Lethsang, Thank you for joining the discussion as I think you bring in good discussion points. I do not agree that so many devalue their oral health care. This does not mean that I havent seen situations where I questioned the misplaced priorities and poor oral care habits. Education of dietary habits and oral care should always be a component in dentistry. However, I have seen many situations where I understand a little of the complexity of problems faced by individuals. Poverty, abuse, mental health problems, illicit drugs usage, etc. wreak havoc on individuals. Likewise, I recognize that even with better dental insurances, annual caps are placed at 1000 -2000 after the patient has paid his/her percentage. With resources tight, people have to choose between rent/mortgage or a crown. I do not quickly agree that they dont care.
You make claims based on calculations and research. I would really find this data very useful. Please post up links to this information. I ran across another person who posted on Dr Bicuspid forum (
http://www.drbicuspid.com/index.aspx?Sec=sup&sub=hyg&pag=dis&ItemID=313099&wf=47) who had first- hand experience with dental therapists utilized in Canada. His arguments are similar to yours. Dr. Todd Hartfields also worked with the dental therapy program in Canada but he has a pro-therapy perspective. I would find a panel with those two very informative.
I have seen some limited data from those offices currently employing dental therapists and heard their accounts. Childrens Dental, a non-for profit, has indicated that employment of DTs has reduced overhead as expected. The two other private dentists for which I included the youtube links have been favorable and hinted economic profitability as it permits the dentists to do more complex procedures. I also recognize that experience is important. A newly graduating dentist or DT will not be as efficient and profitable at the start. Although it is early to gather substantial data, I believe that if dentists can utilize a MLP to do simpler procedures, that it will give them the time to do the more complex and profitable ones.
As of employment, I can think of 4 DTs that are employed in rural areas and a couple in corporate dental and non-for-profits. One or two have started up for smaller offices in the city. Currently several offices that currently employ MLPs have a sliding scale and accept medical assistance. So, yes, DTs do help lower the costs to individuals.
I do not agree with claims that the University of Minnesota is out for money in the creation of the dental therapy program. This does not mean that I think that they have the perfect DT program. There are areas for improvement. I believe it reflects poorly on a dental institution if they cannot employ their graduates. I believe leaders of the school agree with this and are refining the program to meet the needs of the market. Employment rates of DTs are improving.
I still have confidence in supply and demand. The collaborating dentist will insure that DTs are providing quality work. As before mentioned, medical assistance reimbursement rates are too low especially for dentists. I am hopeful that improved rates are also in the future. With larger numbers of those who will qualify on the horizon through Obamacare, I think dentists should definitely look at marketable ideas and explore these possibilities. From the literature review conducted on dental therapy recently, I think dentists in rural areas or who serve these patients should definitely consider employment of dental therapists. (see:
http://www.wkkf.org/news/articles/2...nce-that-dental-therapists-expand-access.aspx)
From my review and experience, I believe that a midlevel provider can help improve access to care. I know that dentists work hard to get accepted into school, study diligently and make great sacrifices to make successful businesses. I am saddened to hear about dentists who retire early due to financial reasons with down-turns in the economy and/or extremely low rates for medical assistance. Likewise, I am disheartened to know of many who are not able to get oral care and these numbers will increase. I know many dental schools that have outreach opportunities for these individuals but it is not in all needed areas and it is not enough. I believe dental therapy might be a viable solution.
I know that ADA has the Community dental health coordinators at two pilot sites. The scope is similar to Primary Dental Health Aides in Alaska. Dr. Mary Williard from Alaska reported that they did not get the success they hoped with just the addition of these providers (oral educators with very limited dental procedures). Dr. Williard then created the dental health aide therapist (very similar to New Zealands model of dental therapy) following. These therapists first received their education in New Zealand. I have had the opportunity to meet Dr. Williard and listen to her story. I have read numerous reports and studies on the DHAT model as well as dental therapy utilized in Canada and New Zealand. There is definite support to explore this idea of a MLP. MLPs are successful in the US in the medical field and oral MLPs are successfully utilized in many developed countries. I know that current employers of dental therapists are keeping data. These collaborating dentists are not going to continue to employ a dental therapist who does inferior work. Likewise, improving access to care and improving profit margin are also important factors. Lethsang, I am looking forward to seeing links that support your theories.
