4.  Addressing Emerging Dental Education and Related Public Interests as Matters of Broad Public Policy

The preceding sections have laid out a case for treating as matters of broad public policy dental education and the public’s related interests in having reasonable access to dental services provided by dentists capable of meeting the oral health care needs of the United States population.   Making this shift to treating dental education as an essential national resource and collective enterprise will require strategic, collaborative efforts on the part of States and the Federal government in a number of key areas, several of which are highlighted below.

Public Interests in Dental Education

Educating Practitioners to Meet the Needs of the Population: Public policy makers–particularly State policymakers–and the public at large have longstanding interests in dental education as it relates to public safety, practitioner competency and the general availability of dental services.  However, the ability of the prevailing model (which allows dental school graduates to enter general practice without additional training) to adequately impart the knowledge and skills necessary for dentists to meet the needs of an increasingly diverse and challenging population is currently an issue.

Access to Services: States and the Federal government have joint public interests in ensuring an adequate supply and distribution of qualified dental practitioners to meet the oral health care needs of the public.  Of particular concern to public policymakers are those members of the public who face significant barriers to accessing services (i.e., those who traditionally have been underserved–individuals with low incomes, developmental disabilities or medically compromising conditions; young children and the elderly; and those in remote rural or many inner-city areas).  The Nation also faces growing challenges in assembling an adequate dental workforce to provide dental services in military and public health facilities.  Building new dental facilities may be a necessary antecedent to expanding care for underserved populations; however, if an adequate supply of dentists is not available, new facilities alone will not produce the intended results.

Public Data Sources to Support Workforce Analyses and Policy Development

Reliable, publicly available data sources on key aspects of dental education (e.g., enrollment levels, student and faculty characteristics, program finances, graduates’ career choices, levels of student indebtedness) and the dental workforce (e.g., number and types of practitioners, practice locations, number of hours worked) are essential for monitoring workforce trends, policy analyses and planning activities.  Such data need to be collected, updated and made available on an ongoing basis to shed light on emerging trends and facilitate the evaluation of policy options and program changes over time.  Likely users of such data include researchers; policy analysts; local, State, regional and Federal officials; and program planners and evaluators.   The ADA and ADEA currently collect and compile data on a number of variables that are relevant to workforce analyses and policy development; however, access to data on the production and distribution of dentists may be restricted or cost-prohibitive for some interested parties.  Moreover, data issues stemming from a reliance on secondary data–such as the problems cited in this report concerning the DDSE unit of analyses–underscore the importance of publicly maintained data sources that provide ready access for the public, researchers and policy analysts.   

Federal Data Sources:  The U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions would seem to be an appropriate entity to carry out this role.  In the past, HRSA has occasionally disseminated data on the location and characteristics of dentists and other health professionals. 

Suggested data sources to be compiled and made available through one or more agencies of the Federal government include, but are not limited to:

• A central repository of publicly accessible data on dental workforce characteristics and trends in all States;
• A central repository of publicly accessible data on dental health professions shortage areas (D-HPSAs); and
• A central repository of publicly accessible data on dental education programs, including enrollment and graduation trends, student characteristics and variables related to program financing (costs and revenues).

Regular release of timely, publicly compiled data sources of this nature could overcome limitations of current privately compiled data sources (e.g., the problems associated with use of the DDSE unit of analysis noted throughout this report) and go a long way towards facilitating more timely and rational policy and program development at both the State and Federal levels. 

State Data Sources:  States also can play a valuable role by collecting and making available detailed information about dentists who are licensed and/or practicing within their jurisdictions.  Examples of useful data include the number, type, location and demographic characteristics of licensed/practicing dentists; which schools or residency programs the State’s dentists attended; length of time in practice; and whether and to what extent dentists participate in Medicaid.  Some States already collect information of this sort through a series of questions that are included in dentists’ license applications.  For optimal effectiveness, however, comparable information should to be collected for all States.

Data on Dental Education Program Costs and Revenues: Analysis of the differences and variations among types of schools and among schools is complicated and confounded by two factors: 1) the use of DDSE as a unit of analysis in reports issued by the ADA and ADEA and 2) the lack of a generally accepted standard for allocating and reporting costs.  The DDSE has been used historically to compare the overall institutional cost per (hypothetical) student based on an admixture of programs in (“undergraduate”/predoctoral) dental education, advanced dental specialities (residencies), allied dental education (e.g., dental hygiene and dental assisting) and non-specialty graduate dental education.  Although the convenience afforded by combining these units may have value to historical users, the use of DDSE as a unit of analysis obscures valid comparisons across institutions (that may or may not offer all component programs) and programs (that have widely varying educational elements, cost structures and potential offsetting sources of revenue).

