The Growing Use of Locums Tenens Dentists

Healthcare Technology Trends in 2024: Enabling Patient Care at Home The Growing Use of Locums Tenens Dentists

Introduction

Why are more dental practices, Federally Qualified Health Centers (FQHCs), Dental Support Organizations (DSOs) and other sites of service using temporary (i.e., locum tenens) dentists?

Why are more dentists embracing this emerging practice style?

How does the locum tenens process work from the practice’s or the FQHC’s perspective and from the dental practitioner’s perspective? What are the cost/benefits of dental locum tenens and what is the role of temporary dental staffing agencies? And how has COVID-19 affected the dental staffing market? AMN Healthcare has prepared this white paper to address these and related questions. It is intended as a resource for dentists, FQHC administrators, practice managers, healthcare policy analysts, journalists and others who monitor healthcare workforce trends, and as a source of information for our clients and dental practitioners.

Trends in locum tenens dentistry in many ways mirror patterns previously established in nurse and physician staffing. A clearer view of locum tenens dentistry emerges with an examination of these patterns.

AMNHealthcare.com | 2

The Growing Use of Locums Tenens Dentists

BACKGROUND: Physicians, Nurses, and Now Dentists Embrace the Temporary Staffing Model

Locum tenens, or the practice of one clinical professional “taking the place of” another, has been accepted in medicine for many years. As far back as the 1800s or earlier physicians would call upon colleagues to “mind the store” for them while they were away on travels or for other reasons. The practice continued into the modern era, though on a limited, ad hoc basis. This began to change in the 1970s when the federal government, concerned about physician shortages in rural areas, offered grants to private companies to help staff these areas. The physician locum tenens staffing industry was born, and hospitals, medical groups and other facilities now invest billions of dollars each year on locum tenens physician staffing. One reason for the rapid growth of the industry is that the physician shortage has grown more widespread, with the Association of American Medical Colleges (AAMC) projecting in a June 2021 study a deficit of up to 124,000 physicians by 2034 ( The Complexities of Physician Supply and Demand. Association of American Medical Colleges. June 2021 ). Hospitals, FQHCs, medical groups and other facilities that cannot find permanent physicians in a timely manner are using locum tenens physicians to maintain services and revenue during the interim. According to Staff Care’s 2020 Review of Temporary Physician Staffing Trends , 85% of hospitals and medical groups use locum tenens physicians, usually to hold a place until permanent physicians can be recruited, to address turnover, or to fill-in while physicians are on vacation, sick or otherwise absent.

AMNHealthcare.com | 3

The Growing Use of Locums Tenens Dentists

Similar dynamics have taken place in nursing, where shortages have led to the widespread use of temporary nurses, often referred to as “travelers.” Widespread shortages of healthcare professionals have created a clinical workforce that has become increasingly mobile and less tied to a particular site of service.

This trend, long confined to other professions, has migrated into dentistry. Below is a review of trends and metrics driving dentist supply and demand and the use locum tenens dentists.

SUPPLY CONSIDERATIONS: Dental Schools and Dental Students Fragmented workforce management models U.S. teaching hospitals have been producing about the same number of physicians – around 30,000 – since a cap on spending on physician training was imposed by Congress in 1997. Similarly, the number of dental school graduates peaked at 5,750 in 1982, then declined for sixteen years and stayed flat at about 4,500 for almost a decade. Since 2011, however, ten new dental schools have been granted accreditation by the Commission on Dental Accreditation and as of 2021 there are 68 accredited dental schools in the U.S. spread across 36 states and 10 dental schools in Canada. According to the American Dental Association (ADA), the total number of students in U.S. dental schools in the 2020-21 academic school year is 25,995, up from 25,807 the previous year. Current predoctoral dental school enrollment now is at an all-time high of 25,995, up from the previous peak of the early 1980s when enrollment reached 22,842.

The dental school class of 2020 had 6,609 graduates, up from 6,350 in 2019.

