Mid-level updates

[DMDWANNABEE]

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In case some of you didn't get the news from the ADA or ASDA, Washington's midlevel proposal was shot down during on of the House's last legislative session. The senate's version of the same bill has not received a hearing yet.

Kansas, North Dakota, Vermont, and New Mexico have all introduced bills, in the beginning of this year, pertaining to the introduction of dental midlevel providers. 2013 will be an interesting legislative year.

 

[theartofzahn]

 

[acoburn73]

The idea of a mid-level dental provider even existing is analogous to the idea of an auto mechanic with no degree becoming an aircraft engineer. It's absurd, through and through, and completely devalues the efforts and expense of a dental education.

 

[Shunwei]

The idea of a mid-level dental provider even existing is analogous to the idea of an auto mechanic with no degree becoming an aircraft engineer. It's absurd, through and through, and completely devalues the efforts and expense of a dental education.

Of course, but you will find some people finding one way or another to defend this type of thing.

 

[DrJeff]

The idea of a mid-level dental provider even existing is analogous to the idea of an auto mechanic with no degree becoming an aircraft engineer. It's absurd, through and through, and completely devalues the efforts and expense of a dental education.

The key point that needs to be made when talking with elected officials about any piece of mid-level legislation isn't "can a mid level perform the procedure?' They are plenty of studies out there based on decades old already existing mid level programs in New Zeland and parts of Canada that show they can. But can a mid-level perform the procedure more cost effectively than a dentist? And that answer is NO!

Mid-levels won't be working with a lower fee schedule than a dentist, mid levels won't be paying less for their chairs, handpieces, restorative materials, cotton rolls, suction tips, electricity, etc, etc, etc. So mid-levels would need more government subsidation to allow them to practice, and in these economic times, if the government needs to divert more of it's limited funds away from direct patient treatment to simply covering the overhead of a clinic, that's providing LESS care. It's facts vs. emotion. And inspite of some folks who emotionally want it to work, the facts of economics show that it doesn't work

 

[emorypredent]

The key point that needs to be made when talking with elected officials about any piece of mid-level legislation isn't "can a mid level perform the procedure?' They are plenty of studies out there based on decades old already existing mid level programs in New Zeland and parts of Canada that show they can. But can a mid-level perform the procedure more cost effectively than a dentist? And that answer is NO!

Mid-levels won't be working with a lower fee schedule than a dentist, mid levels won't be paying less for their chairs, handpieces, restorative materials, cotton rolls, suction tips, electricity, etc, etc, etc. So mid-levels would need more government subsidation to allow them to practice, and in these economic times, if the government needs to divert more of it's limited funds away from direct patient treatment to simply covering the overhead of a clinic, that's providing LESS care. It's facts vs. emotion. And inspite of some folks who emotionally want it to work, the facts of economics show that it doesn't work

As a pre-dent I'm not a big fan of these types of legislation. However, keep in mind mid-levels do not have to worry about paying dental school tuition. Also, many mid-levels will be satisfied with lower incomes since they needed less schooling to get where they are. We will still need dentists for more advanced procedures but the question at hand is (from an objective perspective) can we reduce the number of dentists we need and shift some of the workload to these mid levels that need less training?

 

[coolslugs]

can we reduce the number of dentists we need and shift some of the workload to these mid levels that need less training?

Why would you want to do that to any patients you care about? It's like saying...oh instead of having our doctor do surgery on you today, I am going to have this NP or PA work on you instead.

 

[SoulPower]

The key point that needs to be made when talking with elected officials about any piece of mid-level legislation isn't "can a mid level perform the procedure?' They are plenty of studies out there based on decades old already existing mid level programs in New Zeland and parts of Canada that show they can. But can a mid-level perform the procedure more cost effectively than a dentist? And that answer is NO!

As well as the disconnect between the mid level and the dentist should the patient need more comprehensive tx (crown/bridge/perio what have you)

Do they even know enough to tell?

 

[hellopeople]

can we reduce the number of dentists we need and shift some of the workload to these mid levels that need less training?

I suppose we could, but we won't. They will simply be additional workers on top of the increasing number of dentists that we graduate. Why would the number of graduates be reduced or stabilized? It doesn't help the access to care problem; it only helps a dentist's wallet.

I have to admit though, this drilling and filling business is pretty easy. And more importantly, applying a doctor's "scientific knowledge" to the task would be a joke. I can't come up with a good reason to prevent mid-levels from doing it as long as they aren't diagnosing or choosing the materials. I might be missing something, it being pretty early in my education, but I doubt it.

I imagine the 21st century is going to be a bit more competitive than the 20th. Maybe that's not such a bad thing, I don't know. Either way, it could certainly be worse.

 

[jwdent]

How is a mid-level supposed to provide correct treatment if they cannot diagnose? Are they just going to get referrals from dentists? Anyways I completely agree with DrJeff about the economics of dental therapists. I cannot see how they would be self sustaining. Its not like they would be able to buy a pre established dental practice in a suburban area. A midlevels practice would essentially be a scratch start. Scratch starts can be difficult on a dentist's fees and production. I imagine it would be much more difficult for a midlevel. Would a midlevel be the type of person who would want to take the risk on of a startup?

 

[hellopeople]

How is a mid-level supposed to provide correct treatment if they cannot diagnose? Are they just going to get referrals from dentists? Anyways I completely agree with DrJeff about the economics of dental therapists. I cannot see how they would be self sustaining. Its not like they would be able to buy a pre established dental practice in a suburban area. A midlevels practice would essentially be a scratch start. Scratch starts can be difficult on a dentist's fees and production. I imagine it would be much more difficult for a midlevel. Would a midlevel be the type of person who would want to take the risk on of a startup?

I think the Minnesota therapists are like hygienists in that they work under a dentist. They wouldn't really need to be self-sustaining so long as that arrangement remains intact. It would sort-of be like having a permanent associate, who has no reason to leave you, from the dentist (or corp's) point of view. I don't know if they can diagnose or not over there though.

I always get sucked into these threads. Not really something that I can do anything about, but I just can't seem to help myself ...

 

[jay47]

I suppose we could, but we won't. They will simply be additional workers on top of the increasing number of dentists that we graduate. Why would the number of graduates be reduced or stabilized? It doesn't help the access to care problem; it only helps a dentist's wallet.

I have to admit though, this drilling and filling business is pretty easy. And more importantly, applying a doctor's "scientific knowledge" to the task would be a joke. I can't come up with a good reason to prevent mid-levels from doing it as long as they aren't diagnosing or choosing the materials. I might be missing something, it being pretty early in my education, but I doubt it.

I imagine the 21st century is going to be a bit more competitive than the 20th. Maybe that's not such a bad thing, I don't know. Either way, it could certainly be worse.

Think about this: how many associate dentists are there? Probably many many thousands. How many corporate practices are there? Many many thousands.

What happens when a corporation or clinic owner can hire an dental therapist instead of a dentist and pay much less money AND charge the same fees? (don't kid yourself, the fees won't be lower just because a therapist is working on you, costs are still there)

I'll tell you what happens, thousands of dentists will instantly be out of a job, looking for something new. If you thought corporate was bad now, wait until they can hire therapists to do their work. The model will (and is already) changing from solo practitioner to large group practice, and we will see a consolidation of practices across the nation for a need to increase efficiency to keep up.

Now think about this, what will happen with insurance reimbursements? They will go down because insurance will see a hit in their profits because there are now 3 dental therapists doing 3 times as many procedures as the previous single associate dentist, so they have to increase profitability. Reimbursement is lower for everyone.

 

[yappy]

I understand some peoples replies about being receptive to mid-levels from a pure economic perspective; however, I'm sick of hearing about how top providers (physician or dentist) should fall on the sword for the hope that midlevels will lower prices to consumers. I'll put it out there that I doubt this would happen; but regardless, I see nothing wrong with dentists looking out for their own interests and advocating for their own good. Everyone else is and does.

What I'm saying is that I don't think dentists need to win some philosophical argument that they're most suited to DX and TX. I'm saying that argument is irrelevant (just look at medicine) and dentists should focus on protecting their practice rights for the sole purpose that it's in their best interest. Anything else is a wasted effort.

