3: THE U.S. DENTAL CARE DELIVERY SYSTEM AND MANAGED CARE: AN OVERVIEW

CHAPTER 3 THE U.S. DENTAL CARE DELIVERY SYSTEM AND MANAGED CARE: AN OVERVIEW

This chapter provides an overview of the U.S. dental care delivery system. It is not intended to be a thorough review of the system but rather a brief description of its main components.

A dental care delivery system is efficient when its structure, organization, and performance satisfy the dental needs of the population it serves in the best way possible. This requires efficiency in the education and training of its dental manpower, as well as in the production, distribution, consumption, and financing of dental services. To remain efficient over time, a dental care delivery system must adapt to the changing needs of the population it serves.

DENTAL EDUCATION

An important component of a dental care delivery system is the production of dental manpower, which includes dentists and auxiliary personnel.

The typical education and training of dentists in the United States consists of (1) a college degree (4-year predental program) and (2) an undergraduate dental education (4-year program with emphasis in basic sciences during the first 2 years and clinical sciences in the last 2 years).1 Graduates of such a program, once they pass a state or regional license examination, are permitted to practice dentistry in specific states.

In the past 70 years dental education and training has changed substantially in structure, intensity, and duration. Predental education today has reached, and in many cases has surpassed, the 4-year post—high school education.

Progress in biomedical sciences and the desire to effectively meet the ever-changing dental needs of the American people has led to the division of labor in the dental care delivery system. This division of labor, on the one hand, has led to the creation of allied professions (e.g., dental hygienist, dental assistant, laboratory technician) that require fewer years of education and training and, on the other hand, to postgraduate dental training and specialization. More specifically, today only approximately 42% of dental school graduates practice dentistry immediately (general practitioners); 29% receive postgraduate training in general dentistry (Advanced Education in General Dentistry [AEGD], General Practice Residency [GPR]); and the remaining 29% enter one of the eight recognized dental specialties.1

Recent evaluations regarding the effectiveness of dental education and training underline some obvious weaknesses. They include (1) the need for more effective integration between predental and dental education, (2) the need for more effective integration between basic and clinical sciences, (3) the lack of periodic certification of practicing dentists, and (4) the need for more effective utilization of auxiliary personnel.

Proposals to correct these and other shortcomings of the dental education system are contained in the Pew Commission report, the Institute of Medicine report, and more recently in the advocacy of the “oral physician.”24 A consequence of these proposals would be an increase of at least 1 year in dental education.

ALLIED DENTAL PERSONNEL

Dental hygiene is a licensed dental profession. The great majority of dental hygienists work in the office of private dental practitioners, but approximately 7% are employed by community health centers, school systems, public health departments, nursing homes, and hospitals. State dental licensing boards determine the scope of hygiene practice. In addition to traditional duties such as screening examinations, the application of topical fluorides, patient education, and prophylaxes, in approximately 30 states hygienists can administer injectable dental anesthetics. Some states require hygienists to work under the direct supervision of a dentist, but others allow them to work under indirect supervision without the dentist being physically present. One state, Arizona, permits hygienists to operate independent practices.

As of 1996 approximately 94,000 professionally active dental hygienists were treating patients. The number of hygienists is increasing as more dentists employ at least one part-time or full-time hygienist. In 1998 approximately 70% of general dental practitioners employed a hygienist. The demand for hygienists appears to be increasing as the oral health of the American people improves. Recent data show a large upsurge in the percentage of patients receiving examinations and prophylaxes—services often provided by hygienists—and a decline in the percentage receiving restorative services. This trend is likely to continue as water fluoridation and other preventive methods reduce the prevalence of caries.

The number of hygienists being trained has increased substantially in the past 10 years in response to greater demand by dentists. In 2000 256 accredited dental hygiene schools graduated more than 6000 students annually. Most students are enrolled in 2-year programs that are located in community colleges and technical schools. Approximately 27% of students graduate from 4-year programs based at universities. Twelve universities have master’s degree programs specially designed to train dental hygiene educators.

The other two major allied dental health professions are dental assisting and dental laboratory technologists. These occupations are not state-licensed professions, but graduates of accredited programs are certified. In 1996 201,400 dental assistants and 54,000 dental laboratory technologists were active in practice. Dental assistants work under the direct supervision of dentists, assisting them with the equipment and materials used in patient care. In contrast, most dental laboratory technologists work in independent dental technology laboratories, constructing prostheses based on dentists’ prescriptions. Some large dental practices employ their own dental laboratory technologists.

Approximately half of dental assistants and dental laboratory technologists are educated in 1-year accredited programs; the rest receive their education on the job. Currently, the demand for both occupations appears to be greater than the supply.

The broader dental education system produces approximately 3900 dentists, 4500 dental hygienists, 4500 dental assistants, and 600 laboratory technicians per year, though these numbers have fluctuated significantly over the years (Table 3-1).

