Make dentistry cheaper

by on May 1, 2008 at 2:06 pm in Medicine | Permalink

Can you see what is coming?:

But to the Alaska Dental Society and the American Dental Association, the clinic is a place where the rules of dentistry are flouted daily. The dental groups object not because of any evidence that the clinic provides substandard care, but because it is run by Aurora Johnson, who is not a dentist. After two years of training in a program unique to Alaska, Ms. Johnson performs basic dental work like drilling and filling cavities.

Here is much more.  Get this:

The number of dentists in the United States has been roughly flat since 1990 and is forecast to decline over the next decade. A study last year from the Centers for Disease Control showed that Americans’ dental health was worsening for the first time since statistics began to be kept.

In Alaska, the A.D.A. and the state’s dental society had filed a lawsuit to block the program that trained people like Ms. Johnson, who are called dental therapists. The groups dropped the suit last summer after a state court judge issued a ruling critical of the dentists. But the A.D.A. continues to oppose allowing therapists to operate anywhere in the lower 49 states. Currently, therapists are allowed to practice only in Alaska, and only on Alaska Natives.

The opposition to therapists follows decades of efforts by state dental boards, which are dominated by dentists, to block hygienists from providing care without being supervised by dentists.

The dental associations say they simply want to be sure that patients do not receive substandard care. But some dentists in public health programs contend that dentists in private practice consider therapists low-cost competition. In Alaska, the federally financed program that supplies care to Alaska Natives pays therapists about $60,000 a year, one-half to one-third of what dentists typically earn.

The Alaska program is small, with fewer than a dozen therapists practicing so far. But the early results are promising, according to dental health experts who are studying the program.

As someone who has spent a lot of time at the dentist, I very much like the assistants and I think of the dentist himself as a kind of middle-level manager and salesman.

I thank Greg Rehmke for the pointer.

Eugene May 1, 2008 at 2:15 pm

Straight out of capitalism and freedom…

Charles May 1, 2008 at 2:39 pm

This is actually a big problem. Particularly for low-income people, dental care is either far too expensive, or simply unavailable. And the dental colleges are not increasing their student numbers with the result that the number of dentists continues to decrease.

Kudos to these folks in AK.

Mo May 1, 2008 at 3:00 pm

Can’t the same be said about the AMA?

Among the multitude of Healthcare solutions I have seen, I rarely see the issue of supply control of medical care providers as a significant obstacle in tackling he Healtcare crisis.

anonymous May 1, 2008 at 3:05 pm

I thought the money quote in the article was the matter-of-fact statement that over 100 million Americans
cannot afford dental care. The median income for married households in 2007 was approximately $80,000;
I’m not sure where the cutoff for 100 million would be (roughly the bottom third) but I’d love to know
where their statistics come from.

LB May 1, 2008 at 3:25 pm

Reminds me a lot of a NYT article from October. I know people even in the DC area who save their basic dentistry work for trips to Latin America. And you can even find dentists who work evenings there!

http://www.nytimes.com/2007/10/11/business/11decay.html?_r=1&scp=4&sq=dentists&st=nyt&oref=slogin

Patrick R. Sullivan May 1, 2008 at 3:50 pm

Can’t the same be said about the AMA?

Indeed, it has been. Famously by Milton Friedman, who told of a speech before the AMA where–thinking he had the perfect analogy–told the doctors assembled that occupational licensing laws were the same as saying only Cadillacs could be driven on our highways, because Chevrolets would not be up to standards.

He was stunned when he heard back: ‘That’s right, we can’t accept anything less than Cadillac standards for the American peoples’ health.’

Dave Barnes May 1, 2008 at 4:08 pm

We would need even fewer dentists and more people would have healthier teeth if we would let the commies fluoridate our water.
Cf. http://www.filmsite.org/drst3.html
Cf. http://www.aafp.org/online/en/home/clinical/clinicalrecs/fluoridation.html

Scott May 1, 2008 at 4:51 pm

Exactly what I was thinking Eugene. Friedman would be proud.

Grant May 1, 2008 at 6:09 pm

Is it me, or are the ADA and AMA both evil?

I do feel I should mention that the use of airbags in cars has decreased the need for many types of dental work. I’m not sure if this has anything to do with a decrease in the supply of dentistry, however.

beowulf May 1, 2008 at 7:08 pm

Can’t the same be said about the AMA?

Yes, we do need more medical and dental school seats to keep up with population growth. Either we build new schools or the Feds could mandate (with its purse strings) that medical schools operate on the year-round trimester system used in World War II- Four academic years completed in three calendar years. Alternately, as they do in Europe (and at some US med schools), combine college and med school in one 6 year program. http://research.med.umkc.edu/med_admissions/default.html

At least the AMA hasn’t stopped (not for want of trying) the use of nurse practitioners and physician assistants. These Alaskan dental therapists are the dental version of a NP or PA.

12345 May 1, 2008 at 8:36 pm

– Is it me, or are the ADA and AMA both evil? –

Don’t forget the ABA. It might even be safe to say that organization styled A__A is going to be bad for consumers.

Gil May 1, 2008 at 10:44 pm

Actually dentistry is quite cheap if you have access to a pair of pliers.

thehova May 1, 2008 at 11:56 pm

It seriously pisses me off that even someone as “revolutionary” as Michael Moore refuses to criticize the AMA.

