PHE 610 Module 8 Milestone Three Example

A Phased Path to Dental Therapy: Comparing Options and Recommending a Course of Action

[Student Name]

Southern New Hampshire University

PHE 610: Health Policy and Management

Final Project Milestone Three

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

A Phased Path to Dental Therapy: Comparing Options and Recommending a Course of Action

Introduction

Milestones One and Two set out the problem, a state where most counties lack enough dentists and reservation clinics keep patients waiting for months, and described four options against five criteria. This milestone scores those options and recommends a course of action. The recommendation is a phased approach: in the coming session, let the three tribal health programs hire dental therapists trained through the federal tribal certification route; then, once two years of outcomes have been reported, license dental therapists statewide for practice in shortage areas and safety net settings, with direct Medicaid billing. The sections below show how the scoring leads to that recommendation, how it would be carried out and how the state would know whether it worked.

Weighting the Criteria

Bardach and Patashnik (2020) warn that the hardest part of policy analysis is often the trade-off among criteria, not the projection of outcomes. Weights make those trade-offs explicit. Effectiveness and equity each receive 30 percent, because the problem is a gap in care concentrated among rural and American Indian residents. The remaining 40 percent is split three ways: quality and safety and feasibility take 15 percent apiece, and cost takes 10. Safety is weighted lower than might be expected only because all options except the status quo rest on evidence of acceptable quality; it is treated as a threshold that any option must pass.

Scoring the Options

Table 1 scores each option from 1 (poor) to 5 (strong). Statewide licensure scores highest on effectiveness and equity because it reaches rural non-tribal counties as well as reservations. Tribal-only authorization scores well on effectiveness where it applies but lower on equity, since about two thirds of residents in shortage counties are not tribal members. Higher fees with loan repayment would draw some dentists into Medicaid, but Buchmueller et al. (2016) showed that dentists respond to fees where they are already present, which is not the case in empty counties, so its effectiveness score is modest. It is also the most expensive option. The status quo is cheap and feasible but changes nothing.

Table 1. Weighted Scores for Four Options

Testing the Result

A recommendation should survive reasonable disagreement about weights. If feasibility is raised to 35 percent and effectiveness and equity fall to 20 percent each, tribal-only authorization scores 3.60 and statewide licensure 3.25, and the ranking flips. In other words, the choice between the two leading options depends on how much weight one gives to the chance of passage. Legislators in the two prior sessions clearly weighted feasibility heavily; tribal governments and safety net clinics weight access and equity. A phased option captures most of the benefit of statewide licensure while starting with the option most likely to pass.

The Recommendation

The state should adopt a two-phase policy. In phase one, tribal clinics may hire therapists who hold federal tribal certification, and the Medicaid agency must reimburse their work. Phase two, enacted in the same bill but taking effect three years later unless the legislature votes otherwise, opens a state license to therapists who work in shortage counties or in clinics whose patients are mostly on Medicaid or uninsured, each under a collaborative agreement with a dentist. The automatic second phase is the key design choice: it turns the dental association's demand for in-state evidence into a schedule rather than a veto.

Answering the Safety Objection

The dental association's central objection is that only a dentist's training makes drilling and extraction safe. The evidence does not support that concern for the procedures in the bill. In Alaska, communities with more therapist treatment days saw fewer extractions and more preventive care, not more complications (Chi et al., 2018). The recommendation adds safeguards that answer the objection directly: a limited scope that excludes complex procedures, a requirement that collaborative agreements specify referral rules, and annual reporting of chart reviews to the dental board during phase one.

Implementation Plan

Implementation would follow the stages of the Consolidated Framework for Implementation Research, with attention to the outer setting of professional opposition and the inner setting of agency capacity (Damschroder et al., 2009).

Table 2. Implementation Steps

Evaluation Plan

The evaluation will set the tribal clinics that hire therapists beside comparable clinics that do not, drawing on Medicaid claims and clinic records that begin two years before phase one and continue for three years after it. Five measures will be tracked: dental visits per 1,000 enrollees of all ages; the ratio of restorations to extractions, a marker of whether teeth are being saved; emergency department visits for nontraumatic dental conditions; wait time for a routine appointment; and adverse events reported through chart review. Because untreated decay is among the most common conditions worldwide and its burden falls on disadvantaged groups (Peres et al., 2019), each measure will be broken out by rural, tribal and urban residence.

Conclusion

Statewide licensure would do the most good, but it has failed twice. Tribal-only authorization could pass, but it would leave most residents of shortage counties without a new provider. A phased policy, with an automatic second phase backed by in-state evidence, offers the best balance of effectiveness, equity and feasibility under the weights this analysis set in advance. The final project will develop it into a complete policy analysis.

References

Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.

Buchmueller, T., Miller, S., & Vujicic, M. (2016). How do providers respond to changes in public health insurance coverage? Evidence from adult Medicaid dental benefits. American Economic Journal: Economic Policy, 8(4), 70-102. https://doi.org/10.1257/pol.20150004

Chi, D. L., Lenaker, D., Mancl, L., Dunbar, M., & Babb, M. (2018). Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta. Journal of Public Health Dentistry, 78(2), 175-182. https://doi.org/10.1111/jphd.12263

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Peres, M. A., Macpherson, L. M. D., Weyant, R. J., Daly, B., Venturelli, R., Mathur, M. R., Listl, S., Celeste, R. K., Guarnizo-Herreño, C. C., Kearns, C., Benzian, H., Allison, P., & Watt, R. G. (2019). Oral diseases: A global public health challenge. The Lancet, 394(10194), 249-260. https://doi.org/10.1016/S0140-6736(19)31146-8