AMNHealthcare.com | 4

The Growing Use of Locums Tenens Dentists

Following are data points regarding the dental workforce in the U.S. as compiled by the ADA:

THE U.S. DENTAL WORKFORCE/KEY STATISTICS As of 2020, there were 201,117 dentists working in dentistry (dentists using their dental degree in some fashion) in the U.S. As of 2020, there were 61.04 dentists working in dentistry per 100,000 U.S. population. Ratios vary by state. As of 2020, 34.5% of dentists are female. As of 2020, about one in five professionally active dentists (21.2%) reported that their practice, research, or administration area is an ADA-recognized specialty. Among the 201,117dentists working in dentistry, 17.0% are 34 or younger, 24% are ages 35 - 44, 21.6% are ages 45 - 54, 21.1% are ages 55 - 64, and 16.3% are age 65 and older.

In 2020, the average age of retirement among dentists was 68, up from 66.5 in 2008.

The average first-year cost of dental school in the U.S. is $41,711 for public schools and $75,161 for private schools. 50% of private practice dentists are in solo practice. As of 2020, dentists work an average of 35.7 hours per week. Male dentists work an average of 36.2 hours per week, female dentists work an average of 34.8 hours per week. 70.2% of dentists identify as white, 18% as Asian, 5.9% as Hispanic, 3.8% as black and 2.2% as other.

Source: American Dental Association. 2021.

AMNHealthcare.com | 5

The Growing Use of Locums Tenens Dentists

A Growing Number of Female Dentists In 1976, only 4.6% of graduating dental students were female, a number that increased to 36.4% in 1996, to 48% in 2015 and in 2020 stood at 51.4%, according to the ADA. Over one-third (34.5%) of all practicing dentists now are female. Medicine also has seen a significant influx of females, and today 35% of active patient care physicians are female, while over 50% of medical students are female. An Emerging Shortage Despite growth in the number of dentists being trained, a shortage of dentists in the U.S. is emerging. The U.S. Health Resources and Services Administration (HRSA) released a report projecting a shortage of 15,600 dentists in the U.S. by 2025. All 50 states and the District of Columbia are projected to experience this shortage, the report states. States predicted to have the greatest shortfalls are California at 1,234 too few dentists, Florida, with 1,152 too few, and New York, with 1,024 too few. Spending on dental care suggests that utilization of dental services is on the rise. In 2015, national spending on dental care reached $119.1 billion, up from $97.3 billion in 2007. In 2018, the latest year for which numbers are available, national spending on dental care increased further to $135 billion, according to the Centers for Medicare and Medicaid Services (CMS). Overall employment of dentists is projected to grow eight percent from 2020 to 2030, according to the Bureau of Labor Statistics (BLS). About 5,000 openings for dentists are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force through retirement.

AMNHealthcare.com | 6

The Growing Use of Locums Tenens Dentists

A Maldistribution of Dentists There is a longstanding maldistribution of dentists in the U.S., just as there is a longstanding maldistribution of physicians. This has led to dental shortages in rural and inner-city communities, as well as shortages in certain population groups, such those served by Indian Health Service facilities or correctional facilities. As of 2020, there were 6,486 dental care health professional shortage areas (HPSAs) in the United States and its territories, according to the Health Resources and Services Administration (HRSA). These areas cover a population of 59,941,090, and only 29.28% of their needs are met. Two-thirds (66%) of dental HPSAs are in rural areas, the remaining 34% are in non-rural areas. HRSA considers a population that falls below a minimum standard of one dental provider per 5,000 people to be underserved (or below one dental provider per 4,000 people in areas determined to have a particularly high need for dental services).

According to HRSA, the nation needs 10,716 more dental practitioners to remove these HSPA designations.

