Bootleggers and Baptists: Thereâ€™s Got to be a Better Way

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Bootleggers and Baptists:There’s Got to be a Better Way

Shelly Gehshan, M.P.P.Senior Program Director

National Academy for State HealthPolicy

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What I’ll cover

• State power and responsibility for healthcare workforce

• Theories of regulation• Long term trends• New provider models• How to move forward on new providers

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Key State Government Roles inHealth Care

Public Health Facility/Professional Regulation

Regulation of

Insurance/HMOs

Health Workforce

Education/Training

Provide/Finance ServiceCost Containment

Information

Dissemination

Health System

Monitoring

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Key State Roles in Oral Health

1. Regulation: Facilities & Professionals2. Health Workforce Education3. Public Health4 . Health System Monitoring

5 . Inform ation Dissem ination6. Regulation of Insurance & HMOs7. Provision/Financing of Health Care Services

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Theories of Regulation

• Public Interest theory– Regulators serve public interest, not those

regulated– Should exist where risk of monopoly exists

• Economic theory or the ”Capture theory”– Those regulated craft regs to favor

themselves and society loses– Legislators “captured” by those regulated

(when hard to judge technical issues)

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Another Theory of Regulation

• Bootleggers and Baptists– One group with the moral high ground, paired

with another (very different) group, canachieve change neither group could achievealone

– Undesirable results can occur from rarecollaborations; regulation needed to protectpublic interest and safety

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Regulatory process should…

• Protect public safety through setting andenforcing reliable, consistent standards

• Serve the public interest by ensuringsupply

• Promote competition and consumer choice• Implement statute enacted by legislature

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What Studies Show

• Stricter regulation leads to increases indentists’ income– Higher earnings in more regulated states than

in least regulated states (Kleiner and Kudrle, 2001)

– Higher incomes in states with restrictive useof reciprocity agreements (Holen, 1965)

– Dental board testing standards and reciprocityarrangements protect dentists’ incomes (Maurizi,1974; Conrad and Emerson, 1981)

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Barriers to entry protect incomes

• Physicians:– Correlation between stringency of licensing process

and physicians’ incomes• Nurses:

– Mandatory licensure for RNs has positive impact onRN wages and RN employment relative to LPNs

– Restrictive licensure had significant positive effects onwages for RNs, LPNs, and medical technologists

• Optometrists:– Occupational restrictiveness associated with higher

fees and no improvement in thoroughness of exams

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Source: Albert Guay, “Dental Practice: Prices, Production, and Profit,” JADA,Vol. 136 (March 2005), 359.

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A Few Key Cites• M.M. Kleiner, R.D. Kudrle, “Does regulation affect economic

outcomes? The case of dentistry,” Journal of Law & Economics.18 (2001):547-581.

• G.L. Gaumer, “Regulating health professionals: A review of theempirical literature,” The Milbank Memorial Fund Quarterly:Health and Society. 632 (1984):380-416.

• A. Maurizi, “Occupational licensing and the public interest,” TheJournal of Political Economy. 82 (1974):399-413.

• L. Benham, A. Maurizi, M.W. Reder, “Migration, location andremuneration of medical personnel: Physicians and dentists,”The Review of Economics and Statistics. 50 (1968):332-347.

• A.S. Holen, “Effects of professional licensing arrangements oninterstate labor mobility and resource allocation,” The Journal ofPolitical Economy. 73 (1965):492-498.