Dental Education Financing Issues: Student Indebtedness and Dental Faculty Shortages

Student Indebtedness:  Rising student indebtedness has serious implications for public policy.  The average cost for tuition and fees for 4 years of dental school is approaching $100,000 overall and is considerably higher in private schools.  Average student debt for graduating dentists is roughly $120,000 and is increasing.  Escalating costs and levels of indebtedness have not dissuaded students from pursuing careers in dentistry, most likely because dentistry still provides a good rate of return on the investment in dental education (ADA, 2004a).  However, rising costs and indebtedness are likely to discourage economically disadvantaged and minority students from pursuing dentistry as a career.  Because studies have shown that minority dentists are more likely to provide care to minority patients, rising costs can have a future effect on access to care for vulnerable, underserved populations.  A second aspect of this problem relates to career decisions of graduating dentists.  Data compiled by ADEA suggest that graduates who face substantial educational debt forego careers in dental education or employment in public clinics that treat the underserved.  Moreover, those entering private practice with substantial debt levels will be disinclined to participate in public programs such as Medicaid or the CHIP because of the relatively low reimbursement rates that these programs typically provide.

Faculty Recruitment and Retention:  Faculty recruitment and retention also are matters that public policymakers need to consider seriously.  The growing gap between dental school salaries and incomes earned by dentists in private practice (combined with increasing student indebtedness) has led to rising numbers of vacant faculty positions in dental schools across the country–now in excess of 250 budgeted positions.  Less than 1 percent of graduating dental students report plans to pursue careers in dental education, a rate that is far less than the 5 percent figure that Kennedy (1995) has estimated is needed to meet the collective faculty replacement needs of the Nation’s dental schools.  The less than 1 percent figure also is in stark contrast to the roughly 30 percent of graduating medical students who report they plan to become full-time university faculty (JAMA, 2001).

No single approach is likely to resolve either of these growing problems that have significant public policy implications for the future availability of dental services and the Nation’s dental education infrastructure.  Thus, there would seem to be a clear rationale for increased Federal and State involvement to develop sustainable initiatives to address these issues.

Federal interventions could include:

• Subsidies in the form of grants and scholarships for disadvantaged students who wish to pursue careers in dentistry;
• Loan forgiveness programs for graduates who practice in underserved areas or serve underserved populations;
• Financial incentives (grants, scholarships or loan forgiveness) for graduates who pursue careers as dental faculty; and
• Support for developing and recruiting faculty for community-based teaching programs.

Similar State initiatives to complement Federal programs are likely to be needed.

Linking Public Support for Dental Education to Public Policy Concerns

In light of the growing need for dental services and workforce trends that portend an accelerated decline in dentist-to-population ratios, State and Federal attention and support for dental education are necessary.  The magnitude of the emerging problem and the current political and economic environment require a strategic approach to address the public policy concerns inherent in this issue–i.e., approaches that adopt a broad National strategy for dealing with these issues while, at the same time, recognizing the problems of individual States and educational institutions. 

If carried out in a broader, more strategic fashion, the interventions and initiatives highlighted in the previous section would undoubtedly help address fundamental public policy issues that stem from current and impending problems related to dental education.  Michigan, Minnesota, and Utah provide illustrations of States that have mounted creative efforts to develop more systematic initiatives to link support for dental education and public policy interests.

Using Medicaid Graduate Medical Education (GME) Funds to Support Dental Education Programs in Underserved Communities ^[9]

Example #1–Michigan: Medicaid GME policy in Michigan changed significantly in 1997 when the State took steps to structure payments to bring physician education more in line with its public policy goals to train appropriate numbers of primary care providers, enhance training in rural areas, and support education in ways of particular importance in the treatment of the Medicaid-eligible population (Holmes, 2003).  Historically, no accountability was required of training programs because funding was based on cost, and the State had no idea how much it was contributing to GME.

