It’s always struck me as odd that the dental and medical systems are so separate. Oral health and overall health are closely interlinked, and the mouth is just as much a part of the body as anything else. A commentary in Health Affairs (The Dental-Medical Divide) by Elizabeth A. Mertz, a dental professor at UCSF does a good job of laying out the current state and what to expect going forward. While I learned from the article and agree with many of the conclusions, I do think it’s important that dentistry continue to deviate in some ways from the path followed by the medical profession.
Dentists started as barber/surgeons, and when medical education was organized in the 19thcentury, dentistry was left out. As dentists started to organize themselves, they naturally built up their own, strong organizations that served their interests and perpetuated the status quo. There was no particular pressure (or even opportunity) to integrate with the medical realm, so the separation has persisted.
On the insurance side, there are also some fundamental differences between the medical and dental fields. In medicine, traditional models of insurance make more sense, because there is a need to insure against very high cost, relatively rare events. In dentistry, most of the costs are for routine, preventive care that should not be financially ruinous. Almost everyone has caries (decay/cavities) and about half of adults have periodontal disease, so there’s not a huge pool of healthy people. And at the time Medicare came into existence, it was typical to lose one’s teeth before old age rolled around, so there was less urgency for dental coverage.
Mertz proposes and predicts a number of changes in dentistry that will bring it more into line with the medical profession and which she expects will address some of the current problems. These problems include wide disparities in care and health status, uneven (and unmeasurable) quality, high costs, and lack of accountability. These are all good things to go after, and there is a lot to learn from the transformation to evidence based medicine, coordinated care, and new payment models.
But wait a minute. In the un-reformed world I am a lot more satisfied with my dental practice (Dr. Daniel Whiteman in Brookline, MA -highly recommended) than my physician offices. So before we push dentists all the way down the doctor path let’s consider some of the shortcomings of healthcare delivery system restructuring and try to learn from them in dentistry. I’m thinking of problems like:
- Too many top-down mandates, like meaningful use -that help achieve uniformity but stifle flexibility and innovation while being costly to implement
- Consolidation of practices and vertical integration with hospitals -which can hurt service and drive up costs
- Reduction in autonomy and introduction of inappropriate incentives, which can take the joy out of practice
Here are my hopes for what reform of the dental profession will achieve:
- Preservation of the viability of the solo practice model. I don’t want to go to an office with a bunch of providers and administrators who don’t know me
- Keeping dentistry patient focused. I feel like a respected customer -as well as a patient–when I go to the dentist. Partly it’s because I’m responsible for much of the bill, and also because I have free choice of where I get my care
- A new model of insurance that pays for the big ticket items while providing negotiated discounts for routine care; care that I will pay for myself
- Encouragement of innovative approaches and technologies that improve outcomes, cost and convenience. UltraTooth -which I plan to cover soon- is one such example
- Greater involvement in oversight by people who are knowledgeable but committed to progress, rather than the status quo. For example, the professional societies appear to be slowing the acceptance of LANAP, a laser-based alternative to traditional periodontal surgery