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  2. 2. 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
  3. 3. Southwest Virginia Regional Characteristics
  4. 4. 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
  5. 5. Regional Characteristics
  6. 6. Regional Characteristics Per capital income in 2009• Significantly lower $60,000 per capita income $40,000 $20,000 than state or $0 national average SWVA Virginia US• Older population Percent population 65 and older 20 and little 15 population growth 10 5 0 SWVA Virginia US
  7. 7. Regional Oral Health Needs
  8. 8. Children have poorer oral health in SWVADental Caries Among 3rd Grade Students70605040 Statewide Lenowisco30 Cumberland Plateau2010 0 Untreated Caries Treated Caries Need Early or Urgent CareSource: Virginia Department of Health, Clinical Screening, 2009
  9. 9. Children utilize dental services less frequently in SWVATime Since Last Visit9080706050 Statewide40 Lenowisco30 Cumberland Plateau2010 0 Less than 1 year 1-3 years ago more than 3 years since last visit agoSource: Virginia Department of Health, Clinical Screening, 2009
  10. 10. Type of dental utilization also varies Reason for last visit 90 80 70 60 50 exam, checkup, cleaning 40 planned or emergent 30 treatment 20 10 0 Statewide Lenowisco Cumberland Plateau Source: Virginia Department of Health, Parental Questionnaire, 2009
  11. 11. Children are more likely to have dental insurance (including Medicaid)Dental Insurance Coverage among Third Grade Children100 90 80 70 60 With Dental Insurance 50 40 Unable to Get Dental 30 Insurance 20 10 0 Statewide Lenowisco Cumberland PlateauSource: Virginia Department of Health, Parental Questionnaire, 2009
  12. 12. Adults have poorer oral health outcomes Permanent Teeth Extracted for Decay or Disease 120 100 80 all 6 or more (not all) 60 5 or less 40 none 20 0 Statewide SWVASource: Virginia Department of Health, CDC, Behavioral Risk Factor Surveillance SystemSurvey Data
  13. 13. Adults in SWVA are also less likely to utilize dental servicesAdults who visited a dentists or dental clinic in past year80706050 US40 Virginia30 SWVA2010 0 1999 2002 2004 2006 2008Source: Virginia Department of Health; Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System Survey Data
  14. 14. Adults are less likely to have dental insurance coverageDental Coverage (including dental insurance, HMOs, governmentplans)8070605040 Statewide30 SWVA2010 0 2000 2001 2002 2003 2004 2005 2006 2007 2008Source: Virginia Department of Health, CDC, Behavioral Risk Factor SurveillanceSystem Survey Data
  15. 15. Dental Needs Assessment Survey
  16. 16. 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)
  17. 17. 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 thefollowing most common types of procedure25201510 5 SWVA 0 Virginia
  18. 18. 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%
  19. 19. Dentist Supply and Distribution
  20. 20. 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
  21. 21. Virginia: Dentists per 100,000 Population, 2010Source: Virginia Board of Dentistry
  22. 22. 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
  23. 23. 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)
  24. 24. 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
  25. 25. ResultsVariable Beta zConstant -12.52726 -18.35**PFLOUR 0.0007555 0.79PCI 0.0809451 4.99**PCI2 -0.0014513 -8.52**PINSURE 0.0390566 4.67**PCOLLEGE 0.0418283 9.20**AREA -0.0000143 -0.29NETCOM -0.000011 -1.73INPUT -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.
  26. 26. Residuals as Gaps
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Dental School Workforce and Utilization Impacts
  31. 31. Conceptual Framework
  32. 32. Dental School Peer GroupWe assume class size of 50 and 24 residents for SW schoolDental School Class Size Public/Private LocationArizona School of 68 Private Metro area with moreDentistry (A.T. Still), than 1 millionAZ populationEastern Carolina 50 Public Metro area with lessUniversity, NC than 250,000 populationMarshfield Clinic, WI 50 Private-Proposed Non-metro areaMidwestern University, 50 Private-Proposed Non-metro areaMOUniversity of New 40 Public-Proposed Metro area with 250k-Mexico, NM 1 million populationWest Virginia 50 Public Metro area with lessUniversity, WV than 250,000 population
  33. 33. 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
  34. 34. 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.
  35. 35. Scenarios for Graduates Remaining in the Region Rural/ local student % of New Additional enrollment incoming dentists in underserved class region by persons 2053 receiving care by 2053 Low – private tuition 0.88 3 363 Medium – comparable 1.78 7 737 to VCU High – enhanced 2.50 9 1,037 education pipeline
  36. 36. 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
  37. 37. Scenarios of Clinical Education (annual patients) Traditional Patient- Community- clinic centered clinic based clinicResidents 9,960 9,960 9,960Pre-doctoral 2,243 8,948 8,948studentsTotal 12,203 18,908 18,908SWVA region 7,727 11,974 17,017patients
  38. 38. 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.
  39. 39. Potential Problems in Creating a Southwest Dental School
  40. 40. Potential Problems1. Cost of running dental school, as well as expanding mission of UVA-Wise  Running dental school  Expanding mission of school  Reconfigure institutional resources2. 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 schools3. Clinical services may displace current dentists providing services to publically insured
  41. 41. Possible Alternatives
  42. 42. 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
  43. 43. Full Report available at:• Available at:• Direct link: