There are serious flaws in the methodology used by the federal
government to identify and designate areas with a shortage of oral health care providers and areas of high unmet need, according to a UCSF study.

Researchers in the UCSF Center for California Workforce Studies and the UCSF Center to Address Disparities in Children's Oral Health have challenged the methodology of federal requirements for placement of dentists and dental hygienists in underserved communities and have made recommendations for modifying the Dental Health Professional Shortage Area (DHPSA). The study was published by the UCSF Center for California Work Studies.

In 1970 the federal government established the National Health Service Corps program which placed professionals in areas designated as underserved. To qualify for the placement of professionals and other federal assistance programs, communities must apply for the DHPSA
designation by documenting the provider shortage in the community according to federal standards. Three pieces of current legislation (CA, AB668 and AB982, Federal S1626) question the use of these criteria and call for revising the methods for contemporary oral health system
needs. The legislation supports the analyses done by the Center.

The UCSF researchers recommend modifying the DHPSA criteria to eliminate methodological weaknesses including an over dependence on a population-to-provider ratio which results in an inattention to indicators of need. Their recommendations are designed to inform policy makers, including those involved in current legislative initiatives.

"When the original criteria were developed, the government was concerned with the lack of oral health professionals in rural communities. The theory was that by educating more dentists and placing them in these underserved, rural communities for a limited period of time that access
to care issues would be solved and disparities would be reduced," said Elizabeth Mertz, MPA, UCSF project director at the Center for Health Professions.

"Today we know that just producing more dentists won't solve the problem and that communities of need can be found even in otherwise heavily dentist-populated urban areas. We need a better tool for identifying where and what type of need exists and tailoring the distribution of government resources to the actual need," said Mertz

The lack of oral health professionals in disadvantaged rural and urban areas of the U.S. and resulting lack of access to care for those populations contributes to the striking oral health disparities that exist in our country, Mertz said.

"If we cannot adequately identify communities with a shortage of providers based on high levels of unmet need, the very foundation for the programs and policies which use this criteria is shaken," she said.

The report recommends six steps toward revising the methodology used to designate areas as having a shortage of oral health professionals:

1. Increase the responsibility of state and federal agencies for defining oral health professional shortage areas and thus decrease the substantial burden placed on local communities;

2. Construct an Index of Dental Underservice (IDU) as a new measure for shortage designations based on indicators of need as well as supply;

3. Use state licensure and renewal mechanisms to develop requisite data collection methods and tools to measure the supply, distribution, composition and practice characteristics of the professions;

4. Include an alternative designation process for hard-to-measure areas or populations that do not qualify under the IDU, such as institutionalized elderly or people with disabilities;

5. Allow presumptive DHPSA eligibility for providers documented to serve underserved populations (federally qualified health centers, public health clinics, community health centers, migrant health centers, etc.)

6. Develop rational service areas specific to the dental market rather than rely on county divisions or rational service areas defined for medical services as the de-facto guidelines for dental service
provision.

The communities and populations with oral health disparities are generally rural, poor and/or minority and tend to be the same communities that have shortages of oral health professionals or are not adequately represented in terms of race/ethnicity in the dental workforce. Therefore, the researchers said, any changes in federal methods and programs to address these issues are of great importance to efforts to reduce oral health disparities.

Kevin Grumbach, MD, UCSF professor of family and community medicine, is principal investigator of the study and Joshua Orlans, UCSF research associate, is a co-author.

The study was supported by the National Institute of Dental and Craniofacial Research through the UCSF Center to Address Disparities in Children's Oral Health and by the Center for Information and Analysis, Bureau of the Health Professions. The study contents are the sole responsibility of the authors and do not necessarily represent the official views of NIDCR or HRSA.

To review a copy of the report, please visit the website:
http://futurehealth.ucsf.edu/publications.

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