Jim Ribary loves golf— digging in, analyzing the course, and improving his game by honing in on the nuances of the course. His path to becoming president of the WSDA Board of Directors has been similar — he’s served on committees and as Secretary-Treasurer, Vice President and President-elect over the past eight years, developed an understanding of how the organization works from the ground up, met and befriended the players, and helped shape and define the course of the organization for his tenure and beyond. It didn’t always come naturally. “When I started out I was like a lot of members out there — I really preferred to stay in the background. I just wanted to understand the finances and serve on the Budget and Finance Committee. Now I have the confidence in myself and the issues, know where we want to position ourselves as an organization, and how to best deliver that message to our members. As president, I’m certainly not in the background anymore, but I think taking that time was instrumental.”
His experience can only help — Ribary will preside during a year when many critical issues are moving to the forefront: defining our model of mid-level provider, continuing the work of the Washington Oral Health Initiative, and managing the purchase of a new building for the WSDA. “Every year the new president comes in and sets an agenda at the officer’s retreat – assessing what we hope to accomplish. And I can’t think of a year that we’ve made that happen because there are always bigger issues coming up during the year that take precedence,” he says “So it’s always a surprise what becomes the focus and seeing how we adapt to the situation. I think we’ve done a good job of that in the past and I hope to do the same.”
Carving out time
Although he’s passionate about WSDA politics, Ribary balances that with family, his practice and volunteer work -— and as much time on the golf course as he can fit in, “you wouldn’t know it by watching me play, but it doesn’t dampen my enthusiasm,” says Ribary. He and wife Linda have been married for 13 years and have a lively blended family that includes six children, ages 23-37 and two grandchildren, whom Ribary calls “a complete joy.”
After running his Gig Harbor practice alone for 19 years, Ribary sold half to Dr. Keiko Wada in 1996, and will complete the sale of the remaining half to her this year. His other work has included 29 years in the Army Reserve, four trips to Honduras as a volunteer dentist with Medical Teams International, and serving as one of three dentists on the NORDIC Board of Directors.
Carving out time will be easier once he retires from practice - he notes “By the end of the year I could have a lot more time to spend on pending WSDA issues.”
Choosing the best model
Ribary will need the time — the issues are monumental: defining the best mid-level provider model for greater access to care has been difficult with so many versions and stakeholders in play – from hygienists and dentists, to state legislatures across the US, to national programs in Canada and New Zealand, everyone seems to have an idea of how best to attack it. Here in Washington, the WSDA Board of Directors began to dissect the issue two years ago, with the first of two task forces (Ribary chaired both) assigned with developing a model. Early meetings were less than fruitful — “The first task force was polarized in terms of what procedures should be allowed. By the time everyone was happy, there was nothing this person could do that a hygienist today isn’t already allowed to do. So, when we formed the second task force we decided to look at the issue a different way. We asked if we had a mid-level provider, what would it take to make them valuable to a practice? To what kind of practice? Where? They’d have to be able to do something to take the pressure off what the dentists do, which is why we got into irreversible procedures such as 1-6 classifications of restorations.”
While mid-level providers are unfamiliar here, in Canada, New Zealand and most British Commonwealth countries, dental therapists have been filling a void for the last 80 years – treating close to 96 percent of all children in school-based treatment programs. Arguably, part of that success is due to nationalized medicine, but if the goal is access to care, they’ve achieved it. Here, where dentists do it all, only about 40-50 percent of all Medicaid-eligible obtain dental care. Closing that gulf is the key and figuring out the best way is the subject of much debate — starting with basics, like education and supervision. Ribary states, “For instance, Alaska’s model is a high-school diploma followed by a two-year program – so the question is are they mature enough to perform invasive, permanent procedures? In Minnesota, where two forms of mid level providers are already legislated, they have a dental therapist and advanced dental therapist, modeled on the advanced practice dental hygienist. In their model, the hygienist has a four-year degree followed by a two-year masters degree and can perform the procedures independent of a dentist. Their dental therapist program is a four-year degree program, but only because all their programs at Univ. of Minnesota are four year programs. That means it may include a lot of pre-requisites that have nothing to do with dentistry. The clinical training takes place along side the dental students.”
Taking the message to members
Talk to WSDA officers and you’ll find that initial meetings at component societies about mid-level providers were tough — “It’s a new concept, so the reaction was not only no, but hell no!” Ribary says with a laugh. Officers and WSDA staffers observed and adapted their delivery strategy. “One of the things I’m trying to do now when we go to meetings is to talk to members and let them know that we’re listening and looking for feedback. This is the start of the process — not the end— but we also want to let members know how much we’ve researched the various models, and how what we do looks like from the public’s perspective.” Once the task force has listened and distilled member’s responses, they’ll bring it to the House of Delegates in 2010 and put it to a vote. The hope is that by then, members will be familiar and comfortable with the model. If accepted at the House, WSDA will take it to the Olympia. “Our goal would be program in place in five years, although it may take significantly longer, “ Ribary explains “ It takes at least 5 years for a program to become CODA approved, and realistically I’d add another 5 years to that.”
Ribary stresses that dental hygienists are already making plans for independent advanced practice hygienists to be trained at Eastern Washington University. With a new masters program and federal money in the pipeline, all that is lacking is a venue — either approved by the Legislature or, as EWU has proposed, on tribal land outside state jurisdiction. “We cannot fail to have a viable alternative for the Legislature to review,” Ribary noted gravely.
