Exploring the Impact of Expanded Roles for Dental Hygienists in Ontario Glen Randall Patricia Wakefield DeGroote School of Business McMaster University

Outline Background Objectives Methods Results Discussion / Implications

Background Good oral health has been linked with overall health. ▫Heart and respiratory disease (Matrear, 1998) ▫Pneumonia (Adachi et al., 2002; El-Solh et al., 2004) ▫Risk of Stroke (Grau et al., 1996) ▫Reduction in quality of life for seniors (McGrath and Bedi, 1998; Steele et al., 2004) ▫Low birth wait babies (Offenbacher et al., 1996)

Background Governments have attempted to address issues of access/equity and system efficiency/costs in health care by optimizing the use of health professions: ▫Creating new professions  E.g. Midwives, nurse practitioners, physician assistants ▫Expanding roles (scopes of practice) of existing professions  E.g. Pharmacists, physiotherapists, dental hygienists

Background Human resources account for up to 80% of health care costs One approach to improving the efficiency of the system is to promote labour market adjustments which would alter the skill mix of professionals ▫It has been suggested that there is a labour imbalance between dentists to dental hygienists. ▫The current mix is 1 dentist for every 1.4 dental hygienists ▫Suggested mix of 1 dentist for every 10 dental hygienists (Manga, 2002; Ontario Economic Council, 1976) ▫The public is very comfortable receiving care from a dental hygienist (Perry, Freed, & Kushman, 1997; Edgington & Plimlott, 2000)

Background Following more than a decade of lobbying from the dental hygiene profession, in 2007, the Ontario government passed legislation that would permit dental hygienists to self-initiate (i.e. Services with no order from a dentist) ▫Rational:  Increase choice of service provider ▫Promotes competition and greater consumer control  Enhance access to care / equity of access (vulnerable populations) ▫Improve individual and population health  Improve efficiency and lower cost to health system ▫Through increased competition

Objective To explore and analyze the policy implications associated with an expanded role for dental hygienists in Ontario which allows these professionals to self- initiate some controlled acts. ▫And in particular to assess whether this reform resulted in:  Increase choice of service provider / competition  Enhance access to care / equity of access  Improve efficiency and lower cost to health system

Methods Qualitative case study of this health care reform initiative. ▫Review of administrative data  Policies, legislation, reports, position statements etc. ▫32 in-depth interviews with preventive oral care key informants  Dentists; dental hygienists; professional association; regulatory bodies; policy-makers  Analysis of interview transcripts identifying recurrent themes

Results Increase choice of service provider / competition? ▫Yes, but on a very limited scale  A very small proportion of dental hygienist actually opened an independent practice ▫2,700 of the province’s 11,000 dental hygienists have received authorization from their regulatory to perform self-initiation ▫approximately 150 dental hygienists have opened independent practices (just over 1%) ▫dental hygienists remain unable to prescribe drugs, administer conscious sedation, or order radiographs

Results Enhance access to care / equity of access? ▫Yes, but also on a very limited scale  Greatest value seems to be those dental hygienists who are now providing on-site care: ▫Nursing homes ▫Long-term care facilities ▫Remote areas (including some first nations)

Results Improve efficiency and lower cost to health system ? ▫No, individuals who thought there may have been some cost saving (and lower fees) generally found that the cost of operating independent practices (with all of the associated overheads costs) meant they were not able to have any dramatic reduction in fees charges  One exception were individuals who provided more limited on-site services in urban areas ▫Those who did have lower fees and/or provided services in remote locations viewed their efforts as borderline philanthropic

Results Other findings: ▫Increased tension between dentists and dental hygienists in some cases  Examples of some hygienists being required to sign non- competition agreements with their dentist employer  Significant concerns about non-hygienists doing the work of a hygienist in some dental practices  Examples of some dentists refusing to provide services to patients seen by an dental hygienist in independent practice ▫But also some examples of good working relationships evolving

Discussion / Implications Reliance on free markets may not result in adequate competition (especially in the delivery of health care services) ▫And therefore the associated anticipated cost savings (may have some access benefits) Legislation that changes scopes of practice may not be sufficient to change how services are actually delivered ▫Lack of interest (not entrepreneurial) ▫Need for business training (skills to run a business) ▫Other barriers (relationship with dentists etc.)

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