We are writing regarding the March JADA editorial by Drs. Michael Glick and O.T. Wendel, "Lessons Learned: Implications for Workforce Change" (JADA 2008;139[3]:232, 234).
Lessons learned. Dentistry is no longer health care that works. Dentists should no longer be cutting restorations or extracting teeth, and it isn’t clear as to what else the general dentist should abdicate to "emerging groups of oral health care providers," whom JADA advocates we "invite ... into our midst."
We read about the American Dental Association doing all it can in Minnesota to stop legislation to establish the nation’s first advanced dental hygiene practitioner (ADHP) program. While falling far short of the education of a dentist, ADHPs would be far better trained to perform therapeutic procedures than the dental health aide therapists (DHATs), which the ADA embraced with its refusal to appeal a ruling by a lower court judge with a record of having nearly one-half of his decisions overturned on appeal. The ADA is helping Maine oppose expanding the scope of practice for hygienists and stands ready to fund public affairs programs to oppose other attempts to create midlevel providers.
As the editor of the official publication of the ADA, Dr. Glick says we should invite these emerging groups into our midst. At the same time, the ADA’s leaders spend untold amounts to oppose them. For years, the ADA has asserted there are enough dentists to meet the coming needs of the nation. Now, the authors tell us, citing Oral Health in America,1 that it will take midlevel providers performing as general dentists to meet the needs of "an increasing segment of the population with limited or no access to dental care."
How can the ADA be a credible advocate for dentistry when it condones DHATs in one state, condemns ADHPs in another, decries hygienists working unsupervised in two other states, claims there is no need to increase enrollment in dental schools and then editorializes that there are too few dentists to provide care to a growing number of Americans and, therefore, dentists should welcome midlevel providers?
Is there a true need for mid-level providers? Or is it an attempt by politicians and policy advocates to allocate less funding to dentistry? How can mid-level providers charge less for a filling than a dentist? Are their chairs, equipment, plumbing, malpractice insurance and supplies less expensive? Are they to be employed by private dentists and be subsidized by fee-for-service patients? What incentive is there for dentists to employ a midlevel practitioner? Has this type of cost shifting improved access for medical treatment? Are they to be employed in government-subsidized clinics? Have we declared the Federally Qualified Health Centers and public health models failures, hence the need for these midlevel practitioners? Before accepting the inevitability of midlevel practitioners, a critical examination of the current system is in order.
There is no evidence midlevel providers will contain costs. Low reimbursement is only part of the problem. A burdensome administrative system and problematic patients are systemic to Medicaid and will not change with the advent of a midlevel provider. Rather than advocating a public relations spin, the ADA must be aggressive in pointing out the deficiencies of the existing programs. It is imperative that Congress and state legislatures be told the truth: solving access to care will require the allocation of more funding, combined with a willingness to reform Medicaid and a commitment to deal with irresponsible beneficiaries. Welfare was overhauled, and Medicaid can be, too.
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