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Journal of the American Academy of Physician Assistants:
doi: 10.1097/01.JAA.0000433964.22547.17

Commentaries on health services research

Hooker, Roderick S. PhD, PA-C; Dehn, Richard W. MPA, PA-C, DFAAPA

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Roderick Hooker is an adjunct professor in the George Washington University School of Public Health and Health Services in Washington, D.C. Richard Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. Dr. Hooker and Mr. Dehn are department editors of Citations.

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Dental practitioners and dental therapists


The use of midlevel dental providers (MLDPs, per the study authors) is being debated as a means of reducing oral health disparities and increasing access to care among underserved populations. Dental providers include the advanced dental hygiene practitioner, community dental health coordinator, dental health aide therapist, and dental therapist. These providers are new to the US dental profession, although medicine has used similar positions for years. Medical literature has shown mixed results as to whether these providers improve access to care and increase practice efficiency; however, studies have demonstrated clearly that the quality of care outcomes of these providers is comparable to those of physicians. Studies of MLDPs suggest potential practice and public health benefits. With appropriate training, licensure, supervision, and deployment to geographical areas with significant need, MLDPs could increase access to care to underserved populations and help prevent deaths attributable to untreated dental disease.

Rodriguez TE, Galka AL, Lacy ES, et al. Can midlevel dental providers be a benefit to the American public? Journal of Health Care for the Poor and Underserved. 2013;24(2):892–906.

The introduction of dental therapists is an international movement.1,2 Underwritten by the Kellogg Foundation in Alaska and Minnesota, the dental therapist movement has been a response to major concerns about oral health, including high rates of oral disease, oral health disparities, shortages and maldistribution of the dental workforce, the extreme costs of dental education, and the absence of a public health preventive model for oral healthcare. For those in the United States without dental insurance, dental care is often inaccessible. Dentists generally are unwilling to see patients unless they are either insured or able to prepay for their care.

The pioneering implementation of the Alaska Dental Health Therapist model is the work of Professor Ruth Ballweg and colleagues at the University of Washington. This program dramatically directed the eyes of the US public to issues of dental care access and the individual toll of dental disease. Against the backdrop of Alaska's extreme climates and geographically remote villages, the introduction of dental therapists demonstrated that there are places where dentists will not go. Underserved and geographically isolated populations in the contiguous states were quick to see the parallels in their own communities, where most dentists were unwilling to provide care in remote communities or to populations with great needs but no dental coverage. Although much of the concern and advocacy for dental therapists has been about children's oral healthcare, the same issues apply to older adults, persons with disabilities, and any geographically isolated community.

The Alaska and Minnesota programs—and the publicity that surrounded them—sparked interest in new models of oral healthcare. Dental health aide therapists (sometimes referred to as dental practitioners, dental therapists, or oral health therapists) and two new oral health careers being developed by the American Dental Association can all be part of the solution.

If changes in the US healthcare system continue as projected to provide healthcare for all, the high costs of dental education make it impossible for dentists to be the only clinicians providing oral healthcare. In the same way that less costly PAs and NPs are trained and employed at significantly lower costs than physicians, dental therapists can fill major gaps in the dental delivery system while still allowing dentists to maintain their leadership in oral health.

Commentary by Roderick S. Hooker

1. Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Inter Dental J. 2008;58(2):61–70. Cited Here...

2. Harris R, Burnside G. The role of dental therapists working in four personal dental service pilots: type of patients seen, work undertaken and cost-effectiveness within the context of the dental practice. Brit Dental J. 2004;197(8):491–496. Cited Here...

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Patient poverty, primary care, and providers


This study sought to determine if patient poverty is associated with increased workload for primary care providers. The study linked administrative data identifying patient poverty and comorbidity with survey data about the organizational structure of 63 community health centers (CHCs) in Ontario. Patient poverty was determined in two ways: based on receipt of Ontario Drug Benefits (identifying recipients of welfare, provincial disability support, and low-income seniors' benefits) or residence in low-income neighborhoods. Patient comorbidities were determined through administrative diagnostic data from the CHCs and the Institute for Clinical Evaluative Sciences. Primary care workload was determined by examining provider panel size (the number of patients cared for by a full-time-equivalent primary care provider during a 2-year interval).

The study found that CHCs with higher proportions of poor patients had smaller panel sizes. The smaller panel sizes were entirely explained by the medical comorbidity profile of the poor patients. The researchers concluded that poor patients generate a higher workload for primary care providers in CHCs; however, this is principally because they are sicker than higher-income patients. Further information is required about the spectrum of services used by poor patients in CHCs.

Muldoon L, Rayner J, Dahrouge S. Patient poverty and workload in primary care. Can Fam Physician. 2013;59:384–390.

Health policy researchers often discuss the cost and workforce ramifications of providing medical care for medically underserved and highly impoverished populations. These authors examined two important questions: Does patient poverty generate higher workloads (as measured by smaller panel sizes) for primary care providers in Canadian community health centers; and, if so, is the higher workload due only to increased burden of illness, or do the social problems associated with being poor independently increase workload? These results imply that effective medical care for impoverished populations may not involve additional provider effort beyond what would be expected to account for the increased medical complexity of such patients, but may instead require the addition of personnel such as home health workers and health coaches to the team. Canada has one of the leanest ratios of physician to population ratios and is gradually trying to introduce PAs and nurse practitioners into these settings to improve access to care.

Commentary by Richard W. Dehn

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Peeking into the future with Primary Care 2025


Primary Care 2025: A Scenario Exploration is a project developed by the Institute for Alternative Futures (IAF) with support from the Kresge Foundation to consider the range of forces, challenges, and opportunities shaping primary care in the United States. With the advice and assistance of numerous experts around the country, IAF staff developed four scenarios using the “Aspirational Futures” technique that IAF has developed over the last three decades. The four scenarios explore the different deployment of these advances along with parallel social and economic conditions. The possible paths are the likely expected future (a “zone of conventional expectation” reflecting the extrapolation of known trends), the challenging future (a “zone of growing desperation” which presents a set of plausible challenges that an organization may face), and two visionary paths or “zones of high aspiration,” in which a critical mass of stakeholders pursues visionary strategies and achieves surprising success. The hope is that the Primary Care 2025 scenarios will enable leaders in healthcare to make strategic decisions that more effectively take the future into account.

Institute for Alternative Futures. Primary Care 2025: A Scenario Exploration. Alexandria, VA. January 2012. http:// Care2025Scenarios.pdf.

Over the last decade, health policy researchers have become increasingly concerned about workforce shortages, particularly in regards to the provision of primary care services. During this time, the proportion of physicians and PAs entering primary care practice has decreased, stimulating discussion about how primary care delivery can be restructured to be more efficient, effective, and attractive to providers. Primary Care 2025 is a comprehensive report that constructs four possible scenarios of future primary care delivery, each scenario requiring an increasing degree of structural change that would be demanded of the healthcare system and society. The report provides an interesting comprehensive review of primary care from which these futuristic models are generated, as well as a perspective in the substantial amount of coordinated structural change that would be necessary to obtain the outcomes predicted by the more radical proposals.

Commentary by Richard W. Dehn

© 2013 American Academy of Physician Assistants.


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