ADA to Dental Practioniers: You Can’t Handle the Tooth!

by on January 19, 2012 at 7:35 am in Economics, Medicine | Permalink

From an article at Governing.com:

…dental care is hard to come by in underserved areas of the country. Try finding a dentist in the remotest rural or deepest urban pockets of the land, and for blatantly economic reasons, they just aren’t there. That’s why states are looking to fix the problem by creating a so-called mid-level dental provider. Much like a nurse practitioner (NP) or physician assistant (PA) is to a doctor, this provider would be educated and licensed to perform basic dental services — routine checkups, cleanings, filling cavities and extracting teeth — under the supervision of a fully trained dentist.

…Yet in much the same way that the American Medical Association fought against the creation of NPs and PAs, the American Dental Association (ADA) and its state chapters are lobbying hard to thwart state legislatures as they work to create this new level of dental care providers, who are common and well liked in other parts of the world.

…“Publicly their main objection is safety issues,” Oswald says. “They tried to discredit the model, saying the therapists were not trained to the same level as dentists. In reality, all the research around the world shows that [mid-level providers] provide as good, if not better, care. Every time they stated safety as a factor, we asked for research, which they didn’t have.”

By the way, states with tougher licensing of dentists do not have better dentistry, but they do have higher prices. Almost thirty percent of the US workforce is now required to hold a license including shampoo specialists.

Hat tip: Carpe Diem

Andrew' January 19, 2012 at 8:38 am

Where I live, this is called “going to the dentist.” I only see the dentist for about 5 minutes. I guess we just have to get used to half the population wanting everything formalized.

Noah Yetter January 19, 2012 at 3:52 pm

Same here. Even fillings now are largely performed by technicians. They seem to be just as good at it.

Rahul January 19, 2012 at 8:42 am

The article starts with what seems like a classic example of confusing correlation with causality; or do bad teeth really cause osteoporosis?

>>>Poor oral health has been linked to serious problems like cardiovascular disease, worsening diabetes, osteoporosis and premature birth. Regular dental care is, therefore, a key component in reducing costs associated with the care of those chronic diseases.<<<

Andrew' January 19, 2012 at 8:46 am

Or do dentists really cause good oral health? Not when they charge $250+ for a cleaning last time I went.

Rahul January 19, 2012 at 8:49 am

Well, it does cost $1500 for a root-canal. So they sure have deterrence value!

Andrew' January 19, 2012 at 8:52 am

The whole flipping thing is falling apart and it is way less exciting than Ayn Rand said it would be.

Anthony Lima January 21, 2012 at 10:53 am

The rating agency has a reputation as well. They would be profitable only if their ratings were good.

dearieme January 19, 2012 at 8:47 am

The NHS used to provide dentistry throughout Britain (though you could opt for private dentistry if you liked). Under Mr Blair’s Labour government it became very hard for new patients to sign up for NHS dentists in various parts of the country. That there was so little fuss about it I attribute to large chunks of the media being preparted to cry “NHS in Danger” only if there is a Conservative government in office, or in the offing.

Jon Murphy January 19, 2012 at 9:01 am

Proposal:

In lieu of licensing, why don’t we have a private organization who rates dentists, lawyers, doctors, shampoo specialists, etc.? Similar to the Good Housekeeping Seal of Approval or the BBB? Wouldn’t that reduce the costs of care/service (since more are practicing) and help consumers make informed choices?

Dan Dostal January 19, 2012 at 9:04 pm

Sure, but how do we ensure said private organization is actually doing it’s job? Who metric’s do they live by? How do we ensure the organization isn’t corrupt? How do we ensure that consumers will care? Requiring a license is a much simpler policy move, even if it’s the poorer choice.

Anthony Lima January 21, 2012 at 10:55 am

Anthony Lima January 21, 2012 at 10:53 am
The rating agency has a reputation as well. They would be profitable only if their ratings were reliable.

FERGUS O'ROURKE February 14, 2012 at 2:21 am

Not if the ratings business is a protected oligopoly

Jon Murphy January 19, 2012 at 9:03 am

New Hampshire is considering doing away with licensing requirements for a number of professions, including cosmetology. Surprise surprise, the cosmetologists in Concord want to prevent the bill from being passed “in the interest of public safety.”

