Can we afford to lose the Affordable Care Act??

Health and quality of life are essential to the success of a nation. Dr. Francis S. Collins (Director of the National Institutes of Health) has spoken of how improving a nation’s health can boost economic growth. The World Bank has published an evidence supported theory that 50% of the difference in economic growth between developing and developed nations is attributable to poorer health outcomes and lower life expectancy in the developing nations.
Screen Shot 2016-11-10 at 8.03.40 AM.png
Source: http://www.buttonsonline.com/2016/donald-trump-2016-buttons.html#DT-213

The, highly respected, OECD Observer, has noted that health of citizens and the success of the economy go hand-in-hand. In fact, they state that “health performance and economic performance are interlinked” and “wealthier countries have healthier populations.” Moreover, countries with poorer healthcare frameworks and support structures for their citizens struggle to achieve sustained growth. What wealthy and well-insured Americans must realize is that lack of access to care of the lower income groups is a problem for everyone. In this sense, the Affordable Care Act can be considered a step in the right direction.ACA in Texas.jpgsource: http://progresstexas.org/blog/latest-gop-vote-repeal-obamacare-ignores-benefits-texas

There is already tremendous pressure on the US healthcare system as America ages. My alma mater has published a report on aging and cites concern about adequate healthcare and housing for the expected older population. There will be more non-workers needing support from the working population. Additional pressure is going to fall on Medicare and the intertwined healthcare and economic future of the United States could be unfavorable without prudent leadership.

The Affordable Care Act (ACA) has improved access to millions of Americans and the work is not complete yet – the ACA is a dynamic regulation and must evolve and change as needed. One basic example is that adult oral health was mandated to be offered but not mandated to be taken like medical insurance is. This can result in conflicting activity like treating diabetes without caring for periodontal disease even though one worsens the other and vice versa. It is critically that the new government does not eliminate the ACA but works to diligently improve it.

There is a major problem whenever someone in this nation cannot access healthcare; workers can’t got to work; children can’t go to school and teachers can’t teach. There is an exponentially negative impact on the entire United States and failing to consider the poorest citizens will have terrible consequences for the entire nation. When unskilled workers cannot access healthcare and miss days of work the efficiency of their employer is impacted. The new President of these United States must improve access to healthcare for all Americans, not worsen it!

Legislated Neglect of American Children?

The United States (US) government defines neglect of children as the failure of a parent or guardian to provide necessary food, clothing, shelter, medical care or supervision. Interestingly, the legal responsibility is to the individual and not to an institution or organization. Yet, by it’s own definition of neglect, the US government may have neglected many American children by hindering their right to oral healthcare services.

children-poverty.jpgSource: http://salvationist.ca/2015/03/child-poverty/

One of our recent studies found that 215,073 American children go to a hospital emergency room (ER) with a dental problem each year – is this reasonable? Medicaid was supposed to protect children and ensure equity in spite of their parents’ limited financial resources. Are we okay with the fact that the most vulnerable people, children, cannot find care in a regular setting and have to attend an ER for dental care – a place notoriously inefficient at managing dental problems? In fact, ER visits rarely meet the dental need of patients – 96% of patients going to the ER for a dental problem require a subsequent visit with a dentist.

Although Medicaid is supposed to protect our most vulnerable, the Affordable Care and Patient Protection Act (ACA) has stopped short of mandating dental insurance – it only mandates that dental insurance must be offered. However, the most vulnerable populations are also the least educated and have the lowest health literacy. These groups often choose not to take the dental coverage. Additionally, ACA has allowed the states to choose their own implementation plans and, for example, the state of Utah has chosen to exclude routine and emergency dental care – they only permit prevention. Ummmm, okay Utah.

iStock_000020305431Medium.jpg
Source: http://medlanddental.com.au/tooth-decay/tooth-decay-does-your-child-have-this-disease/

Three-quarters of the children who attend an ER with a dental problem were from areas where mean household income was less than $49,000. Abraham Maslow (1943) was a psychologist who identified a hierarchy of needs. Maslow’s theory suggests that when the lower level needs are not met, individuals are not likely to consider higher level matters to be necessary. For example, if you’re worried about your safety because you live in an unsafe suburb, you are not likely to worry about seeking a dental examination for your child who is not complaining about any pain. Subsequently, the failure to mandate the coupling of medical insurance to dental insurance leaves the most vulnerable population at high risk of neglect and need for urgent oral health interventions.

