Contributor: Harris Contos, DMD, WG’80
To learn more about Harris, click here.
Can dentistry play by the rules of contemporary healthcare and become meaningfully integrated into it? Or will it remain, by its own choice, something historically apart?
The current proposal for dental coverage under Medicare, as of this writing, provides a fitting opportunity to examine the question and dentistry’s place in the solar system of American healthcare. First, a bit of a refresher. While a herculean political achievement at the time, Medicare in retrospect appears a more modest achievement - it lacked innovation, precluded the restructuring of health services, and merely replicated the open-ended financing of Blue Cross and Blue Shield.1 Together with Medicaid, it also helped stoke an era of healthcare cost inflation.2 We have been attempting to deal with the consequences ever since, culminating most recently in the ACA, with its emphasis on integrated comprehensive care, prevention, primary care, population health management, and “value over volume,” all of which hinge upon innovations in delivery models, i.e., ACOs, and especially in value-based payment models. Except for a few conditions deemed “medically necessary,” dental benefits are not included in Medicare, the “socialized medicine” fulmination having been used to good effect back in 1965.3
Why the push for Medicare coverage now?
Of course, the usual suspect is money. Concerns over the spread of COVID-19 resulted in a drastic loss of business and a 17.9 percent drop in net dentist income in 2020 compared to 2019.4 But the effect stands to persist with the volatile recovery of employment and loss of employer-based dental coverage, compounded by the traditionally high out-of-pocket expense of dental treatment for those in low-paying jobs, with few, if any, benefits for those going the self-employment route.5 Given this scenario, it is only logical to seek new markets, especially with the prospect of stable and sufficiently remunerative financing, hence the appeal of the heretofore neglected and ignored Medicare population, in effect making amends for the snubbing of Medicare back in 1965.
In the running for MVP? Hardly.
As outlined above, a range of initiatives and concepts are being employed under healthcare reform to bring better alignment between what we spend for healthcare and what we get in return, to make healthcare “worth it.” Changes are taking place in the systemization of healthcare, in delivery models, in accountability, and especially in how healthcare is financed to realize “value over volume.” In complete contrast, and like a prehistoric insect caught in amber, dentistry continues to organize itself around its central creed of practitioner autonomy, played out through a cottage industry of private practice, fee-for-service artisans adhering to a “volume over value” doctrine. In so doing, it seeks to set and control the terms and conditions under which dental care is perceived and provided.
Thus, although tooth decay is a preventable disease, and retention of a complete natural dentition throughout one’s lifetime is not only conceivable but achievable, dentistry largely minimizes the role of prevention, seeing the occurrence of decay more as a moral failing on the part of the patient with poor oral hygiene habits rather than restriction in preventive measures, such as allowing the independent practice of dental hygienists who could provide the clinical and behavioral modification measures for effective decay prevention.6 As such, dentistry regards tooth decay and tooth loss as inevitabilities, the remedy to which is the centuries-long practice - updated with all the sophisticated and intricate “drill and fill” procedures and armamentaria of “modern dentistry” - of modifying, refashioning, or replacement of tooth structure after the disease process has taken its toll.
This is what dentistry equates with quality dental care and good dental health. Society pays the bill for this perception of dental care in terms of direct payment for such treatments, foregone savings from unrealized prevention, and the suffering, in avoidable pain and debility, by those unable to access care.7
This state of affairs needs to be stacked up against not only the aims of ACA healthcare reforms, but also the assessments of some accomplished, long-experienced, clear-sighted, and truly authentic thought leaders in dental care:8
- The dental profession is overtrained for what dentists do and undertrained for what they should be doing.
- Dentists are paid for, or evaluated based upon, the number of procedures performed, rather than for establishing health. Frequently, this results in overtreatment.
- [F]ew dental educators and academic leaders have given much attention to considering how the current structure and organization of the oral healthcare system acts as a major obstacle for achieving a functional, natural dentition for life for all.
- The majority of dental caries (tooth decay) and periodontal diseases can be managed by individuals practicing healthy lifestyles (particularly diet and hygiene) with support of a range of health professionals. It should not need expensively trained dentists, as is the current model.
- [T]he classically trained dentist is predominantly shaped in a mechanically and technically focused dental curriculum. Therefore, s/he is not adequately prepared for leading teams of oral healthcare personnel that could be responsible for a population’s oral health, diagnosis, control, and prevention of disease, and making of suitable treatment decisions.
- The current practice-based approach to dental treatment and rehabilitation of individuals represents a cul-de-sac from a social, ethical and cost-effectiveness point of view. Improved oral healthcare systems cannot be achieved through minor adjustments to the dental curriculum, the number of dental specialties, payment systems, or the solo-practice-based delivery system. In my view, it necessitates a more profound break with long-standing traditional thinking in dental education and in the organization of oral healthcare delivery.
In conclusion, back to the minors, a lot of work to do.
Contact Harris at: [email protected]
Kissick WL. Medicine’s Dilemmas: Infinite Needs Versus Finite Resources. New Haven: Yale University Press, 1994:71.
Catlin AC and Cowan CA. History of Health Spending in the United States, 1960-2013. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/HistoricalNHEPaper.pdf
Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New York: The New Press, 2017:118-120.
Munson B and Vujicic M et al. How did the COVID-19 pandemic affect dentist earnings? Health Policy Institute Research Brief. American Dental Association. September 2021. https://www.ada.org/publications/ada-news/2021/september/hpi-pandemic-effect-on-income
Handwerker EW and Meyer PB et al. Employment recovery in the wake of the COVID-19 pandemic. United States Bureau of Labor Statistics, December 2020. https://www.bls.gov/opub/mlr/2020/article/employment-recovery.htm.
Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New York: The New Press, 2017:168-177.
Picard A. Making the American Mouth: Dentists and Public Health in the Twentieth Century. New Jersey: Rutgers University Press, 2013:142.
Cohen L and Dahlen G et al. The Future of Oral Health: Dentistry in Crisis - Time for Change. https://lacascada.pressbooks.com/.