Most of the nearly $200 million in GME funds previously included in Medicaid fee-for-service hospital patient care payments and managed care organization (MCO) capitation rates were carved out and directed for redistribution into two different pools.  For the first 3 years of the new policy, a historic cost pool reimbursed each hospital the same amount in payments that it received in 1995, based on that year’s costs for medical education.  A second pool, the primary care pool, seeks to encourage the education of young physicians in the primary care fields of general practice, family practice, preventive medicine, obstetrics and geriatrics.  Payments from the primary care pool to hospitals are based on the institution’s number of residents in primary care and its share of Medicaid patients.  To qualify for reimbursement from either pool, a hospital must submit a report to the State detailing resident profiles and how it is using the funds to support specific public policy goals and priorities.

A third pool, the Innovations in Health Professions Education Grant Fund, was established with GME that funds formerly were included in capitation payments to MCOs to foster innovations in health profession education and accelerate the pace of change currently sweeping the State’s health care delivery system.  Grants are awarded on a competitive basis to programs that support the goals of the new GME initiative, with emphasis on innovative training in managed care arrangements.  Only consortia consisting of at least a hospital, a university and a managed care organization are eligible to apply.  Early funding under this pool supported activities such as making changes in curriculum to add exposure to managed care, developing evidence-based medicine teaching experiences and establishing interdisciplinary education curricula with other health professions.  The funding size of the pool depends on the annual availability of funds.

The State has concluded that funds in this pool have been well spent.  Residency educators say that they now can make changes they have been wishing to make.  University, hospital and health plan officials have been forced to communicate without each other on GME issues in a productive and positive manner.  The new managed care curriculum is largely viewed as useful, but it is too soon to tell whether such changes can be sustained. 

The initiative’s overall effect on addressing State workforce goals is not yet known.  The State believes that such programs would be more effective if a more coherent policy approach could be developed between Medicaid and Medicare and other payers.  State efforts such as Michigan’s may need to exercise caution on how specifically they direct their initiatives regarding State workforce needs.  Physicians have typically responded to other market changes more quickly than to State financing changes. In Michigan, there appears to be no shortage of primary care physicians, but there is evidence of a shortage of some specialists who may not be willing to be part of managed care networks. 

In 2001, a new formula was established that takes into consideration utilization by and service to the State’s Medicaid population.  Previously, funds were distributed based on hospital costs.  New formulas use physician intern and resident full-time equivalents (FTEs) with weighting for Medicaid utilization, hospital case mix, physician enrollment in Medicaid, and physician board certification to distribute funds.  Teaching hospitals now are required to submit annual updates on their intern and resident FTEs.  For a hospital to receive GME funds, the new policy also required participation in a managed care plan.

Furthermore, beginning in 2001, Medicaid agreed to provide funding to educate third- and fourth-year students at the State’s one public dental school that is developing specialized curricula and programs intended to further increase the participation of dentists in Medicaid.  Funding covers teaching and other administrative costs that can be matched under Medicaid’s intergovernmental transfer mechanism to draw additional Federal matching funds and provide new revenue for the State’s dental school. 

Recently, Medicaid Intergovernmental Transfer (IGT) funds have been used to support two physician residency programs in psychiatry that provide considerable training in community mental health settings.  The programs’ affiliated universities use State general funds and a Medicaid GME innovations grant as the State match under IGT to obtain Federal matching funds.  These non-hospital-based residencies otherwise are not eligible for the State’s Medicaid GME payments.

Example #2–Minnesota:  Recognizing that medical education was important to the State’s economy and that a more competitive (managed care) health care market threatened the viability of many State teaching hospitals, the Minnesota Legislature in 1993 charged the commissioner of health with estimating the total costs of medical education and research in the State.  This resulted in a series of advisory committee reports that identified the need for explicit funding of medical education and research and culminated in a 1996 estimate that approximately $37 million (the deficit between teaching program costs and revenues) could be lost as a consequence of competition in the State’s managed care market (Leitz, 2003). 

