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http://www.nytimes.com/2010/11/02/health/02dental.html

[Now a two-year foundation-supported study has reignited the debate over which practitioners are qualified to provide dental care, especially to underserved populations in high-poverty areas. It found that Alaska’s dental therapists provide “safe, competent, appropriate” care. (The therapists refer cases beyond their scope to supervising dentists.)
The study, financed by the W. K. Kellogg, Rasmuson and Bethel Community Services Foundations, examined the work of dental therapists in five rural Alaskan communities. The positive results are consistent with findings from overseas, where dental therapy programs are well established, said Dr. Mary Williard, a dentist who directs the therapist training program for the nonprofit Alaska Native Tribal Health Consortium.
Ten other states, including Connecticut, are considering midlevel dental provider systems for underserved residents. These practitioners can be trained for relatively little money, said Dr. Allen H. Hindin, who is on the board of the Connecticut State Dental Association.
Partly for that reason, he said, the topic has become a “turf issue” — not just economic, but “intellectual and cultural.”
Unlike Alaska, Connecticut has no shortage of dentists. But Dr. Bruce J. Tandy, the state association’s immediate past president, agreed that dentists were wary of losing patients to midlevel practitioners. “Many dentists don’t understand how these individuals are going to be used,” he said, “so they feel threatened.”
In fact, he said, the midlevel providers “can be trained to do certain simple procedures safely,” and they would most likely work in public health clinics, seeing patients whom “most dentists will never see in their offices.”
Still, the American Dental Association — which went to court five years ago in an unsuccessful attempt to block the Alaska program — is firm in its opposition. Dr. Gist, the group’s president, rejected the accusation that dentists fear a loss of income or status if midlevel practitioners are widely allowed. “We don’t consider that it has merit,” he said.]

So, here's my take on the situation......... As we all know, the national debt is ballooning to a point of unsustainability. In order to keep ourselves financially solvent, we're going to have to make very deep cuts to a large number of government programs, including Medicare and state-run Medicaid. If we keep the tax cuts, the cuts would have to be even deeper. If we keep ongoing military ops overseas, even deeper.... In this situation, reimbursements to physicians and dentists will definitely be cut pretty substanially. There's no way around it, as this country is going broke and there's not enough money to keep reimbursements at this level.

For dentists, Medicare/Medicaid reimbursement are much less important for income, than for physicians. However, with low-income Americans unable to afford a dentist, and with the underserved population likely to increase due to demographic change and Medicare/Medicaid spending cuts, we're talking a large and growing segment of people that won't see dentists.

The solution, for the politicians, is to bring in mid level providers. It allows them to provide a service for low income people and do it on the cheap. Dental franchises/mills or even WalMart can just hire a lot of MLPs and do inexpensive dentistry work, so they'll be in favor, especially since it allows them to tap Medicare/Medicaid funds efficiently and on a large scale. Owner dentists might want to get in on this too, as they can use the MLPs to do lower value activities for cheap, thereby freeing them up to more higher value work and increase revenue.

Of course, there will be losers. In this case, it's gonna be the less experienced dentists. MLPs are going to undercut them by doing the same procedures for less money, thereby reducing their potential earning power. A lot of these MLPs might work at public facilities or Dental Mills, but I'd bet a lot of the low cost dental work will be done at the offices of well established dentists with multiple large clinics too. So dentists will be undercutting other dentists, if they can make a buck, in my view.

Once their numbers hit critical mass, and once the dentist shortage becomes dire enough, there will be a push to give MLPs more autonomy, let them do more proceures, and let them have their own clinics.
With the seeming success of MLPs in Alaska and Minnesota, other states are going to want to get in on this, especially with the push by dental hygenists. It wouldn't be too difficult or costly, in terms of just creating 2 year training courses in universities, and will be popular with hygenists if they can increase their income.

The only alternatives, to more MLPs, are to either increase reimbursements a lot, which there is no money for...... Or we could just let a lot of people go untreated, which is politically not popular....... Besides, with the move towards PAs, NPs, and CRNAs, I think the trend is toward more MLPs in general.... Treat more people, cut costs, and cut dentist/physician salaries. Especially if training MLPs is cheap and fast.