The greatest irony in this study is that Medicaid failed to insure every child for routine and emergency dental care, yet it was the major payer when those patients presented to the ER. In the ER it fell under medical insurance (which is mandated). In it’s attempt to reduce expenditure, Medicaid limited dental coverage, however, Medicaid continued to cover those dental problems in the ER.

It’s not just about teeth!

Recently I attended a social event where I was asked why I reversed from 4 days a week of clinical practice and 1 day of academia to 4 days of academia and 1 day of clinical practice – a decision I made almost 10 years ago. I began to answer with “I reduced my days of practice because…” and a fellow guest completed my sentence for me – “…..because it’s just teeth! It must have got boring.”

Preparing for guests over the holidays.PNGSource: http://www.homemaidsimple.com/tips-for-hosting-christmas-dinner-gues/

Dear Guest, it isn’t just about teeth and that isn’t why I moved into academia. It was a growing recognition of how complex and nationally important oral health is, and my interest to contribute to research and policy that would change the nation’s healthcare system for the better. Nobody seems to know the current research that is in conflict with the “just teeth” argument! Nobody seems to know that, when periodontal disease is uncontrolled, a stem cell transplant has hospital charges $85,991 more than when periodontal disease is controlled. Nobody seems to know that when gingival disease is treated, a patients’ annual diabetic costs reduce by $2,840; a patients’ stroke costs reduce $5,681; and a patients’ pregnancy complication costs reduce $2,433. Nobody seems to know that when periodontal disease is controlled, cardiac valve surgery is more successful and associated with hospital charges that are $26,000 less.2173-fort-belvoir-community-hospital-3909.jpg
Source: http://www.hdrinc.com/portfolio/fort-belvoir-community-hospital

In fact, nobody seems to know that about 1.4 million emergency room visits per year are due to common dental problems and incur hospital charges of about $1 billion. Moreover, about $1.2 billion of hospital charges are incurred when 51,000 of those 1.4 million get hospitalized with an average length of stay of 3.44 days – remember, they came to hospital with “just” a dental problem. And it should be recognized this does not include oral cancer or trauma – this is just caries, pulpal disease, periodontal disease or resultant cellulitis. If you’re interested to know, there is another 17,000 hospitalizations per year for oral cancer with hospital charges of over $1 billion. And, jaw fractures result in about 22,000 fracture reduction procedures in US hospitals with charges of another $1 billion.
Hospital.jpg
Source: http://zombie.wikia.com/wiki/Hospitals

It’s not “just” all of the above either – we have found that obesity increases hospital charges among those who were hospitalized for a dental condition. And the presence of mental health conditions increases hospital charges for those attending the hospital with a dental condition. To summarize, we have underestimated the impact of oral health on the human body and the healthcare system. Oral disease is increasing the hospital complications in non-oral surgeries, reducing their success rates and increasing length of stay. And it’s all attributable to the same problem as the dinner guest – we didn’t know any better.

Society has pigeon holed dentistry much to it’s own detriment. It’s difficult for society to think about oral health in terms other than “just teeth,” but, failing to evolve society’s understanding of the importance of oral health will worsen the health of our nation and the efficiency of our healthcare system.

