For Immediate Release
Date: Jun 18th, 2012
Contact: Dr. John Thompson
What Part of the “Affordable Care Act” Has Been Affordable?
The executive board of our state dental association is a representative microcosm of practicing dentists who make up the membership of this organization. During our March meeting there was lengthy discussion regarding the Medicaid program and the new Board of Dentistry Regulations, which will define a new provider category, the public health hygienist. The debate regarding the merits of a public health hygienist was not the issue that drew my attention. There was more than adequate support for the proposal and the definition of services that can be offered. It was the overriding theme presented by the board members who also serve on board of health in their communities that gave me concern.
First, it is commendable that so many of our leaders are also involved in the boards of health or health cooperatives throughout the state and can bring a broader perspective to the discussion. Second, it was the consensus commentary that all services at this level are being reduced by budget cuts from federal, state and local sources. We had debated and approved the merits of a public health hygienist for whom there are no publically-funded positions readily available. The discussion and commentary was parallel to the major issues associated with the Medicaid program. “There is no money” was the sad summary for every solution to problems that are plaguing the oral health support programs throughout the state. Whether it be the county health department or the Medicaid program, more souls are seeking services at the same time funding is being cut. There are federal mandates beginning to be implemented that will add to these rolls to further exacerbate the demand. The state is going to be under federal mandates to provide additional services when it cannot maintain service funding at this time. At present, the state experiment to provide dental service through managed care entities is perceived as a dismal failure, but that is a separate issue.
As I write this, the dental profession is the only source for oral health care services for the projected demand. Studies are being produced that say we are not meeting the demand and will not be able to do so in the foreseeable future. On April 10th the W. K. Kellogg Foundation released this article (1), “Most comprehensive review of dental therapists worldwide shows they provide effective dental care to millions of children. Suggests greater role for mid-level dental providers in the United States”. The principal author of this report is David Nash, DMD, MS, EdD from the University of Kentucky College of Dentistry. Dr. Nash states, “There is no question that dental therapists provide care for children that is high quality and safe. None of the 1,100 documents reviewed found any evidence of compromise to children’s safety or quality of care. Given these findings, the profession of dentistry should support adding dental therapists to the oral health care team.”
The report further states, “In 2014, as part of the Affordable Care Act, an additional 5.3 million children will be entitled to dental coverage under Medicaid, according to the Pew Charitable Trusts. Yet, few dentists treat Medicaid patients now and there have been wide reports of children on Medicaid waiting months to get care.” This report appeared almost simultaneously as an opinion essay in the April 8th New York Times (2). In this piece, Dr. Louis Sullivan calls for Alaska-style dental therapists as a solution to the nation's widespread dental-care access disparities. Dr. Sullivan, who served as secretary of Health and Human Services under President George H. W. Bush, offers the same arguments that have become a constant refrain from therapists' boosters, among them the prevalence of untreated disease, an unsupported claim of a dentist shortage, widespread misuse of emergency rooms by patients with nowhere else to turn and the looming coverage of 5.3 million new pediatric patients under the Affordable Care Act. Dr. Sullivan writes that creating new dental schools is one long-term solution, but notes that graduates might not practice in underserved areas. In the interim, he calls for government to "foster the creation of these midlevel providers" and for dentists to embrace these models.
Dominick P. DePaola, DDS, PhD , the Associate Dean for Academic Affairs, Nova Southeastern University College of Dental Medicine, writing in Dental Abstracts (3), takes the affirmative position that the proliferation of new dental schools is a natural evolution of the profession. “The issues include access to care; the increasing risk of oral disease as people live longer, coupled with the explosive population growth of the elderly; the need for educating a more socially conscious dentist; the need to view oral health as a part of general health with the dentist as an integral part of a primary health care team, including physicians, nurses, pharmacists, allied health personnel, dental therapists, ad community health care advocates; the role of innovation and entrepreneurial spirit inherent in the newer and reinvented schools; and the ability to sustain dentistry as a growth industry.”
Dr. DePaola points to a dramatic growth in Dental Health Profession Shortage Areas (DHPSAs) from 1,300 to 4,600 over the last ten years and 51 million people living in these shortage areas. He translates this to a need for 9,900 additional dentists needed to eliminate the DHPSAs. He states that, “The real problem we have is that as a profession, we have not developed a comprehensive plan to address any increase in demand related to changing economics or demographics…” I would have to point out that all the planning that has been done is in progress or that is contemplated, is useless if there is no plan to pay for its implementation, and that is where real world economics and social planning are in critical conflict.
Whether you agree or disagree with these statistics and/or conclusions is not relevant to this writing. The above does represent a very real perception that the dental profession is currently not meeting the needs of a large segment of a population that for geographical, economic and educational circumstances does not have access to care. This includes a heart wrenching number of children and this is a public relations nightmare.