 

[jay47]

I understand some peoples replies about being receptive to mid-levels from a pure economic perspective; however, I'm sick of hearing about how top providers (physician or dentist) should fall on the sword for the hope that midlevels will lower prices to consumers. I'll put it out there that I doubt this would happen; but regardless, I see nothing wrong with dentists looking out for their own interests and advocating for their own good. Everyone else is and does.

What I'm saying is that I don't think dentists need to win some philosophical argument that they're most suited to DX and TX. I'm saying that argument is irrelevant (just look at medicine) and dentists should focus on protecting their practice rights for the sole purpose that it's in their best interest. Anything else is a wasted effort.

I can tell you there are people in every dental school class who will graduate and get a license and still be incompetent at diagnosing and treating dental problems. That's after 4 years and a rigorous weeding out process. I don't trust someone with 2 years of education to diagnose anything. Drilling and filling is another matter in itself because I see a lot of my classmates' work, and it's not so hot either, but to train for only 2 years doesn't inspire confidence. I'm not saying you can't do it, but in my anecdotal experience- it's not a good idea.

 

[hellopeople]

Think about this: how many associate dentists are there? Probably many many thousands. How many corporate practices are there? Many many thousands.

What happens when a corporation or clinic owner can hire an dental therapist instead of a dentist and pay much less money AND charge the same fees? (don't kid yourself, the fees won't be lower just because a therapist is working on you, costs are still there)

I'll tell you what happens, thousands of dentists will instantly be out of a job, looking for something new. If you thought corporate was bad now, wait until they can hire therapists to do their work. The model will (and is already) changing from solo practitioner to large group practice, and we will see a consolidation of practices across the nation for a need to increase efficiency to keep up.

Now think about this, what will happen with insurance reimbursements? They will go down because insurance will see a hit in their profits because there are now 3 dental therapists doing 3 times as many procedures as the previous single associate dentist, so they have to increase profitability. Reimbursement is lower for everyone.

Sure, I could buy that. I didn't say it wouldn't be bad for dentists, or even that it wouldn't be very bad for dentists. I just said I can't think of a particular reason why that very specific job couldn't be done by a technician. The diagnosis requires medical knowledge; the restoration doesn't seem to require anything beyond a functional knowledge of dental anatomy, occlusion and restorative technique.

Maybe just in case something goes wrong? Idk. This kind of talk is what the ADA is for right? 🙄

 

[coolslugs]

Sure, I could buy that. I didn't say it wouldn't be bad for dentists, or even that it wouldn't be very bad for dentists. I just said I can't think of a particular reason why that very specific job couldn't be done by a technician. The diagnosis requires medical knowledge; the restoration doesn't seem to require anything beyond a functional knowledge of dental anatomy, occlusion and restorative technique.

Maybe just in case something goes wrong? Idk. This kind of talk is what the ADA is for right? 🙄

Well...you know...just in case when your class I or II turns into a root canal or extraction.

 

[J2OS]

Well...you know...just in case when your class I or II turns into a root canal or extraction.

Exactly. If you cant finish the procedure... you should not be allowed to start it. I dont know all the details behind midlevels but to me it is a money grab by the schools and way for few educators to feel they are making a difference when in reality they are doing a disservice to their community and their profession.

Just this week routine extraction of retained root #16... should just roll out right? Easiest tooth to extract under most circumstances... this one doesn't roll so you flap, still doesnt roll so you trough... still doesnt roll, so you create a bit more space eventually rolls an with it 1 cm sinus exposure... Now what, flap advancement for primary closure. What does the therapist do in this case.. This is seemingly "easy" extraction by any GP but can easily go down hill fast. Imagine a "midlevel"

One hour later and erupted #1. Once again should be easiest tooth to extract. Elevate, tooth is loose but hung up on palatal tissue. In course of releasing tissue note tooth ankylosed to palatal bone which subsequently tears palatal tissue. These tears can get pretty nasty. Do I want some one who couldnt even get into dental school managing this? Does Alaska and Washington and Minnesota deserve less than a trained individual?

Next day another patient presents post ext by outside dentist with huge liver clot and inability to stop bleeding... would a midlevel who can extract teeth be able to manage that?

Oh but midlevels will only extract primary teeth. Well, most of the time when a primary tooth doesnt exfoliate on its own there is a reason. Extracting those teeth with spindly roots is not easy. Now attach those to a fearful child with an anxious parent in the corner.

