The State of DentistryWhat Data Tell Us About Your Future Practice Environment

Cassie Yarbrough, MPPHealth Policy ResearcherADA Health Policy Institute

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Overview

• Introduction• The Dental Environment• Changes Impacting the Dental

Profession• Looking Forward and Points of

Strategic Action

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The Dental Environment

• What does the world look like today?

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A Major Transition

Dentistry

Shifts in Source of Dental Care

Financing

The Economy

New Dental Care Delivery

Models

Rising Student

Debt

Affordable Care Act

Change in Oral Health

Status

Shifts in Dental Care Utilization

Patterns

New Dental Schools

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Total Dental Spending ($ millions)

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

$0

$50,000

$100,000

$150,000

$9

2,3

24

$1

09

,93

4$

10

9,2

14

$1

10

,95

7$

11

1,1

59

$1

11

,61

3$

11

0,9

70

Nominal Inflation Adjusted

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Total Dental Spending

1990 1995 2000 2005 2010 2011 2012 20130%

20%

40%

60%

80%

100%

48% 51% 50% 49% 49% 48% 48% 47%

48% 43% 44% 44% 42% 42% 42% 42%

2% 4% 4% 5% 8% 8% 8% 9%

Private insurance Out of pocket CMS programs Other

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Dentist Earnings

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

$100,000

$120,000

$140,000

$160,000

$180,000

$200,000

$220,000

$240,000

$260,000

$280,000

$300,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

$55,000

130,

782

130,

970

133,

451

135,

074

143,

456

144,

591

147,

789

148,

488

151,

217

152,

843

157,

574

166,

858

177,

637

179,

782

177,

658

186,

540

204,

298

212,

642

210,

568

206,

623

215,

618

211,

788

210,

093

215,

876

214,

399

208,

684

200,

169

190,

492

197,

161

190,

735

186,

705

180,

950

1304

1019

2400

All GPs Non-owner GPs Owner GPs GDP

Mea

n Re

al A

nnua

l Net

Inco

me

Real GDP per Capita

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Dental Care Utilization, 2000-2012

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 201230%

35%

40%

45%

50%

42.4%43.1%

44.2%

46.1% 46.1% 46.2%

47.5%47.2%

44.4%

46.4%46.2%45.4%

47.6%

38.9%

40.3%40.9%41.0%

40.6%

39.6%39.3%

39.8%

38.4%37.9%36.8%

36.1%35.4%

38.3%38.2%

39.6% 40.0%40.4%

42.5%41.4%

42.3%41.3%41.7%

40.2%

42.4%42.0%

Children 2-18 Adults 19-64 Adults 65 and older

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Dental Benefits: Children

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120%

20%

40%

60%

80%

100%

57

.8%

57

.3%

55

.2%

55

.6%

54

.7%

53

.9%

54

.5%

52

.0%

52

.1%

52

.0%

48

.7%

49

.0%

49

.7%

20

.5%

23

.0%

25

.8%

27

.1%

28

.3%

29

.9%

29

.8%

30

.9%

30

.6%

32

.5%

35

.5%

36

.8%

37

.2%

21

.7%

19

.7%

18

.9%

17

.3%

17

.0%

16

.2%

15

.6%

17

.1%

17

.3%

15

.4%

15

.8%

14

.2%

13

.1%

Private Medicaid or CHIP Uninsured

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Dental Benefits: Adults

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120%

20%

40%

60%

80%

100%

61

.0%

61

.5%

60

.8%

59

.6%

60

.2%

60

.1%

59

.5%

59

.1%

57

.6%

56

.9%

56

.1%

56

.2%

55

.9%

6.5

%

6.5

%

7.4

%

7.7

%

8.0

%

7.9

%

7.8

%

7.9

%

8.4

%

8.6

%

9.3

%

10

.0%

10

.1%

32

.5%

32

.0%

31

.8%

32

.8%

31

.8%

32

.0%

32

.7%

33

.0%

34

.0%

34

.5%

34

.6%

33

.7%

34

.0%

Private Medicaid Uninsured

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Reasons Why Adults Do Not Plan to Visit a Dentist

All Private Insurance Medicaid Medicare Uninsured

-10%

0%

10%

20%

30%

40%

50%

60%

40

.2%

35

.1%

49

.9%

38

.3% 43

.8%

32

.7%

34

.8%

13

.7%

23

.8%

38

.9%

14

.1% 19

.7%

18

.4%

19

.9%

16

.6%

35

.8%

25

.6%

1. Cost

2. My mouth is healthy and I do not need dental care

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Reasons why High Income Adults Do Not Plan to Visit a Dentist

-20%

0%

20%

40%

60%

53.2%

21.9%17.5%

13.5%10.8%

2.9% 2.0% 1.1%

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Financial Barriers to Dental Care

Prescription Drugs

Dental Care Mental Health Services

Eyeglasses Medical0%

2%

4%

6%

8%

10%

12%

14%

16%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

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Changes

• The Affordable Care Act

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Uninsured Rate as of December 2014

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Dependent Coverage Policy

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Marketplace Dental Benefits, 2014 and 2015

2014 Medical Plans 2015 Medical Plans 2014 Stand-Alone Dental Plans

2015 Stand-Alone Dental Plans

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

72.8%63.8%

0.7%1.3%

58.0%70.4%

26.1%34.4% 42.0%

29.6%

0.4% 0.5%

None Family Child Adult

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Marketplace Questions

• Are consumers buying dental benefits?

