Government assistance programs have been implemented to address the unmet needs of some of these groups, while other groups have been ignored. Dental philanthropic groups and charitable activities by dentists have tried to help fill the gap in treatment needs when government programs have not been entirely successful.⁴ It is a goal of dentistry that "all Americans will be able to receive the dental care they need, regardless of their financial, geographic, health status, or other special circumstances."⁵ Meeting that goal will require the efforts and cooperation of all stakeholders to remove the barriers.

This challenge cannot be solved easily because of the diverse nature and complexity of the problems and the amount of resources that will be needed to solve them. Nonetheless, there are three basic aspects of the access-to-dental-care challenge that must be considered and addressed—regardless of the population segment targeted or the program designed to resolve access issues—if any measure of success is to be expected.

Three factors that are critical in any discussion of a successful access-to-dental-care program are

– effective demand for dental care;

– an adequate dental work force able to respond to that demand;

– an economic environment that supports patients and providers so that they can participate in the program.

These three factors apply to the entire dental care system, as well as to each segment of that system, regardless of the individual characteristics of the group (Figure 1).

View larger version (38K): [in this window] [in a new window]   Figure 1. The dental care access triangle.

	DEMAND FOR DENTAL CARE

TOP ABSTRACT DEMAND FOR DENTAL CARE DENTAL WORK FORCE ECONOMIC ENVIRONMENT SOLVING THE ACCESS PROBLEM CONCLUSIONS REFERENCES

 
There are studies and publications devoted to describing and quantifying the dental care needs that exist and are not being met in multiple and diverse population segments.^6,7 These needs often become the basis for cost projections for treatment, were it to be provided, and future work force requirements to provide this treatment. Unfortunately, this is an unreliable basis on which to make both cost and work force projections, as there is not a one-to-one relationship between the need for dental care and the demand for dental care.⁸

The gap between the number of patients who need dental care and those who seek dental care (the demand for dental care) should be narrowed. Publicly funded and private charitable dental care assistance programs usually concentrate on removing or reducing the financial barriers for potential patients to seek care. There is, however, substantial evidence that there are significant barriers other than financial ones that prevent patients with dental needs from seeking appropriate and timely care.⁹ A culturally sensitive educational plan must be a part of any effort to narrow this gap, as survey data show that for many people the primary reason for not seeking care is that they do not believe they have a dental problem.¹⁰

For example, a three-year pilot project conducted in Massachusetts with Medicaid recipients tested a capitation-based reimbursement plan for dentists. Researchers found that the capitation rate paid to dentists was sufficient as evidenced by the fact that an adequate number of dentists participated in the project (Massachusetts Dental Project, Massachusetts Department of Public Welfare, 1982, unpublished data). Thus, the work force and the economics factors in the triad were addressed adequately. The project involved Medicaid staff members actively reaching out to enroll patients, making appointments for patients with participating dentists and providing patients transportation to and from the dental offices. These efforts resulted in a small increase in utilization of dental services to only a little more than one-half the rate generally experienced with dental benefit plans. The demand factor was insufficient to enable the project to enhance access to care significantly for the targeted population.

Projections of future dental work force requirements made on dental needs alone will be incorrect. To be successful, a program aimed at increasing access to dental care must consider the demand for care and the factors that influence that demand. Programs based on dental needs have the potential for introducing significant inefficiencies into the dental care system, especially if work force adjustments based on dental care needs result in more dentists being educated than are required to satisfy the effective demand for care.

	DENTAL WORK FORCE

TOP ABSTRACT DEMAND FOR DENTAL CARE DENTAL WORK FORCE ECONOMIC ENVIRONMENT SOLVING THE ACCESS PROBLEM CONCLUSIONS REFERENCES

 
Dental work force issues are not difficult to understand, though resolving some of the problems associated with those issues may be complex. In relation to access to care issues, there are two basic work force considerations: the effective number of dentists (taking into consideration demographic accommodations) in the system relative to the demand for dental care, and the distribution of the available dentists relative to where the patients who are seeking care are located. In a market-based dental care system such as that in the United States, both of these factors are determined in the marketplace, with only minor involvement by the government.

