Assessing the contribution of the dental care delivery system to oral health care disparities

Oral disease is a significant health problem in the U.S. and the burden of oral disease falls more heavily on the poor and racial/ethnic minorities who have less access to oral health care.(1, 2) These populations experience disparities in access to dental care, including fewer dentist visits, and this lower utilization has been linked to poorer oral health.(2–4) Disparities are partly due to lack of dental insurance, leading to policies to promote access by providing public insurance and directing federal funds to low-cost providers in dental health shortage areas. Yet, difficulties in access to care for the underserved exist due to the inadequacies of the dental care delivery system.(2, 5, 6) Efforts to improve access often focus on increasing supply of providers, frequently measured as presence of licensed dentists in an area.(7, 8) These efforts are based on the assumption that availability of more dentists will increase access to dental care for everyone. But general supply measures fall short of evaluating the true capacity for providing dental care to the underserved. A comprehensive evaluation should examine characteristics such as part-time employment, size of staff and operatories, accepting public coverage or reduced fees, or multilingual practices. The dearth of such information hinders the development of more effective policies to address systemic barriers that lead to racial/ethnic disparities. Studies of the role of supply using limited licensure or professional association membership data provide a broad overview of supply but lack sufficient detail.(7) Other studies of the role of dental care delivery system in access are slowly emerging. Dental health professional shortage areas are designated based on age of the dentist, the number of hours the dentist works (full-time equivalent or FTE), and the number of allied personnel in the practice.(9) Two studies have indicated that dentists’ characteristics were linked to provision of care to publicly insured patients. Specifically, dentists who were less busy, pediatrician, African American, or Latino were more likely to see Medicaid patients, but dentists who were non-solo, female, and older were less likely to do so.(10, 11) Another study found that bilingual/multilingual capacity in practice, acceptance of discounted fees, multiple practice locations, shorter appointment times, and provision of more operative, periodontic, and surgical care were positively associated with dentists’ provision of care to publicly insured patients.(5) However, few available studies have directly assessed the role of the dental delivery system as measured by a broad range of dentist characteristics on access to care in general and on disparities in access to care in particular. We developed an analytic framework (Figure 1) to examine the role of the dental care delivery system in disparities in access to dental care. This framework complements Andersen’s conceptual framework by developing the contextual indicators of access to care (12) and builds on another framework to identify indicators of service provision by dentists.(13) In this study, we propose that overall measures of supply of dental care include the safety net and private practice dentist supply (e.g., the ratio of full-time equivalent dentists per 5,000 population in private and safety net settings). The capacity for providing care in private practice further consists of personal characteristics of dentists (e.g., sex, years in practice), their practice structure and work characteristics (e.g., number of dental assistants, how busy), financial indicators (e.g., payer source), and cultural competency (e.g., non-English capacity). Access to oral health in general, and for underserved populations in particular, is determined by overall supply and capacity in the private setting, but these effects are modified by population’s characteristics including predisposing, enabling, and the level of need. In our analyses, we anticipated that access is promoted with more public and private practice dentists per 5,000 population. Also, more dentists who accept discounted fees or publicly insured patients, or are multilingual promote access, particularly for the underserved. Alternatively, access in inhibited when dentists are older, newly graduated, female, specialist, white, not busy or overworked or have smaller practices (no hygienists, fewer dental assistants, fewer visits, longer wait times, longer appointment time per visit) or multiple locations. We examined if these effects differed by race/ethnicity and income. Figure 1 The framework for assessing the role of dental care delivery system on access to care overall and for underserved populations