How many times do you drop into a small pit and the decay just does not stop until the pulp? It happens. Now what? oh but they will only work on children but primary teeth class II's can very easily turn into crowns or pulp crowns.

What percentage of children are treated with N2O? A great number. So now midlevels can administer N2O? What next a DEA?

Oh but midlevels will fill a void at community clinics. Las I checked dental jobs at community clinics are highly sought after because of good pay, high ethics, and loan repayment possibility. There is no need for midlevel. On top of that patients at community clinics are not the same patients you see in private practice. Most all should really be in the chair of highly skilled prosthodontist. Most every tooth is broken down to the point of needing extraction or large fillings that often result in pulp exposure. Those with no teeth have significant bone loss and minimal attachment. Almost everyone has a collapsed VDO. "Board Lesions" are few and far between. Now dont get me started on the medical history of this patient population. A great number are diabetic, have some form of heart disease, Hep C, HIV, multiple operations, anticoagulation therapy, multiple allergies, addiction disorder, psychological disorders, etc. etc. Managing these patients properly and safely can be difficult and now lets throw someone in there who is two years out of high school.

The idea of a midlevel in dentistry is fundamentaly flawed. It works in medicine because there is an shortage of primary care. In dentistry >70% of providers ARE PRIMARY CARE. There is no shortage. There is no need.

 

[Shunwei]

Exactly. If you cant finish the procedure... you should not be allowed to start it. I dont know all the details behind midlevels but to me it is a money grab by the schools and way for few educators to feel they are making a difference when in reality they are doing a disservice to their community and their profession.

Just this week routine extraction of retained root #16... should just roll out right? Easiest tooth to extract under most circumstances... this one doesn't roll so you flap, still doesnt roll so you trough... still doesnt roll, so you create a bit more space eventually rolls an with it 1 cm sinus exposure... Now what, flap advancement for primary closure. What does the therapist do in this case.. This is seemingly "easy" extraction by any GP but can easily go down hill fast. Imagine a "midlevel"

One hour later and erupted #1. Once again should be easiest tooth to extract. Elevate, tooth is loose but hung up on palatal tissue. In course of releasing tissue note tooth ankylosed to palatal bone which subsequently tears palatal tissue. These tears can get pretty nasty. Do I want some one who couldnt even get into dental school managing this? Does Alaska and Washington and Minnesota deserve less than a trained individual?

Next day another patient presents post ext by outside dentist with huge liver clot and inability to stop bleeding... would a midlevel who can extract teeth be able to manage that?

Oh but midlevels will only extract primary teeth. Well, most of the time when a primary tooth doesnt exfoliate on its own there is a reason. Extracting those teeth with spindly roots is not easy. Now attach those to a fearful child with an anxious parent in the corner.

How many times do you drop into a small pit and the decay just does not stop until the pulp? It happens. Now what? oh but they will only work on children but primary teeth class II's can very easily turn into crowns or pulp crowns.

What percentage of children are treated with N2O? A great number. So now midlevels can administer N2O? What next a DEA?

Oh but midlevels will fill a void at community clinics. Las I checked dental jobs at community clinics are highly sought after because of good pay, high ethics, and loan repayment possibility. There is no need for midlevel. On top of that patients at community clinics are not the same patients you see in private practice. Most all should really be in the chair of highly skilled prosthodontist. Most every tooth is broken down to the point of needing extraction or large fillings that often result in pulp exposure. Those with no teeth have significant bone loss and minimal attachment. Almost everyone has a collapsed VDO. "Board Lesions" are few and far between. Now dont get me started on the medical history of this patient population. A great number are diabetic, have some form of heart disease, Hep C, HIV, multiple operations, anticoagulation therapy, multiple allergies, addiction disorder, psychological disorders, etc. etc. Managing these patients properly and safely can be difficult and now lets throw someone in there who is two years out of high school.

The idea of a midlevel in dentistry is fundamentaly flawed. It works in medicine because there is an shortage of primary care. In dentistry >70% of providers ARE PRIMARY CARE. There is no shortage. There is no need.

I learned a long time ago to not trust educators or anyone in the academia for what they say or do. They claim to be leaders in the field and cloak their actions under the guise of noble motives.