California leads the nation with 473 dental care HPSAs, requiring 247 practitioners to remove these designations. Missouri is second with 314 dental care HPSAs, requiring 373 practitioners. Texas, Alaska, and Florida follow with 302, 298, and 256 dental care HPSAs, respectively, requiring 431, 35, and 1,320 practitioners.

THE GROWING ROLE OF FQHCS IN DENTAL CARE Often, HPSAs correspond to areas where Federally Qualified Health Centers (FQHCs) are playing a vital role in dental care. FQHCs provide primary and dental care to traditionally underserved populations at low to no cost. They now provide care to over 28 million people per year in close to 9,000 different sites of service. These patients include over 6.8 million dental patients, according to the National Association of Community Health Centers (NACHC). Over 80% of community health centers now provide on-site dental services, an increase of 30% since 2010.

AMNHealthcare.com | 7

The Growing Use of Locums Tenens Dentists

Note: AMN Healthcare is proud to be NACHC’s sole provider of locum tenens staffing services and to partner with community health centers nationwide on physician, dentist, and advanced practitioner staffing efforts. The role FQHCs are playing in dental care increased over the last several years due in part to the fact that in June 2016, the Department of Health and Human Services (HHS) awarded $156 million to 420 FQHCs around the country to help address an overwhelming demand for affordable dental care. The growing role of FQHCs and other no or low-cost dental providers also is driven in part by the fact that many Americans lack dental insurance. According to the National Association of Dental Plans, 39% of Americans (124 million people) have no dental benefits of any kind, compared to about 10% of adults today who do not have medical insurance. As the population ages, lack of dental insurance is becoming an even more pronounced problem as Medicare does not cover the cost of most dental procedures, further enhancing the role of community health centers in dental care. The Effect of COVID-19 The COVID-19 pandemic has had a profound effect on the healthcare industry, creating disruption and financial challenges at hospitals, medical groups, FQHCs, and dental practices of all types. Hospitals lost billions of dollars as elective procedures were shut down to create more resources for treating COVID19 patients. Eight percent of physicians closed their practices, at least temporarily, while many were furloughed, according to the 2020 Survey of America’s Physicians, conducted by Merritt Hawkins on behalf of The Physicians Foundation. Dental practices were hit particularly hard by the pandemic, as patients put off both regular care and dental procedures over concerns about the virus. The following statistics from the ADA’s Health Policy Institute quantify the impact the pandemic has had on dental practices: Annual income earned by general practice dentists declined from $207,234 in 2019 to $170,164 in 2020, a decrease of 17.9% Annual income earned by dental specialists declined from $347,650 in 2019 to $323,776 in 2020, a decrease of 7%. Income for female dental general practices declined more steeply than for males. Female dental GP

income declined by 26.6% from 2019 to 2020, compared to a 14.7% decline for males. Average hours worked per week for dental GPs dropped 16.6% from 2019 to 2021. Average hours worked per week for dental specialists dropped 11.7% from 2019 to 2020. In 2020, dentist received an average of $95,000 in Covid-related financial relief.

The pandemic effectively ended recruiting at many dental practices and led to furloughs or layoffs of dentists, hygienists, and other dental workers. According to NACHC, FQHCs were obliged to layoff 100,000 healthcare professionals during the height of the pandemic.

AMNHealthcare.com | 8

The Growing Use of Locums Tenens Dentists

A MARKET TURNAROUND As has been seen in acute care and outpatient care settings, demand for medical services has rebounded since the pandemic began. The availability of vaccines and the widespread adoption of patient protective equipment (PPE) has restored the confidence of many patients in the safety of healthcare settings, including dental practices. While the delta variant has created patient surges in some areas, shutdowns of elective services are not expected to be as severe as in previous surges, as healthcare facilities are more prepared to cope with them than they were initially. GROWING DEMAND FOR HYGIENISTS A strong sign the demand for dental services has returned is the fact that many dental practices are recruiting dental hygienists and are having a difficult time finding them. A May 2021 poll from the ADA’s Health Policy Institute found that: 36% of owner dentists are recruiting dental assistants, 29% are seeking dental hygienists, 26.5% are looking to hire administrative staff and 13% are in search of associate dentists — all four percentages representing a rise in recruitment since October 2020. Compared with before the pandemic, more than 80% of owner dentists who are currently hiring are finding the recruitment of dental hygienists and assistants to be extremely or very challenging. 66% of dentists said recruitment of dental hygienists was extremely challenging and 20% reported it was very challenging. 59% of dentists found recruitment dental assistants to be extremely challenging and 29% stated it was very challenging.