If you thought that doing a DDS instead of MD was the path to secure money, I think you're in for a mid career surprise. I don't want to deter people away from dentistry. It's probably the best career I can think of, but there's just too much of a reason to open the floodgates for MLPs and too many places where MLPs will find work. Income should remain good, especially for specialists, but docs and dentists are going to be increasingly squeezed by lower reimbursements and more MLPs. Ultimately, dentistry will be like the other professions... If you want to really thrive, you need to be very skilled at what you do and a good businessman.

2 States have brought in MLPs and 10 are considering them. With this study, expect that number to go up.
 

ItsGavinC

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The numbers may go up, but not because of that study. The study is hugely flawed, and looks at 2 years worth of data with a minimal sample size. I believe the data only looks at 5 Alaskan communities and 4 therapists. That's not big enough to draw any proper conclusions.

The big myth in all of this is that a lot of people are going untreated. That isn't the case. Alaska is a special situation and runs into this problem with EVERYTHING (from goods and materials to services).

The truth is that a lot of people are lazy, and that my Medicaid patients have a 75% no-show rate, and also have the highest recurrent caries rate of any of my populations. There simply isn't any inherent value in something that is free. Our government has enslaved people by giving them never-expiring hand-outs.

Access to care isn't an issue. Access to brain cells is.
 

yappy

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To me health care is an interesting paradox. On one hand you have a very inelastic demand curve. Meaning if you need help and are in pain/sick you have everything to lose by not getting help and will eventually seek it.
Despite this, health care is one of the only fields where you bill X for service Y - then are told - "no i'm paying you 1/2X". Where is the dentists leverage? What would happen if dentists decided not to take medicare/caid?
 
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The problem with this kind of pilot study is that the people who participate are not representative of the people who will participate in the future. What I mean is that everyone knows that they are being studied.

For example, I participated in a study on a teaching method when I was in middle school. Everyone is extremely motivated, only the best teacher and students are selected, the lectures are also recorded. Guess what, our score were significantly better than other classes but that does not mean it is the teaching method that worked.

If the program expand and become common I suspect the result is going to be much worse...but by then it is too late.
 

ItsGavinC

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To me health care is an interesting paradox. On one hand you have a very inelastic demand curve. Meaning if you need help and are in pain/sick you have everything to lose by not getting help and will eventually seek it.
Despite this, health care is one of the only fields where you bill X for service Y - then are told - "no i'm paying you 1/2X". Where is the dentists leverage? What would happen if dentists decided not to take medicare/caid?
It's also interesting that in dentistry specifically, nothing makes me happier than seeing kids for recares and they have no cavities. I love it! I'd make lots more if they had cavities, but dentistry is all about prevention.

I can demonstrate incipient decay to parents on BWX, ask them to floss with fluoride there, and then demonstrate to them 6 months later that the area has remineralized. They can see it on the 21.5 inch screen. I'm not making it up. They can wrap their brains around it. But for that to work they have to actually bring their kids to the dentist. I love it when it works, but people are lazy and don't like to come.
 

browncrack

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I agree. Patients are lazy. They don't do what they know they should do because it requires a little bit of effort every single day. They wait until someone else pays to correct a problem that is the result of their own laziness. I am no different, I just don't personally have these problems at the dental office.
 

SeattleRDH

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One, the Kellogg Foundation is funding the DHAT program in Alaska (NOT an independent study!)

Two, Bethel has privately practicing dentists (it is not that remote!)

Three, the DHATs are not trained in dental hygiene, they just drill, fill and extract. So the patients receiving services are not getting preventive care! It was actually said (by people in charge, but off the record) that preventive care would be wasted on "those people." Disgusting!!!!