When considering governmental assistance and access programs, the number of dentists in the system relative to the demand for dental care has two interdependent components: the absolute number of dentists in the system and the number of dentists who are willing to participate in the program. If there is an insufficient absolute number of dentists in the nation, there will not be enough dentists participating in assistance programs to satisfy the demand for dental care generated by those programs. However, the converse—if there is an insufficient number of dentists participating in assistance programs to satisfy the demand for dental care in those programs, there must be an insufficient absolute number of dentists in the nation—is not true.

There has been some discussion that more dentists may be needed currently and in the future than are or will be available in the United States^11–22 because there is inadequate access to dental care for low-income families, people with disabilities and some minorities. The national professionally active dentist-per-1,000 population ratio declined from 0.60 in 1993 to 0.59 in 2000.²³ Projections vary, with some estimating that this ratio will be 0.55 in the year 2020, and others estimating it will be 0.52.²⁴ Recent data show, however, that in approximately one-half of the states, the dentist-to-population ratio increased from 1993 to 1999 (Figure 2).⁵ Several of these states (for example, Massachusetts, New Jersey, New York, California and Florida) have large Medicaid populations, and these states continue to have an access-to-dental-care problem. These data tell us that access-to-dental-care problems can coexist with increased numbers of dentists in a state. Thus, solely increasing the number of dentists in a state, relative to the population in that state, will not solve an access-to-dental-care problem. There is not a direct correlation between the number of dentists in a state and adequate access to dental care in that state for all segments of the population (Figure 2).

View larger version (27K): [in this window] [in a new window]   Figure 2. The percentage change in dentist-to-population ratios, 1993–1999. Source: American Dental Association, Health Policy Resources Center.5

The Institute of Medicine’s comment on work force estimation—which was formulated after a review of several methods used to make work force projections—should be heeded: "The history of work force projections in health care is not encouraging. The problems lie in the marked difficulties of estimating ‘need’ or ‘demand’ (that is, requirements) for either health care services or health care personnel and the somewhat less troublesome challenges of projecting supply."⁸

We know that dentists will establish private practices in areas where there is an adequate concentration of people in the practice catchment area who will seek dental care and have the resources to pay for that care. Elsewhere—especially in some poor urban areas—there may be inadequate financial resources and insufficient demand, so dentists do not establish private practices in those areas, which hinder access to care. In addition, the population in some rural areas may be so sparse that maintaining a dental practice is difficult. The most difficult access challenges may be in poor rural areas, where none of the essential criteria for establishing a private practice is satisfied.

The fees for dental services, which assistance programs traditionally address, are only one of the multiple costs that dental patients must pay to access dental care.

	ECONOMIC ENVIRONMENT

TOP ABSTRACT DEMAND FOR DENTAL CARE DENTAL WORK FORCE ECONOMIC ENVIRONMENT SOLVING THE ACCESS PROBLEM CONCLUSIONS REFERENCES

 
When considering the economic aspects of an assistance program, the discussion almost always centers on the reimbursement received by the providers of services compared with the average reimbursement level in the community or compared with the amount it costs providers to provide those services. This is an important factor in determining the adequacy of the dental work force to provide services in assistance programs and will be discussed later in this section.

The economic aspects of an assistance program also are important to recipients of care and may be important in determining the effective demand for dental care. The fees for dental services, which assistance programs traditionally address, are only one of the multiple costs that dental patients must pay to access dental care. There are real costs associated with the acquisition of dental care, beyond professional fees, and they include income lost while being away from work to get dental care for oneself or a family member, transportation costs from home or school to the dental office, parking fees, and the cost of child care when required. These acquisition costs,^26,27 or opportunity costs, may be of such significance to some people that they cannot even afford "free" dental care.

