By: MA
This week’s readings cover the role of institutions and bureaucracy in public policy. In The Essence of Decision, Allison and Zelikow argue that theoretical models used to explain or predict policy decisions rely on assumptions that shape analysts’ interpretation of events. Since theoretical different models are based on different assumptions, one model may assign importance to some causal factors while another model may consider an entirely different set of factors. Using multiple models to allows analysts to develop a richer understanding of events by considering factors that might otherwise be overlooked by using a single theoretical model.
According to Allison and Zelikow, Model I or the Rational Actor Model, explains policy actions as efforts to achieve specific goals. Policy options are proposed and evaluated according to criteria. The selected option best meets the organization’s goal. Model II, the organizational behavior model, explains policy actions as the result of organizational procedures or practices. Model II says that policies and practices were in place before the specific problem was presented; therefore a policy action results from a pattern of organizational behavior.
Applying these two theoretical models yields different explanations for a state dental association’s lobbying efforts to defeat a proposal to expand access to dental care. Millions of U.S. residents cannot access routine, preventive dental care. The 2000 Surgeon General’s Report, Oral Health in America, highlighted the physical and social consequences of poor oral health including untreated pain, missing work or school and physical health problems. (U.S. Department of Health and Human Services, 2000) The report also highlighted disparities in access to dental care that are most pronounced among low-income people, elderly people, racial and ethnic minorities and among people who live in geographic areas with a shortage of dentists. Between 2008 and 2010, more than 4 million U.S. residents visited an emergency room for a dental problem. (Allareddy et. al., 2014) Research confirms that many of these emergency room visits could be have been avoided if patients received appropriate dental care sooner.
To address the shortage of dental professionals, a Kansas-based coalition including individual dentists, dental hygienists and children’s advocacy groups has pushed for new educational programs to train more dental providers and increase the number of dental professionals who can treat patients across the state. (Carpenter, 2014) In Kansas, four out of five counties do not have enough dentists to meet the demand for care, and 14 counties have no dentists at all. The training programs would prepare mid-level providers, called dental therapists to perform routine preventive services, such as cleanings, fillings and simple extractions; allowing dentists to focus on more serious dental conditions. Dental therapists would be trained at accredited schools, would be required to pass licensing exams, and would be authorized to work only under the supervision of dentists. This model is based on mid-level dental provider programs in existence in numerous countries, which have successfully improved access to dental care. (Gehshan, Hale and Koppleman, 2014)
Since 2011, the Kansas Dental Association, the agency responsible for licensing dental professionals and ensuring that they provide quality care to patients, has lobbied against allowing dental therapists to practice in the state. According to Model I, the rational actor model, the dental association’s opposition could be understood as the association’s best option to serve its mission of protecting patients. In addition, the action could be seen as self-protective. The association argues that it could be accused of negligence or failing to ensure quality dental care if a patient was harmed by a dental therapist.
Applying Model II, the organizational behavior model, yields a different explanation of the dental association’s behavior. According to Allison and Zelikow, in some cases organizational behavior is guided by factors other than efficiency. Behavior may reflect culture, and certain organizational practices are tied to the concept of identity. Thus an organization’s behavior can be understood as an effort to create or reinforce identity. In this example, the association’s refusal to approve dental therapist training programs could be understood as an effort to reinforce dentists’ identity as the only professionals who are capable of providing dental care.
This week’s lead precis asks if there is merit to Roemer’s model of creating new bureaucracies and organizations to drive of change. In some cases, creating new bureaucracies is essential. Consider the function of a state medical (or dental) board, and how it might conflict with innovation in the field. Medical boards are responsible for establishing the licensing requirements and scope of practice for health care professionals to promote quality care. (Carlson and Thompson, 2005) These responsibilities allow medical boards to have substantial control over who is allowed to provide care within the state, which preserves the role of existing providers. But allowing new providers into the field could threaten the medical board’s control over the profession, especially if new providers, who are more receptive to change, begin practicing in the state.
The first dental therapist program in the U.S. was established in Alaska, outside the jurisdiction of the state dental board. In the absence of U.S.-based training programs, a group of Alaskan students were trained as dental therapists in New Zealand; a country where dental therapists have provided comprehensive dental care for more than 50 years. (Commonwealth Fund, 2010) Once their training was complete, the Alaska dental therapists were authorized to practice under a health professionals program operated by The Alaska Native Tribal Health Consortium, a sovereign entity operated by Native Tribes, not the state’s dental association. The Alaska program provided initial evidence to show that dental therapists are a safe and effective solution to improve access to dental care in the U.S. The Alaska program’s success paved the way for other states to consider this model.