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Regulation of Hygiene

• HRSA-funded study (2004) rated stateregulatory environments from 0 (mostrestrictive) to 100 (optimal environment foraccess to hygiene)– States range from 10 (WV) to 97 (CO)– Extreme variation shows faulty balance

between ensuring public safety and providingaccess to hygiene for the population

– Runs counter to other professions

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Long term trends

• Gradual loosening of supervisionrequirements and expansions in scope ofpractice for hygienists

• Evolution of the profession (albeitslowly)—change is the norm

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Supervision and Payment forHygienists

• General supervision in 45 states in dentaloffice or some settings

• Direct access to patients in some settingsin 22 states (AZ, CA, CO, CT, IA, KS, ME, MI, MN,MO, MT, NE, NH, NM, NV, NY, OK, OR, PA, RI,TX, WA)*

• Medicaid can reimburse hygienists directlyin 12 states (CA, CO, CT, ME, MN, MO, MT, NM, NV,OR, WA, WI)**

* Source: American Dental Hygienists’ Association, “Direct Access States,” Available at www.adha.org** Source: American Dental Hygienists’ Association, “States Which Directly Reimburse Dental Hygienists for Services under the Medicaid Program,” Available at www.adha.org.

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

1990: Local Anesthesia Administration

Source: The American Dental Hygienists’ Association

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA



NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA



NHMA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

INOH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA



1995: Direct Access


NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AR

OK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

2000: Direct Access


NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

2008: Direct Access


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State Movement onHygiene Self-Regulation

• 17 states have some form of hygiene self-regulation

• 4 states have own board, or committee withpower (FL, IA, NM, WA)

• 8 states have hygiene committees of stateboard of dentistry that advise on rules (AZ,CA, MI, MO, MT, NV, OK, OR)

• 3 states have hygiene committees withspecific duties (DE, ME, MD)

Source: State Practice Acts, compiled by ADHA Govt. Affairs Division, February, 2008.

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The Need to Use Evidence inScope of Practice Decisions

• Legislators hate scope of practice fights“At the end of the day, I am hopeful that our decisionswill be [based] on science or specifically, easilyunderstood criteria… so that it will be a matter offairness,” Rep. Dianne White Delisi (R-TX) (C. DeLorna, LoneStar Reporter, 6/3/2006)

• New regulatory structures emerging– Some commissions that look at evidence,

impact on access, other state approaches

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Alternative Models to MakeScope of Practice Decisions

• MN—Health Occupations Review Program• NM—Scope of practice review

commission• IA—Reviewing committees (report to DoH)• TX—Health Professions Scope of Practice

Review Commission (legislation)• VA—Board of Health ProfessionsSource: Dower, C, Christian, S, O’Neil, E, “Promising Scope of Practice Models for the Health

Professions,” Center for the Health Professions, UCSF, 2007, pp. 10-12.

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New Models for Dental Providers

• ADA model — Community Dental HealthCoordinator (similar to Primary Dental Health Aidesin Alaska)

• ADHA model — Advanced dental hygienepractitioner

• Pediatric Oral Health Therapist (a dentaltherapist specializing in kids)

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Current Workforce Proposals

• Proposals to expand scope or loosen supervision ofhygienists**– 7 states have proposals far along or completed in the

legislative process (MA, WI, MN, MT, CA, OH, KS)• Proposals to develop new dental practitioners**

– 3 states have proposals far along in the legislativeprocess (MN, MI, MA)

– 11 states are discussing proposals (CO, ME, NM, CA,FL, TX, OH, OR, KS, CT, PA)

**Survey of State Oral Health Coalition Leaders, NASHP 2008

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Community Dental HealthCoordinator

• Prevention: education, fluorides, sealants• Treatment: gingival scaling, polishing• Restoration: atraumatic restorative therapy• Supervision: direct or indirect for services,

general supervision for patient education

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Advanced Dental HygienePractitioner

• Prevention: comprehensive services• Treatment: manage periodontal care,

prophylaxis, prescriptions• Restoration: simple restorations,

extractions• Supervision: general supervision or

unsupervised; in collaborative practice, orprivate dental offices

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Dental therapists

• Prevention: fluoride treatments, sealants• Treatment: x-rays, prophylaxis, gingival

scaling• Restoration: simple restorations, stainless

steel crowns, extractions• Supervision: general supervision under

standing orders

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Newtok Clinic, Yukon-Kuskokwim

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AFHCAN CartAlaska Federal Health Care Access Network

• Wireless Networking• Touchscreen• ECG / Video Dental Camera

and Otoscope / Scanner /Digital Camera

• Mobile – Customized• Patient safe

• WWW. AFHCAN.ORG

ADHP DT CDHCMasters level 2-year program 12-18 months

Licensure IHS certification(like licensure)

Certification

Curriculumalmost final

In 53 countries Planning

Seekingpartners, $,legislation, pilotplanned at 2MN colleges

Proven model,many studiespublished.Pending legis.bars use in lower48.

