Dental Workforce Supply and Demand

CPCA Oral Health Summit

June 7, 2002

Facts and Figures: Supply

• Ratio of dentist-to population is decreasing• Dentistry is the least diverse of the health

professions• Financial incentives for private practice are high,

very small percentage of dentists work in the public sector

• Educational systems are just now beginning to address issues of public service

• Professional incentive programs to serve the underserved are few and have mixed results

Dentists per 100,000 U.S. Population1950-2020

(Valachovic et al. JDE, 2001)

51.5

52.7

49.0

59.5

45

47

49

51

53

55

57

59

61

Actual Projected

Source: Bureau of Health Professions, HRSA, DHHS. Data from the Eighth Report to Congress 1991 and unpublished reports.

1950 1960 1970 1980 1990 2000 2005 2010 2015 2020

Estimated numbers of active oral health personnel, United States, selected years

1980 1990 1996 % Inc. 1990-1996

Dentists 121,900 147,500 154,900 5% Dental hygienists 54,000 81,000 94,000 16% Dental assistants 156,000 201,000 212,000 5% Dental laboratory technicians

43,000 50,000 53,000 6%

US Population (in thousands)

226,546 248,765 265,179 6%

California Population*

23,780,068 29,942,397 32,378,827 8%

Source: Health Resources and Services Administration, 1999, Statistical Abstract of the US, 1998 *Source: State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1970-2040. Sacramento, CA, December 1998.

Estimated Additions of Dentists to theDental Workforce: 1995-2040

(Valachovic et al. JDE, 2001)

-2000 -1500 -1000 -500 0 500 1000 1500

Assumptions: number of graduates remains at 4050 retirement age of 65

year 2014

year 2023-1706

year 1995

year 2040

year 2031

Source: American Association of Dental Schools

MSSAs with a

Shortage of

Primary Care

Dentists: California Counties,

1998

Dentist-to-Population Ranges

Non-ShortageShortageNo Dentists

Percent of Professionally Active Dentists by Gender and Race/Ethnicity

(Valachovic et al. JDE, 2001)

Male 85.9%

Female 14.1%

Native American 0.1%

Asian/Pacific Islander 6.9%

Black/African American 3.4%

Hispanic/Latino 3.3%

White/Caucasian 86.3%

Source: American Dental Association Bureau of Health Professions, HRSA

Variations in the Racial/Ethnic Representation in Dentistry and Medicine

12.2 11.9

23.8

7.0

20.4

71.3

3.8 0.73.4 3.36.9

0.1

86.3

66.0

4.6 5.10.5

78.0

3.0 5.0

11.0

0.5

63.9

6.50.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

White Black Hispanic Asian/PI Am. Indian

USPopulation

Dentists(1996)

First YearDentalStudents(1999)Physicians(1998)

First Year MedicalStudents(1998)

Sources: American Dental Association, Survey Center. The 1999 Survey of Dental Practice, (Chicago, IL: ADA Press, 2000); American Medical Association, Association of American Medical Schools, R.W. Valachovic, R.G. Weaver, J.C. Sinkford and N.K. Haden, “Trends in Dentistry and Dental Education: 2001,” Journal of Dental Education 65 (2001): 539-56, US Bureau of the Census

Percent Distribution of Professionally Active Dental Specialists: 1998

(Valachovic et al. JDE, 2001)

0 5 10 15 20 25 30

Orthodontists

Oral & Maxillofacial Surgeons

Pediatric Dentist

Periodontics

Endodontists

Prosthodontists

Public Health Dentists

Oral Pathologists•79.4% of professionally active dentists are generalists

•20.6% are specialists

Source: American Dental Association

0.8%

5.7%

8.2%

11.9%

14.1%

16.3%

16.4%

26.6%

Value Trends of Entering College Freshmen: 1966-1996

(Valachovic et al. JDE, 2001)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1966 1977 1996

Be well-off financially

Develop a meaningful philosophy of life

Source: Higher Education Research Institute, Univ. of California, Los Angeles

First-Time, First-Year Minority Enrollees in U.S. Dental Schools: 1990-1999

(Valachovic et al. JDE, 2001)

0

200

400

600

800

1000

1200

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Asian/Pacific Islander Black/African-AmericanHispanic/Latino Native American/Alaska Native