To floss or not to floss…

The Associated Press (AP) was established in 1846. AP was the first to break the news of the attacks on Pearl Harbor on December 7, 1941. AP is a non profit collaborative that is co-owned by 1,400 newspapers across these United States. Through it’s collaborators, AP news items reach half of the world every day! That being said, AP has a critical responsibility to report the news accurately and without bias. Unfortunately, AP published an article questioning the value of flossing which could have significant negative effects. Numerous studies have shown that those with lower socioeconomic status (SES) suffer worse health. Moreover, research confirms that those with lower SES have the lowest health literacy. What this means is that the most vulnerable populations are most likely to read too much into the nonsense published by AP about flossing.Screen Shot 2016-08-05 at 2.31.50 PM.pngSource: http://bigstory.ap.org/article/f7e66079d9ba4b4985d7af350619a9e3/medical-benefits-dental-floss-unproven

Basically, what AP is saying is not wrong – there is “weak evidence.” However, the article is written in a way that could be interpreted that there is existing, high quality research that shows the effectiveness of flossing is limited or weak. AP has chosen an alarming headline of “Medical benefits of dental floss unproven.” However, a more appropriate heading could be “Research into the benefits of flossing is not high quality.”floss-is-boss-300x246.jpgSource: http://drtungs.com/blog/?p=128

The weakness is not in the commonsense health activity of flossing…the weakness is in the research. Consider the challenges of studying flossing independent of other factors. Firstly, how do you isolate flossing from all other methods of plaque reduction -even chewing fibrous foods reduces plaque? Some individuals have continuously spaced teeth which allows toothbrush bristles to caress the in-between surfaces and do the job of flossing. Next, someone who doesn’t floss but has a non-cariogenic diet (low sugar, infrequent snacking) is at significantly less risk of decay. There is a multitude of variables that I won’t bother mentioning here. However, the point of this brief blog is simple – AP has been irresponsible in the pursuit of gaining readers – they have allowed misinterpretation to occur to the naïve. Unfortunately, they have paid no regard to the critical health effects their articles could lead to. As mentioned in a previous blog, over 300 people die in our hospitals every year due to a preventable dental complaint. In fact, 1.4 million people go to our emergency rooms with a basic dental problem every year in America. However, in the absence of plaque, decay cannot grow and periodontal disease cannot thrive. How do you remove plaque? Brushing and flossing. Keep on flossing, my friends.

Screen Shot 2016-08-05 at 2.39.21 PM.pngImage source: https://www.freelancer.com/contest/Design-an-emoji-286351-byentry-6933372.html

“It’s not about Oral Hygiene – I floss to save lives!”

In a 1997 episode of the hit TV show, Friends, Phoebe believes that every time she goes to the dentist someone dear to her dies. She makes the, somewhat ridiculous statement,

“That’s why I take such good care of my teeth now, ya know. It’s not about oral hygiene, I floss to save lives.”

friends_lisa_kudrow_phoebe_dvdbash_6.jpg

Source: https://dvdbash.com/2012/04/11/friends-tv-complete-dvd-series-episodes-synopsis-gallery/

But I want to argue today that Phoebe was right…….in a way. Research has shown that, every year in the United States, about 277 people die after being hospitalized with a dental problem. Additionally, about 36 people die in our emergency rooms after attending because of a dental problem. This means that every year over 300 people (close to one per day) die in our hospitals after attending due to a dental condition. Did they die because their dental condition was too severe? Did they die because their dental problem was inappropriately managed by the medical profession (research shows only 67% of dental related emergency visits are managed appropriately by the medical profession)? Or did they die because their dental problem exacerbated a medical condition? The exact cause of death is not known, however, one may argue that if we had prevented the hospital visit we may have postponed the death.

This is research we have conducted over the last 5-7 years and it’s important to note some limitations. We have focused on hospital outcomes – other patients may have died at home, in urgent care facilities or other environments that were not documented and our research is, actually, an underestimation of the true problem!emergency-dentist-las-vegas.jpg
Source: http://unbreaded.com/for-when-you-need-emergency-dental-care/

Dental problems are not taken seriously enough in the United States. While the Patient Protection and Affordable Care act mandated that dental insurance should be offered, it did not mandate that patients must take it. Subsequently, many still lack dental insurance. However, this policy fails to acknowledge the seriousness of dental disease and is a disservice to Americans. Moreover, it is in conflict with cost control in our health system – our own research has shown that, when dental disease is controlled, the hospital charges associated with Stem Cell Transplant and Cardiac Valve surgery is tens of thousands of dollars less per surgery. This is still true after adjusting for confounding factors! The importance of oral health has been misunderstood for far too long and the result is high cost and death.

