The Declining Supply of Dental Services in Kansas

The supply of dentists and the way in which dental practices operate significantly affect the level of care that Kansans receive. A study of the dental workforce com­missioned by the United Methodist Health Ministry Fund shows that a persistent disparity in the supply of dentists between rural and urban areas and the manner in which services are delivered are adversely affecting the oral health of rural Kansans. Further, the oral health of poor Kansans is suffering because of a lack of access to dental care. The major findings of the study are summarized below:

Key Points

• • Many poor and rural Kansans lag significantly behind an accept­ed standard for dental care and oral health.
  • These gaps in services and care are caused in part by a limited supply of dentists—especially in rural areas.
  • Without policy intervention, these service gaps and resulting oral health problems will grow as the supply of dentists declines.
  • State policies and workforce regulations help determine the sup­ply of dentists and the contribu­tions of other dental professionals to the overall supply of services.
  • To improve access to dental ser­vices, policymakers could attempt to increase the supply of dentists by establishing a dental school or an in-state extension of an existing dental school, expanding educa­tion subsidy programs, or requir­ing more students who receive subsidies to practice in under-served areas.
  • Policymakers also could target services towards underserved pop­ulations of the state, and/or sup­port the development of new den­tal practice models, including expanding the types of services that hygienists or other allied pro­fessionals can provide.
  • Dental workforce needs are diffi­cult to predict and can take many years to address, suggesting the need for policymakers to monitor the dental workforce and update policies on an ongoing basis.

Information

This Issue Brief summarizes the key findings from a detailed study of oral health needs and the dental work­force commissioned by the United Methodist Health Ministry Fund. The full report, as well as other KHI studies, can be found online at www.khi.org .

Low-Income Kansans Have More Dental Problems

The availability of dental services in the state of Kansas as a whole, especially in rural areas, and the number and distribution of dentists available to serve the poor and uninsured are reasons for concern. To inform these concerns, the Kansas Health Institute completed a study of the dental workforce in Kansas to determine if there was a shortage of providers and to explore policy options for managing the supply of dental workforce professionals. Sources for the study included the complete licensure records from the Kansas Dental Board; statewide survey data on health status and dental needs; dental claims from the State Children’s Health Insurance Program (SCHIP, or HealthWave); industry data on dental supply, pricing, and utilization; and a comprehensive review of the literature.

Rising Standards, Persistent Needs

Oral health has improved significantly in the U.S. over the last several decades for children, adults, and the elderly. These improvements are generally attributed to widespread and sus­tained fluoridation of public water supplies, to increased utilization of preventive dental care, and to a rising public expectation of healthy teeth. According to an analysis of survey data undertaken for this study, levels of access in Kansas are slightly higher than the national average and are right in line with other states in this region of the country— such as Iowa, Missouri, and Nebraska. However, this study also revealed sizeable gaps in access and dental outcomes for low-income and rural populations. In addition, analyses of HealthWave claims data confirms earlier reports of low participation rates for dentists serving low-income children in the Medicaid and SCHIP programs. Poor access to dental care can have a profound impact on overall health and well-being. Poor oral health can reduce productivity, diminish physical function, and impede social interaction. The pain of an untreated dental problem can lead to the loss of sleep, depression, and other psychological conditions.

The Impact of Supply on Dental Needs

The price of dental services and dentists’ profits have increased significantly in recent decades, while per-capita utilization of dental services has declined. Taken together, these changes cannot be explained solely by changes in consumer preference and need for dental services. The most likely explanation for observed market trends is some sort of supply constraint, which may occur as a natural byproduct of dentists’ market control. Supply limita­tions may also be reflected in dentists’ reallocation of their practices’ time and resources to meet rising demand for preventive and cosmetic services and diminishing need—on average—for restorative services. Whether it is market power, market shifts, or both that are to blame for observed increases in prices and limited levels of supply, the impact on those who live in rural areas and those who are poor is the same. This study suggests that the current dental workforce in Kansas is both insufficient in number and inappropriately distributed geographically to meet the dental needs of the population, and that these shortcomings are likely to deepen as population growth strains an already tight supply of dentists.

Analysis of the dental workforce indicates that access problems in the state derive significantly, though not solely, from the limited and unevenly distributed supply of services available. Access gaps and unmet needs for dental services are concentrated among populations least able to compete financially for the limited number of practice hours offered by dentists, and those who live in rural areas where supply is even tighter. It was not surprising to find that the supply of dentists is significantly greater in more urban areas of the state

The natural uncertainty that underlies projections of this type, coupled with the long lead time required to train dentists, suggests that policymakers should keep a close watch on the number and dis­tribution of dentists so that they can effectively monitor progress in meeting policy goals. Shortages may take many years to correct, and factors contributing to them may change in the meantime. These difficulties suggest that policymakers need to remain engaged in ongoing review and update of policies.

• • • Establish a dental school or an in-state extension of an existing dental school.
    • Use advanced dental students to meet needs in underserved areas as a part of their training.
    • Expand loan repayment programs and/or educational subsidies.
    • Require more subsidized Kansas dental students to locate in underserved areas.
    • Recruit foreign dentists on pro­visional or educational licenses.
    • Enable changes in the dental business model by expanding the types of services that hygienists or other allied dental profession­als can provide and/or allowing allied professionals to bill patients directly.
    • Improve data collection, moni­toring, and reporting of oral health and workforce issues.
    • Increase dentists’ participation in Medicaid with better and sim­pler reimbursement.
    • Consider Medicaid expansions, especially for poor adults.
    • Advocate for national policies that enhance the dental workforce.

While each of these options could be designed to increase access to dental services, many come with significant public or private financial costs, most yield uncertain benefits, and some may bring with them unintended conse­quences. Thus, it may be difficult to obtain public consensus to sup­port a package of policy reforms. Nevertheless, there appears to be widespread agreement that dispari­ties in access to care among poor and rural populations merit the attention of policymakers.