dental management coalition conference · (adjusted by age and sex) number of teeth (toothgrp) mean...

Dental ManagementDental Management Coalition ConferenceCoalition Conference

Chester W. Douglass, DMD, PhDChester W. Douglass, DMD, PhDCambridge Health AllianceCambridge Health Alliance

November 10, 2005November 10, 2005

OutlineOutline

The Practice of Population Based The Practice of Population Based DentistryDentistry

Trends in the Market for Dental CareTrends in the Market for Dental Care Integrating Oral health into Primary Integrating Oral health into Primary

CareCareLeadership needsLeadership needs

Trends in Dentistry:Trends in Dentistry:

Overview of Dental Care Market

DEMAND SIDE TRENDSDEMAND SIDE TRENDS

•Patient Population Trends

• Disease Trends

• Need for Dental Care

Patient ExpectationsPatient Expectations

1.1. By Age CohortBy Age Cohort

2. By Economic Market Segmentation2. By Economic Market Segmentation

Think CohortsThink CohortsLife experience with dental disease Life experience with dental disease and dental care tends to determine and dental care tends to determine

each cohorteach cohort’’s oral health expectations s oral health expectations and behaviorand behavior

Patient Expectations Patient Expectations -- TrendsTrends

1. Demographic1. Demographic

Population SizePopulation Size

Population AgingPopulation Aging

Population DiversityPopulation Diversity2. Epidemiology of Oral Disease2. Epidemiology of Oral Disease3. General Public Awareness of oral health care3. General Public Awareness of oral health care4. More knowledgeable patients about modern 4. More knowledgeable patients about modern

dental servicesdental services5. Patients more aggressive in holding dental 5. Patients more aggressive in holding dental

care providers accountablecare providers accountable

Trends in Dentistry:Trends in Dentistry: DEMAND SIDE TRENDSDEMAND SIDE TRENDS

•Patient Population Trends

• Disease Trends

• Need for Dental Care

Dispelling the Myth Dispelling the Myth that 50 Percent that 50 Percent

of U.S. Schoolchildrenof U.S. Schoolchildren Have Never Had a CavityHave Never Had a Cavity

Burton L. Edelstein, DDS, MPHBurton L. Edelstein, DDS, MPHChester W. Douglass, DDS, PhDChester W. Douglass, DDS, PhD

Public Health Reports, Sept./Oct. 1995 Volume 111

Percent of Schoolchildren Percent of Schoolchildren with Carieswith Caries

US Adult population and Number of US Adult population and Number of Teeth at Risk, 1972Teeth at Risk, 1972

AgeEstimated 1972

Population Teeth at Risk18-24 30.1 25,901,000 779,620,10025-34 26.6 27,397,000 728,760,20035-44 50.8 22,853,000 475,342,40045-64 15.5 * 42,789,000 663,229,50065-87 7.0 ** 19,324,000 135,268,00085+ 3.5 ** 1,559,000 5,456,500

139,823,000 2,787,676,700*mean of 45-54 and 55-64 categories

Functional Teeth per Individual

Source: Reinhardt/Douglass: Future Need for Dentistry

CohortCohort--specific Projections of specific Projections of Adult Teeth at Risk in the US, 1990Adult Teeth at Risk in the US, 1990

(middle series population projections)(middle series population projections)

AgeEstimated 1972

Population Teeth at Risk18-24 28.4 25,794,000 732,549,60025-34 26.7 43,529,000 1,162,224,30035-44 23.4 37,847,000 885,619,80045-64 18.3 * 46,453,000 850,089,90065-87 12.1 * 28,384,000 342,027,20085+ 8.2 ** 3,313,000 27,166,600

185,320,000 3,999,677,400*mean of adjacent catagories

(liberal estimate)


** assumed no difference than projected for year 2000


AgeEstimated 1972

Population Teeth at Risk18-24 28.4 26,226,000 744,818,40025-34 26.7 37,158,000 992,118,60035-44 23.5 40,168,000 943,948,00045-64 19.5 * 70,810,000 1,380,795,00065-87 15.0 * 55,969,000 839,535,00085+ 10.9 * 8,611,000 93,859,900