NAME REDACTED January 19, 2012 at 6:47 pm

Ah New Hampshire, I see that the Free State Project is coming along.

CBBB January 19, 2012 at 9:05 am

Yeah well and then you’re going to turn around and tell me that these wealthy people earned all their money, when in fact we can see a wide variety of these top professions get to overcharge because of licensing. A good deal of the so-called returns to education are likely do to people getting degrees as a stepping stone into a regulated profession like dentistry, medicine, law, accounting.

Slocum January 19, 2012 at 9:46 am

On that topic, you are preaching to the choir here. Professions who use licensing to restrict competition and raise the cost of entry (and prices to the consumer) will get no support from libertarians. It’s progressives who support all those licensing schemes (and want to impose more of them) and libertarians who oppose them. Or are you one of the (brave? foolhardy?) lefties like Yglesias who questions the value of licensing:

http://thinkprogress.org/yglesias/2011/07/19/273414/the-distributional-impact-of-barber-licensing/?mobile=nc

Andrew' January 19, 2012 at 9:49 am

That, and Jeff Sachs has read a lot of cutting edge libertarian thought.

question the question January 19, 2012 at 10:39 am

These libertarians should put their money where their mouths are and refuse tenure.

Starting with Alex and Tyler.

Andrew' January 19, 2012 at 10:45 am

That’s dumb.

CBBB January 19, 2012 at 11:53 am

+10000

JWatts January 19, 2012 at 2:16 pm

Sure and the Liberal should put their money where their mouths are and pay higher taxes. I assure you that, no one else will object

question the question January 19, 2012 at 2:18 pm

Breathtaking non sequitur.

CBBB January 19, 2012 at 11:53 am

My criticism is that on the one hand I see posts like this saying nearly 30% of the workforce is regulated by some sort of licensing regime. But then on the other hand there’s posts claiming that the money earned by these high earners who tend to be doctors, lawyers, etc. is all due to their productive value. It’s a total disconnect.
Also the fact that so many jobs need licensing really puts to rest this notion, presented in so many economic models, that workers can shift around between industries.

Andrew' January 19, 2012 at 12:04 pm

No it’s not. It’s really simple. What are the rents? We don’t know because every certification gets the same status regardless if they are value-added or just rent-seeking.

The tenure comment is dumb for a lot of reasons. For one, if you don’t get/have tenure then, by custom, that means you lose your job. So, even to ignorantly to fall on your sword you’d have to change that custom.

Second, it’s dumb because you don’t want, well, if you are being honest, you don’t want two individuals to lose tenure, you want to change the tenure system. So, what Alex and Tyler might do is sign a pledge that says “if everyone else gives up tenure we will too.” But, they can’t even do this because they’d likely be blackballed by the rent-seekers.

CBBB January 19, 2012 at 12:19 pm

I’m not even for changing tenure necessarily – I’m just doing it for the Cowen Tabbarrok bashing.

CBBB January 19, 2012 at 12:20 pm

But on the topic of regulating professions and licensing agreements I think this poses a big problem for many of the economic models used to justify “free” trade agreements or how productivity increases are good for employment.

Jon Murphy January 19, 2012 at 12:28 pm

There is no hyprocricy here. These doctors/dentists/etc earn their salaries based on their value produced. But they restrict the supply of doctors, therefore increasing the value of the things they produce and increasing their salaries. Economics 101: when you restrict the supply, the price rises.

Andrew' January 19, 2012 at 1:30 pm

Funny, but they haven’t increased the value, they increased the price.

CBBB January 19, 2012 at 3:35 pm

This makes no sense – you know in Econ 101 when price rises supply also rises and you reach your equilibrium but what you have here is a situation where prices rise but supply is restricted which does not lead to the optimal outcome

The Original D January 19, 2012 at 2:00 pm

The goal of regulations on some of these top professions is preventative and is driven by a past calamity. Much of the securities regulation (which includes licensing) is a result of the Great Depression.

