October 25, 2012
By Dr. Jeff Parrish
This month’s ramblings are purposely being composed prior to the 2012 House of Delegates, where your representatives are considering a proposal to support in the Legislature, if necessary, the creation of a midlevel provider: the DHAT (Dental Health Aide Therapist), Enhanced EFDA, Dental Nurse or some other appropriate or deceptive name. The name is not important, nor really is the outcome of the vote by the House. They are not that important because the process will continue with or without us, and what’s happening now is just another phase in a long march. In truth, this and similar other battles have been fought for decades; I know because I have been in the middle of many of them.
Let’s make some general assumptions and observations to help us all put this entire heated discussion in perspective. And, at the end of the day, let’s all just continue to get along (Thank you, Rodney King. RIP).
1. Perception is reality. Government, community advocates, big money foundations with a social agenda, and elements of dentistry perceive there is a huge problem that needs fixing: cost-effective access. The Legislature is weary of our just saying, “NO!!” We can debate the details, but the perception is out there screaming for a fix. One or two key legislators (or a governor) can carry the day either way. Remember that November 6.
2. Perception says the private practice system, as it currently functions, cannot “fix it.” Evidence: the rise in free/low income/FQHC clinics/dental vans and continual demand for more. And non-profits receive various breaks and perks as incentives to provide this care. Sidebar: Is Medicaid/non-profit care inherently “second class”? I would like to see some data to answer the critics either way.
3. Yes, we all know prevention is the key to all this. Convince everyone of that. Figure out a way to do more of it and who’s going to pay for it. It’s obvious we cannot drill our way to success.
4. A discussion for another day: the effects of Obamacare-mandated insurance exchanges and requirement for all children to have dental coverage. What’s covered, what reimbursement schedule, who’s going to provide this care?
5. The “fix” must include changes from dentistry, government, advocacy groups, industry, emergency rooms, dental education and, probably most importantly, patients. But don’t look to government to implement comprehensive change; they generally merely nibble at the edges.
6. Very few dentists (leaders or otherwise) are rabid advocates of a midlevel provider, those leaders involved recognize the potential for very serious mistakes in design without our input. Given their druthers, they would maintain the status quo, but their “druthers” may, however, be gone.
7. Medicine has had its care extenders for decades. It would do us all good to understand the differences between a Nurse Practitioner and a Physician’s Assistant and the parallels between them and the various midlevel proposals in dentistry.
8. Government has us by the short hairs with its licensing power. Government’s first responsibility is public safety. Sometimes it gets really enlightened and considers economics other than their own (as we know, they are broke). Don’t expect economics to be the deciding factor — if it’s not the government’s money nor economically viable on its own, they don’t really care. And educating this new provider is probably not going to require government money.
9. Our representatives in government are motivated by exactly the same things you are: relationships and money. If you don’t have a personal relationship with yours, or if you haven’t given them money, you are part of a much bigger problem. Don’t blame dental leadership if you are not helping. Trial lawyers and teachers’ unions have lots of political clout, wonder why? I don’t like it, but I don’t make the rules.
10. There are folks on both sides who are passionate about the issue, I’m impressed that so many are our younger colleagues. But some arguments are really over the top, e.g., death in the dental chair is not something that is going to be common either way. If it happens, it usually is associated with general anesthesia or a freak occurrence. People are not going to die under our watch so quit using that as an argument. There are plenty of others.
11. The rhetoric used in opposition is the exact same rhetoric we dentists use in opposing changes in dental hygiene or denturist scope, it is the same rhetoric used by hygiene whenever it is suggested that assistants can be trained to scale. Whose ox is getting gored? Good training is good training; competence is competence. New Zealand is New Zealand, and Alaska is Alaska. Neither is necessarily Washington.
12. The rhetoric used in support is, likewise, the same supportive argument used in these other battles — cheaper delivery, cheaper education to achieve competence, efficiency, ability to go where dentists won’t go, and cheaper care. The veracity of it all is not important to decision makers — it just seems it should be so, or let’s do something so I feel better. But then, how many hygienists are actually working in nursing homes?
13. We have long held the “sword we will fall on” is diagnosis, irreversible procedures and dentist as head of the delivery team. We best decide quickly if these are the swords and are there others, or are we just going to take our sword home and let others decide the outcome of the battle?
14. Don’t count on the public to police the providers. There are folks in Florida getting butt-enhancement “collagen” injections in alleys and living rooms. I had patients who had crown and bridge work done in a hotel room by an itinerant dentist. And don’t even think about dental tourism for all kinds of stuff. Dental IQ is not universally high with the public...or legislators.
15. If a midlevel provider is created, relax, you won’t ever have to work with one if you don’t want to.
16. If and when the feces hit the fan from midlevels or denturists, or Diamonte Driver, or the retired bozo recently found out by KING 5 News to be doing apparently lousy RCT’s on all his patients’ teeth, dentistry in general will get splatter. Get over it, it goes with the territory. Publicity is not always truth nor are the issues really conveyed in anything more than 30 second sound bites.
I hope I have given you some things to consider beyond your initial gut reaction. We have survived denturity and other intrusions on our scope. We really have bigger fish to fry right now. No matter how the vote turns out at the House or how the issue is settled in Olympia, don’t be a doofus and blame Rod Wentworth or Danny Warner or Steve Hardymon or WSDA in general. We are well organized and effective, but the battle will continue indefinitely; we need all the foot soldiers we can muster in the future. Dental Action Day will be January 25, 2013 in Olympia. Show up and see how their world really works.