238,942,000 4,995,074,900*mean of adjacent catagories


CohortCohort--specific Projections of specific Projections of Adult Teeth at Risk in the US, 2030Adult Teeth at Risk in the US, 2030

(middle series population projections)(middle series population projections)


Trends in Percent Edentulism in AdultsTrends in Percent Edentulism in Adults Aged 18 to 74: 1971Aged 18 to 74: 1971--19941994

05

101520253035404550

18-74 18-24 25-34 35-44 45-54 55-64 65-74

Perc

ent

1971-1974 1988-1994

Age Groups

14.7

7.7

1.0 0.03.2

9.0

16.0

0.72.8

33.4

9.30

20.1

45.6

28.6

Source: U.S. Dept. of Health and Human Services, National Center for HealthStatistics and National Institute of Dental Research

Mean number of Restored Coronal Surfaces, by Mean number of Restored Coronal Surfaces, by Number of Teeth* (Adjusted for Age and Sex)Number of Teeth* (Adjusted for Age and Sex)

Number ofTeeth(Toothgrp)

Mean SE F Statistic P-value Groupcomparison

P-value

1-10 (1) 7.5 1.37 178.06 .0001 1 vs 2 .001

11-24 (2) 31.8 1.17 1 vs 3 .001

25-32 (3) 50.0 1.95 2 vs 3 .001

*ANOVA model with number of restored coronal surfaces as dependentvariable and age, sex, and tooth group as main effects and possibleinteraction terms.

Mean Number of Sites with Pocket Depth Mean Number of Sites with Pocket Depth >> 4 mm, 4 mm, by Number of Teeth* by Number of Teeth*

(Adjusted by Age and Sex)(Adjusted by Age and Sex)Number ofTeeth(Toothgrp)

Mean SE F Statistic P-value GroupComparison

P-value

1-10 (1) 2.48 0.61 32.41 .001 1 vs 2 .001

11-24(2) 6.96 0.47 1 vs 3 .001

25-32 (3) 10.50 0.84 2 vs 3 .001

*ANOVA model with number of sites with pocket depth > 4mm as dependentvariable and age, sex and tooth group as main effects and possibleinteraction effects.

Comparison of the mean number of DMFS Comparison of the mean number of DMFS among US adults aged 45+ years in NHANES among US adults aged 45+ years in NHANES

I* and NHANES III**I* and NHANES III**NHANES I NHANES III

Age Group Female Male Age Group All

45-49 65.1 59.5 45-54 65.0

50-54 79.0 68.3

55-59 80.0 76.7 55-64 81.4

65-74 88.7

75+ 101.3

Note: Data for all persons regardless of dentate status.NHANES III also provide data specifically for dentate persons

*Brown & Swango, AdvDent Res 1993;7(1):52-60**Winn et al. J Dent Res 1996;75(Spec Iss):642-651.

Dental Utilization by Number of TeethDental Utilization by Number of Teeth

Number of Teeth

DentalUtilization

1-10 11-24 25-32

When did you lastreceive care?*

< 1 year 109(55%) 279 (78%) 136 (89%)

1-3 years 22 (11%) 45 (13%) 10 (6%)

> 3 years 67 (34%) 31 (9%) 7 (5%)

Mean 1.11 1.64 1.97How often havereceived care inpast 12 months?† SD 1.17 1.12 1.01

*Chi-square = 86.15; P<.001† One-way ANOVA; F= 27.5, P<.001

Projected Amount of Need for FPDProjected Amount of Need for FPD’’s and RPDs and RPD’’s s (in Millions of Hours) by Year(in Millions of Hours) by Year

Yearneed

FPD’s + RPD’s = TotalNeed

- AnnualSupply

= ProjectedUnmet

2005 363.1 + 172.3 = 535.4 - 46.7 = 488.7

2010 378.2 + 185.3 = 563.5 - 47.8 = 516.7

2020 402.5 + 207.0 = 609.4 - 49.2 = 560.2

Number US adults (in thousands) who need one Number US adults (in thousands) who need one or two denturesor two dentures