The Kansas Dental Association’s resistance to training dental providers to expand access to care illustrates how institutional behavior may stand in the way of innovation. But the Alaska Dental Therapist example shows that innovation is possible when organizations can work outside the confines of existing structures. Today, dental therapists are practicing in Alaska and Minnesota, and 15 additional states are considering adapting this model. (Gehshan, Hale and Koppleman, 2014)
Additional Works Cited
Drew Carlson and James Thompson, “The Role of State Medical Boards” AMA Journal of Ethics, Volume 7, Number 4 (April 2005) http://journalofethics.ama-assn.org/2005/04/pfor1-0504.html
Tim Carpenter, “Kansas Coalition Puts Shine On Dental Therapist Option For Unmet Demand,” The Topeka Capital Journal (August 28, 2016) http://cjonline.com/news/state/2016-08-28/kansas-coalition-puts-shine-dental-therapist-option-unmet-demand#
The Commonwealth Fund, “Alaska and Minnesota: Expanding Access to Dental Care,” States In Action: Innovations in State Health Policy (March 18, 2010) http://www.commonwealthfund.org/publications/newsletters/states-in-action/2010/mar/march-april-2010/snapshots/alaska-and-minnesota
Shelly Gehshan, Laura Hale and Jane Koppleman, “Expanding the Dental Team: Studies of Two Practices” (Pew Charitable Trusts: February 2014) http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2014/expandingdentalteamreportpdf.pdf
US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General, (US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health: 2000) http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/home.htm
V. Allareddy, S. Rampa, M.K. Lee, R.P. Nalliah RP, “Hospital-Based Emergency Department Visits Involving Dental Conditions: Profile and Predictors of Poor Outcomes and Uesource Utilization” Journal of the American Dental Association, Volume 145, Number 4 (April 2014)
https://www.padental.org/Images/OnlineDocs/Advocacy/DayOnTheHill/JADA_dental_ER_visits.pdf
This week’s readings cover the role of institutions and bureaucracy in public policy. In The Essence of Decision, Allison and Zelikow argue that theoretical models used to explain or predict policy decisions rely on assumptions that shape analysts’ interpretation of events. Since theoretical different models are based on different assumptions, one model may assign importance to some causal factors while another model may consider an entirely different set of factors. Using multiple models to allows analysts to develop a richer understanding of events by considering factors that might otherwise be overlooked by using a single theoretical model.
According to Allison and Zelikow, Model I or the Rational Actor Model, explains policy actions as efforts to achieve specific goals. Policy options are proposed and evaluated according to criteria. The selected option best meets the organization’s goal. Model II, the organizational behavior model, explains policy actions as the result of organizational procedures or practices. Model II says that policies and practices were in place before the specific problem was presented; therefore a policy action results from a pattern of organizational behavior.
Applying these two theoretical models yields different explanations for a state dental association’s lobbying efforts to defeat a proposal to expand access to dental care. Millions of U.S. residents cannot access routine, preventive dental care. The 2000 Surgeon General’s Report, Oral Health in America, highlighted the physical and social consequences of poor oral health including untreated pain, missing work or school and physical health problems. (U.S. Department of Health and Human Services, 2000) The report also highlighted disparities in access to dental care that are most pronounced among low-income people, elderly people, racial and ethnic minorities and among people who live in geographic areas with a shortage of dentists. Between 2008 and 2010, more than 4 million U.S. residents visited an emergency room for a dental problem. (Allareddy et. al., 2014) Research confirms that many of these emergency room visits could be have been avoided if patients received appropriate dental care sooner.
