There was an article in the Washington Post yesterday(7/2) that was critical of dentists. I wrote a reply to the author, Mary Jordan. Here is the link to the article and my reply below.
Dear Ms. Jordan,
As a practicing dentist I could not let the article you wrote on organized dentistry pass. I have been very upset since reading it and feel that you did a poor job of explaining the issue. First of all, dentists do not overwhelmingly support the ADA. Many dentists have refused to join because the ADA is considered ineffective or does not adequately represent dentists’ interests. 64% membership in the ADA is an embarrassment. When I started practicing it was closer to 90%. There were many issues brought up in the article about dentists attempts to stifle competition but I will focus on mid-level providers.
Mid-level provider is the latest attempt by the ADHA, the American Dental Hygiene Association, the hygiene equivalent of the ADA, to expand functions for their members by skirting state dental practice acts. Twenty years ago, they lobbied states to allow independent practice for hygienists again using access to care as an argument. A law was passed in Colorado. Instead of setting up practices in inner cities and treating Medicaid patients, some hygienists set up practices in Vail, a ski area with well to do residents and tourists. Once hygienists realized how expensive it was to set up and run a dental office, most of these practices failed. You cannot make money in a dental office by doing hygiene alone. The fees do not support the costs to run a practice. So now the ADHA has changed its focus to allowing hygienists to perform irreversible operative procedures where reimbursement is much higher.
Thus the push for mid-level providers. They claim that these providers will be less expensive to train. Of course they will. Dentists work hard for 4 years to get an undergraduate degree. We studied very hard to put ourselves in a position to make us qualified candidates for dental school. During our Senior year we applied to dental school and those of us lucky enough to be accepted, spent the next 4 years training to become dentists. Currently, it costs a student up to $400,000 to get through college and dental school. Dentists spend the first 2 years of dental school taking physiology, anatomy, and biochemistry classes with medical students in addition to our dental curriculum. Mid-level providers are dental hygienists who first must become dental hygienists by going to an accredited dental hygiene program right out of high school. These programs are the equivalent of an associates degree at a community college and is a 2 year program. The ADHA proposal for a mid-level provider would establish an additional 2 year program with the curriculum established, not by dentists, but by the ADHA. Their cost would be approximately 1/4 the cost of going to dental school. The problem is that they do not have the breadth of knowledge required to handle all aspects of the job, in particular, emergencies. Once they complete a program they will be permitted to work anywhere. In my state the proposal did not require them to work in an underserved area or to treat Medicaid patients. The requirement that they affiliate with a licensed dentist is a joke. A licensed dentist does not have to be present onsite and is liable for the work done by mid-level providers. Most dentists who I talked to would never accept that liability.
It is an insult to dentists to be told that we are greedy and just trying to stifle competition when our true concern is public safety. Hairdressers doing tooth whitening? What happens when someone who has open tooth decay has this done and their tooth abscesses? Mid-level providers doing fillings and extractions? What happens when a procedure goes bad and there is not a licensed dentist anywhere near the office to do the next phase of treatment?
I would like to ask attorneys, who should determine the parameters of your profession, you or paralegals? Or accountants, should your bookkeeper determine what it takes to become a CPA or be allowed to do what you do by taking an abbreviated course? Or surgeons, should an APRN perform surgery without going through the rigorous training you had?
Doing fillings is more than picking up a drill and drilling a hole in a tooth. That has been our main concern, not competition and not a loss of revenue. Dental fees have traditionally gone up at a much slower rate than the rest of medical costs and I would maintain that the affordability is less a factor of dentists doing dentistry but the fact that middle class income has essentially dropped 30% over the past 30 years. Dentists buy the latest equipment, use the best materials and labs and take many hours of continuing education every year. I am proud to be a dentist and will always fight to uphold the highest standards in my profession. My final question to legislators when I have educated them about this issue is, “who would you allow to treat you and your family?” That has been the final determinant of whether this is a good idea, not arm twisting. Thank you for your time.
Henry M. Rosenberg D.M.D.