The real economics of midlevel providers

Jun 29, 2010

As a dentist who has cared deeply about dental public health since the 1960s, I am compelled to write about midlevel dental providers. These are people without the eight years of education after high school that are required to become a dentist, but who are still allowed by law to do extractions and fillings and give anesthetic injections, among other procedures. They would be able to do these procedures after about 18 months or two years of training after high school.

Proponents of midlevel care show statistics that the quality of care is the same as that of dentists. They say that midlevel providers only do "simple" procedures. In fact, there are no simple procedures in dental healthcare. Except for prophylaxes and sealant placement, restorative dentists provide surgical procedures. Cutting into a tooth is surgery. Extraction of a tooth is surgery. Deep scaling and root planing removes the lining of the gum and surface of the root and is surgery. These procedures are invasive. They require anesthetic injections into tissues with nerves and blood vessels that can be permanently damaged. Injections can cause severe systemic reactions that a midlevel provider is unqualified to treat.

What about examinations of the teeth, gums, occlusion, and oral soft tissues? It takes many years to learn to evaluate all these tissues and the interactions among them. What about the temporomandibular joint? We have come too far to believe that dentistry is only tooth carpentry. It is an integral part of the care of systems that are interconnected throughout the body. A "simple" filling that is placed without considering the many systems involved can cause disease, pain, and dysfunction.

As in all endeavors, things go wrong. A shallow cavity turns out to be deeper than expected and the pulp is involved. A tooth with a large cavity turns out to have cracks running through it and needs a crown. An injection can result in bleeding deep within tissues or even anaphylactic shock that can lead to death. Would you want to be in the dental chair of a midlevel provider when these events happen?

Even worse to imagine would be a "simple" extraction with resulting uncontrolled bleeding. Or one that turns out to be a more difficult extraction than anticipated, and a dentist isn't available to deal with the complications. Would you want to be in this situation with a provider who has not been trained for, and is unable to deal with, your emergency? In rural areas without specialists to handle emergencies, having patients served by a fully qualified dentist is even more important.

Some people say that the dental midlevel provider model is the same as the certified physician assistant or certified nurse practitioner model. They are not the same at all. These health practitioners, while extremely valuable in patient care, do not perform surgical procedures. Can you imagine going to a physician assistant to have a severely damaged finger removed? Of course not. Only a physician, dentist, or chiropodist is trained, qualified, and licensed to perform surgical procedures.

State dental boards protect patients from substandard dental care and substandard dentists. Midlevel providers, with so little knowledge of anatomy, physiology, and most phases of dentistry, must, by definition, provide substandard care compared to licensed dentists. Who wants care that is not up to the standard of that provided by licensed dentists? How will dental boards be able to license nondentists to provide dental treatment and yet still be able to tell some fully trained dentists that they are not good enough to treat patients? Will dental board examinations become irrelevant?

Valid economic model needed

But all of this is beside the point.

This is actually an economic issue that will have to be solved with a valid economic model. The premise of midlevel (nondentist) dental care is based on supposedly lower costs associated with these providers compared to the cost of dentists. You may find the following hard to believe: It does not cost less for a nondentist to provide dental care than it costs for a dentist to provide dental care.

Here's why:

A dental assistant working for a dentist will earn the same wage as an assistant working for a nondentist. So will other employees.
The dental materials, supplies, and equipment used by a dentist and a nondentist cost the same.
Landlords charge the same rents to nondentists, so the rent and utility costs will be the same.
If the nondentists are required to take continuing education, their costs for travel and lodging and the seminars and conventions will be the same or similar.

So the only costs that might be different would be the salaries of the dental provider, dentist, or nondentist. But dentists' salaries make up only a fraction of the total cost of providing dental care. The patient of a nondentist may have a slight economic advantage, but the dangers and disadvantages to the patient by not having a real dentist are immense.

Let's think about the morality of providing two completely different levels of care to different classes of people. Why should rural and poor patients get care that is provided by nondentists? They deserve fully trained dentists, don't they? I think it is morally repugnant to tell poor and rural people that they cannot have the same level of care as other people.

There are plenty of dentists in cities, just as there are plenty of schools, physicians, restaurants, stores, and coffee shops in cities. That's where the largest concentrations of people are. The fixed expenses of rent, utilities, and salaries must be paid regardless of how few patients are treated. If too few people live in an area, no business can survive.

Dental offices are no different. Here's how the midlevel provider model has managed to work financially in Alaska: The providers are on reservations, and costs are paid by the government.

The people in rural communities throughout the U.S. all deserve to have a dental office to care for them. Unfortunately, rural areas do not have enough people to make it economically possible. If it were economically possible, a dental office would already be there. So it comes to the government subsidizing dental care in rural communities. This is necessary whether a nondentist or a dentist is providing the care.

The solution to the problem of limited access to dental care turns out to be one that rests squarely on the shoulders of politicians. Healthcare providers, including dentists, physicians, nondentists, or nonphysicians, cannot afford to practice where there are not enough people to meet expenses and make a fair profit. Nor can they afford to practice by accepting fees that are lower than the cost of providing treatment. Therefore, government subsidies are needed to maintain practices in such areas. These subsidized practices should have fully qualified dentists to serve the needs of the surrounding communities.

I'd like to hear from those with opposing viewpoints. Let's debate.

Robert Wartell, D.D.S., is a general dentist in private practice in Santa Fe, NM, with an emphasis on temporomandibular disorders and oral appliances for sleep apnea. He's been practicing since private practice was truly private -- a relationship between him and the patient, with no third parties involved.