To partially address the deficit, the Legislature that same year authorized creation of a Medical Education and Research Cost (MERC) Trust Fund to capture new and existing State sources of medical education funds.  In 1997, lawmakers appropriated $5 million in new funding from the State’s general fund and $3.5 million from an existing State health care provider tax pool. ^[10]   Sponsoring institutions are eligible to apply on behalf of their accredited programs and are responsible for distributing the funds to the more than 300 training sites that actually incur the cost of medical education (including non-hospital settings).  Eligible applicants are accredited programs that train physicians, advanced practice nurses, physician assistants, doctor of pharmacy practitioners and dentists.  Reports from the training institutions are required to document that the distribution was made appropriately.  In 1998, the Legislature provided ongoing support for the trust fund by appropriating $10 million from the State general fund for distribution in FY 1999 and by increasing the Department of Health budget by $5 million annually beginning in FY 2000. ^[11]

Lawmakers also agreed in 1997 to carve out GME funds from Medicaid managed care rates beginning in 1999.  The funds are directed to the MERC trust fund for direct distribution to medical and dental teaching programs.  Distribution of payments, which did not begin until 2001, is based both on the extent of educational programs and Medicaid revenue volume at respective teaching sites. 

Presently, funding sources for the MERC trust fund include:

• Tobacco settlement fund–Payment of $350 million to a medical education endowment is split between MERC and the State’s academic health centers.  In 2001, MERC received $7.3 million.
• Medicaid matching funds–Through an amendment to the State Medicaid plan, Federal matching funds procured through the intergovernmental transfer mechanism have increased GME payment levels to teaching hospitals.  Each year, transfers of about $5 million in State tobacco settlement funds awarded to the University of Minnesota Academic Medical Center and $2.4 million from the University of Minnesota to Medicaid are used to obtain Federal matching funds to support MERC’s new dental GME innovations pool.  Medicaid matching funds for GME provider distribution are distributed to MERC through the Department of Health. 
• State general fund payments. 
• Medicaid managed care “carve-out.”  

MERC funds support more than 2,000 FTE trainees at 400 training sites.  The funding formula is cost-based—based on the cost per trainee in each discipline.  In the first 3 years, MERC has distributed more than $53 million.  Distribution of payments is not linked to State workforce or policy goals for specific health professions because officials do not feel that they presently have adequate data to support such decisions.

Example #3–Utah: In 1995, two technical advisory groups to the Utah Health Policy Commission concluded that the State’s major academic health center and residency training programs were significantly threatened by changes that were occurring in the health care system and projected changes in Federal policy for funding GME.  To develop a basis for making policy decisions in response to these changes, the commission requested an independent study to determine GME costs and revenue sources statewide.  Anticipating that Utah’s academic training centers would have to further compete on price and quality for patients, the commission was interested in possibly using the study results to begin the difficult task of separating the cost of training from the cost of patient care in these institutions. 

Since the study concluded that GME funding sources were being eroded, the State Legislature in 1997 created the Medical Education Council to address various issues associated with funding for health professions education in Utah (Squire, 2003).  The mission of the council is to find ways to stabilize such funding by effectively determining the costs of health professions education and to better understand and address the State’s health workforce needs.  The council currently is conducting extensive workforce planning and analyses that, combined with the cost study findings, will provide the basis for distributing GME payments more accountably and is developing a rational State health workforce policy.

In its effort to both improve GME funding and address State health workforce needs, the council in the late 1990s developed and submitted a proposal to HCFA (now CMS) that would allow Utah to establish a broad-based, multiple payer mechanism to finance graduate medical education.  The proposal called for payments under this mechanism to be made directly to the training programs, not to the affiliated service institutions (teaching hospitals).  Payments would reward outcomes that address State workforce objectives. 

Although HCFA initially insisted the demonstration incorporate Medicare, Medicaid and other State funds, the Federal waiver that ultimately was approved will apply only to Medicare GME payments.  Effective January 2003, all Medicare funds covering direct and indirect GME costs are being paid directly to the statewide council for 5 years.  Under the demonstration project, the council will create a new formula for distributing Medicare indirect GME funds based upon actual documented costs and will develop a statewide physician resident rotation information system to assist with payment verification. 

In 2001, the council reached an agreement with the State Medicaid program to begin using appropriated State medical school funds as the State share for drawing down Federal matching funds under the IGT mechanism to enhance Medicaid support for graduate medical education in Utah’s three teaching hospitals.  The total amount in the Medicaid GME payment pool was estimated at approximately $20 million.  Funds in the Medicaid pool also will cover dental and podiatry education based at these hospitals.  The additional Federal matching funds will be weighted to provide increased support to train certain physician specialties that are considered by the council to be in short supply.

