A total of $2.6 trillion was spent in 2010 on health care in the United States, and of this amount, 56% consisted of wages for health care workers. Labor is by far the largest category of expense. Health care, as it is designed and delivered today, is very labor-intensive.(1) The 16.4 million U.S. health care employees represented 11.8% of the total employed labor force in 2010.(1) Health care has experienced no gains over the past 20 years in labor productivity, defined as output per worker. As well, health care labor is becoming more expensive more rapidly than other types of labor. Add to this, 34 million additional people over the next 10 years will receive health insurance coverage under the Affordable Care Act (ACA).(2,3) A report by the McKinsey Global Institute states that for the United States to return to full employment, as many as 22.5 million jobs would need to be created, with 5.2 million, or 23%, in the health care sector.(4) One way to improve the labor structure in health care can be achieved by increasing productivity. We will need to redesign the care delivery model very basically, to use a different quantity and mix of personnel performing a much higher value set of activities. This could definitely affect dental hygiene and dentistry, and is one of the reasons we need to redefine our educational structure to meet future demands. Approaches that encourage delegation of tasks from physicians and nurses to other workers, or from dentists to dental hygienists and dental therapists may provide opportunities for additional savings and increased productivity.
A large obstacle to such an extensive reform is the intricacy of the federal and state reimbursement rules and requirements for scope of practice, licensure, and staffing ratios. Examples of the current inflexibility is the requirement that all imaging centers have a physician on hand at all times if intravenous contrast may be administered, or that oral care offices have a dentist present even when a preventive prophylaxis is being performed.(5) In reality, other health care professionals could be (and in some cases are) adequately educated and trained to respond effectively to medical emergencies, which would allow physicians and dentists to fill higher-productivity roles. The profession of law has experienced such a transformation, with the number of jobs for paralegals and legal assistants growing 2.5 times as quickly as that for attorneys in the 2000s.(1) Some states have expanded practice setting for dental hygienists, increasing access to care. Examples are Registered Dental Hygienist in Alternative Practice in California, and Dental Hygienist, Limited Access Permit, in Oregon.(6,7) This trend is troubling as we enter a phase of transformation in health care. Today, more than 60% of non-physician labor is nonclinical and is fragmented across various provider organizations, payer systems, and delivery models.(8) For every physician, only six of the sixteen non-physician workers have clinical roles, including registered nurses, allied health professionals, aides, care coordinators, and medical assistants. This is not predominantly associated with delivering better patient outcomes, lowering costs, or increasing access to care.(8) Federal and state laws and other policies limit how professionals can help meet the growing need for primary care, such as nurses and dental hygienists.(9) Look for future issues of this newsletter as I share more information from the “Transforming Dental Hygiene Education” Symposium.References 1. Kocher R and Sahni N R. Rethinking Health Care Labor. N Engl J Med 365; 15, p 1370-1372. October 13, 2011. 2. Congressional Budget Office. CBO’s March estimate of the effects of the insurance coverage provisions contained in the Patient Protection and Affordable Care Act (Public Law 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152). March 2011. (http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf) 3. http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/121xx/doc12119/03-30-healthcarelegislation.pdf. 4. McKinsey Global Institute. An economy that works: job creation and America’s future. June 2011. http://www.mckinsey.com/insights/employment_and_growth/an_economy_that_works_for_us_job_creation. 5. American College of Radiology. ACR practice guideline for the use of intravascular contrast media. 2007. Revised 2012. (http://www.acr.org/~/media/536212D711524DA5A4532407082C89BA.pdf) 6. http://www.dhcc.ca.gov/consumers/duties_rdhap.shtml. 7. http://licenseinfo.oregon.gov/index.cfm?fuseaction=license_seng&link_item_id=14703. 8. Kocher R. The Downside of Health Care Job Growth. Harvard Business Review. September 23, 2013. http://blogs.hbr.org/2013/09/the-downside-of-health-care-job-growth/. 9. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=79.