Age Group 1991 2000 2010 2020

25-34 858 670 613 601

35-44 3770 3841 2928 261445-54 5612 7332 7711 5850

55-64 7667 7836 10,232 10,595

65-74 7675 6837 7054 9164

75-84 6166 6613 5934 6381

85+ 1900 2287 2654 2681

Total 33,648 35,416 37,126 37,886

Demand at 90%Utilization

30,283 31,874 33,413 34,097

Total numberof edentulousarches

53,839 56,493 59,265 61,043


Supply Side Trends

Dental Workforce

•Dentist

•Allied Dental Trends

Graduating Debt by Graduating Debt by Type of U.S. Dental School: 1979Type of U.S. Dental School: 1979--20002000

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Average of All Schools Public State-related Private

Source: American Dental Education Association

PRIVATE

PRIVATE-STATERELATED

PUBLIC

ALL SCHOOLS

Percent Distribution of Percent Distribution of Professionally Active Dental Specialists: 1998Professionally Active Dental Specialists: 1998

0 5 10 15 20 25 30

Orthodontists

Oral & Maxillofacial Surgeons

Pediatric Dentist

Periodontics

Endodontists

Prosthodontists

Public Health Dentists

Oral Pathologists••79.4% of 79.4% of professionally active professionally active dentists are dentists are generalists generalists

••20.6% are specialists20.6% are specialists

Source: American Dental Association

0.8%

5.7%

8.2%

11.9%

14.1%

16.3%

16.4%

26.6%

U.S. Dental School GraduatesU.S. Dental School Graduates 19551955--19991999

0

1,000

2,000

3,000

4,000

5,000

6,000

1955 1960 1965 1970 1975 1980 1985 1990 1995

Source: American Dental Association

5,756

4,095

3,181

Estimated Additions of Dentists to theEstimated Additions of Dentists to the Dental Workforce: 1995Dental Workforce: 1995--20402040

-2000 -1500 -1000 -500 0 500 1000 1500

Assumptions: number of graduates remains at 4050

retirement age of 65

year 2014

year 2023-1706

year 1995

year 2040

year 2031

Source: American Association of Dental Schools

Dentists per 100,000 U.S. PopulationDentists per 100,000 U.S. Population 19501950--20202020

51.552.7

49.0

59.5

45

47

49

51

53

55

57

59

61

Actual Projected

Source: Bureau of Health Professions, HRSA, DHHS. Data from the Eighth Report to Congress 1991and unpublished reports.

1950 1960 1970 1980 1990 2000 2005 2010 2015 2020


•Economic Market

•Dental Benefits

Dental Benefit PlansDental Benefit Plans Total: 162 million in US have dental benefitsTotal: 162 million in US have dental benefits

What kind of coverage is it?What kind of coverage is it?

60 million 60 million -- Indemnity plans (what we Indemnity plans (what we used to call dental insurance)used to call dental insurance)

54 million 54 million -- PPO plans (discounted PPO plans (discounted dental fees)dental fees)

27 million 27 million -- Dental HMOs (includes Dental HMOs (includes dental Medicaid!)dental Medicaid!)

21 million 21 million -- ““ReferralReferral”” dental plansdental plansTotal: 162 millionTotal: 162 million

Trends in Dental Benefit PlansTrends in Dental Benefit Plans

1. Indemnity plans are declining1. Indemnity plans are declining2. Medicaid has had cuts in services covered2. Medicaid has had cuts in services covered

Technically, the number of people covered is still Technically, the number of people covered is still the samethe same

3. State Medicaid programs were reorganized3. State Medicaid programs were reorganized4. The 21 million people with new Referral plans is 4. The 21 million people with new Referral plans is

a misuse of the term a misuse of the term ““insuranceinsurance””..5. DHMOs stopped growing in 2000.5. DHMOs stopped growing in 2000.