While experts assume there will be some shortage of workforce by 2014, between an increase in the number of dentists in the workforce and a downturn in the economy, dentists aren’t feeling the heat to define a mid-level provider right now. The problem is that by the time they do, it could be too late to implement an effective solution. The WSDA’s goal is to be ahead of the curve, dictate legislation rather than react to it, and secure a program that addresses the needs of the public and still ensures their safety. But, fighting members’ misconceptions about where and how mid-level providers would be introduced into the dental community is a challenge — “90-95% of all practices are not set up to benefit from using this model,” says Ribary, “they simply don’t have enough chairs nor do they see the volume of patients necessary. It doesn’t matter whether you’re in Gig Harbor or Seattle, you’re going to find that there are people who can’t afford dentistry, so anything we can do to expand the number of people whose needs are met in community clinics among the uninsured and working poor is going to be a benefit to the community.” No one envisions mid-level providers encroaching on private practices either here or across the country, but working with legislators to craft bills can be tricky, everyone needs to feel that concessions have been made without losing sight of key elements like education and supervision.
Part of the big picture
While mid-level providers are a key piece of a cohesive plan to improve access there are other, critical, elements that make up the web of care for the working poor and uninsured. For instance, Ribary notes “You look at the oral health initiative and there are bits and pieces that are all parts of the puzzle, each part helping a little bit. If we have a dental navigator to help the uninsured find access to care, that’s part of it; EFDAs can address some access needs, but with only 35 graduates now, it’s still too early to know the role they’ll assume; if children have a dental health assessment prior to school that will help, even if we don’t necessarily have a means for them to be treated at this time. It will help educate parents about the importance of taking care of a child’s teeth.” Ribary’s wife, Linda agrees. As a former first-grade teacher she saw all too often how misinformed parents could be “You can’t imagine how many times parents told me they weren’t worried about their child’s rotting teeth — they felt that as baby teeth, they weren’t important. We had to try and impress upon them the role they play as placeholders for the permanent teeth to come. It wasn’t always clear.” Experiences like that compelled Dr. Ribary to start the Adopt-a-School pilot program in Gig Harbor four years ago. He was getting calls from local nurses about children, with toothaches and abscesses, who did not have insurance or the money to see a dentist. Ribary cobbled together a band of local dentists in the Peninsula School District willing to treat the emergency cases for free. “Once seen by a volunteer dentist there is no restriction to the work they can do, and some do more than just alleviate the emergency situation – many dentists go beyond the initial need.” Today, the Adopt-a-School program is successfully run by the Washington Oral Health Foundation, with 130 dentists who provide emergency care to 215 schools across the state. Additionally, new programs like Washington Solutions to Dental Access (see accompanying article on page 8) and a new state initiative to compliment existing programs.
The importance of grass roots dentistry
The WSDA takes the grass roots message to its members every year – get involved, bring your message to capital hill — and Jim Ribary is a believer, having seen first hand how the involvement of dentists has shaped legislation “I was probably the least political person when I first started in the WSDA, and I think that’s the way many members are. The less I heard about political issues, the better. I think the first time I really felt my views change was one time when I was down in Olympia with Dr. Savage, and we able to make a recommendation about the composition of the DQAC Board that the Governor not only heard, but followed. To me that was like a light going off, I got it.” By continuing to work proactively in politics, WSDA can affect change on all kinds of issues from increasing Medicaid rates to limiting licensing fees to making sure that we have input on critical issues affecting the industry like mid-level providers and insurance regulation. “And,” Ribary adds, “with so much pressure on the WSDA to do something about access to care, we can use the grass roots effort let Olympia know it can’t all be about charitable care – the state has to step up to the plate as well.”
With so much at stake, Ribary isn’t shy about addressing the need to drive membership, saying “Those are the things that keep dental leadership awake at night – how do we attract more people? We’re a large organization and maybe there is some resistance to the cost of membership, but look at what we’re doing on behalf of all dentists in the state, whether or not they’re members. We understand their struggles but would love to have them join the association. We have incredible membership benefits — the Pacific Northwest Dental Conference, the WSDA News, the new, cutting edge Web site that will be unveiled this fall, and the cost savings we offer through our endorsed companies program.” He continues, saying “When you consider what we’ve accomplished to date, membership is really affordable.”
Acquiring a permanent home for the WSDA is part of remaining affordable. “The more costs we can control, the more stable our association will be going forward. When you buy a building you control costs to some degree, and can expect to see appreciation in most markets. To that end, we’re raising capital by increasing dues $100 a year for three years. I understand that on the surface an increase of $100 can seem controversial, but in the course of a year you probably spend $100 in ways you don’t even notice. Looking forward, I can’t imagine that owning a building isn’t going to be more economical in the long run.”
It’s just one more way that Jim Ribary and the Board of Directors of the WSDA are looking out for all members and the future of this organization. “A year ago I had some trepidation,” says Ribary, “that feeling in the pit of my stomach asking ‘can I do this?’ Today, he attacks issues the same way he attacks his golf game — methodically, carefully, and with an eye for keeping the WSDA and its members out of the rough.