• Are the dental benefits “good”?• Are consumers using the dental

benefits they purchase?

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Are Consumers Buying Dental Benefits?

Under 18

18-25 26-34 35-44 45-54 55-64 65+0%

10%

20%

30%

20.1% 21.7%26.7%

23.5%19.5%

16.1%10.8%

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Are Dental Benefits “Good”?

First Dollar Coverage for Preventive Pediatric Services?

Medical Plans with Embedded Pediatric Dental Benefits

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Click icon to add picture

Are Consumers Using These Benefits?

?

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Medicaid Expansion15% of

general dentists

50% of

pediatric dentists

are accepting new Medicaid patients

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Medicaid Expansion

IN*NE*SC*LA*VT

WY*VA*SD*DC

MT*MNMI

PA+NJKYAR

NC*MACTNY

WI*AK*CAIAIL

NMOHORRI

WAND+COLi

mite

d A

dult

Den

tal B

enef

its in

Med

icai

dE

xten

sive

Adu

lt D

enta

l Ben

efits

in M

edic

aid

0% 50% 100% 150% 200% 250%11.1%12.2%14.2%15.0%15.3%15.4%15.6%

21.7%25.8%

30.4%45.9%

66.9%93.2%

156.0%198.0%

205.2%9.2%9.6%

27.9%30.4%30.6%

38.2%43.7%

60.8%77.5%

91.1%93.2%

101.4%102.3%

119.5%127.8%

152.5%

9.2% to 205.2% Potential Increase in Medicaid Adults Seeking Dental Services

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Total ACA Benefits Expansion

IL

OH PA MI

NJ AR NM IA ND WI

NC LA VA IN AK MT NE SD WY0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Estimated 2014 Medicaid Increase 2014 Adult Federal SADP Enrollment

States Not Expanding Medicaid under the ACA

States Expanding Med-icaid under the ACA

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Let’s Assume Demand Goes Up…

• Are there enough dentists to keep up?

• Will they want to treat these new patients?

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Dentists per 100,000 Population

2003 2008 2013 2018 2023 2028 203350

52

54

56

58

60

62

64

66

59.160.0

61.762.6 63.1 63.2 63.3

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Percent of Dentists “Not Busy Enough”

Nor

th D

akot

aRh

ode

Isla

ndVe

rmon

tVi

rgin

iaM

inne

sota

Mas

sach

usett

sAr

kans

asW

isco

nsin

Tenn

esse

ePe

nnsy

lvan

iaTe

xas

Mar

ylan

dIn

dian

aN

ew M

exic

oIo

wa

New

Yor

kO

rego

nN

orth

Car

olin

aCo

lora

doN

ew Je

rsey

U.S

. Ave

rage

Ohi

o Ca

lifor

nia

Mic

higa

nSo

uth

Caro

lina

Geo

rgia

Alab

ama

Conn

ectic

utW

ashi

ngto

nIll

inoi

sM

isso

uri

Flor

ida

Ariz

ona

Uta

hKe

ntuc

ky

0%

10%

20%

30%

40%

50%

60%

6%

36%

55%

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Child Medicaid Reimbursement, 2014

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Adult Medicaid Reimbursement, 2014

IL NJ MI MN WA CA RI WI OR CT CO NY KY OH PA IA VA MA NC IN NM SD DC WY VT MT AK ND AR

0%

10%

20%

30%

40%

50%

60%

70%

13

.8%

60

.5%

Pe

rce

nta

ge

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Opportunities and Strategies

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Emphasis on Value

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Leveraging the Value Agenda

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Increased Care Coordination

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Consumerism

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Increase Dental Care Utilization

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Rethink the Role of the Dental Practice

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Practice Consolidation

The trend toward larger, consolidated multi-site practices is expected to continue, driven by changes in practice patterns of new dentists, a drive for efficiency, and increased competition for patients.

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Career Choices – Group Practice

Dentists in large group practices… – reported lower satisfaction levels associated with work hours,

scheduling, and overall work-life balance– reported less ability to influence the organization or to advance within

it– reported higher satisfaction levels with income and benefits– were less likely to report feeling stressed in their jobs– were less likely to be satisfied with the care delivered in their practice– were less likely to report satisfaction with their careers in dentistry

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Student DebtWhat are the trends in dental student debt? How does this compare to higher education in general?What is the impact of dental student debt on career choices?

– Pursue advanced education – Work in private practice or public health, government, faculty

position– Own a practice– Hours worked per year– Accept uninsured and Medicaid patients

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Student Debt

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Student Debt

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Student Debt

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Thank You!

For more information visit the ADA Health Policy Institute at:

www.ada.org/hpi