It's really too bad that the ADA turned their backs on Alaska. It's coming back to bite them in the butt I think because all of these lower 48 states are now looking to the "model" that was set up by the DHATs. Alaska has a pretty - shall I say - interesting political system that is not lacking in questionable practices. (Uncle Ted, reality star Palin, the bridge to nowhere....) The state is called the Last Frontier for a reason (can you say wild west?). So don't trust these "studies." From healthcare to the environment there are people in power in the state who have "studies" published all the time that push their agenda.

I love my home state and after graduation I am going back to practice. As a dentist. And do it right!

Oh man this stuff gets me fired up!
 

ItsGavinC

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It was actually said (by people in charge, but off the record) that preventive care would be wasted on "those people." Disgusting!!!!
You make excellent points.

I don't find that statement disgusting, but a reality. What I find troublesome is that it is applied as a blanket to a group of people. There are MANY people I see every day that receive no benefit from our preventive care. The best preventive care is brushing your teeth at your home. A lot of what we do is wasted on a lot of people, including preventive care. Still, it's our job to provide the service and help them to the degree they are willing to take responsibility for their own health.
 

dentstd

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I absolutely hate them and their very existence, but they may be needed. Teaching them to give preventative service or how to give oral hygiene instructions isn't hard. Takes an hour at the most to train them in that respect.

The dentists' solution to a rapidly increasing need of underserved has been to open more dental school, in hopes that SOME of them'll go to underserved cities. Just to have them flock to major cities like everyone else and saturate an already saturated market. Universities have been naive in thinking opening more schools will accomplish this, despite long standing history saying otherwise. The ADA has been incompetent. Our solution has been ineffective, so now it's someone else' turn at it.

If we want to combat dental therapists, the question is how do WE fight the underserved battle, not how to prevent someone else from doing so. How do WE put more dentists in cities in dire need? How do we reduce our operating costs, so that we can cater to lower income patients? (ex. polyvinyl siloxane is expensive as hell, so perhaps we need more competition in dental manufacturing to reduce costs).
 
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Simiam

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The numbers may go up, but not because of that study. The study is hugely flawed, and looks at 2 years worth of data with a minimal sample size. I believe the data only looks at 5 Alaskan communities and 4 therapists. That's not big enough to draw any proper conclusions.

The big myth in all of this is that a lot of people are going untreated. That isn't the case. Alaska is a special situation and runs into this problem with EVERYTHING (from goods and materials to services).

The truth is that a lot of people are lazy, and that my Medicaid patients have a 75% no-show rate, and also have the highest recurrent caries rate of any of my populations. There simply isn't any inherent value in something that is free. Our government has enslaved people by giving them never-expiring hand-outs.

Access to care isn't an issue. Access to brain cells is.
Didn't the ADA have a study/argument on the difference between access to care and utilization rates? I can't find it, but I know I've seen info on it.

One, the Kellogg Foundation is funding the DHAT program in Alaska (NOT an independent study!)

Two, Bethel has privately practicing dentists (it is not that remote!)

Three, the DHATs are not trained in dental hygiene, they just drill, fill and extract. So the patients receiving services are not getting preventive care! It was actually said (by people in charge, but off the record) that preventive care would be wasted on "those people." Disgusting!!!!

It's really too bad that the ADA turned their backs on Alaska. It's coming back to bite them in the butt I think because all of these lower 48 states are now looking to the "model" that was set up by the DHATs. Alaska has a pretty - shall I say - interesting political system that is not lacking in questionable practices. (Uncle Ted, reality star Palin, the bridge to nowhere....) The state is called the Last Frontier for a reason (can you say wild west?). So don't trust these "studies." From healthcare to the environment there are people in power in the state who have "studies" published all the time that push their agenda.

I love my home state and after graduation I am going back to practice. As a dentist. And do it right!

Oh man this stuff gets me fired up!
It's sad that with minimal training they will/are able to perform irreversible procedures that could be severely detrimental to the patient population. I would like to see a study on the the necessity of RCT due to perf'd pulp chambers by these drill and fill DHATs vs DMD/DDS... :cool: and another study regarding post op complications in general. My guess is that DHATs will be doing more harm than good.