When resources are limited, the determination of how they will be spent is made by balancing the benefit that will accrue by acquiring particular goods or services (marginal benefit) with the cost of obtaining them (marginal cost). The potential benefit must outweigh the cost, otherwise the goods or services will not be acquired.²⁸ Understanding and appreciating the effect of opportunity costs on the demand for dental care, especially in marginalized population groups, may be difficult to understand.

Understanding the effect of reimbursement rates paid to providers and how these rates affect the supply of providers is more straightforward, however. The relationship is direct, and the two factors move together; that is, as reimbursement rates fall, so do providers’ participation rates.

A dental practice is a business, and the revenues it generates must surpass its costs. When the revenues that may be generated by participation in a subsidized assistance program fall significantly below the costs associated with providing services, a rational business decision dictates that participation in such a program is not viable, all other things being equal. The average overhead—cost of providing services—in dental offices across the United States is approximately 60 percent of gross revenues,²⁹ exclusive of any compensation to the dentist. Many public assistance programs provide reimbursement at rates far below that level.

The point has been advanced by some that in programs that offer public assistance to disadvantaged patients—children in particular—providers should not base their charges on their usual fees. Instead, they should accept fees that reflect only the cost of providing services with no portion of general overhead included. This may be a tenable situation in a practice that has only a few patients who receive public assistance, as the full fees paid by paying patients can subsidize adequately the reimbursed fees, which often cover less than the total cost for providing those services. However, this has not been the experience of hospitals and medical providers during the managed-care years, and it has led to financial crisis and failure to survive in some instances.

On the other hand, it is easier to understand the situation in practices with a large number of patients who are enrolled in public assistance programs—mostly located in poorer areas—that have fewer paying patients whose fees can subsidize the inadequate fees paid by those who are receiving public assistance. For those practices, such a reimbursement scheme would not be tenable.

Much as with patients’ opportunity costs, some costs dentists experience are not related directly to the provision of services. Administrative costs associated with a public assistance program can add significantly to dental offices’ overhead costs. Therefore, the low reimbursement rates coupled with high administrative costs make it difficult for some dental offices to participate in public assistance programs with those characteristics.

There is no one solution to the problem of inadequate access to dental care for underserved segments of the population.

	SOLVING THE ACCESS PROBLEM

TOP ABSTRACT DEMAND FOR DENTAL CARE DENTAL WORK FORCE ECONOMIC ENVIRONMENT SOLVING THE ACCESS PROBLEM CONCLUSIONS REFERENCES

 
There is no one solution to the problem of inadequate access to dental care for underserved segments of the population. Nonetheless, progress toward improving the status quo can be made by addressing the factors that constitute adequate access to care. Efforts to do this must be coordinated, or the access problems may be exacerbated rather than improved. For example, successful efforts to increase the demand for dental care will cause chaos if there is not a concomitant increase in the number of dentists who are willing to provide that care. By the same token, educating more dentists to provide care without increasing the demand for dental care will be equally disruptive because productivity will decline as a result of unused office capacity. The interdependence of the three basic factors—effective demand for dental care, an adequate dental work force able to respond to that demand and an economic environment that supports patients and providers so that they can participate in the program—must be considered when adjustments are made in public assistance programs.

Demand for dental care. Educational programs for parents and children that demonstrate the importance of good oral health to general health and well-being, as well as the need to begin dental visits at an early age, will help motivate families to enter the dental care system and increase the demand for dental care.³⁰ Ways to reduce the acquisition costs faced by low-income families also should be explored. As assistance programs continue to improve, some of these costs will be reduced without additional expenditures by the program. For example, as more dentists participate in assistance programs, patients’ transportation costs and their time away from work required to receive care may be reduced because it will be more likely that a dentist will be located close to the patient.

