FEATURES
This column represents the opinions of the author and not necessarily those of the American Dental Association.
HEALTH POLICY PERSPECTIVES
Rethinking dentist shortages Marko Vujicic, PhD
W
ith the US health care system in the midst of a major transition spurred on by the Affordable Care Act, there is renewed debate over health workforce policy issues. One key question is whether the United States will face physician, nurse, and other health care provider shortages as health insurance coverage expands and several health care occupations experience aging and other demographic transitions. Dentistry is part of this debate. Much has been written over the years— empirical research, anecdote, and commentary—on whether the United States is facing, or will face, a dentist shortage. I classify this as one of those “soap opera” topics in health policy: You can tune out for several years, and when you return you realize you have not missed much of the plot. Assessing the current and future adequacy of the dentist workforce is both conceptually and empirically challenging. It requires modeling labor market choices of dentists, dental school enrollment levels, and demand for dental care. It also requires a good understanding of barriers to dental care on the part of the population—what economists would call demand-side behavior. This brings me to a new analysis of the future supply of and future demand for dentists released by the Health Resources and Services Administration (HRSA) in March.1 This
analysis models the future supply of and demand for dentists through 2025. The analysis predicts that, nationally, increases in dentist supply will not meet the increases in demand for dentists, leading to an exacerbation of the existing shortage. Furthermore, the analysis predicts that every state and the District of Columbia will experience a dentist shortage by 2025. HRSA needs to be commended for taking a leadership role in developing a sophisticated empirical simulation model2 that aims to predict demand for and supply of various types of health care professionals, including dentists. The agency is taking considerable strides to expand data availability and research efforts in this critical area of health policy. However, there are several important aspects of HRSA’s dentist workforce projections that merit discussion. The modeling of dentist supply, overall, is sound and empirically grounded. HRSA’s model predicts a rising supply of dentists. The American Dental Association Health Policy Institute recently developed a sophisticated empirical model to predict the future supply of dentists, and the analysis also predicts a rising supply of dentists.3 Although there is no way to make an apples-to-apples comparison between the two models, both give the same big picture conclusion: there will be more dentists in the market in the coming years. HRSA’s demand modeling is where there are some larger issues. The analysis, in my view, is based on assumptions that are inconsistent
with the best available empirical evidence. Most importantly, HRSA assumes that dental care use patterns will remain constant through 2025 for various segments of the US population. The best available data show that although dental care use has increased among children, dental care use among adults has declined steadily for more than a decade.4 The decline in dental care use among adults has caused a significant slowdown in dental spending,5 a significant increase in the level of unused capacity in the dental care system,6 and stagnating dentist earnings.7 The best available evidence suggests that current dental care use trends will continue unless major reforms occur to influence dental benefits coverage rates or demand for dental care. In my view, such reforms are not on the horizon. The Affordable Care Act will expand dental benefits coverage to children and to low-income adults in many states via Medicaid expansion. However, the increase in dental benefits coverage among adults in Medicaid because of the Affordable Care Act —up to 8.3 million adults nationally8—will not translate into increased dental care visits unless states take bold action to reform their Medicaid programs. Perhaps more importantly, HRSA’s shortage estimates are based on the health care professional shortage designation methodology.9 This methodology has undergone several changes aimed at addressing some of the shortcomings.10 Nevertheless, the core flaw of relying on simplistic population-to-provider
JADA 146(5)
http://jada.ada.org
May 2015 347
FEATURES
60%
50%
PERCENTAGE
40%
30%
20%
0%
North Dakota South Dakota Kansas Connecticut Arkansas West Virginia Wisconsin Montana Massachusetts Texas Pennsylvania Alabama Nevada Kentucky Indiana Oklahoma Maine New York Ohio Oregon New Mexico United States Tennessee Illinois Maryland Michigan Mississippi New Jersey North Carolina California South Carolina Washington New Hampshire Arizona Colorado Florida Idaho
10%
STATE
Figure. Percentage of general and specialist dentists who report they are not busy enough and could see more patients, 2013. Source: American Dental Association Health Policy Institute Survey of Dental Practice.