It is critical to note in our study focuses on periodontal disease and dental caries – both are completely preventable. Is it reasonable that, in a developed nation like the United States in 2016, one person per day dies from a preventable dental disease? I don’t think it is reasonable. While we have extraordinary medical advances like artificial limbs, face transplants and robotic assisted surgery we fail to control a basic preventable disease – 92% of American adults have dental caries and 26% still have untreated dental caries. Why? Because the importance of dentistry has been underestimated and the impact of oral health on systemic health has been misunderstood.

What can dentists learn from Madonna?

Madonna Ciccone is a graduate of University of Michigan where she studied Dance. After graduation in 1978, she moved to New York City where a terrible thing happened – she was raped. This is a life changing experience that is hard to recover from. However, Madonna released her first album in 1981 – “Everybody.” It was a huge hit in dance clubs and Madonna became known as the Queen of the Dance Club.

Screen Shot 2016-04-27 at 4.48.56 PM.pngSource: https://www.youtube.com/watch?v=7rdlu0-Y3Mg&list=RD7rdlu0-Y3Mg#t=2

With her new-found fame she was interviewed by a magazine who, jokingly, asked what she wanted to do when she grew up. She responded that she wanted to be the most recognized artist in the world. In late 1983 Madonna released “Holiday” which was her first big hit. However, she received some criticism for switching genre because this was a pop song – not a dance club beat. Nonetheless, it rocketed to #1 where it remained there for some time.

Next, Madonna appeared in a movie – “A Certain Sacrifice” – which was a huge flop. Madonna was heavily criticized because she was supposed to be a singer – not an actress. 1986 to 1990 was a golden era for Madonna as she produced six albums and had seven #1 hits. However, in the early 1990s she also released a risqué photographic booked entitled “Sex” – obviously, this was widely criticized. Next, Madonna appeared in Evita – a musical that involved a lot of classical singing and ballads. She was, again, criticized for changing genres.

Screen Shot 2016-05-03 at 3.17.30 PM.pngSource: http://www.fanpop.com/clubs/madonna/images/1419385/title/madonna-photo

However, Madonna’s vision was to be the most recognized artist in the world. She didn’t say she wanted to be the most recognized musician in the world. She didn’t say she wanted to be the best artist in the world. I didn’t need to tell you her last name for you to realize it was Madonna the artist. I would say that she achieved her vision.

What about dentists? How good are we at thinking about the bigger picture and how effectively do we stay true to our vision? Dentists tend to be very detail oriented and this may be in conflict with the bigger picture task of our profession – to eradicate oral disease and eradicate the need for dentists.

When a dentist treats a child who has caries do we think about the bigger picture? We may give dietary counseling to the child and, perhaps, to the parent. But do we give dietary advise to the siblings? Do we find out if there are other children (cousins, adopted children, others) who live in the house who may be subject to the same social determinants of health? Do we, for instance, think about the risk factors the child may face at school like cariogenic food? Do we think about whether the child lives in a fluoridated region? The anti-fluoridation groups are extremely well organized and active – should we advocate with those local governments in support of water fluoridation? When water fluoridation is up for discussion very few dentists attend these debates. What impact would it have if, for example, 3,000 dentists attended such a meeting? Society would learn that our profession truly values prevention. The organized few (anti-fluoride groups) are succeeding against the disorganized many (dental, public health and scientific professions) because we aren’t focused on the bigger picture like Madonna has been.

We control dental disease just enough to keep our profession going. What if we achieved ubiquitous fluoridation, regular check-ups and the pairing of dental insurance with medical insurance? Unfortunately, very little of the profession’s resources are utilized to target these matters and most of the resources (and skills) are targeting disease control. We have forgotten our vision and lost sight of the bigger picture – we need to learn from Madonna!

