Sigh… another “exposé” on the shortcomings of the “dental care system” in our country. This one is nearly an hour long, done by PBS. I’m not going to write a long post about this program, however. I’ll try to get to my points efficiently and then let you come to your own conclusions after you’ve watched the video. And, if you’re a dentist, you should watch the whole thing. It’s long. Just take the time and watch it. See video and commentary after the jump.
The show is divided up into segments about the various avenues by which a patient “in trouble” may obtain low cost dentistry.
Don’t Drink the Medicaid
They first talk about Medicaid and lament that so few dentists will accept it. They do mention the extremely low compensation offered by most Medicaid fee schedules. It comes to about 20 cents on the dollar. The reality is that represents a net LOSS for virtually any private dental practice. A BIG net loss.
Another significant issue (that they did not mention) with Medicaid is the tremendous risks it presents to any dentist who signs up (contractually). When you get in bed with the Federal Government, you are on the hook in ways you rarely hear about. If you are even suspected of fraud (say a disgruntled ex-employee files a report), you are GUILTY until proven innocent. They can padlock your front door. They can seize your records and computers. They can freeze assets and bank accounts. And, they can do all that BEFORE you go to trial. In other words, they can ruin your life irreparably while you wait YEARS to clear your name (assuming you are innocent).
Personally, I would not sign up for Medicaid if they paid me DOUBLE my private fees. I honestly wouldn’t. I’m not willing to surrender my Constitutional rights for any amount of money. I’d be doubly-crazy to do it for pennies on the dollar. If I’m going to work on certain patients for a loss (aka charity), I’m doing it on MY terms.
Organized Dentistry Does Not Represent Me (as usual)!
The clowns they had speaking on behalf of “organized dentistry” were an embarrassment. Once again, they’ve convinced me to not rejoin the ADA. I understand these hack journalists edit interviews to suit their own agenda, and they can make even the most polished spokesman look like a fool. But, I dare say these “leaders” of dentistry needed no help in that department.
Dental Mills – It’s Not What’s for Breakfast
This PBS program also brings up the corporate dental mills that “specialize” in working with Medicaid. Seeing some of the kids suffering was heart-wrenching. To consider that some of my colleagues may be “gaming the system” at the expense of these kids is unconscionable.
One thing that bothered me is that there is no mention at all of the PARENTS’ responsibility and accountability for the NEGLECT of their own children. My kids don’t have a mouthful of cavities. It’s not because they have “access to care.” It’s because they have access to a toothbrush and floss. And, it’s because they DON’T have access to an unlimited amount of Coca-Cola and Sour Patch Kids candy.
They say they can’t afford to go to a “regular” dentist. Yet, I’d be willing to bet most of them have an iPhone with a $100 / month data plan.
Rocky Mountain Low
The segment on Aspen Dental was sickening to me. The presentation of denture options to the patient came across like buying carpeting for your house. The dentist says, “What we will do is do an upper denture. There’s no way around it.” He then quite literally whips out a brochure and says, “Here we go. We make a number of different dentures, which is really complicated.” REALLY? Complicated? After insulting the patient’s intelligence, he goes on, “We organize them based on the type of warranty.” Warranty?? Are these car tires? Gosh, maybe I slept through that class, but I am not aware of dentures being distinguished by “warranty types.”
The office manager presented various “packages” with distinct “warranties.” These clinics are touted as being a more affordable alternative to private offices. Yet, the denture “package” being pushed on this patient was about $6,800. Now, my fees are fairly high. And, I’ll just say this: This patient isn’t saving a whole lot by going to the “affordable” dental clinic.
We Just Need Some Dental Therapy
I’m adding this commentary after my friend, Dawn, mentioned this part of the program in the comments below. In my haste to get my thoughts written, I skipped this section. So, now I’m adding it. 🙂
The concept of a “dental therapist” (DT) or “mid-level provider” has gained traction in some parts of the country. The idea is that a lesser-trained individual could deliver basic care at lower costs to those who don’t have much money to spend or to provide care in “under-served” communities… where dentists won’t go.
Personally, I don’t see how they will provide similar (even basic) services as dentists at a lower cost. Will their overhead magically be less than ours? Where will they get funding to build their offices? And, how will they repay it?