Dental work force. Although there may be some areas where there genuinely are inadequate numbers of dentists available to meet the demand for dental services, care must be taken before more dentists are produced to ensure that there is a true shortage of dentists and not an uneven distribution of dentists in an area that has been affected by economic or area desirability problems. An inappropriate increase in the number of dentists produced will have no effect on the access to dental care for underserved population groups. It will only duplicate the oversupply of dentists that existed in the 1970s and 1980s, with the concurrent decrease in the productivity levels of the dental care system experienced during that period.

Proposals have been advanced by various groups to expand the duties that dental auxiliary personnel are allowed to perform to include some services that traditionally only dentists have been authorized to provide. Although, with adequate supervision by a dentist, this may be an appropriate approach to easing an inadequate access problem, in certain circumstances, care must be taken to ensure that a fragmented, two-tiered delivery system does not develop.

Although some minor adjustments could enhance efficiency, the current dental team structure should remain intact. True access to care is not achieved when only a limited number of services are available to patients. The entire dental delivery structure must be in place to ensure that adequate access to preventive, diagnostic and therapeutic dental services is achieved.

Economic environment. An economic environment must be created that provides the proper incentives for participation in the dental care system for both patients and dentists. The benefits of good oral health as perceived by patients must outweigh the real costs they must pay to achieve it. In addition, payments to dentists must be appropriate in relation to the costs to provide services. The balance between reimbursement and costs can be achieved by increasing reimbursements, reducing costs or both. A reduction in administrative costs, for example, is the equivalent of an increase in reimbursement with no additional costs to the program.

The success of the recent Healthy Kids Dental demonstration program in Michigan,³¹ which was designed to alleviate the low reimbursement rates and administrative burden associated with the traditional Medicaid program, illustrates the effect on access to dental care that improving those two factors had. In the 37 counties in which this demonstration project was being conducted, the number of dentists treating Medicaid patients increased by 300 percent and the number of children who received care increased by 43 percent during the first year. The costs for each child enrolled in the demonstration project were about two and one-half times the costs for a child enrolled in the traditional Medicaid program, and the costs for a child who received dental care as part of the demonstration project were about one and three-quarters times the costs for a child who received dental care under the traditional Medicaid program. It is reasonable to expect that these costs will moderate significantly after the initial accumulated unmet dental needs have been addressed; this is a phenomenon that has been seen with traditional dental insurance plans when they are introduced for the first time.

	CONCLUSIONS

TOP ABSTRACT DEMAND FOR DENTAL CARE DENTAL WORK FORCE ECONOMIC ENVIRONMENT SOLVING THE ACCESS PROBLEM CONCLUSIONS REFERENCES

 
It may be difficult to solve the problem of adequate access to dental care for underserved population groups, particularly those who are the beneficiaries of assistance programs, but how to do it is no mystery. Educating patients and their families about the importance of good oral health, providing adequate reimbursement for providers of care and reducing the administrative burden associated with participating in a program will go a long way toward addressing access problems. With demand and economic issues addressed, work force issues will be resolved without intervention through the operation of the free market.

States typically expand Medicaid benefits during good economic times when the number of people who need assistance decreases, and they reduce Medicaid benefits during difficult economic times when the number of people who need assistance increases. This traditional boom-bust cycle of the Medicaid program should be corrected. To do so, states need to make a firm, long-term commitment to help disadvantaged people receive oral health care. A sustainable Medicaid program must be developed. It will take strong political will and public support to do so. Absent that commitment, there will be little progress toward improving access to dental care for economically underprivileged Americans.

When developing programs to address concerns about access to dental care, three factors must be addressed adequately: the effective demand for dental care, an adequate dental work force to provide dental care and an economic environment that provides incentives for patients and dentists to enter the system. Programs that do not adequately address all of these factors are doomed to failure at worst, or limited success at best.

View larger version (105K): [in this window] [in a new window]   Dr. Guay is the chief policy advisor, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "guaya{at}ada.org". Address reprint requests to Dr. Guay.