Lastly, to address the original post that references the ignorance of scope of practice. All licensed dental professional including DTs are required to pass and take a MN jurisprudence exam. The collaborating dentist has to sign and submit an agreement to the board of dentistry of what the DT will do in his/her office within their scope of practice. I dont think a collaborating dentist would risk suspension of license.
Certain areas are saturated based on current dental costs, yes, but there is huge potential to expand the profession by making care more accessable through prevention, education, expansion and cost reduction. Throwing DTs at a population is not going to solve anything and I never suggested that. But instantly percieving DTs as a threat to the dental proffession is simply not true.
I was skeptical of DTs as well, I have a brother and father that are dentists so when I did my MPH I actually set out to show that it would be a detriment to the dental profession more than one paper I wrote. By the end of the program I had done a complete 180. I'm heading of to dental school in a month and I am sure I will get plenty of criticism there as well, but where many see a threat, I see potential solutions.
(By the way I would love to see the journal articles you have stating that a mid level provider model will not help improve access to oral care. I honestly never came across anything even remotely suggesting that when I was researching DTs)
I wish i could figure out how to quote paragraphs separately I apologize.
Joshwake - Here is the study which shows dental therapists in conjunction with dentists do not improve a communities dental health. Again, this is because you arent opening up any doors to new patients as Ive gone over in my long post. This is a very important part of this discussion -
it's been shown that it doesnt improve access to care.
The cost reduction to the public brought about by the difference in an MLP and an associates salary
are not enough to lower the new demand curve to such an extent to tap new demand.
I simply do not understand how yourself and others in your position say they dont know of this research. Or of this next one.
http://www.ada.org/7440.aspx
This one did an economic analysis of introducing MLP's in America. You can read their conclusions. If after reading you still think its a solution then again we will have to agree to disagree.
http://www.ada.org/8096.aspx
Josh please list out here what you found in your MPH research that convinced you and made you do a 180. Bullet points. Links. Research.
Dentamax - It is commonly accepted in the dental world that 100 million americans do not see the dentist each year because of misplaced priorities and the cost of dentistry. Stating you dont believe this is the case without anything to back it up isnt helping the discussion move forward. You dont even give your reasoning.
Your next point says certain clinics employ DT's and are reporting that its economically viable. This isnt the argument. DT's will make a dental office run more profitably if it cannot service their population with their capacity. The clinic will realize the difference between a dentists salary and the DT's compensation.
This difference isnt enough to lower the demand curve enough to bring in new demand Do you think lowering a crown from 1000 to 900 will bring in a flood of new people willing to get work done? How about 800? What is the pricing point which will bring in new demand? How did you come up with this number? How can we see if the MLP model can get us to this number? For a fully trained MLP with experience, how much can he comfortably produce on a full fee basis per year using his limited procedure mix? Is this an important number? Has anyone already done it? Why am I asking this?
Your next paragraph you say the dt would allow the operating dds to focus on more complex procedures. Again this isnt the argument.
DT's would be the ideal solution, if this were a problem.
Next paragraph you dont think minnesota or other schools are pushing this program because of the money. I am sorry that is naive. There is a large education tuition bubble in this country right now. This isnt an opinion its a commonly held viewpoint in the economic sector. This is why ten new dental schools have opened up or are about to open up recently. it is now 300k to get thru d school compared to 120k just a decade ago. Compare that with inflation since 2000 and you see a huge jump.
Scrolling down you continue to quote dentists employing DT's and it working out. Again, this isnt addressing our national access to care issue. Its allowing the dentist who is already at capacity to see more patients who would still be seen otherwise. Its not bringing in patients who had an access to care issue. I sincerely feel like you two arent understanding what access to care means in this regard, as it pertains to dentistry. I feel like I laid it out pretty plainly in my first post.
quoting
"As of employment, I can think of 4 DTs that are employed in rural areas and a couple in corporate dental and non-for-profits. One or two have started up for smaller offices in the city. Currently several offices that currently employ MLPs have a sliding scale and accept medical assistance. So, yes, DTs do help lower the costs to individuals."
Sliding scale clinics arent run at a profit. Theyre run with government subsidies. Having one with mlp's and keeping their doors open does not mean they help lower costs to individuals.
It doesnt even suggest it. The argument can be made that this would lower the subsidy the clinic would need to keep its doors open which is a logical argument to make, and not one either have you have even touched on. However, the better solution would be to fix the broken medicaid system. Why do you think an mlp would be the better solution?