The PBS program implied that the DTs were similarly trained. However, it is my understanding that their education is simply 18 – 24 months of vocational training. They don’t go to college first. They don’t get a Bachelor degree first. They just need a high school diploma or equivalent and a six-week online anatomy and physiology course.
Holy SHIT! It seems I wasted FOUR YEARS getting an undergrad degree. I took 2 semesters of General Chemistry, 2 semesters of Organic Chemistry (TOUGH!), 2 semesters of Physics along with full semester courses in Genetics, Anatomy, Physiology, and other courses totaling 124 semester hours. THEN, I spent four AGONIZING years in Dental School. But, yeah… the “dental therapist” has the “same training” as me… just fewer procedures.
Yet, the shit-for-brains ADA president could not effectively articulate the difference between my education and the high school graduate with 6 weeks of an ONLINE anatomy course who then was taught in 18 months how to “drill and fill” teeth. Thanks a lot President Shit-for-Brains!
(Deep breath)… OK… You know what? If people are willing to let these high school graduate, tooth-carpenter “dental therapists” perform surgical procedures on them, then HAVE AT IT! Best of luck! Seriously. The lawyers will have a freakin’ field day. They lawyers will be so busy with these folks, they won’t have time to pay any attention to the real dentists.
It’s All Our Fault
OK… the program didn’t quite put all the blame on dentists. But, the general tone was that dentists were uncaring, profiteering predators. Ironically, the show began and ended with examples of charitable deeds by dentists. That’s not enough, of course! However, the overall implication was that Dentistry had not come up with solutions for those who don’t have “insurance” or can’t “afford” dental care.
Of course, all of us in dentistry know that dental “insurance” isn’t insurance at all. It’s a pre-paid dental benefit. My dentist friend and fellow blogger, Dr. Alan Mead, aptly refers to it as a “gift card from a control freak.” And, the maximum annual benefit is the same as it was in 1965… about $1,000. Back then a patient could get a lot of treatment for $1,000 in a year. Now, we call it the “tooth of the year club.” It’s a joke.
Consider that the maximum annual benefit from any dental plan would not cover the yearly average “uninsured” patient’s iPhone bill. But, yeah… they “need” dental insurance in order to have “access” to preventive and restorative dental care.
I’ve done my fair share of charity treatment right in my office with no fanfare. It doesn’t get reported or tracked by any entity. I just do it. Most of us just do it. We do what we can.
Sadly, the notion of self-reliance and accountability is all but extinct in America. We are a nation of parents who indulge their children at every opportunity. Worse yet, many believe they are entitled to health care (among other things). Nothing was said about dental disease being nearly 100% preventable with little more than some personal effort at the bathroom sink every morning and every night. Two minutes!
You Don’t Have to Be Rich, to Be Cavity-free.
I physically helped my kids brush their teeth every day until about age 6. No dental degree needed. No money or “insurance” needed. All you need is to CARE as a PARENT. We brushed and we flossed. My kids learned to love it. Now they brush and floss on their own. My son even uses a floss-threader around his fixed orthodontic retainer. Neither have had any cavities.
Ultimately, I found the program to be rather depressing. It’s depressing because I recognize there is a dearth of public awareness when it comes to oral health. Dental CARE is not expensive. Repairing dental NEGLECT can be rather expensive. I find the notion of lumping the blame for poor oral health on the profession of Dentistry as an overt display of abject and willful ignorance at best… and contemptuous at worst.
No Man Owns the Talents of Another
I won’t hold my breath waiting for the ADA to make any positive contribution to the discussion. But, if we don’t raise our voices in some way, we can expect the current nanny-state trend to infect Dentistry. And, if the day ever comes that my licensure is made contingent on working in any sort of federal entitlement program, I will drop the keys to my office on the front desk and walk out the door. I will not be an indentured servant (no pun intended) while I incur all the financial and legal risks.
Crap… it ended up being a long post! That’s all I’m going to say for now. OK… chime in with comments below!
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Dr. Mike, I always enjoy your skillful writings and agree 100% with this one. It is mostly the managed care situation where “having a heart” isn’t allowed because of corporate rules. I just returned from a seminar where the dentist had set up his initial practice in a blue collar neighborhood. He remembers a 17 year-old Medicaid patient who was graduating from high school. He asked what she was going to do after graduation….college, the service, etc. Her answer was, “No, I will just let Momma take care of me!” He immediately decided to sell and open a new practice where a high percentage of people move forward in life to the benefit of themselves and others.