ratios remains, which significantly limits the insight that can be gleaned into provider adequacy. Treating the United States, or a state, or even a county, as a single market is far too aggregate an approach to assessing provider adequacy. More broadly, two major factors that are absolutely critical are largely absent from the current debate on dentist shortages. First, there is strong evidence of significant unused capacity within the dental care system today. The figure shows the percentage of professionally active dentists who report they are not busy enough and could see more patients in select states where data are available. Nationally, this is more than 1 of 3 dentists.6 In Florida, it is 1 of 2. Busyness levels have been decreasing, open chair time has been increasing, and appointment waiting times have decreased in
348 JADA 146(5) http://jada.ada.org
recent years. As the supply of dentists in the market increases in the coming years, and given the stagnant aggregate demand for dental care, busyness levels could continue to decrease. However, the data are crystal clear: the dental care system today, in aggregate, has significant unused capacity. Second, there is compelling evidence to show that the main barriers to dental care are overwhelmingly financial and are not related to the availability of providers. For example, results of a new study show that cost and low perceived need are by far the top reasons adults avoid going to the dentist.11 Factors related to the availability of dentists were much further down the list. Results from another similar study showed that the main barriers to dental care among adults are due to financial factors.12
May 2015
The fact that there is significant unused capacity within the dental care system and that the most important barriers to dental care are financial leads to an important policy implication. In the current situation, adding additional dental care providers to the market is unlikely to address the most critical issues concerning access to dental care. Rather, the evidence strongly suggests that policy makers ought to focus on solutions that address the demand-side constraints the US population faces—especially lowincome Americans—in accessing dental care. Thankfully, there is a strong empirical evidence base on which policy makers can draw. For example, research suggests that there are a set of critical enabling conditions that make Medicaid programs successful—a combination of patient education and outreach,
FEATURES
streamlined administrative procedures, and enhanced provider incentives.13,14 Many states have seen significant increases in dental care use among children receiving Medicaid this past decade not as a result of dentist workforce expansion but as a result of comprehensive Medicaid reforms.15 Results from one study suggest that the existing dental care system already has the capacity to absorb large inflows of patients in Medicaid under the right policy conditions.16 Specific to the Medicaid population, access to dental care is unlikely to improve without comprehensive reforms to Medicaid programs in several states. Simply increasing the total number of dentists in the market is not the solution. The American Dental Association Health Policy Institute currently is engaged in several research initiatives in partnership with other academic and government agencies that explore provider adequacy by using novel methodologies that account for local market conditions. This research has the potential to provide a much stronger conceptual and empirical backdrop to the shortage debate. n http://dx.doi.org/10.1016/j.adaj.2015.03.016 Copyright ª 2015 American Dental Association. All rights reserved.
Dr. Vujicic is chief economist and vice president, Health Policy Institute, American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected]. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures.
1. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. National and state-level projections of dentists and dental hygienists in the U.S., 2012-2025. Rockville, MD: US Department of Health and Human Services; 2015. Available at. http://bhw. hrsa.gov/healthworkforce/supplydemand/ dentistry/nationalstatelevelprojectionsdentists. pdf. Accessed March 18, 2015. 2. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. Technical documentation for Health Resources and Services Administration’s health workforce simulation model. Rockville, MD: US Department of Health and Human Services; 2014. Available at. http://bhpr.hrsa.gov/healthworkforce/supply demand/simulationmodeldocumentation.pdf. Accessed March 18, 2015. 3. Munson B, Vujicic M. Supply of dentists in the United States is likely to grow. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_1.ashx. Accessed March 18, 2015. 4. Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_4.ashx. Accessed March 18, 2015. 5. Wall T, Vujicic M. No growth in U.S. dental spending in 2013. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1214_4.ashx. Accessed March 18, 2015. 6. Munson B, Vujicic M. Dentist earnings not recovering with economic growth. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1214_1.ashx. Accessed March 18, 2015. 7. Vujicic M. The ‘invisible hand; and the market for dental care. JADA. 2014;145(11):1167-1169. 8. Vujicic M. The booming Medicaid market. JADA. 2015;146(2):136-138.