I think there’s too much rent-seeking at the top too. But you can’t simultaneously complain that people at the top make out like bandits because of rent-seeking, but “there oughta be a law!” to prevent financial meltdowns because of bad behavior. Licensing regulates behavior, and it stands to reason that the people getting regulated will have a vested interest in how that licensing process works and is enforced.

CBBB January 19, 2012 at 3:38 pm

Yeah there’s a balance – but my point is this is yet another example of how people who generate a lot of income do so because of special protections or privileges. Doctors are a good example – the number of doctors is absolutely limited by the number of medical placements available – if there’s 10 people who are all great candidates but only 5 spots in medical school only 5 of those people are going to get to be doctors even though all 10 would have made good doctors.

Kevin January 19, 2012 at 9:22 am

Underserved populations generally fall into 2 categories: 1) pediatric patients, and 2) geriatric patients. Serving the poorest in these communities requires more training, not less. I think there are residencies after dental school for each “speciality,” if a dentist wants to make a practice exclusively tailored to either group.
In any event, these two groups usually have more problems, more complications, and require more careful care than groups which receive more regular care. In short, it’s harder. For example, a dentist or intermediate specialist would have to know and understand all the medications a geriatric patient was on before doing something as minimal as administering an anesthetic. Similarly, with pediatric patients in poor areas, dentists or intermediate specialist would see some very bad cases of oral hygiene. It sounds nice to have a professional tooth scraper, but the underserved populations rarely come to dentists for such minimal care.

I’m not against the idea of the intermediate specialist as a measure against supra-market premiums for the professions, but do not like that it’s being heralded as some sort of white knight. Poor communities don’t need cleanings; they need crowns, and removable/fixed dentures. That is pricey, even if only materials are considered. Realistically, all these new intermediate specialists will work at dental chop shops, like Aspen Dental, in an assembly-line manner and still charge a hefty sum. Cleaning teeth, after all, does require training and is difficult.

Lesson(?): Brush. With a SonicCare. And Floss.

KLO January 19, 2012 at 9:34 am

Formal licensing requirements do not, by themselves, reduce the number of entrants into a profession. In most professions, they actually increase the number of entrants by allowing people with an interest in, but no connection to, a profession a relatively straightforward pathway into that profession. So, for example, there is no shortage of barbers or masseurs even though many states have licensing requirements for both.

The only licensing requirements that do serve to protect existing members from new entrants are those that effectively impose an artificially low cap on the number of license holders. Dentists must attend schools of dentistry which are in short supply. Most of the other professions which economists moan about are not subject to the same limitations on new entrants.

Sandeep January 19, 2012 at 10:44 am

Bad analogy. The time, cost and amount of training needed for barbers, masseurs etc. is much lower for barbers, masseurs etc., so the licensing restrictions don’t affect those professions much.

Your comment Dentists must attend schools of dentistry which are in short supply. is bad reading comprehension (in fact so spectacularly bad that you are probably not so much making a mistake as being intentionally dishonest) : he is talking not about dentists being allowed to practice dentistry but nurse practitioners and physician assistants being allowed.

KLO January 19, 2012 at 10:56 am

If they don’t affect the profession much, then why is Alex so worried about them? Note that he linked to a criticism of licensing for shampoo specialists, which suggests that he thinks that licensing requirements do have some important economic effect even at the lower end.

@Sandeep: Your comment Dentists must attend schools of dentistry which are in short supply. is bad reading comprehension (in fact so spectacularly bad that you are probably not so much making a mistake as being intentionally dishonest) : he is talking not about dentists being allowed to practice dentistry but nurse practitioners and physician assistants being allowed.

No, he is talking about licensing requirements, using, as an example, dentists. Alex is arguing that dentists use licensing requirements to block competition from other licensed and unlicensed professionals and thereby raise wages. I am agreeing with him. Dentists do this. But just because dentists do this through licensing requirements does not mean that all, or even most, licensing requirements have this effect. Despite calling me “probably intentionally dishonest,” you also apparently agree with me. To you, licensing for barbers and masseurs not sufficiently costly to have any significant effect. I totally agree. Why you feel the need to personally attack me is beyond me.