I absolutely hate them and their very existence, but they may be needed. Teaching them to give preventative service or how to give oral hygiene instructions isn't hard. Takes an hour at the most to train them in that respect.

The dentists' solution to a rapidly increasing need of underserved has been to open more dental school, in hopes that SOME of them'll go to underserved cities. Just to have them flock to major cities like everyone else and saturate an already saturated market. Universities have been naive in thinking opening more schools will accomplish this, despite long standing history saying otherwise. The ADA has been incompetent. Our solution has been ineffective, so now it's someone else' turn at it.

If we want to combat dental therapists, the question is how do WE fight the underserved battle, not how to prevent someone else from doing so. How do WE put more dentists in cities in dire need? How do we reduce our operating costs, so that we can cater to lower income patients? (ex. polyvinyl siloxane is expensive as hell, so perhaps we need more competition in dental manufacturing to reduce costs).
the whole idea of MLP does not make sense in dentistry.
A major cost in dentistry is the cost of the materials we use to perform our procedures. Nurse Practitioners vs MD don't have the same issue in regards to diagnosing the bread and butter of a practice.
 

iDreamofDent

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As I've been reading about the whole MLP situation, I've found myself becoming more and more upset at the nonsensical nature of the position. It really seems to me that the whole position was created for political popularity...what voters like more than anything else (and rightfully so) is something at a lower cost than it was previously available for. The problem with providing such a service in healthcare, and ESPECIALLY dentistry, is that the skills and knowledge base of the practitioner will be severely eroded. But whereas in medicine a NP or PA will just be prescribing a drug based on what is accepted as protocol, in dentistry such MLPs will be performing surgical procedures!!! This actually scares me.... A LOT... I can not argue that the current alaskan program is not filling unmet needs, because it is, but once this thing takes off it will become a completely different beast. For example what are the entrance requirements into the program...a GED...how long is the program? 2 years, and in fact the majority of the classes aren't clinical. Now who in their right mind would allow someone 2 years out of highschool perform an extraction on them?? suppose something went wrong. Dentists have proven through a rigorous 4 year college curriculum that they are capable of analyzing situations and thinking critically towards a solution, that may be unique to each case. Then they have proven through an even more rigorous 4 year dental school curriculum that they posses the composure under pressure to makes critical decisions and that their clinical abilities are satisfactory to practice. All the while being tested, SAT-->DAT--->NBDE I--->II-->etc...

Someone who has undergone such extensive training and review is qualified to perform an extraction and then think on the fly to deal with whatever may have gone wrong..To let anyone else, simply endangers public health. Suppose they are granted autonomy of practice as well, to set up private offices. Well there would be a great incentive for them NOT to refer patients to a dentist. This would lead to improper treatments being applied as the MLP tries to draw from their limited treatment ability to accommodate the widest array of patients, to try and prevent their income from being lost to a dentist.

Sure on paper it looks good, get something for less, but the money saved might as well be spent at a casino because your taking a major risk with your health.
 

wash123

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It seems that a big part, if not all, of access to care has to do with patients ability to pay and their seeking treatment rather than location. I don't see how the dental therapist will help fix this problem. Is someone going to force them to only take medicaid? Make a law so they can only charge certain amounts? All of which would be horrible and should never happen. So how do they help again?
 

DrJeff

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It seems that a big part, if not all, of access to care has to do with patients ability to pay and their seeking treatment rather than location. I don't see how the dental therapist will help fix this problem. Is someone going to force them to only take medicaid? Make a law so they can only charge certain amounts? All of which would be horrible and should never happen. So how do they help again?
Ding, ding, ding!!! We have a winner!

The main underlying problem with the entire concept of a midlevel the the economics of the concept (and idea that very few people seem to want to address!) Can a midlevel when properly trained do clinically acceptable work - yup - there's multiple midlevel programs already inplace around the world that show this.