Dentists do not typically practice in large groups, in hospitals, in public health clinics or in medical centers. Dentists pay their own way through dental professional schools and generally graduate with very significant debt. The average dental student now has $200,000 in educational loans at graduation and this burden has grown as federal and state resources have been withdrawn from state-supported universities across the nation. I do now know the specific debt burden that graduates of independent colleges of dentistry, such as Nova will have upon graduation. I do know that debt burdens of this magnitude make it almost impossible for new graduates to return to underserved areas that depend on public funding for Medicaid programs.
A dental practice is a small business that delivers a health service. There has to be a revenue stream for any small business to survive. The paucity of public funding that is now available for Medicaid reimbursement and the bureaucracy that controls access to care virtually precludes profitability for an existing practice and a huge impediment for a new practitioner willing to establish in what might be an underserved, but Medicaid-entitled area. Dentists do not have federal or state support when they establish a practice. They go to a bank with a business plan that must demonstrate a cash flow that allows for operation of the business: payroll, payback of student debt, living expenses and most certainly payback of a business loan with interest. Business planners have a difficult time making this a feasible proposition based on Medicaid fee reimbursements.
There were logical questions that came to mind as I listened to the many questions and good ideas bantered back and forth at that board meeting. How much will it cost to establish training programs for mid-level providers? How much will it cost to provide federal or state clinics for them to practice? Will they be expected to be employees of existing dental practices and will there be funding to pay for the services they might provide? I can go on and on with the what ifs because that is really what all of the above is about…what if we created a new level of provider and…
We have a very willing work force that can be expanded, but also at an unknown cost. What if we returned adequate funding to dental education? Would we see a decrease in student debt? What if we funded Medicaid at levels that would allow for an adequate fee structure? Would it allow for practices to extend services by using expanded dental auxiliary personnel? What if we provided incentives for new graduate dentists to establish in underserved areas where populations have real access to care problems? Would they return there? What if we effectively employed public health hygienists to provide services and preventive education? Could we reduce the need for services by preventing disease? I am sitting here writing this and I just received an e-mail that the Board of Dentistry has filed a new regulation with language that actually creates the public health hygienist in Kentucky.
There is a certainty with any of these scenarios; a plan without adequate plans for funding will not work. Resources must be a part of the commitment. I will tell you that I did read the first 987 pages of the Affordable Care Act before it was passed on Christmas Eve 2009, based on hypothetical savings and “pie in the sky” tax income with hope that real funding might be available by the Chinese New Year. I must admit that I truly support the intentions of the Affordable Care Act. However I remain extremely critical of the process and the act, itself, based on only what I read and the frank inconsistency and obvious unintended consequences that I saw in less than one-half of the document that I did read. While I do believe the Supreme Court will declare unconstitutional significant portions of the law and create a new dialog, I am also convinced that forces have been set in motion that will not be deterred. Dentistry will be a vital part of any health care initiative and we have a seat at the table where decisions will be made.
Dentistry must make the case that we have the capacity to provide superior oral health care based on the core small business model that currently exists. We are not a hospital or clinic-based service and the economic models are not parallel. There are changes that we must be willing to make in our practice model and we must be open to change. I have not offered solutions, only observations based on my experiences, which include many years of working closely with dental students, teaching practice management and operating a small business (dental practice) for 42 years. I am going to close this already too-long missive with a quote from a book I read this winter, That Used to Be US: How America Fell Behind in the World it Invented and How We Can Come Back (4). Thomas L. Friedman wrote, “Optimism or pessimism about America’s future cannot simply be a function of our capacity to do great things or our history of having done great things. It also has to be a function of our will actually to do those things, again.”
1. W. K. Kellogg Foundation, Burness Communications, “Embargoed for Release until April 10, 2012, Most comprehensive review of dental therapists worldwide shows they provide effective dental care to millions of children.” e-mail from April 5, 2012; David A. Nash, D.M.D., M.S., Ed.D., William R. Willard Professor of Dental Education, Professor of Pediatric Dentistry, College of Dentistry University of Kentucky, Lexington, Ky.; Jay W. Friedman, D.D.S., M.P.H., Public Health Dental Consultant, Los Angeles, Calif.; Kavita R. Mathu-Muju, D.M.D., M.P.H., Assistant Professor of Pediatric Dentistry, Faculty of Dentistry, University of British Columbia, Vancouver, B.C. A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States, April 2012,
2. Louis W. Sullivan, MD, OP-ED Contributor; April 8, 2012, “ Dental Insurance, but No Dentist”, The New York Times, The Opinion Pages, http://www.nytimes.com/2012/04/09/opinion/dental-insurance-but-no-dentists.html, April 9, 2012.
3. Dominic P. DePaola, DDS, PhD, Commentary, “The new dental schools: threats or opportunities?”, Dental Abstracts, volume 57, issue 2, page 60, March/April 2012.
4. Thomas L. Friedman, Michael Mandelbaum, 2011, That Used To Be Us: How America Fell Behind In the World It Invented and How We Can Come Back; Farrar, Strauss & Giroux; New York.