Monday, February 27, 2012

Can't find a dentist? "Not our problem," says MA dentists.

You can always count on inefficient industries to try to use government to protect their market positions.  Several years ago, objections were raised to "minute clinics" operating out of pharmacies.  At the time, I noted:

We can expect that there will objections to this from people representing established health care practices or institutions. You can be sure that those objections will often be phrased in terms of protecting the public from substandard or uncoordinated care. That is always the first refuge of people concerned about protecting market share for established players. I have seen it before in many industries.

This time it is the dental societies who oppose the licensing of dental assistants who would carry out low-level dental procedures -- replacing crowns, pulling teeth, and taking care of fillings.  Martha Bebinger produced an excellent report on this topic on public radio station WBUR.

A Midwest dental society was forthright about its concerns:

The Minnesota Dental Society fought creation of a mid-level dental provider and dentists in this clinic initially refused to work with Fogarty. Dr. Thomas Spray, who is supervising Fogarty on this day, says she’s working out well, but he still feels a bit threatened by the change.

“Just the idea of someone being able to do what we (dentists) do with less schooling is maybe a little unsettling, but as long as these providers don’t become competitors with us,” (Spray pauses here) “if they become competitors with us they can certainly charge a lot less than we do and might create a problem for us financially.”

Martha notes:

In Massachusetts, one in six residents lives in an area with a shortage of dental care, including parts of central and western Massachusetts, Cape Cod and many low-income urban communities. In addition, almost 750,000 low-income residents on MassHealth have coverage to get their teeth cleaned or pulled, but nothing more. Health care advocates are pressing the Legislature to restore full dental benefits. 

What is the extent of the shortage?  For example, the federal Health Resources and Services Administration notes a shortage of dentists for low income people in Worcester Country generally, and specifically for the following community health centers in Worcester -- Edward M. Kennedy Community Health Center; Family Health Center of Worcester, Inc., Community Healthlink -- and for Community Health Connections in Fitchburg, Gardner and Leominster.

That makes the following circumlocution from the Massachusetts association all the more striking:

Dr. Charles Silvius, president of the Massachusetts Dental Society, says dental therapists are not the answer for patients who can’t get care.

“We’re almost setting up a two-tier system of care,” he warns. “People who are geographically located near a dentist or have the ability to pay for it will be treated by dentists. And those who are more remote or possibly don’t have health care coverage are going to be treated by non-dentists, and I don’t think that’s moral or ethical.”

So, we dentists are not going to provide care to certain populations in the state.  But, we'll certainly oppose anybody else doing it.  How moral and ethical is that?

Dental health is an incredibly important component of overall health.  I think the American Dental Association puts the issue very well:

It is a disgrace that so many Americans still lack access to basic oral health care. Kids and adults miss sleep, school and work due to untreated dental disease. They can't eat properly; they can't smile. 

For years, the American Dental Association has been striving to raise awareness and develop solutions so more people can receive dental care. Dentists lead many of these efforts, but they can't do it alone. We all have a stake in this issue. Government, business leaders, insurance companies, health care professionals and individuals all must work together to get better dental care to the millions of Americans who don't receive it.

Oral health care must be a priority. Untreated dental disease can lead to serious health problems: infection, damage to bone or nerve, and tooth loss. Infection from tooth disease can spread to other parts of the body and may even lead to death. Clearly, oral health is just as important as the health of the rest of your body.

Pain from untreated dental decay results in lost school and work hours. Many with tooth pain seek care in hospital emergency rooms, most of which aren't well equipped to handle dental emergencies, and where the cost of treatment is far greater than a dental office visit. That's why we as a society must help provide access to dental care to underserved people. All of us -- government, business leaders, insurance companies, health care professionals and individuals -- must develop access to dental care solutions that work in our communities.

Note to Massachusetts dentists:  "All of us."


DKBerry said...

Agree dental assistants may be a very effective means to provide constrained dental service efficiently.

Paul... how is it you take a position opposing the status quo for dental services ...

... yet you subscribe to the premise that we need to protect white elephant general hospital constructs from the viscious attacks of the specialty hospitals that deliver more effective results in their area at lower cost to deliver those services?

You can't have it both ways ... you can't like Minute Clinics and dental assistants ... and not like the idea of specialty hospitals.

In the U.S. manufacturing sector there are no General Factories. So how come we think that General Hospitals is a good idea delivering the best clinical outcomes at a competitive price?

Paul Levy said...

Read again what I say about the cancer hospitals in NH. If there is a state certificate of need process, it should apply to them.

That's very different from a minute clinic fixing bee stings and the like at a pharmacy. These cancer centers are delivering tertiary care.

I am not saying general hospitals are the best mode for delivering care, by the way.

(While we are at it, do you have some proof that those cancer centers deliver better results?)

Paul Levy said...

On the general hospital issue, too, look at my comments from previous posts, e.g.,

I think Clay Christensen has it right.

Thomas said...

Long a problem here in another midwest M-word state. My father was a small town dentist who was appalled by the big city dental oligarchs who refused to see Medicare/Medicaid pts and resisted allied health professionals getting more training. Same story. Complete control of the marketplace with government playing along. We are hearing of pressure from AHP's on this again this year, but the dentists refuse to participate - other than to barnstorm the legislature with rhetoric of higher risks and lower value.

The comparison between General Hospitals and General Manufacturing is a straw man that doesn't stand up to scrutiny. Most hospitals don't get to choose who walks in the door and with what. The whole idea of referral centers and tiers of care is completely ignored. Ridiculous. What, you want a pneumonia hospital, a kidney hospital, a cancer hospital, a gall bladder hospital, etc?

Small hospitals can do many things well, and do just that every day. We refer out the big stuff to the specialists at larger tertiary/quaternary centers.

It scales; it works.

If dentists won't/can't deliver basic dental care to the rural populace, find someone who will. BTW, how will a lower level provider, presumably reimbursed at lower rates, be able to afford the high overhead costs of a dental office if this is the argument dentists use to avoid it in the first place?


DKBerry said...

Paul ... "You can always count on inefficient industries to try to use government to protect their market positions." Absolutely.

Didn't mean to convey a comparison between pharmacy based 'minute clinics' and NH cancer hospitals. I didn't even mention them in my reply. However, if either provide effective clinical outcome and efficient use of health care resources then protectionism through government action is misguided.

As your post states ... this view applies to dentistal societies lobbying against dental assistants able to provide effective and efficient services to an underserved community.

I retract my accusation of your support of the white elephant academic/general hospital/medical center construct. But the demise of specialty hospital growth is due to the Administration seeking AHA support of PPACA through up a roadblock of further specialty hospital growth.

As I quoted you up top here ... "You can always count on inefficient industries to try to use government to protect their market positions." So we can add the dentist lobby to that of the general hospital and academic institution lobby for standing in the way of potential health care effectiveness and efficiency improvements.

It's the intervention by those who are failing that's the comparison I was pointing at.

Paul Levy said...

Thanks, DK!