Saturday, January 28, 2012

Open Letter to Dr. Daniel Davidson: Is CDA Being Open minded or Absent Minded

Part I, Introduction:  

Dr. Daniel Davidson, current president of California Dental Association, in an email addressed to members on January 20, 2012 stated:  As your association president, I am writing this letter to respond to discussions and communications about SB 694 (Padilla) taking place in the environment. This bill, sponsored by The Children’s Partnership, seeks to reinstate a dental director and authorize a rigorous scientific study addressing safety, quality and cost-effectiveness of allowing non-dentists to perform advanced dental procedures on children only in a public health clinic setting.”  He further states:  “In supporting SB 694, CDA has been accused of supporting the creation of a new dental workforce position, specifically one that would experiment on underserved children or create a two-tiered system of care. To be clear, the proposed legislation does not call for the creation of a new dental provider, but rather a careful scientific study of whether non-dentists can perform some expanded procedures safely and with high quality, and “Until the results of the study are complete, any permanent changes in scope of practice or creation of a new type of dental provider will be opposed by CDA”.

“The Children’s Partnership” is supported and partnered with at least 20 health insurance companies as well as Kellogg Foundation which recently raised the issue of access to dental care in rural areas and published a survey stating most Americans think the best solution is to let non-dentists perform irreversible dental procedures on children and is currently providing grants to fund the training for “mid-level” dental providers.

Two questions remain unanswered here; why would a state professional association whose job is to promote public health and safety and its members’ best interests entertain a bill introduced and supported by organizations that are for-profit with major financial interest in getting that bill passed when it should know very well passing of such bill is in direct conflict with public’s health and safety and its members best interests? And the second question:  why would Kellogg Foundation provide grants for training mid-level providers and not real dentists to work in these rural areas.  Surely if any foundation pays for dental education of dentists in exchange of commitment to work in certain areas for certain number of years, many dental students would take advantage of this opportunity.  Wouldn’t this eliminate the safety factor and access issue all together? 

Surely there are other ways of addressing access to care without imposing potential harm and irreversible, permanent physical and psychological damages upon children in under served areas, while respecting the rights and interests of dental professionals too.  Those may not be as beneficial for health insurance companies and may even lower their profit margin to some extent.  The question is which is the more practical solution:  addressing the issue of access to care by lowering the cost of healthcare and implementing serious preventive approaches which would ultimately benefit the public’s best interest or sacrificing health and safety of our children by destroying the integrity of a profession and introducing mid-level providers which would ultimately save the insurance industry millions of dollars in expenditure but leave everyone else with irreversible losses!  

Part II:  Do We Really Need a Rigorous Scientific Study to Access the Viability of This Bill?

This bill, sponsored by The Children’s Partnership, seeks to reinstate a dental director and authorize a rigorous scientific study addressing
1.  safety,
2.  Quality and
3.  Cost-effectiveness
of allowing non-dentists to perform advanced dental procedures on children only in a public health clinic setting.” 

If the mid-level provider is going to only practice in a public health clinic setting and if dentist presence is needed for supervision anyways, why not just let the dentist and auxiliary work like they always have together?

Is there need for a “rigorous scientific study” to arrive at a meaningful answer?  Let’s use a very similar example here:

Would you consider a non-mechanic check the safety of the airplane that you are traveling on and fix it if any repair is needed while paying the same fee for the ticket?  Of course in this scenario the airline company is benefiting from hiring non-mechanics vs. mechanics to perform the same job by paying non-mechanics lower salaries.   Would you agree to the use of sub-standards material and parts in repairing the airplane if that would lower the cost of the ticket?  Do you think any study is needed to find out if non-mechanics using quality parts to repair airplanes would lower the cost of airfare?  The answer is no, when overhead is the same, ticket price remains the same and only airline company benefits from paying a reduced salary.  Do you think any study is needed to find out if using substandard parts in the hands of non-mechanics, while being cost effective….yields safe and decent results?  Would you let your child travel on such airplane?  It would be much safer to not travel than to travel in such conditions.  What if an airline company makes such claim; do you think any liability insurance company would insure that flight’s safety?  If so who pays the cost of liability? 

Is it ok for government to pass laws which clearly endanger health and safety of children or public?  What if such laws benefit certain businesses that happen to be amongst most powerful lobbyists? Unfortunately this happens quite often in our country and hopefully our professional association will not be the first of its kind to actually support or assist such practice against its mission statement.