STRUCTURE AND ORGANIZATION OF THE DENTAL CARE DELIVERY SYSTEM

Characteristics of Dentists

The trends in dental education and increases in population and income over time have led to an increase in dental manpower. The most recent available data (Table 3-2) indicate that in 1998 the total number of dentists in the United States was 183,000 whereas the number of active private practitioners was 138,449 (less than 76% of the total). Table 3-2 indicates that the number of people per active private practitioner was 1952. It is estimated that the dentist/population ratio was approximately 58 per 100,000 in 2000 and will be 47 per 100,000 by 2020. According to these estimates, the absolute number of active dentists started to decline in 2001.5

Table 3-2 Number of Dentists, Population, and Population/Dentists Ratio in the United States 1998

Category of Dentist Percent Number
Total number of dentists 100.00 183,000
Professionally active dentists 81.61 149,350
Active private practitioners 75.66 138,449
Male 86.36 119,565
Female 13.64 18,884
Population   270,299,000
Population/active private practitioners   1,952

From American Dental Association: Distribution of dentists in the United States by region and state, 1998, Chicago, 2000, The Association.

Another important trend is the changing gender of the dentist workforce. The number of female dentists is increasing rapidly and accounted for almost 14% of the total number of active private practitioners in 1998.6

Table 3-3 shows the distribution of active dentists in private practice by specialty. General practitioners account for approximately 80% of practitioners. This 80/20 split between general practitioners and specialists is the opposite of that in medicine.

Table 3-3 Distribution of Active Private Practitioners by Specialty in the United States, 1991

Dental Specialty Percent Number
General practitioner 81.51 112,564
Specialist 18.49 25,530
Oral and maxillofacial surgeon 3.76 5,188
Endodontist 1.86 2,567
Orthodontist 6.04 8,342
Oral pathologist 0.08 108
Public health dentist 0.18 244
Prosthodontist 1.68 2,323
Periodontist 2.76 3,810
Pediatric dentist 2.13 2,948
total 100.00 138,094

Data from American Dental Association: Distribution of dentists in the United States by region and state, 1991, Chicago, 1993, The Association.

Table 3-4 presents the distribution of active practitioners across the nine regions of the country. Dentists are in every area, but significant variation in the number of people per dentist among regions exists. The primary determinants of the number of dentists in an area are population and per capita income.7

Table 3-5 shows the age distribution of active private practitioners. This table carries an important message regarding the future supply of dental manpower. In the next 10 to 20 years the number of retiring dentists will outpace the new entrants into the profession.

Table 3-5 Age Distribution of Active Private Practitioners in the United States, 1998

Age of Dentist Number of Dentists Percent of Total
<35 18,274 13.2
35–44 41,946 30.3
45–54 43,054 31.1
55–64 22,703 16.4
65+ 12,459 9.0
Total 138,436 100.0

From American Dental Association: Distribution of dentists in the United States by region and state, 1998, Chicago, 2000, The Association.

Characteristics of Dental Practices

The organization and characteristics of dental practices play an important role in determining the efficiency of the delivery system. First, the size of a dental practice may have significant consequences on access to dental care, as well as the unit cost or fees of dental services. The presence of economies or diseconomies of scale and the extent of dental markets are the main determinants of the dental practice size.

Table 3-6 indicates that dentists are organized in small-size practices. In fact, almost 96% of all dental practices consist of one-dentist (82.6%) or two-dentist (13.3%) practices. Approximately 4% of all dental practices are considered group practices: three or more dentists who share expenses or revenue. Given that this pattern of dental practice size has persisted for many years, it strongly suggests lack of significant economies of scale with larger practice size. This and additional evidence seem to run contrary to conventional wisdom that larger practices are more efficient than smaller practices.8

Table 3-6 Distribution of Active Private Practitioners and Dental Practices by Size

Size of Practice Percent of All Dentists Percent of All Practices*
One dentist 65.8 82.6
Two dentists 21.1 13.3
Three or more dentists 13.1 4.1

* The total number of practices (110,230) was estimated assuming that the mean number of dentists in the category “three or more dentists” is four.

From the 1998 survey of dental practice, ADA, March 2000.

Table 3-7 offers additional evidence of the relatively small size of dental practices. This table shows the square feet of office space, number of operatories, and number of auxiliary staff members in an average dental practice. It also gives the frequency of use of specific units of equipment. Table 3-8 provides further details regarding the frequency and number of specific types of auxiliary staff members employed by dental practices. Although the average dental practice employs four auxiliaries, the number varies from zero to more than seven auxiliary staff members (Table 3-9).

Table 3-7 Mean Office Space, Number of Operatories, Number of Auxiliaries, and Office Equipment, All Active Private Practitioners, 1998

Square feet of office space 1,755
Number of operatories 4.4
Number of auxiliaries 4.2
Dental office equipment* % using
1. Composing light curing unit 92.6
2. High speed air handpiece with fiberoptics 71.2
3. Panoramic X-ray unit 54.1
4. Ultrasonic scaling unit 86.8
5. Electrosurgical unit 45.1
6. Nitrous oxide analgesic equi/>

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 3: THE U.S. DENTAL CARE DELIVERY SYSTEM AND MANAGED CARE: AN OVERVIEW
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