9. US Department of Health and Human Services, Health Resources and Services Administration. Shortage designation: health professional shortage areas & medically underserved areas/populations. Available at: http:// www.hrsa.gov/shortage/. Accessed March 18, 2015. 10. US Government Accountability Office. Health professional shortage areas: problems remain with primary care shortage area designation system. Washington, DC: US Government Accountability Office; 2006. GAO-07–84. Available at. http://www.gao.gov/new.items/ d0784.pdf. Accessed March 18, 2015. 11. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. Health Policy Institute Research Brief. American Dental Association. November 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1114_1.ashx. Accessed March 18, 2015. 12. Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/ w/media/ADA/Science%20and%20Research/ HPI/Files/HPIBrief_1014_2.ashx. Accessed March 18, 2015. 13. US Government Accountability Office. Factors contributing the low use of dental services by low-income populations. Washington, DC: US Government Accountability Office; 2000. GAO/HEHS-00–149. Available at. http:// www.gao.gov/assets/240/230602.pdf. Accessed March 18, 2015. 14. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2): 187-193. 15. Nasseh K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland, and Texas [published online ahead of print December 7, 2014]. Health Serv Res. http://dx.doi.org/1 0.1111/1475-6773.12265. 16. Buchmueller T, Miller S, Vujicic M. How do providers respond to public health insurance expansions? Evidence from Adult Medicaid Dental Benefits. Cambridge, MA: National Bureau of Economic Research; 2014. National Bureau of Economic Research Working Paper 20053. Available at. http://www.nber.org/papers/ w20053. Accessed March 18, 2015.
JADA 146(5)
http://jada.ada.org
May 2015 349
This column represents the opinions of the author and not necessarily those of the American Dental Association.
HEALTH POLICY PERSPECTIVES
Rethinking dentist shortages Marko Vujicic, PhD
W
ith the US health care system in the midst of a major transition spurred on by the Affordable Care Act, there is renewed debate over health workforce policy issues. One key question is whether the United States will face physician, nurse, and other health care provider shortages as health insurance coverage expands and several health care occupations experience aging and other demographic transitions. Dentistry is part of this debate. Much has been written over the years— empirical research, anecdote, and commentary—on whether the United States is facing, or will face, a dentist shortage. I classify this as one of those “soap opera” topics in health policy: You can tune out for several years, and when you return you realize you have not missed much of the plot. Assessing the current and future adequacy of the dentist workforce is both conceptually and empirically challenging. It requires modeling labor market choices of dentists, dental school enrollment levels, and demand for dental care. It also requires a good understanding of barriers to dental care on the part of the population—what economists would call demand-side behavior. This brings me to a new analysis of the future supply of and future demand for dentists released by the Health Resources and Services Administration (HRSA) in March.1 This
analysis models the future supply of and demand for dentists through 2025. The analysis predicts that, nationally, increases in dentist supply will not meet the increases in demand for dentists, leading to an exacerbation of the existing shortage. Furthermore, the analysis predicts that every state and the District of Columbia will experience a dentist shortage by 2025. HRSA needs to be commended for taking a leadership role in developing a sophisticated empirical simulation model2 that aims to predict demand for and supply of various types of health care professionals, including dentists. The agency is taking considerable strides to expand data availability and research efforts in this critical area of health policy. However, there are several important aspects of HRSA’s dentist workforce projections that merit discussion. The modeling of dentist supply, overall, is sound and empirically grounded. HRSA’s model predicts a rising supply of dentists. The American Dental Association Health Policy Institute recently developed a sophisticated empirical model to predict the future supply of dentists, and the analysis also predicts a rising supply of dentists.3 Although there is no way to make an apples-to-apples comparison between the two models, both give the same big picture conclusion: there will be more dentists in the market in the coming years. HRSA’s demand modeling is where there are some larger issues. The analysis, in my view, is based on assumptions that are inconsistent