Andrew' January 19, 2012 at 11:45 am

If not for the mesh of certification we wouldn’t distinguish between this group of obiviously qualified people we call dentists and this other group of not obviously qualified people called, whatever we call them.

Sandeep January 20, 2012 at 8:45 am

Okay, I think I misinterpreted what you said. So sorry for that. I am not a native English speaker, so when you said “Dentists must attend…” I thought you were stubbornly insisting that those who practice in this profession attend those schools. Had you said “Dentists have been required to attend…” I wouldn’t have been confused.

Also, talking of barbershops : you may be right, but while I don’t have the link now, somewhere I read that most barbers used to be men at one time, but licensing requirements threw them out of work by giving advantage to women who were more into beauty-parlor-type business. This doesn’t contradict what you said, but this is an example of a licensing law where the set of people who enter a profession, though not the number of people, could be affected.

Cliff January 19, 2012 at 11:10 am

Where is your evidence that increasing the cost and difficulty of entering a profession does not reduce entry into the profession?

KLO January 19, 2012 at 12:03 pm

Obviously, increasing the cost or difficulty of entering a profession will reduce the number of entrants. The question is whether licensing requirements increase the cost or difficult of entering a profession. In some cases, they certainly do. Many people who want to become doctors are unable to do so, because they cannot get into medical school or a find a residency program. Large numbers of these people would make fine doctors. In other cases, licensing requirements provide a clear pathway into professions that may have previously had largely informal barriers to entry that were harder to overcome than the more formal licensing barriers. Evidence of this can be seen in the relationship between the number of new entrants in a profession and the introduction of licensing requirements. For example, the number of massage therapists has greatly increased since the introduction of licensing requirements for this profession. Before the license requirements, few people probably considered massage therapy a profession and training programs were largely non-existent. Those who were interested needed to study on their own or as an apprentice to an experienced massage therapist. Now all you need to do is sign up for a 10-week course and obtain a simple license to become a message therapists. Thus, licensing helped reduce informal barriers into the profession and thereby increased the number of new entrants.

Andrew' January 19, 2012 at 1:33 pm

It’s interesting. However, combine the two things and what you have if everything becomes licensed you get people choosing careers based on the costs of the licensing. In other words, too many massage therapists and two few medical personnel (“doctor” is part artifact of the licensing regime).

Wil W January 19, 2012 at 9:38 am

Just a note, but I think this is an issue across other medical professions as well and part of the reason for high medical costs.

Another example is midwifery and OB/GYN groups like the American Congress of Obstetricians and Gynecologists(ACOG). Even though again Midwifery is common throughout the world (even Western Europe) in the US groups like ACOG have members with money to loose if quality midwives become common.

Quotes like this one:
…“Publicly their main objection is safety issues,” Oswald says. “They tried to discredit the model, saying the therapists were not trained to the same level as dentists. In reality, all the research around the world shows that [mid-level providers] provide as good, if not better, care. Every time they stated safety as a factor, we asked for research, which they didn’t have.”
Applies in the exact same way, just switch up the profession.

I would venture to guess that there are many other medical professions where this is true.

Lewis January 19, 2012 at 9:45 am

How can you oppose a progressive income tax knowing that these people–dentists, doctors, lawyers–use the power of the state to inflate their earnings? Alabama is the worst. A regressive tax system and more licensing requirements than any state in the country. A huge, stacked deck against people whose family background did not value education from the get-go.

Andrew' January 19, 2012 at 10:51 am

Because I plan to make a shit load of money and I won’t have any rents. How can you support progressive taxation rather than just getting rid of the rents?

Bernard Guerrero January 19, 2012 at 11:48 am

Aye. Lewis, you’re asking those of us who don’t require a licensing regime to continue suffering the effects of licensing regimes and then accept a higher rate of taxation _on ourselves_ in order to make up for it? Silly.

Rahul January 19, 2012 at 11:50 am

Occupation tagged taxation schedules?

Andrew' January 19, 2012 at 12:06 pm

Or, brain explode time, certify private certification organizations.

Rahul January 19, 2012 at 12:12 pm

Who certifies the certifiers? Turtles all the way, eh?