Insured Insured vsvs Uninsured WorkersUninsured Workers 19881988--20022002

61.4 59.7 57.7 56.6 55.2 53.9 52.6 52.2

12.9 13.4 14.1 15.1 15.6 15.8 16.3 16.2

0

10

20

30

40

50

60

70

1988 1990 1992 1994 1996 1998 2000 2002

Employer-Covered Uninsured

%

Economic ClimateEconomic Climate

Weak economic growthWeak economic growth

Jobless recovery is slowJobless recovery is slow

Recovering Financial MarketsRecovering Financial Markets

Depressed tax revenuesDepressed tax revenues

State budget deficitsState budget deficits

Escalating health care costsEscalating health care costs

Social program cutsSocial program cuts

Medicare program limitationsMedicare program limitations

Medicaid program cutsMedicaid program cuts


Economic Behavior in a Sellers Market

National Health and Dental Service National Health and Dental Service Expenditures: 1980Expenditures: 1980--19981998

1990 1992 1993 1994 1995 1996 1997 1998

National Health Expenditures Dental Service Expenditures

$1149.1

$31.6 $53.8

4.5%* 4.7%*

$699. 4

* Dental Expenditures as a Percent of Total Health Expenditures

In B

illio

ns o

f Dol

lars

% A

nnual Increase

Annual Inflation Rates of Medical Care, Annual Inflation Rates of Medical Care, Dental Care, and All Goods & ServicesDental Care, and All Goods & Services

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

DENTISTS

PHYSICIANS

ALL ITEMS

TRENDSTRENDS

Population size increasingPopulation size increasing

Population agingPopulation aging

Population diversityPopulation diversity

ethnicethnic

household incomehousehold income

Current recessionCurrent recession

Current loss of jobsCurrent loss of jobs

Increase retention of teethIncrease retention of teeth

Projected decline in supply of dentistsProjected decline in supply of dentists

Rising dental fee inflation ratesRising dental fee inflation rates

Possible Outcomes among 55Possible Outcomes among 55--75 75 year olds who have low incomes year olds who have low incomes

and/or no dental insurance:and/or no dental insurance:

increasing needincreasing need

increasing amounts of untreated increasing amounts of untreated disease in all low income age disease in all low income age groupsgroups

limited services from Medicaidlimited services from Medicaid

Possible Outcomes among 55Possible Outcomes among 55--75 year 75 year olds who have incomes or dental olds who have incomes or dental

insurance:insurance:

increasing needincreasing need

increasing demandincreasing demand

higher prices for serviceshigher prices for services

longer waiting times for appointmentslonger waiting times for appointments

more closed practicesmore closed practices

Integrating Oral Health and Integrating Oral Health and Primary CarePrimary Care

Scenario I: Increase coordination and Scenario I: Increase coordination and improve referralsimprove referrals

Scenario II: Expand scope of practiceScenario II: Expand scope of practice

Scenario III: Focus on integrated oral Scenario III: Focus on integrated oral health care risk assessmenthealth care risk assessment

IntegrationIntegration

oror

CollaborationCollaboration

Primary Primary

vs.vs.

Secondary CareSecondary Care

I.I. System BarriersSystem Barriers•• Graduate EducationGraduate Education•• Insurance CoverageInsurance Coverage•• Reimbursement StructuresReimbursement Structures•• Referral NetworksReferral Networks

II.II. Practice BarriersPractice Barriers•• Differences in Practice EnvironmentsDifferences in Practice Environments•• Lack of Routine Communication SystemLack of Routine Communication System•• Clinical TrainingClinical Training•• Professional Culture DifferencesProfessional Culture Differences

Integrating Oral Health and Integrating Oral Health and Primary CarePrimary Care

Integrating preventive dentistry into primary Integrating preventive dentistry into primary medical care (RDH in medical setting)medical care (RDH in medical setting)

Integrating primary care medicine into dental Integrating primary care medicine into dental care practice (RN in dental office)care practice (RN in dental office)

Integrating oral health care into school health Integrating oral health care into school health care systems or community dental care care systems or community dental care programs for children where parents can be programs for children where parents can be reachedreached

Example: Somerville Early Head Start ProgramExample: Somerville Early Head Start Program

Scenario IScenario I

Screening procedures should include Screening procedures should include dentists screening children and adults dentists screening children and adults

Automatic referrals by medical Automatic referrals by medical practitioners for preventive dental care for practitioners for preventive dental care for pregnant womenpregnant women

CrossCross--referrals for ororeferrals for oro--facial infectionsfacial infections

CoCo--ordination of treatment of chronic ordination of treatment of chronic diseasesdiseases

