This document discusses the oral health needs and dentist supply in Southwest Virginia. It finds that the region has poorer oral health outcomes, lower utilization of dental services, and fewer dentists per capita than the rest of the state. A dental school could help address these issues by training new dentists, some of whom may remain in the region, and through clinical education programs. However, concerns include the high cost of operating a dental school and recruiting faculty. Alternative options discussed include expanding existing community health programs and utilizing other dental providers.

1. ORAL HEALTH CONSEQUENCES
OF A SOUTHWEST VIRGINIA
REGION
DENTAL SCHOOL
Center for Economic and Policy Studies

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. Southwest Virginia Regional
Characteristics

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. Regional Characteristics

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. Regional Oral Health Needs

8. Children have poorer oral health in SWVA
Dental Caries Among 3rd Grade Students
70
60
50
40 Statewide
Lenowisco
30
Cumberland Plateau
20
10
0
Untreated Caries Treated Caries Need Early or
Urgent Care
Source: Virginia Department of Health, Clinical Screening, 2009

9. Children utilize dental services
less frequently in SWVA
Time Since Last Visit
90
80
70
60
50 Statewide
40 Lenowisco
30 Cumberland Plateau
20
10
0
Less than 1 year 1-3 years ago more than 3 years
since last visit ago
Source: Virginia Department of Health, Clinical Screening, 2009

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. Children are more likely to have dental
insurance (including Medicaid)
Dental Insurance Coverage among Third Grade Children
100
90
80
70
60 With Dental Insurance
50
40 Unable to Get Dental
30 Insurance
20
10
0
Statewide Lenowisco Cumberland
Plateau
Source: Virginia Department of Health, Parental Questionnaire, 2009

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 SWVA
Source: Virginia Department of Health, CDC, Behavioral Risk Factor Surveillance System
Survey Data

13. Adults in SWVA are also less
likely to utilize dental services
Adults who visited a dentists or dental clinic in past year
80
70
60
50 US
40 Virginia
30 SWVA
20
10
0
1999 2002 2004 2006 2008
Source: Virginia Department of Health; Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance
System Survey Data

14. Adults are less likely to have
dental insurance coverage
Dental Coverage (including dental insurance, HMOs, government
plans)
80
70
60
50
40 Statewide
30 SWVA
20
10
0
2000 2001 2002 2003 2004 2005 2006 2007 2008
Source: Virginia Department of Health, CDC, Behavioral Risk Factor Surveillance
System Survey Data

15. Dental Needs Assessment
Survey

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. 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 the
following most common types of procedure
25
20
15
10
5 SWVA
0 Virginia

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. Dentist Supply and
Distribution

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. Virginia: Dentists per 100,000
Population, 2010
Source: Virginia Board of Dentistry

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. 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. 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. Results
Variable Beta z
Constant -12.52726 -18.35**
PFLOUR 0.0007555 0.79
PCI 0.0809451 4.99**
PCI2 -0.0014513 -8.52**
PINSURE 0.0390566 4.67**
PCOLLEGE 0.0418283 9.20**
AREA -0.0000143 -0.29
NETCOM -0.000011 -1.73
INPUT -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. Residuals as Gaps

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. 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. 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. Dental School Workforce
and Utilization Impacts

31. Conceptual Framework

32. Dental School Peer Group
We assume class size of 50 and 24 residents for SW school
Dental School Class Size Public/Private Location
Arizona School of 68 Private Metro area with more
Dentistry (A.T. Still), than 1 million
AZ population
Eastern Carolina 50 Public Metro area with less
University, NC than 250,000
population
Marshfield Clinic, WI 50 Private-Proposed Non-metro area
Midwestern University, 50 Private-Proposed Non-metro area
MO
University of New 40 Public-Proposed Metro area with 250k-
Mexico, NM 1 million population
West Virginia 50 Public Metro area with less
University, WV than 250,000
population

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. 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. 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. 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. Scenarios of Clinical Education
(annual patients)
Traditional Patient- Community-
clinic centered clinic based clinic
Residents 9,960 9,960 9,960
Pre-doctoral 2,243 8,948 8,948
students
Total 12,203 18,908 18,908
SWVA region 7,727 11,974 17,017
patients

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. Potential Problems in Creating
a Southwest Dental School

40. Potential Problems
1. Cost of running dental school, as well as expanding
mission of UVA-Wise
 Running dental school
 Expanding mission of school
 Reconfigure institutional resources
2. 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 schools
3. Clinical services may displace current dentists
providing services to publically insured

41. Possible Alternatives

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. Full Report available at:
• Available at:
http://www.coopercenter.org/econ
• Direct link:
http://tinyurl.com/3zqzo9t