Andrew' January 19, 2012 at 1:36 pm

Not exactly. Create a general framework for a government recognized certification program. Then you wouldn’t have to deal directly with rent seekers which you are not at all qualified to do anyway. It’s funny to me that the government can do what consumers can’t possibly be expected to do, and yet democratic accountability and all that. And additionally, anyone meeting the generic requirements to be a recognized certification agency can certify service providers allowing for more competition on certification dimensions rather than political pull dimensions.

I don’t do this for a living. That’s part of the point.

Andrew' January 19, 2012 at 1:38 pm

Basically, partly it’s the principles of generic quality auditing. I don’t care what you do, just say what you are going to do, then I come in and determine if you did what you said you were going to do. It’s kind of what they do anyway to some extent with the industry comment, just in a very convoluted and Godfather-esque way.

Silas Barta January 19, 2012 at 10:36 am

Hat tip: Carpe Diem

More like Carpe Dentum lol m i rite?

Dale January 19, 2012 at 10:40 am

While I agree with the qualitative picture that licensing has been increasing, I am not convinced by the quantitative estimates. The 30% figure sounds too high to me and when I look at the cited paper, the details are unconvincing. First, the Gallup poll data used may well be subject to selection bias. It is also very unclear what denominator was used to give the 30% estimate. The earlier years’ data is even sketchier as it is derived from Census data via a procedure described in a footnote that is anything but transparent. As an example, it is unclear that recording somebody’s occupation is a good measure of whether or not they need to be licensed. In the case of a dentist, I don’t have a problem. But if somebody’s occupation is more vaguely defined, they might need a license despite that occupation not being listed on the “official” list of licensed occupations.

In any case, there is simply not enough detail in the paper to be able to judge the reliability of any of the data points. If ind both the magnitude of the current estimate (30%) and the size of the trend over time unconvincing.

Master of None January 19, 2012 at 10:41 am

I have a question/thought.
If all licensing regulations were repealed tomorrow, the prices of many services would quickly fall.
This would lead to lower wages for providers of those services, except that wages are sticky, so more likely would lead to higher unemployment.
Would you argue that since this is a short-run adjustment, it is still desirable? What would abolishing licenses do to RGDP in the short-run/long-run?

And finally, for Tyler, does ones answer to the above have implications for ones thoughts on mobility/fairness/happiness with respect to yesterday’s post? Specifically #3, “less aggregate happiness”?

http://marginalrevolution.com/marginalrevolution/2012/01/why-economic-mobility-measures-are-overrated.html

Cliff January 19, 2012 at 11:13 am

What is the mechanism for the higher unemployment? Wages would only fall (after accounting for licensing costs) if there were new entrants into the industry.

Master of None January 19, 2012 at 11:24 am

That’s what the post is about… new entrants and new substitutes are pretty much a given when you remove the licensing requirements.

Tom January 19, 2012 at 1:25 pm

If there are new entrants, employment increases. Some of the old may drop out, but not likely as many who enter. The decreased prices should increase services sought for another boost to overall employment.

Master of None January 19, 2012 at 3:14 pm

The number of employed may increase, but likely not as fast as the wage declines. Substituting $40,000 dental hygenists for $100,000 dentists… do you think you need 2.5x the number of hygenists per dentist being replaced? No.

TallDave January 19, 2012 at 10:58 am

I dated a woman from New Mexico, she told me when they were kids their parents would take them south of the border for their dentistry because it only cost about $1/filling.

KLO January 19, 2012 at 11:08 am

Was that before or after Mexico required dentists to obtain a license prior to practicing dentistry?

Rahul January 19, 2012 at 11:10 am

That sounds suspiciously low. A filling costs more than a dollar even in India.

TallDave January 19, 2012 at 11:45 am

Well, this would have been the 1970s or early 80s.

Bill January 19, 2012 at 11:15 am

How were her teeth?

question the question January 19, 2012 at 11:38 am

Packed with adobe.

Rahul January 19, 2012 at 11:45 am

…and the anesthetic used was Mezcal

Bernard Guerrero January 19, 2012 at 11:51 am

I like mezcal…”para todo mal, mezcal, y para todo bien también.”

Andrew' January 19, 2012 at 11:46 am

Perfect, missing her front four.

