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CAN'T GET THERE FROM HERE
The
Futile Attempt to Resolve the Access Issue
Access to dental care has been declared a public
health issue. Addressing barriers to access began
early in 2008 in California since this state
demonstrated the most prominent access issues for
its population of 36 million. Over half of California'
population consists of ethnic minorities. There are only
4,000 dentists available to serve the patients who
qualify for Medi-Cal and another several thousand
dentists willing to serve the over-million-plus children
through their CHIP (California Children's Health
Insurance Program). But due to California's woeful
economic situation, many of these programs are
currently being severely cut. Add to this another 10
million Californians who do not have dental insurance
and it has been reported that over 300 areas have
been designated as dental professional shortage
areas. In short, California has a very large population
in need of dental care and significant obstacles to
accessing care.
So the CDA began to address the access problem in
October 2008, throwing workforce groups, taskforce
groups, subcommittees, including public health and
well regarded academicians, at the access problem.
With California's lead, access to dental care soon
became a nationally recognized issue which then
prompted national, state and regional dental
organizations to become engaged.
Within a short period of time, a national group was
formed known as The Boston Group. Observing the
legislative process that created another kind of dental
provider in Minnesota to address their access
problems, California, Washington and Oregon
explored more proactive approaches to alter the dental
workforce in these states. Soon Connecticut, Maine,
Massachusetts, Minnesota, New Hampshire, Rhode
Island and Vermont, and later Missouri and New
Mexico, joined this Boston Group. Representatives
from each of these state dental organizations met
initially several times in Boston.
This group reviewed the duties of dental assistants
(DAs), registered dental assistants (RDAs), expanded
function dental auxiliaries (EFDAs), registered dental
hygienists (RDHs). They proposed new models of
care delivery, including Advanced Dental Hygiene
Practitioners or Oral Health Practitioners (OHPs) and
Midlevel Dental Providers. They received lots of
presentations, engaged in off-line, electronic and
network conversations, and then made
recommendations.
In March 2009, the ADA convened an ADA Access
Summit with representatives from a number of these
communities interested in addressing the issue of
access and improving oral health. The purpose of this
summit was to address what the profession was
going to do to assure oral health through prevention
and treatment for underserved populations. They were
able to come up with a common vision, identify new
approaches to address the disparities in access and
began to draft an implementation plan.
In May 2009, The PEW Charitable Trust released a
report "Help Wanted: A Policy Maker's Guide to New
Dental Providers." The report recommended improving
access through expansion of the dental workforce.
Their conclusion, "New thinking and action are needed
to respond to the serious dental access problem
facing the states."
So, at this time, everyone recognizes we have a dental
access problem and that we need to address it.
Everyone understands this is a serious public health
issue. Recommendations and a number of activities
abound, but little is really being done. Why? Because
dentistry is dominated by dentists in private practice
and what is not being addressed is the current culture
and context of the over 140,000 dentists and the
institutions and organizations that directly support
them.
The context of practicing dentists is not public health.
The context and culture which private practice dentists
think, act and operate within is small, for-profit
business. Nearly all dentists are acculturated and
trained in doing highly technical work to restore health
and beauty to patients who can pay for it. The dental
schools, graduate programs, national and state dental
meetings, the CE programs, the consultants, the
journals, magazines and periodicals, the vendors and
suppliers, all promote and reinforce this culture and
strengthen this context. Inside this context, inside this
culture, access is not an issue.
Context is decisive. Culture is superior-ordinate.
Ideologies, philosophies, commitments, language,
perceptions, are clearly different between the two
domains of business and public health. Few dental
students graduating today have any intention of
addressing the access issue. What they are primed for
is private practice and making a good living. What do
you think will be the dentists' attitude creating other
forms of providers in dentistry, such as super
hygienists or midlevel providers? Look at history -
denturists, independent RDAs, dentists from other
countries or even other states. What is the predictable
response?
Sure there are hundreds of community clinics and
thousands of volunteer activities in many dental
communities. But when it comes to access, the
number of clinics and the real level of dental care
available through volunteerism are woefully
inadequate to address the access issue. What's being
done today is analogous to trying to put out a burning
ten story building with a few buckets of water.
Ultimately what is needed is a transformation of the
system, a shift in context. And given what the
stakeholders with the money currently have invested in
the current system, access will remain an issue until
the Federal government brings its heavy hand down on
the profession and makes it do something.
Dr. Marc B. Cooper
The Mastery Company
MasteryCompany.com
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Dr. Marc B. Cooper
President and CEO
The Mastery Company
Mr. Chris Creamer
President
Sahalie Press
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