Cue Cards

12/02/2009 07:29:00

As much as I’d love to stand up here present a comprehensive solution to affordability & access, I have about 20 minutes to get through all this. Also I didn’t get a whole lot of sleep last night so we’ll see how that goes. [slide] In 2000 the surgeon general released for the first time a report on oral health in America officially recognizing it’s importance to the general health and well-being of the public. Within the report several obstacles to oral health were identified. The vast majority of these hurdles are a direct result of limitations applied to the oral health workforce. [slide] New Zealand’s utilization of dental therapists in elementary schools has been well documented as a success. The program has an over 97% participation rate, and seen the virtual elimination of permanent tooth loss. Without government action, similar community programs are impossible under current restriction of scope of practice, workforce mobility, and flexibility. However, an audacious, but simple solution exists. [slide] Eliminate Dental & Medical Licensing [slide] State licensing boards manage the licensure process, help determine scope of practice, investigate public complaints, discipline practitioners, and report their activities to the public. The primary goal of licensing is to protect the public.

[slide] However, it has been found, not by me, that most patient protections are entirely unrelated to state licensing, state licensing efforts are redundant to efforts taken at the point of care, and as a whole works against established protective measures. I know a lot of you are losing your heads right now. First thing is first, knowledge and experience, not a silly piece of paper, decide your abilities as a dentist. The sole reason for credentialing is to disclose our expertise to the public. With that in mind, I can say with absolute certainty that graduating in 4 months from this school is a far more significant statement about our competency than the outdated, unethical, extortion we are subjected to for two days in May. [slide] [slide] Here is an outline of what licensing really accomplishes: It limits your professional autonomy, restricts the workforce, and controls the supply of oral health providers, fostering an anti-competitive culture, and artificially inflating the cost of care. The assumption that competition is detrimental to patients and is incompatible with health care is extremely misinformed. The system doesn’t come close to adequately addressing incompetence and shelters dentists from accountability. Self-policing creates an ethical dilemma leading to decisions not to disclose violations, and lenient punishments. [slide] Here is an excerpt from the Dental Board of CA Disciplinary Guidelines: The Board requests that the ALJ clearly state factual basis his or her decision. This is especially important should the ALJ deviate from the recommended guidelines. The rationale for the deviation should be reflected in the decision to enable the Board to understand the reasons for the deviation and to evaluate the appropriateness of the decision.

If you go on to read the recommended punishments you’ll find that only sexual abuse of a patient, and violation of probation result in loss of license. Otherwise, your sentenced to some unspeakable combination of mandatory CE hours, and ethics counseling. I have some facts from medical licensing studies since the systems are comparable and the studies highlight the issues at bar. [slide] 45% of physicians with direct knowledge of an impaired or incompetent employee did not always report. 46% did not report a serious medical error on at least one occasion, and those reporting did not necessarily report to the state board. [slide] Despite the state goal of protecting the public, licensing boards don’t even listen to the people. A 2004-2005 survey of licensing institutions found they do not believe public complaints are a good indicator of problems with practitioners. [slide] It is difficult and expensive to establish substandard care, and as a result disciplinary actions are most often taken to address sexual abuse, and substance abuse. [slide] The courts are the only venue with the funds and incentive to handle negligence. A recent study of Florida physicians found that of physicians with malpractice payouts above $1 million only 16% had been sanctioned by state medical boards, and of those who had made 10 or more payouts between 1990 and 2005 only one third were disciplined. Some of you might be saying that dental licensing boards are more effective, but I doubt it. [slide] It is not just reluctance in pursuing negligent dentists that is a problem, continued competency is not evaluated whatsoever.

Even the licensure examinations result in the unethical treatment of patients. [slide] If licensing were ended tomorrow patients would continue to be well protected. [slide] Concern over reputation and liability creates incentives to develop clinical knowledge, skills and competence well beyond those associated with licensing. Private elective credentialing would signal your experience, and skill set to the public, as well as evaluate for continued competency. An extensive market for various levels of credentials would develop to meet demand. The supply and flexibility of the oral health workforce would be regulated by market factors, and insurability. Insurers have the power to require additional training and supervision as part of their terms. It is in the best interests of the insurers to provide guidance and incentives for oral health providers to maintain a high quality of care. Disciplinary action would continue to be handled effectively by the courts, and provide full disclosure to the public of all offenses. Some of you might be concerned by this because you have bought into the propaganda that malpractice lawsuits have contributed to the rise in health care. However, every credible study has found this to be false. [slide] The world without licensing is a far better place Community programs like the one in New Zealand would be easily established and promote awareness in addition to providing treatment Competition would mandate innovation, development of new markets for care, and expansion of existing ones. Improved ethics and elimination of ethical dilemmas plaguing disciplinary action

Improvements in workforce flexibility and mobility along with an increase in the supply of independent oral health providers would decrease the cost of care and the cost of delivering it Lastly there would be improved patient care and protection of patients beyond the current model [slide] Although I think the elimination of dental licensing is an important step towards improving affordability and access in dentistry, it must be part of a multi-faceted approach including: Creation of a competitive culture and the decentralization of professional power Elimination of intellectual property system Insurance Reform Coordinated efforts to educate and expand public awareness At Home Diagnostic and Prevention Kits Medical Data portability Online Consultations Full transparency and disclosure to the public Reputation Management to improve visibility and establish trust A Well Developed Network of Elective Private Credentialing Development of Legal Precedents [slide] So in conclusion: Down with the State, down with State Law, and down with Dental licensing

Rebuttal Notes

12/02/2009 07:29:00

Why do you think it is anti-competitive? • 90% practice success rate should be evidence enough How would it affect education? • Costs would have to come down otherwise alternative forms of training would take the place of the current model Various entry level educational hurdles would feed into developed apprenticeships and residencies. All offices would have to maintain farm programs for staff experience teaching would improve informed consent Who prescribes prescription drugs? • That is an additional certification Improved Ethics? • Reputation would be increasingly important and maintaining patient trust in the profession • With alternative oral health providers these would elevate in importance o There is no alternative now Malpractice Lawsuits? • Found an article in the Boston Globe • Researchers found that payments grew an average of 4 percent annually during the years covered by the study, or 52 percent overall since 1991, but only 1.6 percent a year since 2000. The increases are roughly equivalent to the overall rise in healthcare costs. • Meanwhile, malpractice insurance premiums for internists, general surgeons, and obstetricians have skyrocketed since 2000, jumping 20 to 25 percent in 2002 alone Competition vs Care? • Patient and doctor are not competing against one another • Incorrect assumption competition is a zero sum game o By enriching yourself you enrich others • Patients are more intelligent than we give them credit for

o Doctors have the power of knowledge and patients have the power of choice  Removing obstacles to second opinions and allowing for more direct comparisons would strengthen their power of choice Community programs and oversight? • Schools or other facilities hosting community programs would assume liability and the duty to select and retain only competent providers becoming defacto treatment centers o Would receive recommendations or contractual requirements from insurer • Additionally, it is my experience that the school would overcompensate for lack of dental knowledge by selecting overqualified candidates Insurance oversight • Physician owned insurance providers account for 60% of malpractice insurance industry. • A survey evaluating those providers found that they are effective in identifying negligence prone behavior and play an important role in deterring substandard performance How does mobility & flexibility increase affordability • Flexibility would decrease costs within private practices because staff could easily be adapted to many positions without the premium paid for members with an additional license • Flexibility could allow for a reduction in doctor hours per procedure o Allow more patients to be seen o Valuable doctor time not wasted • Mobility between states would allow doctors with innovative and successful models for patient care to easily expand to other markets

12/02/2009 07:29:00

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