There are serious flaws in the methodology used by the federal government
identify and designate areas with a shortage of oral health care providers
areas of high unmet need, according to a UCSF study.
Researchers in the UCSF Center for California Workforce Studies and the
Center to Address Disparities in Children's Oral Health have challenged
methodology of federal requirements for placement of dentists and
hygienists in underserved communities and have made recommendations
modifying the Dental Health Professional Shortage Area (DHPSA). The study
published by the UCSF Center for California Work Studies.
In 1970 the federal government established the National Health Service
program which placed professionals in areas designated as underserved.
qualify for the placement of professionals and other federal
programs, communities must apply for the DHPSA designation by documenting
the provider shortage in the community according to federal standards.
pieces of current legislation (CA, AB668 and AB982, Federal S1626) question
use of these criteria and call for revising the methods for contemporary
health system needs. The legislation supports the analyses done by the
The UCSF researchers recommend modifying the DHPSA criteria to
methodological weaknesses including an over dependence on a
population-to-provider ratio which results in an inattention to indicators
need. Their recommendations are designed to inform policy makers,
those involved in current legislative initiatives.
"When the original criteria were developed, the government was concerned
the lack of oral health professionals in rural communities. The theory
that by educating more dentists and placing them in these underserved,
communities for a limited period of time that access to care issues would
solved and disparities would be reduced," said Elizabeth Mertz, MPA,
project director at the Center for Health Professions.
"Today we know that just producing more dentists won't solve the problem
that communities of need can be found even in otherwise heavily
dentist-populated urban areas. We need a better tool for identifying where
what type of need exists and tailoring the distribution of government
to the actual need," said Mertz.
The lack of oral health professionals in disadvantaged rural and urban
the U.S. and resulting lack of access to care for those populations
to the striking oral health disparities that exist in our country, Mertz
"If we cannot adequately identify communities with a shortage of
based on high levels of unmet need, the very foundation for the programs
policies which use this criteria is shaken," she said.
The report recommends six steps toward revising the methodology used
designate areas as having a shortage of oral health
1. Increase the responsibility of state and federal agencies for defining
health professional shortage areas and thus decrease the substantial
placed on local communities;
2. Construct an Index of Dental Underservice (IDU) as a new measure
shortage designations based on indicators of need as well as
3. Use state licensure and renewal mechanisms to develop requisite
collection methods and tools to measure the supply, distribution,
and practice characteristics of the professions;
4. Include an alternative designation process for hard-to-measure areas
populations that do not qualify under the IDU, such as
elderly or people with disabilities;
5. Allow presumptive DHPSA eligibility for providers documented to
underserved populations (federally qualified health centers, public
clinics, community health centers, migrant health centers, etc.)
6. Develop rational service areas specific to the dental market rather
rely on county divisions or rational service areas defined for medical
as the de-facto guidelines for dental service provision.
The communities and populations with oral health disparities are
rural, poor and/or minority and tend to be the same communities that
shortages of oral health professionals or are not adequately represented
terms of race/ethnicity in the dental workforce. Therefore, the
said, any changes in federal methods and programs to address these issues
of great importance to efforts to reduce oral health disparities.
Kevin Grumbach, MD, UCSF professor of family and community medicine,
principal investigator of the study and Joshua Orlans, UCSF research
is a co-author.
The study was supported by the National Institute of Dental and
Research through the UCSF Center to Address Disparities in Children's
Health and by the Center for Information and Analysis, Bureau of the
Professions. The study contents are the sole responsibility of the authors
do not necessarily represent the official views of NIDCR or HRSA.