971

576

205245

17421515 25

Source: American Dental Education Association

Workforce Development

Issues include:• Distribution and composition

– Learn from other professions struggles

• Diversity• Education and training

– AEGD/GPR/CE

• Competencies• Competition for young workers

The current system does not have thecapacity to serve the underserved

Workforce ProgramsRecruitment, Retention, Training, Placement, CE

• Loan Repayment / Scholarships– NHSC, CASLR, IHS, Local/Private

• Post-Bac Program– Additional help for those without resources - financial and

educational• Education Partnership Programs

– Track interested students from primary on up• Service Learning

– Educational Partnership Agreement Dental Pilot Initiative (USC, UCLA, UOP)/RWJ pipeline program

• ABCD Program – Training component teaches new skills for practicing dental

professionals

Dental HPSA DesignationsRequirements• Must be rational service area (MSSA)• Requires 5000:1 pop/ FTE dentist ratio• Or 4000:1 pop/FTE ratio with high needs• Contiguous area analysis requiredBenefits Include• National Health Service Corps Placement• NHSC scholarships (select areas)• Funding preference for residency training

programs in GPR for those who place graduates in shortage areas

Policy and Research: DHPSAs

• AB 668: California Dental Loan Forgiveness Program– Currently being evaluated by OHSPD– 2 key differences – matching funds can be

from any source, HPSA criteria may not apply

• HRSA Evaluation of HPSA process at national level, found lack of articulation between process and goals of program

• Center for Health Professions Study of Methdology in process

Facts and Figures: Demand• Dentists have enjoyed and increase in net

income indicating adequate demand for current services

• Large portions of CA’s population does not receive care

• Underserved populations suffer a disproportionate share of dental disease, but are least likely to attain services

• Need and demand for services

are not the same

Supply vs. Demand

Consumersneed

perceptionlocation

costs

Providerscultural comp

supplyprevention

costs

BIG GAP

System Issues: Reimbursement, Safety Net, Public Health

There is a disconnect between the professional agenda and practice realities of dental professionals and the public health goal of equity in access and optimally healthy communities.

Access Barriers: Financial, Process, Attitudinal, Physical

Demand by Underserved Populations

• Demand vs. Need– Demand = function (quantity, price)– Quantity of Services is Low, Price is High =

Demand is Low– Then why the overcrowded clinics, long wait

lists, complaints about lack of Medicaid providers, and ER Incidents?

– NEED is high– Difference between met and unmet demand is

UNMET NEED

Barriers to Access

• Physical– no services available in clinics, or for underserved

populations

• Financial– Capital costs, inability to attract providers, lack of

reimbursement for preventive only

• Attitudinal– beliefs or perceptions that impede delivering or obtaining

care – latent demand

• Process– navigational barriers - knowledge about eligibility, how to

get dental care outside of ER

Unmet Need and Latent Demand

• Increasing quantity of services and decreasing price will decrease unmet need.

• Demand for restorative services is activated with pain, no need to increase this demand!

• Demand for preventive services (which may be latent) can be activated, through outreach and education, referrals, or exposure in other settings

PreventiveCare

RestorativeCare

Differentiate Markets for Preventive and Restorative Services

• Quantity of services is diminishing in overall market – Shortage of Dentists, particularly in public market

– Hygienist and Assistant ranks growing, but linked to dentists

• Market for preventive and restorative services is link through practice acts

• Strategies vary for increasing access to preventive and restorative care: different costs, different financing, and different providers

Redefining the Oral Health Care Workforce• Interdisciplinary models for

care delivery exist• Expand roles of non-oral health professionals to

assist in prevention, referrals and oral health education

• Easiest to reach underserved populations in existing settings (primary care clinics, WIC offices, schools)

• Many barriers as professional boundaries and traditional modes of practice are change averse

Challenge for Primary Care• Can primary care systems help increase access to

oral health care for underserved, and reduce levels of disease, particularly in the most vulnerable, poor, children, elderly, and disabled?

• Is there a way to integrate both preventive and restorative oral health services into primary care?

• Can you entice the next generation of oral health providers to work in primary care settings?

• Will oral health and primary health care be able to bridge professional gaps and confront legal, educational and practice barriers that currently stand in the way of integrating care?

3333 California Street, Suite 410

San Francisco, CA 94118

415-476-8181 phone

415-476-4113 fax

http://futurehealth.ucsf.edu

Presentation Available at

http://futurehealth.ucsf.edu/resources/roadshow.html