth Care
Public Health Facility/Professional Regulation
Regulation of
Insurance/HMOs
Health Workforce
Education/Training
Provide/Finance ServiceCost Containment
Information
Dissemination
Health System
Monitoring
4
Key State Roles in Oral Health
1. Regulation: Facilities & Professionals2. Health Workforce Education3. Public Health4 . Health System Monitoring
5 . Inform ation Dissem ination6. Regulation of Insurance & HMOs7. Provision/Financing of Health Care Services
5
Theories of Regulation
• Public Interest theory– Regulators serve public interest, not those
regulated– Should exist where risk of monopoly exists
• Economic theory or the ”Capture theory”– Those regulated craft regs to favor
themselves and society loses– Legislators “captured” by those regulated
(when hard to judge technical issues)
6
Another Theory of Regulation
• Bootleggers and Baptists– One group with the moral high ground, paired
with another (very different) group, canachieve change neither group could achievealone
– Undesirable results can occur from rarecollaborations; regulation needed to protectpublic interest and safety
7
Regulatory process should…
• Protect public safety through setting andenforcing reliable, consistent standards
• Serve the public interest by ensuringsupply
• Promote competition and consumer choice• Implement statute enacted by legislature
8
What Studies Show
• Stricter regulation leads to increases indentists’ income– Higher earnings in more regulated states than
in least regulated states (Kleiner and Kudrle, 2001)
– Higher incomes in states with restrictive useof reciprocity agreements (Holen, 1965)
– Dental board testing standards and reciprocityarrangements protect dentists’ incomes (Maurizi,1974; Conrad and Emerson, 1981)
9
Barriers to entry protect incomes
• Physicians:– Correlation between stringency of licensing process
and physicians’ incomes• Nurses:
– Mandatory licensure for RNs has positive impact onRN wages and RN employment relative to LPNs
– Restrictive licensure had significant positive effects onwages for RNs, LPNs, and medical technologists
• Optometrists:– Occupational restrictiveness associated with higher
fees and no improvement in thoroughness of exams
10
Source: Albert Guay, “Dental Practice: Prices, Production, and Profit,” JADA,Vol. 136 (March 2005), 359.
11
A Few Key Cites• M.M. Kleiner, R.D. Kudrle, “Does regulation affect economic
outcomes? The case of dentistry,” Journal of Law & Economics.18 (2001):547-581.
• G.L. Gaumer, “Regulating health professionals: A review of theempirical literature,” The Milbank Memorial Fund Quarterly:Health and Society. 632 (1984):380-416.
• A. Maurizi, “Occupational licensing and the public interest,” TheJournal of Political Economy. 82 (1974):399-413.
• L. Benham, A. Maurizi, M.W. Reder, “Migration, location andremuneration of medical personnel: Physicians and dentists,”The Review of Economics and Statistics. 50 (1968):332-347.
• A.S. Holen, “Effects of professional licensing arrangements oninterstate labor mobility and resource allocation,” The Journal ofPolitical Economy. 73 (1965):492-498.
12
Regulation of Hygiene
• HRSA-funded study (2004) rated stateregulatory environments from 0 (mostrestrictive) to 100 (optimal environment foraccess to hygiene)– States range from 10 (WV) to 97 (CO)– Extreme variation shows faulty balance
between ensuring public safety and providingaccess to hygiene for the population
– Runs counter to other professions
13
14
Long term trends
• Gradual loosening of supervisionrequirements and expansions in scope ofpractice for hygienists
• Evolution of the profession (albeitslowly)—change is the norm
15
Supervision and Payment forHygienists
• General supervision in 45 states in dentaloffice or some settings
• Direct access to patients in some settingsin 22 states (AZ, CA, CO, CT, IA, KS, ME, MI, MN,MO, MT, NE, NH, NM, NV, NY, OK, OR, PA, RI,TX, WA)*
• Medicaid can reimburse hygienists directlyin 12 states (CA, CO, CT, ME, MN, MO, MT, NM, NV,OR, WA, WI)**
* Source: American Dental Hygienists’ Association, “Direct Access States,” Available at www.adha.org** Source: American Dental Hygienists’ Association, “States Which Directly Reimburse Dental Hygienists for Services under the Medicaid Program,” Available at www.adha.org.