I read the study you linked which expounds the virtues of a DT. It specifically says they can work on children and increase the access to care. This is referring to medicaid children. Children which we have the capacity to see if we fixed the rates and the red tape. Why do you propose to create an MLP instead of fix medicare? I know the answer you should say.....but sadly I dont think you do as I dont believe you have a firm grasp of the situation. What they talk about here is putting the DT in our school systems to get these kids care. Where do you think the money comes to pay for these dental therapists? Uncle Sam. You, me, aunt betty. So yes if you do this, its like putting a nurse in school. The kids have more access to care. This would work. But youve just created a new position on uncle sams dime. Medicaid is already paid for by the people and is already in place. Why not fix it so these kids get care? What concerns me is neither of you bring up the few arguments you have going for you. This scenario here would be the main reason you would want MLP's introduced. And if you do so, what you have done, in effect, is provide a medicaid clinic without a copay. It ends by saying it costs 99 per child compared to 198 per child in the private sector. Of course its going to reduce overall cost when comparing MLP to private pay instead of their version of medicaid, which those children are on. If this happened in the usa, do you know what we just did? We solved the access to care problem, the facet of "people dont value their oral health as they should enough to take their child to the medicaid clinic" by providing free care at school where no one has to make an appointment. You could argue that this in fact has merit. Neither of you have. I even like it. Welcome to socialism. Is that what we want? Making our neighbors pay because we dont want to be an adult and take our child to the dentist?
You then end saying you are interested in seeing stuff that supports my theories. For the third time, very little of what Ive wrote is opinion or theoretical. Everything Im reading from both of your posts is all theory, "i think", "i heard in canada/new zealand". One of you even quoted MLP's in medicine....not realizing they DID IN FACT have an access to care issue brought about by too few providers.
A different problem than what dentistry has Again, ask yourself to define what our access to care problem is. I highly suspect you think its different from what it really is. Read my first post. Its numbered. Its laid out. For whats its worth in medicine we still have an access to care issue because the MLP's arent working on the population segment they were made for. Theyre now saturating already saturated areas. Ask a medical doctor who keeps up with this stuff their opinion on them.
And lastly you say mlp is successful in other countries. Again, their access to care issue was a different one. I feel like im a broken record.
If youd like to do your own analysis. Create a spreadsheet. Make it a P and L of a dental office. Populate it with real numbers. Overhead, loan payments, salaries, rents, cost of production, insurance, write offs etc. Put in the cost of your associate vs the cost of the mlp. Put in the increase in gross production from the mlp. Compare it to the one where you employ an associate. And then come back and tell us what the reduction in fee was to the american public. I am going to guess and say you cant. If you can't, how are you possibly making the argument that this is economically viable. Guess what - people who do that for a living have and it doesnt work.
Ive done it - it doesnt work. The government has done it - it doesnt work.
How many dentists are in America? Whats the population in the USA? How much population can a dentist treat per year? Do either of you know without looking it up and crunching the numbers? How many dentists will be needed to service the growing baby boomer retirees? Have we compared that to the sudden influx in dental schools and graduates and compared them to dental retirees? Whats the picture look like 20 years down the road? Why am I asking this?
I apologize if any part of this post sounds harsh. I just cant believe both of you came back and still used the argument of "i think" and "i feel" and then asked me to provide two major studies found by a google search. One of you then suggested something Ive written was a theory. I didnt originally post links because I wrongly assumed you guys were familiar with the subject matter. It would have been like linking the wikipedia entry on potassium after I stated your heart would quit from a lack of potassium. Two papers that should be familiar by anyone wanting to discuss the pros and cons of such a large issue.
I just want everyone to know, full disclosure. It is in my personal best interests and in the interest of my financial success that MLP's do start to sweep the nation. I could just as easily post here and sway some of your opinions the other way. It would certainly behoove me personally to do so.
However, it has got to be realized that we have looked at this model and it is not solving any access to care issues. Any extra amount being seen is being paid for by your taxes. In no way do they lower the cost of dentistry to the consumer in an amount significant enough to increase access to care.
This entire post by me was not needed as all pertinent facts were laid out in my original as well as many other posts by other contributors. In this thread. On this page. That you read before you replied.