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Make dentistry cheaper
Can you see what is coming?:
But to the Alaska Dental Society and the American Dental Association, the clinic is a place where the rules of dentistry are flouted daily. The dental groups object not because of any evidence that the clinic provides substandard care, but because it is run by Aurora Johnson, who is not a dentist. After two years of training in a program unique to Alaska, Ms. Johnson performs basic dental work like drilling and filling cavities.
Here is much more. Get this:
The number of dentists in the United States has been roughly flat since 1990 and is forecast to decline over the next decade. A study last year from the Centers for Disease Control showed that Americans’ dental health was worsening for the first time since statistics began to be kept.
In Alaska, the A.D.A. and the state’s dental society had filed a lawsuit to block the program that trained people like Ms. Johnson, who are called dental therapists. The groups dropped the suit last summer after a state court judge issued a ruling critical of the dentists. But the A.D.A. continues to oppose allowing therapists to operate anywhere in the lower 49 states. Currently, therapists are allowed to practice only in Alaska, and only on Alaska Natives.
The opposition to therapists follows decades of efforts by state dental boards, which are dominated by dentists, to block hygienists from providing care without being supervised by dentists.
The dental associations say they simply want to be sure that patients do not receive substandard care. But some dentists in public health programs contend that dentists in private practice consider therapists low-cost competition. In Alaska, the federally financed program that supplies care to Alaska Natives pays therapists about $60,000 a year, one-half to one-third of what dentists typically earn.
The Alaska program is small, with fewer than a dozen therapists practicing so far. But the early results are promising, according to dental health experts who are studying the program.
As someone who has spent a lot of time at the dentist, I very much like the assistants and I think of the dentist himself as a kind of middle-level manager and salesman.
I thank Greg Rehmke for the pointer.
Posted by Tyler Cowen on May 1, 2008 at 02:06 PM in Medicine | Permalink
Comments
Straight out of capitalism and freedom...
Posted by: Eugene at May 1, 2008 2:15:36 PM
Straight out of capitalism and freedom...
Posted by: Eugene at May 1, 2008 2:15:36 PM
This is actually a big problem. Particularly for low-income people, dental care is either far too expensive, or simply unavailable. And the dental colleges are not increasing their student numbers with the result that the number of dentists continues to decrease.
Kudos to these folks in AK.
Posted by: Charles at May 1, 2008 2:39:43 PM
Apparently the natives are expendable.
Posted by: John goodman at May 1, 2008 2:43:28 PM
Can't the same be said about the AMA?
Among the multitude of Healthcare solutions I have seen, I rarely see the issue of supply control of medical care providers as a significant obstacle in tackling he Healtcare crisis.
Posted by: Mo at May 1, 2008 3:00:00 PM
This has been a major political issue in Alaska for years. The rural villages cannot support local dentists, and travel costs are high enough that few people are willing or able to pay for a traveling dentist. The result is that Alaska natives have some of the worst teeth in the nation.
The worst part is that the ADA is not offering alternatives or actual solutions to the problem of providing dental care in small, isolated towns, they're just suing to make suing on principle. If you think dental care is expensive where you live, you don't even want to know what it's like in rural Alaska.
Posted by: Sean at May 1, 2008 3:04:10 PM
I thought the money quote in the article was the matter-of-fact statement that over 100 million Americans
cannot afford dental care. The median income for married households in 2007 was approximately $80,000;
I'm not sure where the cutoff for 100 million would be (roughly the bottom third) but I'd love to know
where their statistics come from.
Posted by: anonymous at May 1, 2008 3:05:35 PM
Clinics rule in health care savings. Monopolies destroy clinics.
Posted by: Matt at May 1, 2008 3:12:22 PM
Reminds me a lot of a NYT article from October. I know people even in the DC area who save their basic dentistry work for trips to Latin America. And you can even find dentists who work evenings there!
http://www.nytimes.com/2007/10/11/business/11decay.html?_r=1&scp=4&sq=dentists&st=nyt&oref=slogin
Posted by: LB at May 1, 2008 3:25:48 PM
Perhaps you should change providers such that you could state "...the dentist herself" and see if that doesn't change your opinion?
On a more serious note, there is an acute shortage of providers, especially for those who rely on state or federal subsidized care. The cause is basic: when a provider accepts patients from the state healthcare pool, they accept very low reimbursement rates--often well below the marginal cost of the procedure. To make it work, the provider must become a volume business, and an efficient one at that. This can be physically and mentally draining. There is no financial incentive to do so. Typically only the new, the bad, or the genuinely altruistic ever try. Being a healthcare provider comes with a relatively high burden of liability, so opening markets for lower-cost providers of basic services may result in increasing educational, licensing and regulatory costs (hygiene, therapist) and a smaller-than-anticipated benefit for those basic services. And why on earth wouldn't newly independent hygienists and therapists chase similar margins from the same high-yielding patient populations that DMD/DDSs typically prefer? It's a complicated problem, but one worthy of creative thinking.
Posted by: anon at May 1, 2008 3:27:01 PM
Can't the same be said about the AMA?
Indeed, it has been. Famously by Milton Friedman, who told of a speech before the AMA where--thinking he had the perfect analogy--told the doctors assembled that occupational licensing laws were the same as saying only Cadillacs could be driven on our highways, because Chevrolets would not be up to standards.
He was stunned when he heard back: 'That's right, we can't accept anything less than Cadillac standards for the American peoples' health.'
Posted by: Patrick R. Sullivan at May 1, 2008 3:50:52 PM
First-person story: "How to get your teeth fixed in Mexico". (Man, there are a lot of Google ads if you search on [tijuana dentist].)
Posted by: Don Marti at May 1, 2008 3:51:29 PM
We would need even fewer dentists and more people would have healthier teeth if we would let the commies fluoridate our water.