Scenario IIScenario II

Pediatricians and pediatric nurses should Pediatricians and pediatric nurses should screen patients for oral health and provide screen patients for oral health and provide preventive dental carepreventive dental care

Staff of nursing facilities should assist Staff of nursing facilities should assist elderly individuals with the use of elderly individuals with the use of chlorhexidine mouthwashchlorhexidine mouthwash

Dentists can monitor patientsDentists can monitor patients’’ general general health and medical practitioners can health and medical practitioners can monitor patientsmonitor patients’’ oral healthoral health

Scenario IIIScenario III

Common risk factors such as diet, poor Common risk factors such as diet, poor hygiene, tobacco use, stress, oral bacteria hygiene, tobacco use, stress, oral bacteria etc. are recognized and emphasized in etc. are recognized and emphasized in patient carepatient care

Integrated health care risk assessment Integrated health care risk assessment model is better than an isolated diseasemodel is better than an isolated disease-- specific model as it addresses factors specific model as it addresses factors common to oral and general healthcommon to oral and general health


Business Management

in Professional Organizations

Structure in Management StylesStructure in Management Styles

More StructureMore Structure vs.vs. Less StructureLess Structure

Task OrientedTask Oriented vs.vs. Motivation/Shared GoalsMotivation/Shared Goals

Rules & RegulationsRules & Regulations vs.vs. Common SenseCommon Sense

Paper WorkPaper Work vs.vs. RelationshipsRelationships

Time SheetsTime Sheets vs.vs. Flex TimeFlex Time

CheckingChecking vs.vs. TrustTrust

Matching Organizational and Matching Organizational and Individual GoalsIndividual Goals

Individual behavior reinforces Individual behavior reinforces organizational purposesorganizational purposes

Promotes organizational loyaltyPromotes organizational loyalty

Facilitates agreement about Facilitates agreement about organizational goalsorganizational goals

Increases job satisfactionIncreases job satisfaction

Promotes work valuesPromotes work values

Taking Risks as a ManagerTaking Risks as a Manager

ItIt’’s s allall a risk on some levela risk on some level

Not knowing what canNot knowing what can’’t be done is an advantaget be done is an advantage

Estimate probability of successEstimate probability of success

Work to limit downsideWork to limit downside

Mavericks are neededMavericks are needed

a difficult fit in large organizationsa difficult fit in large organizations

tend to be entrepreneurs in small organizationtend to be entrepreneurs in small organization

Need COOs/Clinic Managers who lead within the Need COOs/Clinic Managers who lead within the organizationorganization

Leadership Leadership -- Definition and Definition and

StylesStyles

Formal and InformalFormal and Informal

Definition: Ability to Definition: Ability to stimulate people to stimulate people to

DO somethingDO something

Attributes of Effective LeadersAttributes of Effective Leaders

1a.1a.Have vision and purposeHave vision and purpose

1b.1b.Know their goalsKnow their goals

1c. Commitment over long term1c. Commitment over long term

1d.1d.Flexibility on pathwayFlexibility on pathway

2a.2a.PreparedPrepared

2b. Knows WIT to achieve2b. Knows WIT to achieve

2c. Have experienced success2c. Have experienced success

Attributes of Effective LeadersAttributes of Effective Leaders (cont(cont’’d)d)

3a.3a. Listens to othersListens to others

3b.3b. Creates team attitudeCreates team attitude

3c. Can identify win3c. Can identify win--win situationswin situations

3d. Can hire and keep excellent employees3d. Can hire and keep excellent employees

3e.3e. Works for the benefit of employeesWorks for the benefit of employees

4a. Is not self conscious4a. Is not self conscious

4b. Has ego strength, but not a problem4b. Has ego strength, but not a problem

4c.4c. No fear of failureNo fear of failure

4d. Is principled4d. Is principled

Results of TrendsResults of Trends ConclusionsConclusions

Safety net InfrastructureSafety net Infrastructure

ProvidersProviders

NumbersNumbers

DiversityDiversity

Allied Dental Care ProvidersAllied Dental Care Providers

Operational ManagementOperational Management

LeadershipLeadership

dental management coalition conference · (adjusted by age and sex) number of teeth (toothgrp) mean...

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