Fillings. I suspect the teeth were obviously better than they would have been without “access” (barf) to affordable dentistry. Again, inputs and outputs.

Just had an idea for a new reality show, “Half a Day.” Give me half a day of training and by the afternoon I’ll do any of these things that can’t possibly be done without 6 years of schooling and many years and hundreds of dollars of certification. If you the government can write a certification for it, it’s easy.

Nick_L January 19, 2012 at 11:41 am

Imagine that, a dentist asking “is it safe?”. Do let us know how your next trip to your dentist goes, Alex.

Joe Beer January 19, 2012 at 11:49 am

Licensing is intended to mitigate asymmetric information, right? Consumers in some circumstances may have a difficult time discerning quality when it comes to health care providers and licensing, especially when linked to a formal eduction path, provides a lower bound on quality. The effect of asymmetric information on the efficient allocation of resources is probably minimal when we’re talking shampoo and haircut, but on something like dentistry might it be a different story? For example, a basic cleaning is a relatively straightforward procedure that lots of folks with good fine motor skills and an inexhaustible tolerance for bad breath could do. But the diagnosis of carious lesions, gum disease, cracked teeth, oral cancer, etc are to some extent wrapped up in that cleaning and exam–the quality of care is dictated by the education, intelligence and experience of several people during the visit. The ability to discern quality has a temporal component too–you may think things are great on the day of treatment, only to discover later that a sub-par dental provider missed an obvious oral cancer lesion or left microscopic amounts of decay under a crown which subsequently failed at year four instead of year 25. That’s just an example, but it’s not far off the mark I suspect. Maintaining educational requirements may be possible without the license requirement, but how would it work? What’s the alternative prescription for quality discrimination under asymmetric information, esp. given a premise that reputation alone is insufficient due to lags in assessing quality outcomes?

This has implications for lots of professions (auto mechanics, doctors, economists). Perhaps the first question is: what’s the degree of market failure for which we’re considering corrective regulation? What’s the welfare implication?

Bill January 19, 2012 at 1:47 pm

Good points.

I think what you also want to do with licensing is two other things:

1. Compare across jurisdictional boundaries to see whether licensure requirements are too tight or of no value. You can do some natural experiments comparing different states, different countries, etc. if you wanted to do so.

2. You have to recognize a different problem and address it: State legislatures have no expertise and resources to assess licensure standards, and they unfortunately then have to rely on the professional associations for information. How to address this deficiency could be interesting

a. Health Insurers might have an interest in funding research on standards and licensure;

b. State legislatures could fund research by their medical schools on licensure requirements;

c. Private foundations could get involved as a way to reduce costs for certain populations (Bill and Melinda, are you listening)

d. Some economists could do cross state and cross country studies on licensure and health outcomes

e. Para professionals–eg. nurse anaesthestists, physicians assistants, pharmacists, etc.—could be enlisted to chip away at the licensing requirements of docs, or expanding the scope of their own practice so that they in effect are competing against docs.

f. To the extent certain practices become highly mechanized, through software and imaging, for example, we could declare, for example, an automatic system which tells you a result (reads your tests, reads the xray) as not the practice of medicine. Or, we could promote self-diagnostic autonomous systems to supplant doctors–Hello Watson.

bertrand January 19, 2012 at 4:30 pm

The standard answer is nothing stops you from certifying dentists or doctors as being different from other practitioners IF you don’t ban alternatives. Just like we don’t ban most safe medical supplements. But the ADA wants to ban mid-level dental practitioners just as the AMA tries to heavily restrict midwives. Have them both compete in the market. IF the certified dentists are that much better, customers will seek them out but don’t pretend that because a Lexus is a better car that no one should be allowed to buy a Kia. After all, if we’re concerned about safety, shouldn’t we ban small, cheap cars?

Bill January 19, 2012 at 5:05 pm

That doesn’t mean the ADA wins. As I noted, what you need to do is your homework, form alliances with competitive practioners, and provide information. Midwifes and midlevels should make their case, provide information….and let the battle begin. The alternative answer is to let me pull your teeth because I saw a Youtube video on the subject.

