ORAL HEALTH CONSEQUENCES

OF A SOUTHWEST VIRGINIA

REGION

DENTAL SCHOOL

Center for Economic and Policy Studies

Organization of Presentation

• Southwest Virginia Regional Characteristics

• Regional Oral Health Needs

• Dental Needs Assessment Survey

• Dentist Supply and Distribution

• Dental School Workforce and Utilization

• Potential Problems in Creating a Southwest

Dental School

• Possible Alternatives

Southwest Virginia Regional

Characteristics

Regional Characteristics

• Buchanan, Dickenson, Lee, Russell, Scott, Tazewell, and Wise, and one independent city, Norton

• No incorporated area with more than 5,000 residents

• Proximate to larger urban areas Kingsport – Bristol, VA-TN metropolitan area

(includes Scott County)

Bluefield, WV-VA micropolitan area (includes Tazewell County)

Johnson City, TN metropolitan area

Regional Characteristics

• Significantly lower

per capita income

than state or

national average

• Older population

and little

population growth

$0

$20,000

$40,000

$60,000

SWVA Virginia US

0

5

10

15

20

SWVA Virginia US

Percent population 65 and older

Per capital income in 2009

Regional Characteristics

Regional Oral Health Needs

Children have poorer oral health in SWVA

Dental Caries Among 3rd Grade Students

Source: Virginia Department of Health, Clinical Screening, 2009

0

10

20

30

40

50

60

70

Untreated Caries Treated Caries Need Early orUrgent Care

Statewide

Lenowisco

Cumberland Plateau

Children utilize dental services

less frequently in SWVA

Time Since Last Visit

Source: Virginia Department of Health, Clinical Screening, 2009

0

10

20

30

40

50

60

70

80

90

Less than 1 yearsince last visit

1-3 years ago more than 3 yearsago

Statewide

Lenowisco

Cumberland Plateau

Type of dental utilization also varies

Reason for last visit

Source: Virginia Department of Health, Parental Questionnaire, 2009

0

10

20

30

40

50

60

70

80

90

Statewide Lenowisco CumberlandPlateau

exam, checkup, cleaning

planned or emergenttreatment

Children are more likely to have dental

insurance (including Medicaid)

Dental Insurance Coverage among Third Grade Children

Source: Virginia Department of Health, Parental Questionnaire, 2009

0

10

20

30

40

50

60

70

80

90

100

Statewide Lenowisco CumberlandPlateau

With Dental Insurance

Unable to Get DentalInsurance

Adults have poorer oral health

outcomes

Permanent Teeth Extracted for Decay or Disease

Source: Virginia Department of Health, CDC, Behavioral Risk Factor Surveillance System Survey Data

0

20

40

60

80

100

120

Statewide SWVA

all

6 or more (not all)

5 or less

none

Adults in SWVA are also less

likely to utilize dental services

Adults who visited a dentists or dental clinic in past year

Source: Virginia Department of Health; Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System Survey Data

0

10

20

30

40

50

60

70

80

1999 2002 2004 2006 2008

US

Virginia

SWVA

Adults are less likely to have

dental insurance coverage

Dental Coverage (including dental insurance, HMOs, government plans)

Source: Virginia Department of Health, CDC, Behavioral Risk Factor Surveillance System Survey Data

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006 2007 2008

Statewide

SWVA

Dental Needs Assessment

Survey

Dental Needs Assessment

Survey

• Survey mailed in December 2010

• 28 questions

• 54 dentists in SWVA and 54 randomly

selected from elsewhere in Virginia Response 66.7% from SWVA (36 responses of 54

total)

Response 35.2% from elsewhere (19 responses of 54

total)

Dental Needs Assessment

Survey

• SWVA residents obtained fewer

examinations, cleanings, crowns and more

fillings, extractions, dentures. Estimate of percentage of visits at your office that involve the

following most common types of procedure

0

5

10

15

20

25

SWVA

Virginia

Dental Needs Assessment

Survey

• Share of patients with private insurance lower SWVA 48.6%

Virginia 69.6%

• Fewer patients lived within 5 miles SWVA 26%

Virginia 54%

• Chose dental location based on “where I grew up” SWVA 50%

Virginia 31%

• Inadequate dentists to meet demand SWVA 28%

Virginia 0%

Dentist Supply and

Distribution

Demand versus Needs

• Need-Based Approach. Population

based approach (e.g., HRSA HPSA

definitions).

• Demand-Based Approach. Effective

demand based on consumer willingness

and ability to pay.

• 62 licensed dentists per capita in Virginia

compared to 25 dentists per capita in SW

Virginia

Virginia: Dentists per 100,000

Population, 2010

Source: Virginia Board of Dentistry

What helps explain the

disparities?

Supply Urbanization

(e.g., Central Place Theory)

Input prices

Demand Dental Services Demand=g(prices of dental services,

oral health, income, prices of other goods, tastes and preferences)

Oral Health=f(age, education, household production of health, dental services)

Dentists, auxiliaries, other dental office personnel, capital, and technology are combined to produce dental services

Demand/Supply Analysis

(1) Qd=D(P, POP, INC, INC2, PFLUOR, PCOLL, PINSURE, AREA, NETCOM)

price of dental care (P),

population (POP),

income (INC),

% population with county water fluoridation (PFLUOR),

% population with a college degree (PCOLL),

% population with regular health insurance (PINSURE)

transportation costs of accessing dental services: county land area (AREA) & amount of net in-commuting (NETCOM)

(2) Qs=S(P, INPUT, URBANPOP)

price of dental care (P),

input prices (INPUT),

urbanization economies (URBANPOP)