To address the shortage of dental professionals, a Kansas-based coalition including individual dentists, dental hygienists and children’s advocacy groups has pushed for new educational programs to train more dental providers and increase the number of dental professionals who can treat patients across the state. (Carpenter, 2014) In Kansas, four out of five counties do not have enough dentists to meet the demand for care, and 14 counties have no dentists at all. The training programs would prepare mid-level providers, called dental therapists to perform routine preventive services, such as cleanings, fillings and simple extractions; allowing dentists to focus on more serious dental conditions. Dental therapists would be trained at accredited schools, would be required to pass licensing exams, and would be authorized to work only under the supervision of dentists. This model is based on mid-level dental provider programs in existence in numerous countries, which have successfully improved access to dental care. (Gehshan, Hale and Koppleman, 2014)
Since 2011, the Kansas Dental Association, the agency responsible for licensing dental professionals and ensuring that they provide quality care to patients, has lobbied against allowing dental therapists to practice in the state. According to Model I, the rational actor model, the dental association’s opposition could be understood as the association’s best option to serve its mission of protecting patients. In addition, the action could be seen as self-protective. The association argues that it could be accused of negligence or failing to ensure quality dental care if a patient was harmed by a dental therapist.
Applying Model II, the organizational behavior model, yields a different explanation of the dental association’s behavior. According to Allison and Zelikow, in some cases organizational behavior is guided by factors other than efficiency. Behavior may reflect culture, and certain organizational practices are tied to the concept of identity. Thus an organization’s behavior can be understood as an effort to create or reinforce identity. In this example, the association’s refusal to approve dental therapist training programs could be understood as an effort to reinforce dentists’ identity as the only professionals who are capable of providing dental care.
This week’s lead precis asks if there is merit to Roemer’s model of creating new bureaucracies and organizations to drive of change. In some cases, creating new bureaucracies is essential. Consider the function of a state medical (or dental) board, and how it might conflict with innovation in the field. Medical boards are responsible for establishing the licensing requirements and scope of practice for health care professionals to promote quality care. (Carlson and Thompson, 2005) These responsibilities allow medical boards to have substantial control over who is allowed to provide care within the state, which preserves the role of existing providers. But allowing new providers into the field could threaten the medical board’s control over the profession, especially if new providers, who are more receptive to change, begin practicing in the state.
The first dental therapist program in the U.S. was established in Alaska, outside the jurisdiction of the state dental board. In the absence of U.S.-based training programs, a group of Alaskan students were trained as dental therapists in New Zealand; a country where dental therapists have provided comprehensive dental care for more than 50 years. (Commonwealth Fund, 2010) Once their training was complete, the Alaska dental therapists were authorized to practice under a health professionals program operated by The Alaska Native Tribal Health Consortium, a sovereign entity operated by Native Tribes, not the state’s dental association. The Alaska program provided initial evidence to show that dental therapists are a safe and effective solution to improve access to dental care in the U.S. The Alaska program’s success paved the way for other states to consider this model.
The Kansas Dental Association’s resistance to training dental providers to expand access to care illustrates how institutional behavior may stand in the way of innovation. But the Alaska Dental Therapist example shows that innovation is possible when organizations can work outside the confines of existing structures. Today, dental therapists are practicing in Alaska and Minnesota, and 15 additional states are considering adapting this model. (Gehshan, Hale and Koppleman, 2014)
Additional Works Cited
Drew Carlson and James Thompson, “The Role of State Medical Boards” AMA Journal of Ethics, Volume 7, Number 4 (April 2005) http://journalofethics.ama-assn.org/2005/04/pfor1-0504.html
Tim Carpenter, “Kansas Coalition Puts Shine On Dental Therapist Option For Unmet Demand,” The Topeka Capital Journal (August 28, 2016) http://cjonline.com/news/state/2016-08-28/kansas-coalition-puts-shine-dental-therapist-option-unmet-demand#
The Commonwealth Fund, “Alaska and Minnesota: Expanding Access to Dental Care,” States In Action: Innovations in State Health Policy (March 18, 2010) http://www.commonwealthfund.org/publications/newsletters/states-in-action/2010/mar/march-april-2010/snapshots/alaska-and-minnesota
Shelly Gehshan, Laura Hale and Jane Koppleman, “Expanding the Dental Team: Studies of Two Practices” (Pew Charitable Trusts: February 2014) http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2014/expandingdentalteamreportpdf.pdf
US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General, (US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health: 2000) http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/home.htm
V. Allareddy, S. Rampa, M.K. Lee, R.P. Nalliah RP, “Hospital-Based Emergency Department Visits Involving Dental Conditions: Profile and Predictors of Poor Outcomes and Uesource Utilization” Journal of the American Dental Association, Volume 145, Number 4 (April 2014)
https://www.padental.org/Images/OnlineDocs/Advocacy/DayOnTheHill/JADA_dental_ER_visits.pdf