Don’t get me wrong. I think it is extremely idealistic to think that you are not going to have licensure. What you need to do is use the steps I mentioned above to change licensure and add more alternatives and provide information.

Joe Beer January 20, 2012 at 10:17 am

Wouldn’t Pigou say that if we’re concerned about safety we need to ban big expensive cars? As for the Lexus-Kia continuum, it’s not a very good example. There are standard quality metrics that are readily available and easily understood. You know what you’re getting when you buy a Kia, and if used properly it won’t hurt you. The same cannot be said for sub-standard dental care. Also, the business of dentistry is far removed from the business of medicine…you can price shop for dentists, and there is some downward pressure on prices (unlike medicine). The question is ‘would society be worse off, at the margin, in the absence of licensure?’ and I’m merely supposing that the answer varies based on the risk associated with the degree of market failure. So it’s different across professions.

Take chiropractic…I know almost nothing about it, but it seems that there’s a huge variance in quality and it’s difficult for consumers to judge. Presumably, there are many people who could benefit from chiro that chose not to pursue it do to quality uncertainty. If standards were better established (through license requirements) and the lower bound on quality were higher, would society be better or worse off given higher prices for care?

NAME REDACTED January 19, 2012 at 7:16 pm

“Licensing is intended to mitigate asymmetric information, right?”

No, thats a post hoc justification for it by economists.

Bill January 19, 2012 at 9:23 pm

Licensing is designed to correct for assymetric information and to prevent consumer ripoff. The issue is whether there is good or bad licensing.

If you want to read about this, look up Akerloff’s piece on lemons, and a US Supreme court antitrust case, California Dental, which deals with overbroad advertising regulation and whether the dental society engaged in price fixing by denying certain types of price advertising..

Careless January 19, 2012 at 11:50 am

I think we need to add “titles containing terrible puns” to the list of ways to tell an Alex post from a Tyler post

Urso January 19, 2012 at 11:54 am

This could be applied to lawyers as well; some brave US state needs to set up a solicitor/barrister model.

Rahul January 19, 2012 at 11:59 am

Aren’t “paralegals” a step in that direction?

Andrew' January 19, 2012 at 12:07 pm

It’s the same thing. The lawyer doesn’t want to let people know that it’s not him doing the work. It’s just easier to see the girl with no letters sticking metal in your mouth.

Urso January 19, 2012 at 12:25 pm

What the paralegal does is the rote, low value added stuff; but the client ends up paying a premium for it anyway.

Urso January 19, 2012 at 12:23 pm

Not really, because a paralegal can’t do anything without an attorney signing off on it. So in the end you’re paying for a lawyer. Also in my experience paralegals predictably overestimate just how much of a lawyer’s job they could do.

A better example would be to say that graduates from lower-ranked law schools fit this niche. But we still make those graduates jump through the same hoops even if they never plan to practice any kind of particularly complex law. There should be an entirely separate track, 2 years instead of 3, more practically minded, except when you graduate you’re limited in what kinds of things you can do.

The Original D January 19, 2012 at 2:08 pm

Overestimate in terms of skillset or in terms of billable hours?

Bill January 19, 2012 at 5:08 pm

Urso, We do have will kits and software incorporation software, etc. that supplant both lawyers and paralegals. I personally think you could also credential lawyers without requiring the school have a certain size library before it is ABA accredited, for example.

Urso January 20, 2012 at 12:03 pm

For what it’s worth I would recommend those software kits to literally no one. And I agree the ABA accreditation standards are fairly silly and could be changed, but that’s really picking at the edges of the issue without addressing the major problem.

Agent Smith January 20, 2012 at 4:34 pm

The ABA lost control of the profession many years ago. There are only several hundred law school and now several states allow people that attended non-accreditation schools to take the BAR.

The ABA is NOTHING compared to the demists and doctor’s rent-seeking organisations.