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
1990: Local Anesthesia Administration
Source: The American Dental Hygienists’ Association
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
1996: Local Anesthesia Administration
Source: The American Dental Hygienists’ Association
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
Source: The American Dental Hygienists’ Association
2002: Local Anesthesia Administration
NHMA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
INOH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
2008: Local Anesthesia Administration
Source: The American Dental Hygienists’ Association
1995: Direct Access
Source: The American Dental Hygienists’ Association
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AR
OK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AROK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
2000: Direct Access
Source: The American Dental Hygienists’ Association
NH MA
ME
NJ
CTRI
DE
VT
NY
DC
MD
NC
PA
VAWV
FL
GA
SC
KY
IN OH
MI
TN
MSAL
MO
IL
IA
MN
WI
LA
AROK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AK
AZ
NM
IDOR
WA
NV
CA
2008: Direct Access
Source: The American Dental Hygienists’ Association
23
State Movement onHygiene Self-Regulation
• 17 states have some form of hygiene self-regulation
• 4 states have own board, or committee withpower (FL, IA, NM, WA)
• 8 states have hygiene committees of stateboard of dentistry that advise on rules (AZ,CA, MI, MO, MT, NV, OK, OR)
• 3 states have hygiene committees withspecific duties (DE, ME, MD)
Source: State Practice Acts, compiled by ADHA Govt. Affairs Division, February, 2008.
24
The Need to Use Evidence inScope of Practice Decisions
• Legislators hate scope of practice fights“At the end of the day, I am hopeful that our decisionswill be [based] on science or specifically, easilyunderstood criteria… so that it will be a matter offairness,” Rep. Dianne White Delisi (R-TX) (C. DeLorna, LoneStar Reporter, 6/3/2006)
• New regulatory structures emerging– Some commissions that look at evidence,
impact on access, other state approaches
25
Alternative Models to MakeScope of Practice Decisions
• MN—Health Occupations Review Program• NM—Scope of practice review
commission• IA—Reviewing committees (report to DoH)• TX—Health Professions Scope of Practice
Review Commission (legislation)• VA—Board of Health ProfessionsSource: Dower, C, Christian, S, O’Neil, E, “Promising Scope of Practice Models for the Health
Professions,” Center for the Health Professions, UCSF, 2007, pp. 10-12.
26
New Models for Dental Providers
• ADA model — Community Dental HealthCoordinator (similar to Primary Dental Health Aidesin Alaska)
• ADHA model — Advanced dental hygienepractitioner
• Pediatric Oral Health Therapist (a dentaltherapist specializing in kids)
27
Current Workforce Proposals
• Proposals to expand scope or loosen supervision ofhygienists**– 7 states have proposals far along or completed in the
legislative process (MA, WI, MN, MT, CA, OH, KS)• Proposals to develop new dental practitioners**
– 3 states have proposals far along in the legislativeprocess (MN, MI, MA)
– 11 states are discussing proposals (CO, ME, NM, CA,FL, TX, OH, OR, KS, CT, PA)
**Survey of State Oral Health Coalition Leaders, NASHP 2008
28
Community Dental HealthCoordinator
• Prevention: education, fluorides, sealants• Treatment: gingival scaling, polishing• Restoration: atraumatic restorative therapy• Supervision: direct or indirect for services,
general supervision for patient education
29
Advanced Dental HygienePractitioner
• Prevention: comprehensive services• Treatment: manage periodontal care,
prophylaxis, prescriptions• Restoration: simple restorations,
extractions• Supervision: general supervision or
unsupervised; in collaborative practice, orprivate dental offices
30
Dental therapists
• Prevention: fluoride treatments, sealants• Treatment: x-rays, prophylaxis, gingival
scaling• Restoration: simple restorations, stainless
steel crowns, extractions• Supervision: general supervision under
standing orders
31
Newtok Clinic, Yukon-Kuskokwim
32
AFHCAN CartAlaska Federal Health Care Access Network
• Wireless Networking• Touchscreen• ECG / Video Dental Camera
and Otoscope / Scanner /Digital Camera
• Mobile – Customized• Patient safe
• WWW. AFHCAN.ORG
ADHP DT CDHCMasters level 2-year program 12-18 months
Licensure IHS certification(like licensure)
Certification
Curriculumalmost final
In 53 countries Planning
Seekingpartners, $,legislation, pilotplanned at 2MN colleges
Proven model,many studiespublished.Pending legis.bars use in lower48.