Source: ADA News. June 9, 2021

AMN Healthcare has observed that many dental practices are in growing need of dentists but are delaying recruitment efforts until they have the necessary dental hygienists in place.

AMNHealthcare.com | 9

The Growing Use of Locums Tenens Dentists

USE OF LOCUM TENENS DENTISTS RISING An emerging shortage of dentists and the industry rebound from COVID-19 have led to a significant increase in the use of locum tenens dentists in recent years. Prior to 2005, AMN Healthcare received virtually no requests for locum tenens dentists, with virtually 100% of the requests we received to fill “temporary days” being for physicians. By 2015, however, 5% of our total temporary days requested were for dentists. That number rose to 6% in 2019, dropped in 2020 due to the pandemic, but is expected to be 5% in 2021, a 50% increase over the previous year.

Based on the requests we receive, the types of dentists in most demand as locum tenens are as follows:

DENTISTS IN MOST DEMAND AS LOCUM TENENS 1. General Practice 2. Pediatrics 3. Endodontic 4. Oral and Maxillofacial

The graphs below include further data reflecting supply and demand trends in dentistry.

NUMBER OF DENTISTS BY SPECIALTY AND PER POPULATION/2019

SPECIALTY

NUMBER OF DENTISTS

DENTISTS PER 100,000

Dental Public Health

1,076

0,36

Endodontics

4,445

1,48

General Practice

163,563

54,52

Oral and Maxillofacial

0,03

Oral Pathology

476

0,16

Oral Surgeon

6,450

2,15

Orthodontics

9,475

3,16

Pedodontics

4,932

1,64

Periodontics

5,106

1,70

Prosthodontics

3,359

1,12

Source: Kaiser Family Foundation and www.statefacts.org

AMNHealthcare.com | 10

The Growing Use of Locums Tenens Dentists

LOCUM TENENS DENTISTS FILLING GAPS Following the pattern set by locum tenens physicians in the 1970s, locum tenens dentists today are frequently used in rural areas, particularly by FQHCs, and in urban areas. In general, FQHCs use locum tenens dentists to provide services while they seek to recruit permanent dentists. Since recruiting dentists and other clinicians to rural areas and inner-city areas can be challenging, some FQHCs have become reliant on locum tenens dentists to work assignments that can last for months or even over a year. Private dental practices in both rural and metropolitan areas also use locum tenens dentists. Typically, private practice dentists use locum tenens dentists to fill in during maternity leave, vacations, illness, or military deployment. They also may use temporary dentists to maintain services from the time they have recruited a new graduate to the time the graduate is licensed and is able to practice.

Some practices are using locum tenens dentists to fill in for dentists who were furloughed and who now have either retired or are unwilling to return to their former employers.

AMNHealthcare.com | 11

The Growing Use of Locums Tenens Dentists

DSOs USING LOCUM TENENS Increasingly, locum tenens dentists are being used by Dental Support Organizations (DSOs) to help build new dental practices or expand existing ones. DSOs are corporate owned entities that provide management, marketing and recruiting support services and have at least one dentist owner – marketing and recruiting support. Just as in medicine, dental practices are experiencing more corporate ownership and consolidation as dentists seek to cope with shifting economic pressures and the challenges presented by COVID-19.