What folks behind the midlevel movement seem to ignore in the discussions is can a midlevel provide service to the "underserved" in a more economically feasible manner than a dentist? (lets be honest, the biggest issue with "access to care" for the underserved is the fee schedule that "medicaid" pays and our ability as clinicians to actually cover our own operating costs with those fees) and the answer to this is "no" The midlevel will have the exact same medicaid fee schedule that the dentist does, just like a nurse practitioner/etc has the same fee schedule that a MD/DO does. Will say a dental chair cost a midlevel less than it does a dentist?? No. Will electricity cost a midlevel less than a dentist?? no Will a handpiece cost a midlevel less than a dentist?? No Will restorative material cost a midlevel less than a dentist?? No When it comes to actual clinical care delivery to the "underserved" that the midlevel concept is designed to work on, the overhead of the midlevel won't be any different than that of the dentist. So that midlevel will then need to provide to most amount of service (procedures) in the least amount of time to minimize overhead and maximize billing to ensure their economic viability. If not, the government will end up spending more $$ to subsized the midlevel, at which point one could easily argue that the additional funds that would need to be spent subsized the midlevel could get a much better return if they were spent augmenting the medicaid fees, so more, quicker working dentists will sign up. Then the catch 22 becomes, in the current fiscal situation many states are in, do they really want more more care being giving, and hence more dollars being spent??
 

ItsGavinC

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It seems that a big part, if not all, of access to care has to do with patients ability to pay and their seeking treatment rather than location.
This is why the term "access to care" is 100% silly political rhetoric designed to make political parties or candidates appear compassionate. It isn't an issue that really exists.

Those individuals that do live in rural communities also have to travel to get gas, groceries, entertainment, etc., and traveling to the doctor or dentist is no different.
 

DrJeff

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This is why the term "access to care" is 100% silly political rhetoric designed to make political parties or candidates appear compassionate. It isn't an issue that really exists.

Those individuals that do live in rural communities also have to travel to get gas, groceries, entertainment, etc., and traveling to the doctor or dentist is no different.
Yup! I strongly feel that we in the dental profession HAVE to get away from the term "access to care" and change it to "UTILIZATION of services" That will help eliminate the emotional response that politicians love to have as THEY :rolleyes: try and come up with this utopian model that provides 100% access, when in reality with respect to dentistry, the *cough* underserved *cough* nationwide have a utilization rate that is less than 50%. There's no doubt that there's limited resources available to treat the *cough* underserved *cough* so our politicians(hopefully with our guidance as frontline dental care givers) should be focusing on getting the most out of those dollars by putting them to use on those that actively seek care, rather than using them in a way that will try and increase the percentage of folks seeking care, when many of them will never seek care even if available to them!

And yup, living in a rural community myself, I can say with 100% certainty that folks don't think twice about having to drive/travel 20,30, 50+ miles to get to something (medical care, shopping, entertainment, etc) that may all may be available withing a small radius to those living in an urban/suburban setting. Heck both my wife and I each average 25,000+ miles a year on our cars, and we're not by any means the only people living where we do that do the same
 

wash123

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should be focusing on getting the most out of those dollars by putting them to use on those that actively seek care, rather than using them in a way that will try and increase the percentage of folks seeking care, when many of them will never seek care even if available to them!
I couln't agree more! Maybe the ADA proposal to increase Medicaid reimbursement to the 75th percentile of dental fees would be a good fit for using those dollars to help the care seekers? I think the ADA proposal would help fix a lot of problems regarding "access to care." They showed an increase in utilization in other programs (such as the Healthy Kids Dental program in Michigan) when the reimbursement improved. Although, utilization was only 44% in Michigan after the reimbursement increased and more dentists accepted the program - which hits your last point about people not seeking care.
 
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Do yall know how many amalgams were placed by the DHATs and studied for the very biased, subjective, self-serving Kellogg study??? 9. Nine. Nueve.. How can you conclude anything after 9 times.. Wow
 

SeattleRDH

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Do yall know how many amalgams were placed by the DHATs and studied for the very biased, subjective, self-serving Kellogg study??? 9. Nine. Nueve.. How can you conclude anything after 9 times.. Wow
Exactly!

And from what I've heard they are not letting anyone else in to do an independent study (as was their agreement when they settled with the ADA).