PBS' Frontline series has been a great example of quality in television journalism. I heard about the episode that was released about 2 months ago that focused on the challenges of the dental care system in America. So I went online to review it. And I drew some conclusions and formed some opinions. I also have some solid advice I'd like to offer to our readers.
Our country has a crisis on our hands. Patients can't get access to dental care as readily as they can for medical care. But from a wellness standpoint, I feel that there are a lot of patients who could manage their diet, lifestyle choices, and their own preventive dental care in much better ways. But the issue I agree with in the Frontline piece--the problem of uniting patients with affordable healthcare--is growing.
Beyond lifestyle changes, another factor in creating the growing problem is that the historically more accessible medical insurance model for care--which is also failing--is not applied in dentistry. You say, "hey, wait--there's dental insurance, and it's like medical insurance!" WRONG. There are a significantly lesser number of insurance providers and subscribers for dental insurance to create an environment for dental care that would even come close to rivaling access to medicine. Let's not forget that this is correlated with the embarrassingly low level of reimbursement and insulting iron curtain of restrictions and limitations evolved by dental insurance policies. This is not a figurative statement I'm about to make, it's a fact: dental insurance reimbursement levels are stalled at levels seen in the 1960's and '70's.
An economic downturn and high level of unemployment has created a ripple effect that I am able to gauge with just my pool of patients. I would consider my community to be an average suburban/rural community--lots of families, lots of commuting employees to distant offices/work locations, a wide variety of age groups and career types. I witnessed about 20% of the patient pool disappear from my work schedule in 2008-2009 at Cascadia Dentistry. And upon further research, I noticed that across the nation that was generally the trend. Unemployment increases led to less cash flow for dental care for a lot of patients. The fallout from the unemployment and economic downturns are still occurring in my practice and abroad.
Another truth about dental care: there are a lot of people who are more susceptible to the perils of dental disease that really need more help than they can provide themselves. Said another way: no matter how much preventive care and attention is paid to managing their lifestyle, high-risk dental patients will always exist. And if more of those high-risk patients are unemployed? The dental health epidemic starts to snowball even further.
I started to envision a hypothesis where all dental patients that 100% access to care would be able to have the properly planned and executed dental care, given the dental professionals are all made equal. BUt as the Frontline piece illuminated, that hypothesis is a fantasy. This industry has a lot of variability in the style of how healthcare is delivered, and also in how business models dictate the performance of dental care providers.
The business models profiled on Frontline seem to be god working models for dentistry to cut costs--in theory. I have some doubts about the business model of corporate dentistry. Corporations and small businesses are alike in many ways. Both entities have operating costs and profit/loss goals. The main differences between them in my view are 1) the personal approach and continuity of the doctor-patient relationship (being able to see the same doctor consistently over time) and 2) the established set of rules for meeting profit/loss and productivity goals. Tying income to productivity (which means the amount or volume of dental procedures completed), can create the wrong emphasis in a dental practice. In my opinion, creating incentives for dental care providers to generate more productivity usually results in corruption of the doctor-patient relationship. Up-selling happens in dentistry to meet production goals if that is how the business model is managed, and I don't feel good about it. I feel the true mission of dentistry and dental businesses is to meet the goals of the patient first, and introduce those patients to opportunities to have treatment they didn't know were available to meet their goals.
So now we turn to a look at mid-level providers (MLPs). They are now being introduced in some areas of the country. They can
improve access to dental care. Lower costs are important to achieve,
and a mid-level provider can help. Frontline interviewed an MLP as saying her training and skill for certain procedures was "exactly like...dentists." That statement is questionable. The consequence of MLPs, is that they are unable to work unsupervised; as it stands, our nation's MLPs require dentist supervision to plan and execute care. MLPs are also limited in their scope of care; they can't perform dentistry to the same level of excellence for all the needed procedures a patient may seek. And the level of training is limited to a few restorative procedures. It is also uncertain what the continuing education expecttions or intent will be for MLPs. But my biggest concern is that MLPs run the risk of caring for a patient that requires a change in treatment while in the midst of receiving care. This could compromise the patient's treatment result. A dentist would ultimetely have to step in and complete the unfinished care, possibly not until a later date with the patient in limbo until that occurs. The expertise and vast knowledge of alternative remedies for any patient are at the fingertips of a well-trained dentist.
Also, the experience and ability for an MLP to perform the standard of care for patients is debatable. A lot of time and experience has been built by dentists to deliver the best care for their patients. Just because an MLP can fill a cavity, build a mouthguard or provide preventive care, doesn't mean they can execute an emergency root canal, manage complex infections, or solve ongoing challenges for high-risk dental decay patients in an efficient or effective way. Those few examples I listed require high-level medical and dental training that MLPs do not receive. In my opinion, the best use of MLPs is to work in tandem with a dentist, but the catch-22 is that it still bottlenecks the access to dentistry for a huge number of patients-in-need.
So what the Frontline episode showed me is that there are a number of great things happening to improve access to care, but we have a long way to go as a profession to make it work well.
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