As noted in a May 17, 2021 article in Group Dentistry Now:

M&A activity is at an all-time high in the dental industry. COVID-19 has certainly been an accelerant for increased activity coupled with political uncertainty and inflationary pressures. While there is a lot of emerging group and mid-market activity, what has been fascinating is the appetite of large platforms for large strategic acquisitions.

In November of 2020, Aspen Dental Management Inc. announced its acquisition of Clear Choice Management Services, while in December of 2020, Smile Brands completed their acquisition of Midwest Dental, adding 230 additional locations, mostly in the Midwest and Northeast. Smile Brands now has over 650 dental practice locations. In May 2021, Heartland Dental, the nation’s leading DSO, announced that it had signed an agreement to enter a strategic transaction with American Dental Partners Inc. (ADPI). Through this transaction, Heartland Dental and ADPI will have a combined network of over 2,300 supported dentists, in more than 1,400 locations across 38 states nationwide.

These corporate entities often have the resources and operational skills to incorporate the use of locum tenens dentists into their strategic expansion and service plans.

AMN Healthcare has observed that the strongest reemergence of demand for locum tenens physicians has been among private practices, DSOs and FQHCs, while demand has not yet recovered as strongly at long- term care facilities, among mobile dental providers or at Indian Health Service facilities, most likely due to continuing COVID-19 concerns and challenges.

AMNHealthcare.com | 12

The Growing Use of Locums Tenens Dentists

THE TEMP-TO-PERM MODEL In addition, locum tenens dentists can be used to secure a new associate through the “temp-to-perm” process, in which an established dentist can evaluate the work of a temporary dentist before making an offer of permanent employment. Once the locum tenens dentist is permanently employed, he or she may eventually purchase the hiring dentist’s practice. Dental practices also may rotate locum tenens dentists in specialty areas such as endodontics or periodontics through the practice one day a month or as needed, in order to provide services that might otherwise be referred out.

Costs vs. Benefits If a dentist is out due to illness, vacation or other reasons, production obviously stops and others in the practice, such as office managers and hygienists, may be idle. In addition, wait times for both routine appointments and high revenue generating procedures can back up, causing patients to seek services elsewhere. Locum tenens dentists can maintain continuity of care, enhancing patient convenience and satisfaction, and can be a means for maintaining revenue. Locum tenens staffing agencies generally provide two billing options -- a per diem option or a production option. In a per diem option, the practice pays a daily rate for the temporary dentist’s services. The daily rate may vary but usually is in the hundreds of dollars and will only exceed three figures in extraordinary circumstances. In the production formula, the practice pays the staffing agency a percentage of the revenue generated by the locum tenens dentist once an agreed upon base line of revenue has been reached.

AMNHealthcare.com | 13

The Growing Use of Locums Tenens Dentists

Integration and Billing Prior to the temporary dentist’s arrival, the locum tenens agency will forward the practice or FQHC information about the dentist, including his or her resume, clinical capabilities, and references. A pre-assignment phone conference then is arranged between the temporary dentist, a staffing agency representative and the practice. It is important for the temporary dentist to understand the types of procedures performed at the practice. The practice should determine whether the dentist is proficient in these procedures and the time it takes for him or her to complete them. The expectation is that the practice or FQHC will inform the locum tenens dentist of its standards of care and that the locum tenens dentist will accommodate himself or herself to these standards. The practice or FQHC also should forward the patient schedule during the assignment period to the locum tenens dentist and ensure that the dentist can handle what has been scheduled. Patients should be informed that their regular dentist is out for the day or week, but that he or she will be seen by a dentist handpicked by their regular dentist. This may be more convenient for patients than referring them to another dentist at a practice with which they are unfamiliar. Generally, services provided by a locum tenens dentist must be billed for under a separate Medicaid or other provider number. Obtaining a new number typically takes about four weeks to three months. Usually, the locum tenens dentist is in place, seeing patients, while the new provider number is being obtained. The practice can in some situations “back bill” for work done by the locum tenens dentist when the new provider number is received.