ADA has approved$2 M for 3 pilotprojects; pilot ruledillegal in MI
ADHP DT CDHCTrue midlevelprovider(RDH + 2 yrs)
Function likemidlevels, buteducated inless time
Close to dentalassistant, socialworker (not amidlevel)
Post-RDHcareer track
High schoolgrads
High schoolgrads
Could besupported byreimbursableservices
Could besupported byreimbursableservices
Supported bygrants? Fewreimbursableservices
ADHP DT CDHC
Pool ofRDHs readyto train
Recruited fromunderservedareas, groups
Dental assistants,community healthworkers
Riskassessment,casemanagement
Basicpreventive andrestorativeservices
Prevention,education, case-finding fordentists
Useful toexpandsafety net
Useful toexpand safetynet
Useful forprevention,limited use insafety net
ProceduresADHP
(proposed)DT
(AK model)CDHC
(proposed)EFDA
Atraumatic RestorativeTechnique (ART) X X
Placement oftemporary restorations X X X X
Simple restorations X X X
Light cure composites X
Simple extractions X XLab processed crowns X X
Pulpotomy X X
Pulp capping X X
Restorative Capacity of Providers
Source: NASHP, “Clinical Capacity of Current and Proposed Providers,” Table developed byNASHP, February 2008
37
38
Thoughts on implementation
39
Nurse PractitionerWorkforce Growth
Source: Unpublished data from the National Organization of Nurse Practitioner Faculties; Analysis by the Centerfor Health Professions, UCSF, 2004.
40
Growth of Physician Assistants 1980-2020
Source: Bureau of Labor Statistics and American Academy of Physician Assistants; Analysis by The RobertGraham Center, 2004.
41
Why Dentists Oppose Midlevels
• Would create a two-tier system of care• There’s no shortage of dentists• It’s illegal for non-dentists to do dentistry;
they would jeopardize patient safety• Inefficient if they practice independently• They would take patients away from
private dentists
42
Answering Those Concerns
• We have 2 tiers now (private, public)• Documented shortages in many areas• States regulation can protect public safety• Efficient business models can be
developed• Private dentists don’t treat 1/3 of the
public; won’t lose business
43
Irreversible procedures
• This is a political communications term,not a clinical term
• Opposition not based on public safety orclinical competence of new providers
• Hygienists now permitted to do“irreversible” procedures (e.g. anesthesia)
• States and communities want moresources of restorative care
44
Dental Practice Income
• About 45% of patient visits are for hygieneservices
• About half from insurance, half cash• Very sensitive to downturns in the
economy• Overhead averages about $.60-$.65 of
each dollar earned
45
46
Important Partners
• Payors—Medicaid, SCHIP, privateinsurers, business
• Coalitions—Provider associations, dental/medical leaders
• Legislators, local and state agency leaders• Universities, training programs• Safety net clinics, rural providers• Foundations
47
Bootleggers or Baptists?
• Consider regulatory structure (separatecommittee? Board of Health?)
• Ensure objective sources of evidence forlegislatures in amending practice acts
• Target new providers to safety netsettings?
• Think through referral, oversightagreements with dentists
48
Important Steps
• State and local policy communities cometo consensus, not national groups
• Focus on the underserved, not providers• Communicate solutions, don’t assume
people understand• Seek investments from foundations,
governments
49