ADA has approved$2 M for 3 pilotprojects; pilot ruledillegal in MI

ADHP DT CDHCTrue midlevelprovider(RDH + 2 yrs)

Function likemidlevels, buteducated inless time

Close to dentalassistant, socialworker (not amidlevel)

Post-RDHcareer track

High schoolgrads

High schoolgrads

Could besupported byreimbursableservices

Could besupported byreimbursableservices

Supported bygrants? Fewreimbursableservices

ADHP DT CDHC

Pool ofRDHs readyto train

Recruited fromunderservedareas, groups

Dental assistants,community healthworkers

Riskassessment,casemanagement

Basicpreventive andrestorativeservices

Prevention,education, case-finding fordentists

Useful toexpandsafety net

Useful toexpand safetynet

Useful forprevention,limited use insafety net

ProceduresADHP

(proposed)DT

(AK model)CDHC

(proposed)EFDA

Atraumatic RestorativeTechnique (ART) X X

Placement oftemporary restorations X X X X

Simple restorations X X X

Light cure composites X

Simple extractions X XLab processed crowns X X

Pulpotomy X X

Pulp capping X X

Restorative Capacity of Providers

Source: NASHP, “Clinical Capacity of Current and Proposed Providers,” Table developed byNASHP, February 2008

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Thoughts on implementation

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Nurse PractitionerWorkforce Growth

Source: Unpublished data from the National Organization of Nurse Practitioner Faculties; Analysis by the Centerfor Health Professions, UCSF, 2004.

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Growth of Physician Assistants 1980-2020

Source: Bureau of Labor Statistics and American Academy of Physician Assistants; Analysis by The RobertGraham Center, 2004.

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Why Dentists Oppose Midlevels

• Would create a two-tier system of care• There’s no shortage of dentists• It’s illegal for non-dentists to do dentistry;

they would jeopardize patient safety• Inefficient if they practice independently• They would take patients away from

private dentists

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Answering Those Concerns

• We have 2 tiers now (private, public)• Documented shortages in many areas• States regulation can protect public safety• Efficient business models can be

developed• Private dentists don’t treat 1/3 of the

public; won’t lose business

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Irreversible procedures

• This is a political communications term,not a clinical term

• Opposition not based on public safety orclinical competence of new providers

• Hygienists now permitted to do“irreversible” procedures (e.g. anesthesia)

• States and communities want moresources of restorative care

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Dental Practice Income

• About 45% of patient visits are for hygieneservices

• About half from insurance, half cash• Very sensitive to downturns in the

economy• Overhead averages about $.60-$.65 of

each dollar earned

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Important Partners

• Payors—Medicaid, SCHIP, privateinsurers, business

• Coalitions—Provider associations, dental/medical leaders

• Legislators, local and state agency leaders• Universities, training programs• Safety net clinics, rural providers• Foundations

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Bootleggers or Baptists?

• Consider regulatory structure (separatecommittee? Board of Health?)

• Ensure objective sources of evidence forlegislatures in amending practice acts

• Target new providers to safety netsettings?

• Think through referral, oversightagreements with dentists

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Important Steps

• State and local policy communities cometo consensus, not national groups

• Focus on the underserved, not providers• Communicate solutions, don’t assume

people understand• Seek investments from foundations,

governments

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Documents

Bootleggers and Baptists: Thereâ€™s Got to be a Better Way