 

[emorypredent]

I'm not trying to advocate for mid-levels but at a certain point we need to find a balance between quality and access. For example, why should we let a GP do stuff that an oral surgeon does? Many dentists are 100% OK with GPs doing stuff related to oral surgery. What about GPs that do Ortho? Doesn't every patient deserve the best? Using the logic above I could say "how could I expect a GP that couldn't get into Ortho to produce high quality work?"

Another example, it would be great if we could dispatch a cardiologist to anyone that calls 911 with a heart attack but usually the best that can be done is get them a paramedic. This is a life threatening emergency that is high risk, but we are OK sending out paramedics instead of physicians web A LOT can go wrong.

So yeah mid-levels might not be able to treat every case presented to them but it's really no different than a GP that might start something and if things head south may refer to a specialist.

I really do not know enough about the matter, largely because much remains to be developed. However, it's obvious many people here are just looking for reasons to argue against the concept instead of objectively examining the prospects. One of the main reasons I left the law track is that I didn't like the idea of arguing a point just because it benefited me and not because it was the right thing.

Bottom line: Financially, as a pre-dent, I do not like the idea of mid-levels cause it might reduce my earning potential. However, I think it's important that we keep an open mind and realize that at a certain point of training we get diminishing returns.

 

[mike3kgt]

Bottom line: Financially, as a pre-dent, I do not like the idea of mid-levels cause it might reduce my earning potential. However, I think it's important that we keep an open mind and realize that at a certain point of training we get diminishing returns.

It's beyond simple earning potential. So many politicians believe we do simple procedures all day such as "cleaning teeth" "filling teeth" or "pulling teeth". In reality, we are "debriding, removing pathogens", "removing an infection and placing a dressing" and "performing local surgical procedures to remove a diseased body part."

The problems lie in the fact that we are performing procedures that are serious and require high levels of training. People who do not fully understand how difficult dentistry can be will often say that you can delegate this to a technician and get the same result for less investment (years, $$, training).

We, as dentists, are to blame as well. When GPs and students talk to each other, they use terminology like "cleaning" "pulling" "filling when we should be saying "prophylaxis" or "managing extractions" and "restoring".

 

[coolslugs]

I'm not trying to advocate for mid-levels but at a certain point we need to find a balance between quality and access. For example, why should we let a GP do stuff that an oral surgeon does? Many dentists are 100% OK with GPs doing stuff related to oral surgery. What about GPs that do Ortho? Doesn't every patient deserve the best? Using the logic above I could say "how could I expect a GP that couldn't get into Ortho to produce high quality work?"

Another example, it would be great if we could dispatch a cardiologist to anyone that calls 911 with a heart attack but usually the best that can be done is get them a paramedic. This is a life threatening emergency that is high risk, but we are OK sending out paramedics instead of physicians web A LOT can go wrong.

So yeah mid-levels might not be able to treat every case presented to them but it's really no different than a GP that might start something and if things head south may refer to a specialist.

I really do not know enough about the matter, largely because much remains to be developed. However, it's obvious many people here are just looking for reasons to argue against the concept instead of objectively examining the prospects. One of the main reasons I left the law track is that I didn't like the idea of arguing a point just because it benefited me and not because it was the right thing.

Bottom line: Financially, as a pre-dent, I do not like the idea of mid-levels cause it might reduce my earning potential. However, I think it's important that we keep an open mind and realize that at a certain point of training we get diminishing returns.

Dentists are bound by the ADA code of conduct and dentistry is a self-governing profession. You will learn about this in dental school. So from an ethical standpoint, dentists have 2 more years and a much more rigorous curriculum than mid-level providers. Dentists are taught to evaluate anything from medical history to patient's needs to dental problem before presenting a comprehensive treatment plan and an alternative treatment plan. Dentists are also taught to evaluate one's own abilities to do procedures...and refer anything that's beyond his or her own skill set. Does a mid-level provider have enough training to know the difference? If they will need a GP's help, then why not have a GP in that area in the first place? Why waste resources to train a mid-level provider instead to using that resource to get a GP in the area?
Here is a comparison for you:
a) Dental therapist doing a Class I --> there is a deep cavity and penetrates into the pulp --> tooth now needs a root canal --> Dental therapist must find a dentist.
b) Dentist doing a Class I --> there is a deep cavity and penetrates into the pulp --> tooth now needs a root canal --> Dentist do the root canal.