Thanks, Rob! Interesting vignette of the entitlement mentality. Today, we can change the name: “No, I will just let Obama (rhymes with momma) take care of me!”
Hi Mike,
Your comments are right on target, as usual.
My 2 favorite comments (which could/should be the ADA’s new campaign):
The problem is not access to care, it is access to a toothbrush and floss.
Dental CARE is not expensive. Repairing dental NEGLECT can be rather expensive.
I personally feel that those 2 comments added to the apparent 24/7 availability of sugary drinks and candy snacks added to the lack of parental instruction and direction are the root of this problem. The kids I see with their scrubbed-clean faces also have scrubbed clean teeth and vice-versa.
Here is a paranoid thought. This is part of a campaign to create the appearance of as “Dental Crisis” so that dental care can be sucked into the looming national healthcare catastrophe
Hi Larry!
Paranoid? No way. This administration’s cabinet is known to live by the adage, “let no crisis go to waste.”
I love dentistry and being a dentist. But, if they ever try to force me to work for the gov’t, I’m out. I already did some volunteer time for Uncle Sam with the U.S. Navy. No regrets about that, either. But, I didn’t have to build (and personally pay for) the aircraft carrier in which I practiced. I paid DEARLY to build my private practice. It is NOT “public property.” And, in these here United States, I supposedly have the 4th Amendment protecting me from seizure. Supposedly.
I participated in the AGD’s Nation of Smiles – Outreach Event last week in Philadelphia. They had originally set up the event anticipating half extractions and half restorative treatment. They pulled in some oral surgeons and residents in case a tough situation arose. After a couple hours it shifted to 25% extractions and 75% restorative. Hmm. Yes, there are unmet dental needs but not as bad as expected (at least in PA, which until a year ago had one of the most generous MA adult benefit programs in the nation).
Great post Mike, and very timely as the SCOTUS upheld the healthcare reform…..More people not taking responsibility.
Really good blog post, Mike! One of your best. Seriously. I was so exasperated by the show that I just froze up. I haven’t really written anything. I probably should. Thanks for the post!
I have a lot to say, but I will keep it short. The most offensive part of the Frontline report, to me personally, was the insinuation by both the Dental Therapist and the journalist that the Therapist was as trained as a dentist. They kept pushing that and the rep from the ADA did a very poor job in explaining why that just isn’t so.
Good point, Dawn. I forgot / didn’t get around to writing about that segment of the program. And, I agree that the ADA clown did a VERY poor job. Apparently, these “therapists” don’t even get an undergrad degree. So, no O-chem. No Physics. No Physiology. Maybe my limited understanding is incorrect. But, based on my interpretation… Well… I’ll just say “let them eat cake.” People get what they wish for, and they may regret it.
I’ll be happy to differentiate myself (to the public) from a therapist.
I thought to myself that they have truly reduced us to mechanics. The therapist said something like, “I’m as trained as a dentist, just not in as many procedures,” as though all we are is technicians doing procedures. We have an extensive knowledge of systems, anatomy, biochemistry, etc… We have to analyze each patient as an individual and figure out the complexities of their problems, not just drill and fill. Random drilling is not on the docket in the office of any dentist I’ve encountered. It was truly insulting.
OK, Dawn… ya got me going. I added a section to the article above on dental therapists.
In speaking of my Nation of Smiles participation (above) and previous work in both non-profit and for-profit dental practices, DHT’s are the last folks that should be working with that population! The health histories you come across are phenomenal! You had better be on top of your game. Society needs the best and brightest treating this segment, not those barely qualified to hold a handpiece (I’ll include both DHT’s and recent grads(non-mentored/supervised) in this group).
What no one ever mentions in these stories is that dental disease is a PERSONAL disease.
You can have all the education, training, fluoridation, access to care, sealants, and God knows what else you can think of available for patients and the overwhelming majority will NOT access the care, or take the time each day to take care of their own mouths.
In my practice, there isn’t a day that goes by where we don’t teach our current patients how to take care of themselves to prevent dental problems from happening…and these patients who already have the ability to access care STILL don’t do what’s recommended! These are the cream of the crop patients…the ones who actually go to the dentist and we can’t get all of them to take care of themselves.
The problem is a personal problem that we’re trying to treat socially.