Furthermore, the Utah Legislature in 2001 appropriated $566,000 in general funds to the University of Utah regional dental education program with the intent that it be used as the State share under IGT to obtain Federal matching funds to enhance dental residency education at the university.  Utah does not have a dental school.

Universal Dental Residency (PGY-1) Training: A Policy Strategy for Accelerating System Change to Serve Public Interests

Universal Dental Residency (PGY-1) Training: What It Means and What It Would Entail:  In 1995, the Institute of Medicine (IOM, 1995) called for the creation of a number of graduate dental education (residency) positions sufficient to accommodate all graduates by 2005.  In 1999, the Journal of Dental Education (AADS, 1999) published a series of articles in a special issue that set forth a focused and compelling rationale for a mandatory, post-graduate year of dental residency education (PGY-1).  The rationale rests on two primary points:

1. An assessment of the competencies (and their underlying knowledge and skills) that a workforce dominated by general practitioners will require to meet the oral health needs of the public in the coming century; and
2. An objective assessment of what the predoctoral curriculum realistically can be expected to deliver.

A former dean and author of one of the AADS papers (Kennedy, 1999) asserted that, until the dental profession in general and dental regulators come to the same conclusion (about mandatory PGY-1 training), debate will continue and dental education will not have the opportunity to comprehensively reconceptualize and restructure the predoctoral curriculum.  The recent action by New York to adopt PGY-1 as a requirement for initial licensure beginning in 2007 and interest by other large States (e.g., California) would seem to indicate growing support for this concept; however, broader support could hasten implementation.

Advantages of Universal PGY-1: From a public policy perspective, the advantages of a universal PGY-1 include:

• Enhanced health and safety of the public as a result of the additional, more complex experiences and competencies afforded by PGY-1 training;
• Greater opportunities for dentists to be exposed to more diverse patients in more diverse settings as part of their clinical education;
• Creation of a “driver” to expand dental residency training sites and programs, thereby expanding access to care “platforms” within underserved communities;
• Opportunities to expand service delivery to underserved populations using more skilled practitioners (i.e., dental residents instead of predoctoral dental students);
• Expansion of training and access to care sites for States that do not have dental schools; and
• Evidence that graduates of general dentists trained in advanced (residency) training programs are more likely to treat medically compromised and underserved populations (AADS, 1999; Atchison et al., 2002).

Community Health Centers (CHCs) as Training Sites for Dental Education: Creating a universal PGY-1 experience would require expansion of dental residency training programs.  Some of this expansion could come from increasing the number of residents in existing programs, with the remainder coming from the creation of new programs or new program sites (such as has been done through for general dentistry and pediatric dentistry with Federal Title VII, Section 747, funds administered by HRSA).  It is generally anticipated that the majority of new residency training program sites, at least those supported by public funds, would be used for expansion of primary care residency programs (i.e., programs in general dentistry and pediatric dentistry). 

It seems reasonable that some of these programs will be established in hospital settings and will be financed through GME funding.  However, there also seems to be merit in considering community clinic sites, especially in underserved communities (e.g., federally qualified health centers–FQHCs), for a significant portion of this expansion.  Linking dental residencies and FQHCs or other CHCs could provide not only rich patient care experiences (because of the more complex needs of patients who use these facilities), but also could provide the financial foundation necessary to support the costs of PGY-1 education.  Additional benefits of co-locating dental residencies in FQHCs or CHCs include the opportunities for interaction of dental residents and primary medical residents with attending staff, thereby enhancing dental residents’ active involvement as part of the primary care team. 

Once established, these community-based sites also may serve as additional clinical training sites for predoctoral dental students as part of their extramural experiences.  However, acquisition of fundamental technical skills and core knowledge will likely continue to occur primarily within dental school settings.

Catalyzing System Change: Formicola et al. (1999) succinctly summarized the situation with respect to creating a National system to support universal PGY-1 as follows:  “After 20 years of debate and discussion, it appears that conditions are right for moving toward a mandatory postdoctoral year in dentistry.  These conditions are: 1) the fewest number of graduates to accommodate in a PGY-1 year since 1982; 2) credible reports from the profession and from others outside the profession that urge dentistry to require a PGY-1 year; 3) Federal legislation that allows dentistry to expand the number of residency positions in hospitals and off-site locations;^[12] 4) a means of ensuring the quality of a PGY-1 year through the existing accreditation process; and 5) a means of monitoring individual compliance with the requirement through existing State licensing agencies.”