Also don't hate on paramedics...their job is to stabilize the patient and get the patient to the hospital ASAP. A doctor wouldn't be able to do much more on an ambulance without a team and it is poor use of resources.

 

[J2OS]

I'm not trying to advocate for mid-levels but at a certain point we need to find a balance between quality and access. For example, why should we let a GP do stuff that an oral surgeon does? Many dentists are 100% OK with GPs doing stuff related to oral surgery. What about GPs that do Ortho? Doesn't every patient deserve the best? Using the logic above I could say "how could I expect a GP that couldn't get into Ortho to produce high quality work?"

Another example, it would be great if we could dispatch a cardiologist to anyone that calls 911 with a heart attack but usually the best that can be done is get them a paramedic. This is a life threatening emergency that is high risk, but we are OK sending out paramedics instead of physicians web A LOT can go wrong.

So yeah mid-levels might not be able to treat every case presented to them but it's really no different than a GP that might start something and if things head south may refer to a specialist.

I really do not know enough about the matter, largely because much remains to be developed. However, it's obvious many people here are just looking for reasons to argue against the concept instead of objectively examining the prospects. One of the main reasons I left the law track is that I didn't like the idea of arguing a point just because it benefited me and not because it was the right thing.

Bottom line: Financially, as a pre-dent, I do not like the idea of mid-levels cause it might reduce my earning potential. However, I think it's important that we keep an open mind and realize that at a certain point of training we get diminishing returns.

Not only do predents not like the idea of midlevels... The large majority of Dentists do not like the idea of midlevels. The fact remains dentistry has no need as >75% are general dentists ie primary care providers. Mid levels in medicine were created to fill a void in primary care need due to the high percentage of specialists.

Second, mid levels are not prepared to work in community health. Patients are way to sick and treatment is way to complex. You are not dealing with healthy 18 yo with a couple class II board lesions.

Third, if general dentists referred out every extraction, every root canal, every denture, every complex restorative case there would not be enough specialists to see the patients and now we would have a REAL shortage of providers. Dentistry has long prescribed to the 80/20 rule. This rule was not created via an arbitrary method, it developed over time through a natural process. GP's can handle 80% of any case and then there are the 20% that should be referred. If you pump out too many generalists that 20% will shrink to 10% and maybe less because GP's will over extend just to put food on the table. Quality will start to disappear.

Should extractions and rct be referred? Yes 20%. Those 20% consist of FBI wisdom teeth, some PBI, pathology, Some teeth tied to a medically compromised patient, teeth tied to a pt who wants deep sedation. OS can not necessarily extract better but they can manage the complex medical hx and the deep sedation better. Any tooth the GP does not feel comfortable extracting should be referred along with REAL ORAL SX ie orthagnathic sx, facial fractures, complex reconstruction. Root canals with dilacerated roots or crown, or internal or external resorption. Roots with complex anatomy, retreatments, apicos, pathology. If the case is selected properly and provider has the right tools and training they should be able to perform and very good rct on the right tooth. Once again any tooth the GP is not comfortable with shoudl be referred. Pt with moderate to advanced perio should be ref for eval. Most common are of law suit is over perio dx. GPs should be able to do most restorative and crown and bridge and removable but pt with extreme loss of VDO, complex tx planning for extensive restorative, CB, dentures should be ref if GP does not have proper training. Complex ortho involving full brackets and not just straighten a bit of crowding via invisalign or uprighting or extruding a few teeth must be ref if GP does not have the training.

The bottom line is 80/20 and if you choose to do that 20% you need to be prepared to manage the complications that arise. mid level can not mangage the complications as they are not allowed to by law. This does not mean they will not try to. They are asked to do dentistry with one arm tied behind their back. It is not fair to them or their patient. And who gets sued if the bur gets caught in the floor of the mouth and midlevel does nothing, or the the patient aspirates the bur, or pathology goes un identified, etc. etc.?

Bottom line is Dentistry in general is already midlevel. How much lower do we need to go.