Becky Hargrove January 19, 2012 at 12:01 pm

The question is…who steps outside of that circle of (regulated) protection first? The dental hygienist does not like being under the thumb of the dentist, the dentist does not want the dental hygienist to take what could be his profit, and the hygienist does not want someone with less experience making it even harder for her to make a living. No one will reach agreement on such things until they are considered in a perspective where doing what is reasonable is not perceived as ‘giving in’ and monetarily being punished for doing so. Single changes that are so hard to fight for in the first place, change the integrity of the remaining structure.

drkdentaloffice January 19, 2012 at 2:41 pm

This site is becoming a challenge to the practitioners from saving the tooth and it’s good to visit the site and is also discussing a various questions related to the dental cavity issues…………..

Rahul January 19, 2012 at 3:53 pm

Am I overreacting; or have we started seeing the advent of targeted, context-dependent, automated spam? Impressive!

Ed January 19, 2012 at 6:16 pm

Responding to Joe Beer’s point at 11:49, the diagnostic services he describes should not be required to be a licensed dentist.

The licensing regime should be concerned with two things:

1. That the dentist type not hurt their patients.

2. That the dentist type is able and willing to provide the services that they promise.

So if you want to go into the business of cleaning teeth, and state up front that that is what you are going to do, no fillings, straightening, diagnosis of oral cancer, and so on, then you should be able to get a license to clean teeth. Then you can learn the skills to do the other stuff, get licensed for that, and add that to your practice.

What I am advocating is switching to a series of microlicenses for specific procedures. The idea is that these would be cheaper and quicker to obtain, but you still don’t x ray people unless you know how to avoid giving people radiation. It would sabotage my idea if the microlicenses were not cheaper than the all-or-nothing license. “Dentist” would be a term for people who graduated from dental school, and if you did that you could advertise as such and probably make more money than someone who didn’t go to dental school but can do a few of the procedures. But if all you want is your teeth cleaned, you can go to someone who just does that. You can just get your teeth cleaned semiannually and see a “real” dentist once every five years or so for a more thorough checkup. A dental office can employ, maybe on a part time basis, a number of people with various microlicenses and be able to provide more services to more patients than is currently the case.

But its not the concern of the government that a business provides top-shelf goods or services. If consumers want that and can afford that they can pay for it. Where the government has to focus is to prevent actual harm or fraud from happening.

Bill January 19, 2012 at 9:29 pm

What do you do if you see cancer or a cavity? Not report?

If you report a cavity or cancer, then won’t the consumer assume that you would report, even if you disclaim a reporting obligation?

I think you need to figure out a line further down the road than just what you offered, because, no matter what you say, there probably would be expectancy of disclosure, and there probably would be reporting, and then thereafter an expectancy, even if you disclaimed.

I think, without knowing more, that you probably could get some training that covered detection and that’s probably where I would draw the line.

No drilling please.

Bill January 19, 2012 at 9:49 pm

Ed, You might also want to think about the economies of scale and scope issue, beyond just licensing.

So, what we have today is a teeth cleaner, hygenist, sharing the same equipment and office with the dentist, who dances in for five minutes to review the hygenists work and look at the x-ray.

Now, assume a separate market: this time, the hygenist has her same equipment, chair etc., and tells you to go to the dentist to see if you have a cavity. Dentist sees you know for 15 minutes (including prep time and receptionist) in a separate office.

I bet the bill is higher–both on duplication of equipment, and from the loss of being able to use LESS of the dentiists time in the second visit versus the fly by visit in the integrated dentistry example.

What I thing would save money, and encourage dentists to subsitute technicians for their own work, would be some type of capitated payment arrangement.

Joe Beer January 20, 2012 at 10:30 am

I think you meant “licensed tooth scraper” not “licensed dentist.” The diagnostic services I described are precisely what a dentist does, and should do, and should be required to do. Incidentally, a license per se does neither of those two things unless it’s bound with some educational and experience requirements. I think Bill is right about the other stuff, though I see if from a pure liability standpoint. The MRI tech at the hospital may clearly see your fractured ribs, but will never tell you they’re there…it’s up to the radiologist, who comes along as part of the MRI package. Disaggregating that package has costs that, as Bill says, are likely to be higher than the package itself.

The original idea here was a mid-level provider -for underserved populations- which is different than the direction the comments have taken.

Sargeant Tomato January 19, 2012 at 11:34 pm

The ADA is an unnecessary union. It does nothing but complicate dental care for patients and most dentists.

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