For some reason beyond my understanding, the left feels squeamish voicing any concerns over the AMA and how their restrictive supply side policies impact those without health insurance.

Ned May 2, 2008 at 8:45 am

It may come a shock, but the AMA has nothing to do with regulating the supply of physicians. Anyone is free to start a medical school, and the accreditation process does not involve the AMA. Physician licenses are issued by th
e states with no input from the AMA. The Flexner Report was a sad commentary on the condition of medical practice in this country and spurred many reforms to put the marginal practitioners out of business. For a look at what it was like before these reforms, see http://www.amazon.com/Charlatan-Americas-Dangerous-Huckster-Flimflam/dp/0307339882/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1209731653&sr=8-1

Yes, there is a problem with access to adequate medical and dental care in remote rural areas such as parts of Alaska, and allowing paraprofessionals such as dental therapists and nurse practitioners to work independently in these areas may be a reasonable solution. But don’t carry it too far – do you really want to allow Dr. Quack to treat brain tumors with herbal remedies?

SteveH May 2, 2008 at 12:53 pm

A lot of people who comment here know something about economics but nothing about health policy. I, on the other hand, know a lot about health policy and little about economics. Ned is right, everyone else’s comments about the AMA acting as a cartel are at least 30 years out of date. In addition, there isn’t any evidence that increasing the supply of physicians brings down health care costs. In fact, the evidence runs in the other direction; increasing numbers of docs means health care costs go up. The only exception to this rule is that having more general practitioners rather than specialists gives better overall results while keeping costs down.

On the other hand, there is nothing good I can say about the ADA. There is a vast cultural difference between dentists and physicians which I can summarize by saying one is a very well paying trade and the other is a profession. The Med Schools try to inculcate some ethical code of conduct which includes, at least in theory, some obligation to treat the ill even when they may not be able to pay for treatment. Dentists don’t have any such obligation in theory or practice which leads to crap like their lawsuit to block the Dental Health Aides in AK.

Nurse Practitioners and Physician Assistants are now well-established and the AMA didn’t stand in their way with nearly the ferocity that the ADA has used to prevent hygienists from being able to practice independently or to try to kill the AK program. There’s a movement by hygienists to license Advanced Practice Hygienists who would be able to practice independently. See http://www.adha.org/news/04212008-adhp-mn.htm for an example. This kind of thing would do more to make dental care available to the underserved than opening more dental schools ever would.

Ned May 2, 2008 at 1:27 pm

“Could a doctor do that today? As far as I know there is no place where an uninsured person can simply pay for a visit to a doctor’s office.”

Most health care providers, including physicians, dentists and hospitals, are delighted to take payment in cash and will often offer a discount for such. If nothing else, it saves them billing and collection costs. Try it sometime.

SteveH May 2, 2008 at 1:45 pm

“But, only state and federal government stand in the way of allowing up to, say, 5,000 trained doctors, nurses, and dentists per year receive visas to work in the U.S.”

About one quarter of all physicians practicing in the US are foreign medical graduates. That’s quite a lot. You might also consider how much other countries would want to open med schools, at considerable expense, just to provide care to US citizens. Why should they?

Here’s an excerpt from a recent New England Journal of Med article:

“The total number of [medical] students remained essentially unchanged between 1980 and 2000 at about 16,000 graduates, whereas the U.S. population grew by about 71 million people. However, the number of licensed physicians increased substantially, because of the doubling of the number of graduates of schools of allopathic medicine before 1981, the robust expansion of colleges of osteopathic medicine, and a continuing flow of international medical graduates (IMGs), most of whom remain in the United States to practice after completion of their advanced training… The United States was able to maintain an adequate supply of physicians because the number of entry-level allopathic residency positions (24,085 in 2006) greatly exceeded the number of graduates of U.S. medical schools (15,925 in 2006). Because of this differential, teaching hospitals were able to employ thousands of IMGs each year to fill their advanced-training positions and to provide care to patients. As of 2005, IMGs represented 25.3% of all practicing physicians in the United States.8 In total, the number of active physicians grew from 453,165 (200 per 100,000 population) in 1980, to 601,237 (241.7 per 100,000) in 1990, to 783,852 (278.5 per 100,000) in 2000.”

http://content.nejm.org/cgi/content/full/358/16/1741

It’s clear physician supply hasn’t been restrained, but it’s also clear that med students follow the incentives which are to specialize, specialize, specialize. Specialists make lots more money. And they perform many more expensive procedures but, as I said above, the evidence doesn’t show that improves the care provided. It simply costs more.

Craig Glackman May 3, 2008 at 6:26 am

More than capitalism and freedom, pure Mancur Olson (The Logic of Collective Action; The Rise and Decline of Nations; Power and Prosperity).

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candy May 14, 2009 at 11:21 pm

it is better to declain

kate May 14, 2009 at 11:25 pm

it is not bad

BonifaasPim January 19, 2011 at 9:11 am

I don’t think that this therapists could undermine the classical dental care. This initiative should be considered as a complementary service and not a competitive one. Bonifaas Pim orthodontist Tucson

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