 

 

 

Research shouldn’t solve rich people’s problems

The major problem in dentistry is still access to care. It’s not debt- Dental students have a tremendous return on investment when they start earning. It’s not Mid-level providers – Dental Therapists do not position themselves to be our (dentists’) competition. They have not had the training that we had and could be our partners if we would only let them. It’s not group practices (pg69 of hyperlink) – many group practice models are better for the patient and the provider than the traditional solo- and small-practice models in dentistry. The major problem is access. Even with Medicaid expansion through the Affordable Care Act, dental insurance is not mandated and many have chosen not to take advantage. The most vulnerable populations have the least knowledge and health literacy to make a wise decision about whether to take the dental insurance or not.

aclinicaltrials.jpg
source: http://www.cloudbyz.com/ctms.html

There are, currently, 336 clinical trials (with known status) being conducted about dental prevention. At the same time there are over 1,000 clinical trials on implants, dental materials, dental lasers, dental tissue regeneration, tissue grafting, digital impressions, digital xrays, Isolite and computer aided design and computer aided manufacture in dentistry. The bottom line is that a lot more resources like money, expert researchers and time are directed toward “high end” dentistry with little for the “low end.” But the problem is at the low end! We need more effective preventive techniques, we need better restorations so that the natural progression from restoration to crown to implant stops.

Dental-Laser-Tamiami-300x199.jpg
source: http://akshaylaserdentalcare.com/dental-laser

Most people know there is controversy about dental amalgam and the mercury component -at this moment there are 14 clinical trials on dental amalgam. However, much less rumor and concern surrounds dental composites even though it contains a material known to be associated with cardiovascular disease and may contribute to childhood obesity! Though the literature isn’t strong for either amalgam or composite being toxic to patients, the fact remains that we don’t have a perfect restorative material. When this fundamental issue isn’t resolved, why do we pour millions of dollars into perfecting the implant?

The answer, unfortunately, is profit. Clinical trial funders are more willing to fund trials that could turn profitable for them. Moreover, implant companies and dental laser companies are wealthy enough to support these trials themselves. Motivational interviewing, fluoridation and fluoride varnish are less sexy interventions that do not seem to attract the funding they need. Government support needs to prioritize prevention programs and solving issues of motivation and compliance for dental patients. Otherwise, dentistry risks becoming a luxury item like Rolex watches and Hermès handbags.

 

 

You Reap what you Incentivize.

In dentistry, we’ve been incentivizing intervention and volume. That’s because the fee for service reimbursement model rewards us when we cut, drill, excise and extract. And there has been no emphasis on quality or efficiency. We haven’t been incentivized to watch, to monitor, to prevent or to improve.

V-blog: “You Reap what you Incentivize.”

Screen Shot 2016-02-18 at 9.04.04 AM.png

 

Source: http://quotesgram.com/reap-what-you-sow-quotes/#aC31W0bPMs

Is Autonomy the strength or weakness of the Dental Profession?

For today’s blog I want to highlight three studies. The first is about motives to enter the Dental profession; the second about the reasons why Dentists leave the public sector; and the third about what practice setting creates the most job satisfaction for Dentists. All three have, basically, the same conclusion – autonomy!

Dr-Ted-Pinney-dental-specialty.jpg
*source= http://www.mydentalhub.com/wordpress/wp-content/uploads/2014/11/Dr-Ted-Pinney-dental-specialty.jpg

College students who want autonomy choose Dentistry as a career – they want to make their own decisions. Public Health Dentists quit because of a lack of autonomy. The practice setting that is most satisfying to Dentists is the one that affords the most autonomy – Solo Practice. But consider this question – is autonomy in conflict with standardization?

In the United States, 58% of Dentists are in Solo private practice – an environment where the Dentist can enjoy autonomy in decision making. I can speak about my own small practice experiences – I worked in a 4 Dentist practice and taught at the University 1 afternoon per week before I decided to reverse that commitment in 2008. As a small private practice owner I did little to pursue best practices or evidence based dentistry – I was only interested in what works in my hands.

Monthly, I would read only the coverstory of the Journal of the American Dental Association and I received most of my continuing education from dental supply companies. If my co-workers saw one of my patients and disagreed with something I did – they would keep it to themselves because they would rather keep the peace than confront me. Additionally, I would afford them the same kindness. The result of this is that no one ever gave me feedback to improve.