That doesn’t mean we shouldn’t try to help people improve their oral health care, but we must ALWAYS realize that some people will not listen and just like a “woman’s right to choose” what she does with her body; our patients ultimately have a right to choose what they do with their bodies and should be held accountable for such choices.
You are exactly right, of course, Mike! Even in the Navy, where service men and women could obtain top-notch care for FREE… they had to be nearly dragged in.
The whole notion of “access to care” is truly delusional.
Spot on commentary per usual Mike. So much wrong with all this one doesn’t know where to start. I fear honest hard working dentists may be greatly impacted by this growing entitlement mentality in the time to come? If anything thank you for reminding me again why I am not a member of the ADA and why I will remain so.
Aspen Dental – I could start my own blog on their business model.
That is where Dr. Robert Bates (founder and owner of the failed Allcare Dental & Dentures) got his start. He took their playbook and created his own empire.
I am the legal custodian of records for their largest office. In retrieving the records, I had full access to the closed office. This allowed me to see the set up and review operation manuals. Many of their abandoned patients are now part of my practice. The only folks that know more about their operations are former employees.
There are 2 parts to how they sell dentures. The show had the one issue – length of warranty (this covered an annual exam, annual reline, free repair of defects in workmanship during the period covered). Then there were the 5 different qualities of denture. Lowest was processed with cold cure acrylic, no gingival anatomy and limited selection of teeth (lowest quality, esthetics possible) to Hollywood that were the most beautiful model dentures I’ve seen (They had 5 different models there that made it easy for the lay person to see the difference). The trick was the * that allowed them to upgrade at their own discression from the lower 2 offerings to the middle of the road stuff (which is what they did – heat cured acrylic with decent looking teeth and ok gingival anatomy). It would cost too much to process 5 different types of dentures, 2-3 was manageable. When they say each office has a denture lab – that is true and false. There is a lab that does the denture work up to the try in stage, then it is sent to a central lab for processing, then sent back to the office for final finishing. They can also do relines and repairs at the in office lab.
I also love the “Dentures – Same Day of Extractions” advertising. People don’t realize that you can’t show up on their door step for extractions and get a denture your first visit. But once they are there, they sign on the dotted line. These mills will sell them an “Immediate Denture” and promise them a free denture if needed in 6 months. This is not billed at the $299 you see in ads! Immediates are for folks only having a couple remaining teeth removed and should be fine with a reline months later. They were selling these for full mouth extractions and were hideous. Found one that had a 10 mm upper anterior buccal flange! Extractions – if multi-rooted were routinely billed as surgical. Any extraction area with multiple extractions “received” alveoplasty. Frenectomies were routine for dentures. Their individual fees were not high – they just billed for anything and everything they could. (Including selling a rotary toothbrush and Peridex to the lady seen on the show who was getting dentures!)
Mike, my apologies for the long post but felt what I had to share was worthwhile.
Post away, Bob! 🙂 Beware of bargains, eh?
isn’t it a well known fact that heart disease is caused by cardiologists and cancer is caused by oncologists and surgeons. I mean, those diseases didn’t exist before the specialists existed……right? Why is this approach never tried with Medicine but is always being tried with dentistry?
Good points, Maurice. And, restaurants are responsible for starvation and malnutrition! 🙁
http://news.yahoo.com/death-greed-dentist-american-children-risk-160952338–abc-news-topstories.html
Just reading the user comments on the above article gets me mad and fired up.
Dentist are just protecting turf with not allowing dental therapist. Other developed countries use them, they can work for less than dentist, and they can do basic procedures to provide access to care — they are fantastic.
Dentists learn dentistry in the clinics not in the classroom. So cry me a river about taking all that undergraduate crap — yeah it sucks, but we all know it doesn’t make your fillings and extraction work any better.
Hi Joshua,
Would you share your credentials that qualify you to regale us with your wisdom on how dentistry is taught, learned, and practiced?
Joshua,
It works for other countries, because they didnt have enough dentists to serve their population. It wont work here because we have enough dentists. Access to care issue is found in the sticks and for people on medicaid, neither of which is addressed or solved by introducing a mid level provider.
My overhead runs about 70 percent. So of you take my pay out of the equation and I work for free a thousand dollars of dentistry will still cost the patient about seven hundred dollars. This is still unaffordable for poor people. Sad but true
Yet, many have the latest cell phone, which runs $600 – $1100 these days.
My cell phone is 5 years old (Galaxy S4).