AMNHealthcare.com | 14

The Growing Use of Locums Tenens Dentists

Roles and Opportunities for Locum Tenens Dentists Locum dentistry positions may be in a private practice, to cover a maternity leave or other leave absence. Other assignments are meant to fill a vacancy while the practice looks to hire a full-time dentist. If the temporary position is a good fit for both parties, the locum dentist may be considered for that permanent position. Corporate dental practices, community health centers and government facilities also need locum tenens dentists. In a corporate practice, the new dentist might find a good fit with the work, but not like the location and try another geographic area within the corporate practice. Dentists choose locums because it offers the flexibility to pick and choose what opportunities they want to explore. Some dentists like to work for three months and then take some time off. Dentists can choose where and when they want to work at their discretion, they are not required to work at any specific setting or any specific time. Dentists can select locum tenens opportunities through agencies such as AMN Healthcare. The agency pays the dentist a daily rate, travel to and from the assignment, and local accommodation. There should never be a cost to the dentist from the staffing agency for any service provided. Instead, the staffing agency is paid by the dental practice or other facility requiring the locum tenens dentist.

AMNHealthcare.com | 15

The Growing Use of Locums Tenens Dentists

We receive thousands of staffing requests for locum tenens dentists annually. Most assignments are for general dentistry positions, but pediatric assignments and specialty positions also are available. Some assignments are full-time, while others are one or two days per week or a solid week to cover a vacation. As dental practices recover and respond to the pandemic, locum tenens opportunities are abundant, though to have to greatest selection dentists should be open geographically and not limit themselves to only local opportunities. We assist dentists in securing a license in the states where opportunities are available, if necessary and offers comprehensive licensure services to broaden a dentist’s ability to provide dental care to patients across the nation.

The hiring practice sets the pay rates for locum dentists, and the amount depends on the local market. Liability insurance is typically covered, and the locum tenens dentist receives reimbursement for lodging and mileage. Some locum tenens dentists travel alone, while others travel with their pets or a friend or family member. Most dental practices have put COVID-19 safety protocols in place, and masks and vaccines are strongly recommended when working locum tenens. Dental practices are obliged to follow government mask andvaccine mandates, which require that workers be vaccinated or being tested for COVID-19 on a weekly basis.

AMNHealthcare.com | 16

The Growing Use of Locums Tenens Dentists

About AMN Healthcare AMN Healthcare is a leading provider of locum tenens staffing services in the United States (NYSE: AMN) and the largest healthcare workforce solutions organization in the nation. As part of our role as industry leaders, we generate original survey data regarding trends in locum tenens staffing, presents educational seminars on physician staffing and related topics, and develops a series of white papers examining physician and advanced practitioner staffing issues. AMN Healthcare executives authored the book on locum tenens staffing. Entitled, Have Stethoscope, Will Travel: Staff Care’s Guide to Locum Tenens, the book outlines locum tenens staffing principles, uses and procedures for both healthcare facilities and physicians. This white paper is one is a series that AMN Healthcare has produced. Others in the series include: Nurse Practitioners and Physician Assistants: Supply, Distribution, and Scope of Practice Considerations Women in Medicine: A Review of Changing Physician Demographics, Female Physicians by Specialty, State and Related Data Physician Supply Comparisons: Physicians by Select Specialties Practicing in Each State

and Licensed in Each State but Practicing Elsewhere The Physician Shortage: Data Points and State Rankings Population Health Management Psychiatry: “The Silent Shortage” The Aging Physician Workforce: A Demographic Dilemma The Economic Impact of Physicians

For additional information about our services, white papers, speaking presentations or related matters, contact:

LEARN MORE

BACK TO FRONT

AMNHealthcare.com

AMNHealthcare.com | 17

Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17

www.amnhealthcare.com

Made with FlippingBook. PDF to flipbook with ease