with the best available empirical evidence. Most importantly, HRSA assumes that dental care use patterns will remain constant through 2025 for various segments of the US population. The best available data show that although dental care use has increased among children, dental care use among adults has declined steadily for more than a decade.4 The decline in dental care use among adults has caused a significant slowdown in dental spending,5 a significant increase in the level of unused capacity in the dental care system,6 and stagnating dentist earnings.7 The best available evidence suggests that current dental care use trends will continue unless major reforms occur to influence dental benefits coverage rates or demand for dental care. In my view, such reforms are not on the horizon. The Affordable Care Act will expand dental benefits coverage to children and to low-income adults in many states via Medicaid expansion. However, the increase in dental benefits coverage among adults in Medicaid because of the Affordable Care Act —up to 8.3 million adults nationally8—will not translate into increased dental care visits unless states take bold action to reform their Medicaid programs. Perhaps more importantly, HRSA’s shortage estimates are based on the health care professional shortage designation methodology.9 This methodology has undergone several changes aimed at addressing some of the shortcomings.10 Nevertheless, the core flaw of relying on simplistic population-to-provider
JADA 146(5)
http://jada.ada.org
May 2015 347
FEATURES
60%
50%
PERCENTAGE
40%
30%
20%
0%
North Dakota South Dakota Kansas Connecticut Arkansas West Virginia Wisconsin Montana Massachusetts Texas Pennsylvania Alabama Nevada Kentucky Indiana Oklahoma Maine New York Ohio Oregon New Mexico United States Tennessee Illinois Maryland Michigan Mississippi New Jersey North Carolina California South Carolina Washington New Hampshire Arizona Colorado Florida Idaho
10%
STATE
Figure. Percentage of general and specialist dentists who report they are not busy enough and could see more patients, 2013. Source: American Dental Association Health Policy Institute Survey of Dental Practice.
ratios remains, which significantly limits the insight that can be gleaned into provider adequacy. Treating the United States, or a state, or even a county, as a single market is far too aggregate an approach to assessing provider adequacy. More broadly, two major factors that are absolutely critical are largely absent from the current debate on dentist shortages. First, there is strong evidence of significant unused capacity within the dental care system today. The figure shows the percentage of professionally active dentists who report they are not busy enough and could see more patients in select states where data are available. Nationally, this is more than 1 of 3 dentists.6 In Florida, it is 1 of 2. Busyness levels have been decreasing, open chair time has been increasing, and appointment waiting times have decreased in
348 JADA 146(5) http://jada.ada.org
recent years. As the supply of dentists in the market increases in the coming years, and given the stagnant aggregate demand for dental care, busyness levels could continue to decrease. However, the data are crystal clear: the dental care system today, in aggregate, has significant unused capacity. Second, there is compelling evidence to show that the main barriers to dental care are overwhelmingly financial and are not related to the availability of providers. For example, results of a new study show that cost and low perceived need are by far the top reasons adults avoid going to the dentist.11 Factors related to the availability of dentists were much further down the list. Results from another similar study showed that the main barriers to dental care among adults are due to financial factors.12
May 2015
The fact that there is significant unused capacity within the dental care system and that the most important barriers to dental care are financial leads to an important policy implication. In the current situation, adding additional dental care providers to the market is unlikely to address the most critical issues concerning access to dental care. Rather, the evidence strongly suggests that policy makers ought to focus on solutions that address the demand-side constraints the US population faces—especially lowincome Americans—in accessing dental care. Thankfully, there is a strong empirical evidence base on which policy makers can draw. For example, research suggests that there are a set of critical enabling conditions that make Medicaid programs successful—a combination of patient education and outreach,
FEATURES
streamlined administrative procedures, and enhanced provider incentives.13,14 Many states have seen significant increases in dental care use among children receiving Medicaid this past decade not as a result of dentist workforce expansion but as a result of comprehensive Medicaid reforms.15 Results from one study suggest that the existing dental care system already has the capacity to absorb large inflows of patients in Medicaid under the right policy conditions.16 Specific to the Medicaid population, access to dental care is unlikely to improve without comprehensive reforms to Medicaid programs in several states. Simply increasing the total number of dentists in the market is not the solution. The American Dental Association Health Policy Institute currently is engaged in several research initiatives in partnership with other academic and government agencies that explore provider adequacy by using novel methodologies that account for local market conditions. This research has the potential to provide a much stronger conceptual and empirical backdrop to the shortage debate. n http://dx.doi.org/10.1016/j.adaj.2015.03.016 Copyright ª 2015 American Dental Association. All rights reserved.