It can be taken for granted, then, that one Dental Practice may have enormous variability in processes, materials and methods compared to another. Yet, we cannot argue that one is, necessarily, superior to the other because evidence about best practices is exceedingly limited in dental medicine. This is both the strength and risk of the Dental Profession – the variety means every patient can find a practice environment and provider operating style that suites them, however, standardization and true quality gains are near impossible.

istock_000019428373xsmall.jpg
*Source= http://www.learningmarket.org/page.cfm/link=189

Thus, we confront a fundamental issue in our profession – that we value autonomy and seek uniqueness rather than valuing standardization and seeking best practices. This is a culture that may be in conflict with what is best for our patients. Our colleagues in Medicine have a very different perspective. Extensive research in Medicine demonstrates that standardization leads to reduced mortality, better quality and fewer complications. Moreover, checklists have never been broadly implemented in Dentistry even though we know checklists reduce medical error and improve outcomes. Dentistry needs a paradigm shift – rather than doing what works best in our hands we need a culture that pursues best practices and standards of care.

Confessions of a Jerk Dentist…

My first job was as an Associate Dentist (one of only two)  in a small community hospital in Renmark, South Australia. If you follow the hyperlink and zoom out…you will see that we are one of the last hospitals before you head north into the Outback. We were an important resource for Aboriginal Australians and Mine Workers in the Outback.

native-large.jpg

Source: http://www.carusosnaturalhealth.com.au/Article/341/discover-how-australian-aboriginals-used-the-healing-power-of-herbs

Within 6months my boss retired and I inherited the role of Dental Director……and I inherited a group of administrative staff and clinical assistants who were wonderful women born and raised in the area. In this region, Aboriginals had a reputation (among Non-Aboriginals) of drinking alcohol excessively, generally being good-for-nothing and failing to attend their medical appointments. None of my staff was Aboriginal.

When Aboriginal patients rang (recognized by their name) with oro-facial pain we would schedule them such that their appointment would be the last for the day (5.30pm). This was because, if the Aboriginal patient failed to attend (as we knew they would) we could go home early. This was a practice long established by my team and, rather than try to change it, I adopted it. Often, the postponement until the end of the day was unnecessary because we had openings (apart from 1 other dentist I had 7 Dental Therapists working for me too)…but those appointments were saved for other “more reliable” patients that may call later…but would be offered earlier emergency times because they were “more reliable” attenders.

koori_kids_and_jac_with_patient_007.jpg

Source: http://www.awahs.com.au/what/programs/201012224494.asp

2016 is my 16th year practicing Dentistry and, on reflection, I recognize how awful and unprofessional my team and I were. I now acknowledge that severe cases may not have been able to wait until the end of the day and my Aboriginal patients may have found an alternative intervention.…hence, failing their appointment with us. Also, many traditional Aboriginals do not own a car and rely on public transport or ride-share arrangements. An end of the day appointment would be less convenient for such a set-up (for example, our grocery store and most other places of business would close at 6pm). Factors like this perpetuated our belief that “Aboriginals are poor attenders.”  This is discrimination by race and the intentional withholding of care based on race. It is deeply disheartening to reflect and realize how you may have contributed to someone’s poor health outcome by what seemed like a silly office tradition.

So what? My perspective is that it is critical that we, as healthcare providers, step back and consider how are we negatively impacting our patients’ health outcomes? Are we offering the best care to Medicaid patients or just offering a compromised alternative because we assume they won’t pay out-of-pocket. Do we assume a patient won’t improve their oral hygiene, and therefore, offer a complete denture rather than the opportunity to try and maintain their periodontally involved dentition? How aggressively do we work at getting a patient with hypertension to see their primary care physician? By the way, is compliance our problem or should we just drill fill and bill?

Some time ago we wrote a paper entitled “What is the Dental Profession’s Contribution to Worsening Access-to-Care Problems” and we received close to 50 heated emails from angry dentists. They felt we were undermining the reputation of our profession. Previous blogs have talked about how our Dental Profession has opposed Dental Therapists and how the solo-practice model may be in conflict with achieving improvements in quality. It’s time we worried less about how we are perceived by society, and worry more about delivering the highest quality care to them. The improved reputation will follow!