Part III:  Safety

Is it safe to allow non-dentists perform advanced dental procedures?  Absolutely not!  Safety only comes with proper and adequate training; any short cuts lead to short and long term disasters.

-          We all remember our first year in dental school clinic, how would we rate the safety of our practice at that time?
-          If any study proves it safe to practice dentistry with any less training than provided to general dentists now, there is no need for additional training.
-          If mid-level providers are deemed safe and able to perform advanced dental procedures, advanced general dentistry residency programs become obsolete;
-          Would any dentist allow a dental student work on his/her child’s teeth performing complex dental procedures?
-          Do mid-level providers carry liability insurance?  if so then hygienists and registered dental assistants should carry their own liability insurance and if not, how does anyone expect the general dentist to carry liability for so many auxiliary providers?
-          If anyone claims the practice of performing advanced dental procedures on children is safe by a non-dentist, why should hygienists not be allowed in all states to administer local anesthetic?  Or to perform periodontal surgery?  After all, no one can deny the fact that every hygienist by far has more clinical experience than any mid-level provider;
-          Surely the functions of dental assistants need to be reconsidered and revised and at least cavitron use which couldn’t possibly create any irreversible harm should be included in their list of allowed functions;

Part IV:  Quality

What is the measure of “quality” of care in dentistry?  What do we consider “quality” dental care?  Quality of care is directly proportional to level of training and clinical experience.  Every dentist will agree that practice of dentistry is an ongoing, practice of learning and implementing what one has learned. 

Does any dentist believe it is possible to deliver quality dental care, even simple dental care with less practice than what is provided in our current dental school curriculum?
-          Do any of us consider the care we provided in our first year of clinic in dental school same in quality as the care we provide many years later?
-          If acceptable quality of dental care is delivered with less training, a recent graduate from dental school should have a much higher salary than the current market rate and the experienced dentist should have much higher network fees negotiated with insurance companies.

If studies show quality safe care provided by mid-level providers, there should be no need for supervision?  After all, didn’t we all get our doctorate degree upon proof of practice of safe and acceptable quality dental care? 

Is it possible to deliver advanced dental care with less training than what is provided to a general dentist?  No, if anything more training in the form of post doctoral residencies is needed and recommended.

Part V:  Cost-Effectiveness

Is it possible to lower the cost of providing dental care without compromising safety and quality?  Absolutely not!  What are some factors involved in delivery of safe and acceptable quality dental care?

-          proper training
-          adequate experience
-          access to properly trained auxiliary staff (dental assistants, dental hygienists, dental lab staff)
-          access to proper instruments and tools
-          access to quality dental material
-          utilization of proper sterilization techniques
-          utilization of technology
-          utilization of proper disposal techniques
-          knowledge and ability to handle emergency situations

Every single item mentioned above costs money, regardless of who is paying for it.  Now let’s find out if mid-level providers would provide a more “cost-effective” dental care which is safe and of reasonable quality.  In order to provide cheaper care, cost of providing care should be reduced and let’s see which one of the above categories can we cut back on without compromising safety and quality in a very adverse manner?

Of course “mid-level” provider is certainly at a major advantage for spending less on educational costs….of course that leads to lower experience and less training which ultimately brings down the safety and quality of care. 

Are “mid-level” providers going to work with auxiliary staff?  If so the cost would be the same for them as it would for general dentists so no savings possible there.  If they don’t use auxiliary, well no doubt, safety and quality is yet again compromised.

Proper instruments and tools cost the same for mid-level providers and dentists so unless they plan on using low quality tools and instruments which directly affects the safety and quality of care, no saving is possible here either.

Same rational applies to dental material, sterilization, technology and disposal.

As for preparedness for dental emergencies, we all know time is of essence…if the mid-level provider declines liability and is not properly trained to handle emergencies, that increases the risks of the patients while the emergency is being reported to supervising dentist and then to the appropriate medical authorities.  As such, no saving is really possible here either as I think it is strictly unethical to allow any one to treat a patient without knowing proper measures of handling emergencies related to providing care.

Conclusion:  there is a simple correlation between safety, quality and cost-effectiveness in every walk of life.  Everyone knows ensuring safety and quality costs money.  While in my opinion it maybe alright to lower costs and increase savings by cutting corners in certain areas, I don’t think any well informed parent would agree to compromise the health and safety of his/her child even if it money is being saved.  Would any proper study, no matter how rigorous and scientific it is ever show the same level of safety and quality in dental work rendered by a dentist vs. non-dentist?  Absolutely not, unless the study is designed with a rigorous degree of bias!