Dr. Vujicic is chief economist and vice president, Health Policy Institute, American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected]. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures.
1. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. National and state-level projections of dentists and dental hygienists in the U.S., 2012-2025. Rockville, MD: US Department of Health and Human Services; 2015. Available at. http://bhw. hrsa.gov/healthworkforce/supplydemand/ dentistry/nationalstatelevelprojectionsdentists. pdf. Accessed March 18, 2015. 2. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. Technical documentation for Health Resources and Services Administration’s health workforce simulation model. Rockville, MD: US Department of Health and Human Services; 2014. Available at. http://bhpr.hrsa.gov/healthworkforce/supply demand/simulationmodeldocumentation.pdf. Accessed March 18, 2015. 3. Munson B, Vujicic M. Supply of dentists in the United States is likely to grow. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_1.ashx. Accessed March 18, 2015. 4. Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1014_4.ashx. Accessed March 18, 2015. 5. Wall T, Vujicic M. No growth in U.S. dental spending in 2013. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1214_4.ashx. Accessed March 18, 2015. 6. Munson B, Vujicic M. Dentist earnings not recovering with economic growth. Health Policy Institute Research Brief. American Dental Association. December 2014. Available at: http:// www.ada.org/w/media/ADA/Science%20and% 20Research/HPI/Files/HPIBrief_1214_1.ashx. Accessed March 18, 2015. 7. Vujicic M. The ‘invisible hand; and the market for dental care. JADA. 2014;145(11):1167-1169. 8. Vujicic M. The booming Medicaid market. JADA. 2015;146(2):136-138.
9. US Department of Health and Human Services, Health Resources and Services Administration. Shortage designation: health professional shortage areas & medically underserved areas/populations. Available at: http:// www.hrsa.gov/shortage/. Accessed March 18, 2015. 10. US Government Accountability Office. Health professional shortage areas: problems remain with primary care shortage area designation system. Washington, DC: US Government Accountability Office; 2006. GAO-07–84. Available at. http://www.gao.gov/new.items/ d0784.pdf. Accessed March 18, 2015. 11. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. Health Policy Institute Research Brief. American Dental Association. November 2014. Available at: http://www.ada.org/w/media/ ADA/Science%20and%20Research/HPI/Files/ HPIBrief_1114_1.ashx. Accessed March 18, 2015. 12. Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy Institute Research Brief. American Dental Association. October 2014. Available at: http://www.ada.org/ w/media/ADA/Science%20and%20Research/ HPI/Files/HPIBrief_1014_2.ashx. Accessed March 18, 2015. 13. US Government Accountability Office. Factors contributing the low use of dental services by low-income populations. Washington, DC: US Government Accountability Office; 2000. GAO/HEHS-00–149. Available at. http:// www.gao.gov/assets/240/230602.pdf. Accessed March 18, 2015. 14. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2): 187-193. 15. Nasseh K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland, and Texas [published online ahead of print December 7, 2014]. Health Serv Res. http://dx.doi.org/1 0.1111/1475-6773.12265. 16. Buchmueller T, Miller S, Vujicic M. How do providers respond to public health insurance expansions? Evidence from Adult Medicaid Dental Benefits. Cambridge, MA: National Bureau of Economic Research; 2014. National Bureau of Economic Research Working Paper 20053. Available at. http://www.nber.org/papers/ w20053. Accessed March 18, 2015.
JADA 146(5)
http://jada.ada.org
May 2015 349