Demand/Supply Analysis

• Reduced Form Equation

Q=E(POP, INC, INC2, PFLUOR, PCOLL, PINSURE, AREA, NETCOM, INPUT, URBANPOP)

• Poisson regression

Count model

Appropriate for discrete, positive values of dependent variable

• 134 counties/independent cities are the units of analysis

Results

Variable Beta z

Constant -12.52726 -18.35**

PFLOUR 0.0007555 0.79

PCI 0.0809451 4.99**

PCI2 -0.0014513 -8.52**

PINSURE 0.0390566 4.67**

PCOLLEGE 0.0418283 9.20**

AREA -0.0000143 -0.29

NETCOM -0.000011 -1.73

INPUT -0.0005541 -2.04*

URBANPOP 0.0001628 2.40*

Pseudo R2 0.5878

* Statistically significant at 0.05 level. ** Statistically significant at 0.01 level.

Residuals as Gaps

Conclusions

• Income, insurance, and education are the most important factors in predicting the quantity of dentists in an area

• There is an unexplained residual/ dental gap of approximately 18 dentists in SWVA after controlling for underlying supply and demand factors Slightly less than ¼ of gap between SW and state

is unexplained

The rest can be accounted for by primarily effective demand differences

Why is there a gap?

• Dynamic Shortages A shortage may occur when demand and supply

factors shift over time

Adjustment process may take several years

• Information Asymmetry Principal-agent problem in health care markets

Health care providers are able to move to health care professional surplus regions and induce demand for their services

• Monopsony Insurance companies as primary purchasers may

exercise monopsony power as buyers

What is driving dentist location

patterns?

• Entrance Growth in dual income families (household migration decision-

making differs from traditional breadwinner model)

Growing preferences for urban amenities, especially among young adults Richard Florida. 2002. The Rise of the Creative Class.

Changing graduate demographics (female, Asian, suburban residents)

• Attrition Retiring cohort of baby-boomers who diffused to rural markets

because of saturation of metro dentist markets in the past

• Policy Decreased federal/state support for health workforce programs

and public dental schools

Dental School Workforce

and Utilization Impacts

Conceptual Framework

Dental School Peer Group

Dental School Class Size Public/Private Location

Arizona School of

Dentistry (A.T. Still),

AZ

68 Private Metro area with more

than 1 million

population

Eastern Carolina

University, NC

50 Public Metro area with less

than 250,000

population

Marshfield Clinic, WI 50 Private-Proposed Non-metro area

Midwestern University,

MO

50 Private-Proposed Non-metro area

University of New

Mexico, NM

40 Public-Proposed Metro area with 250k-

1 million population

West Virginia

University, WV

50 Public Metro area with less

than 250,000

population

We assume class size of 50 and 24 residents for SW school

Southwest Dental School

Impacts

• Mechanisms of Regional Impact Some graduates remain and supplement workforce

Students in clinical phase and residents provide services locally

Clinic faculty provide services locally

• Mechanisms of Utilization Impact Private practice dentists provide less than 10% of

care to underserved population (similar to state average)

Clinic provides access to underserved population and percentage drawn from region varies based on clinical model

Workforce Impacts

• Education Pipeline

Rural regions are more likely to retain

graduates when they recruit students from a

rural or local background, when schools

provide a rural curriculum and rotations, and

when an untapped market for regional dental

services exists.

Scenarios for Graduates Remaining

in the Region

Rural/ local student

enrollment

% of

incoming

class

New

dentists in

region by

2053

Additional

underserved

persons

receiving care

by 2053

Low – private tuition 0.88 3 363

Medium – comparable

to VCU

1.78 7 737

High – enhanced

education pipeline

2.50 9 1,037

Clinical Education Models

• Traditional - teaching laboratories, students typically treat patients while faculty observe.

• Patient-centered - Faculty, students and residents provide care in a delivery system similar to private practices, with auxiliary staff and program financial viability.

• Community-based - assignment of students to community clinics and private practices for multiple-week rotations

Scenarios of Clinical Education

(annual patients)

Traditional

clinic

Patient-

centered clinic

Community-

based clinic

Residents 9,960 9,960

9,960

Pre-doctoral

students

2,243 8,948 8,948

Total 12,203 18,908 18,908

SWVA region

patients

7,727 11,974 17,017

Conclusions

• Dental care workforce would be boosted by equivalent of 16-29 FTE

For upper limit, 12 of those would be providing for underserved population

• Between 8,100 and 18,000 underserved patients would receive care depending on the education pipeline and dental school clinic model.

• Utilization rates would rise between 64.0% to 68.9% from current level of 60.1%.

This is still below the state (75.2%) and national (71.3%) rates.

Potential Problems in Creating

a Southwest Dental School

Potential Problems

1. Cost of running dental school, as well as expanding mission of UVA-Wise Running dental school

Expanding mission of school

Reconfigure institutional resources

2. Faculty recruitment and retention Faculty to teach graduate courses

60% faculty are dental specialists in need of much higher salaries

Growing number of existing vacancies of dental schools

3. Clinical services may displace current dentists providing services to publically insured

Possible Alternatives

Some Options

• Expanded Dental pipeline/ college preparatory program

• Additional Federally Qualified Health Care Center (FQHC) Dental Clinics Southwest Virginia Regional Dental Center

• Alternative providers

Dental Health Aide Therapists

Dental hygienists with expanded functions/ reduced oversight

Expanded use of primary care physicians

Full Report available at:

• Available at:

http://www.coopercenter.org/econ

• Direct link:

http://tinyurl.com/3zqzo9t