Cf. http://www.filmsite.org/drst3.html
Cf. http://www.aafp.org/online/en/home/clinical/clinicalrecs/fluoridation.html
Posted by: Dave Barnes at May 1, 2008 4:08:21 PM
Ok, but why aren't there more dental shops with 1 dentist and 20 dental assistants, at least in urban areas? Shouldn't they be able to supply low cost care?
Posted by: Measure for Measure at May 1, 2008 4:37:17 PM
Exactly what I was thinking Eugene. Friedman would be proud.
Posted by: Scott at May 1, 2008 4:51:39 PM
This is actually a big problem. Particularly for low-income people, dental care is either far too expensive, or simply unavailable. And the dental colleges are not increasing their student numbers with the result that the number of dentists continues to decrease.
Perhaps, but I've also found that lots of people really overestimate the cost of a simple preventive cleaning. I know quite a few people who just will not go without insurance; this despite cleaning visits being $50-$100 (and the cost of major dentistry enormous.) They just assume that the cost would be too high.
Posted by: John Thacker at May 1, 2008 5:13:31 PM
Is it me, or are the ADA and AMA both evil?
I do feel I should mention that the use of airbags in cars has decreased the need for many types of dental work. I'm not sure if this has anything to do with a decrease in the supply of dentistry, however.
Posted by: Grant at May 1, 2008 6:09:59 PM
for good teeth and healthy gums:
1) first rinse in the morning: 20- 30 seconds, with hydrogen peroxide (cleans your mouth and whitens your teeth)
2) brush with an electric toothbrush, 2 minutes total, 30 seconds per "side", twice each day (after breakfast and before going to bed - sleep with a clean mouth)
3) use a good toothpaste (I like Colgate Total, ymmmv)
4) gargle and rinse with a generic tartar control mouthwash
5) have teeth cleaned by dentist/dental technician twice each year ($75 - $125), after which dentist inspects for other problems
You can floss if you want using regular floss or an electric flosser. I don't floss and after I started using the protocol above about 2 years ago my dentist told me (and continues to tell me) "You're doing a GREAT job flossing!"...
Posted by: chug at May 1, 2008 6:28:00 PM
Can't the same be said about the AMA?
Yes, we do need more medical and dental school seats to keep up with population growth. Either we build new schools or the Feds could mandate (with its purse strings) that medical schools operate on the year-round trimester system used in World War II- Four academic years completed in three calendar years. Alternately, as they do in Europe (and at some US med schools), combine college and med school in one 6 year program. http://research.med.umkc.edu/med_admissions/default.html
At least the AMA hasn't stopped (not for want of trying) the use of nurse practitioners and physician assistants. These Alaskan dental therapists are the dental version of a NP or PA.
Posted by: beowulf at May 1, 2008 7:08:19 PM
I can get the libertarian arguments, especially for people that are unserved.
You could say the same thing about physicians. However, I actually read the Flexner report and it was pretty persuasive. He was pretty upfront about raising incomes, and was concerned with a race to the bottom by grossly under qualified drs.
http://www.carnegiefoundation.org/publications/pub.asp?key=43&subkey=977
I found the actual report a lot more interesting then the endless arguments from secondary sources.
Posted by: Ziggurat at May 1, 2008 7:14:12 PM
-- Is it me, or are the ADA and AMA both evil? --
Don't forget the ABA. It might even be safe to say that organization styled A__A is going to be bad for consumers.
Posted by: 12345 at May 1, 2008 8:36:56 PM
If a service is valuable, it does not become less valuable because it is adequately provided by a more briefly educated professional. In the medical world, physician assistants and nurse practitioners have not flocked to serve the poor in any greater numbers than MDs. They tend to work in the surgery and radiology fields where they, like their physician counterparts, make more money. This should come as no surprise to any economist or, for that matter, businessperson.
Posted by: mrrunangun at May 1, 2008 9:48:50 PM
Actually dentistry is quite cheap if you have access to a pair of pliers.
Posted by: Gil at May 1, 2008 10:44:58 PM
"Is it me, or are the ADA and AMA both evil?"
Throw in the ABA for the trifecta. Every professional association, especially those that also serve as de facto licensing agencies, need to be culled.
Posted by: moises malone at May 1, 2008 11:26:54 PM
It seriously pisses me off that even someone as "revolutionary" as Michael Moore refuses to criticize the AMA.
For some reason beyond my understanding, the left feels squeamish voicing any concerns over the AMA and how their restrictive supply side policies impact those without health insurance.
Posted by: thehova at May 1, 2008 11:56:00 PM
Dentists accept welfare for the rich. They don't make it on their own. Their tuition and/or dental schools are government subsidized. They are given permission to drill holes in people's teeth by state governments.
Their dental unions, with loads of money from businesses that profit from dental products, lobby our legislators to get laws passed that puts more money in their own pockets and less dental work in our mouths.
According to the Wall Street Journal, many dentists make three times as much money than physicians while working fewer hours and fewer days doing less critical work. In fact, about 5% of dental practics are Spas with massage therapists, etc.
There's a whole bunch of physicians, physician assistants, nurse practitioners and other specialists you can choose to go to - alternative or mainstream for anything that ails any of your body parts.
But when you need work on a tooth - it's the dentist you must see. Organized dentistry makes sure the number of dentists is low to enable them to charge such outlandish fees and allow them to ignore great numbers of U.S. citizens who have no where else to go to fix their teeth.
In the short term, dentists must be mandated to treat a certain number of individuals based on a dentist's net income. Long term - allow dental therapists in every state.
We know dentists love mandates because they are behind almost every fluoridation mandate in this country.
And if you truly believe fluoridation hurt dentists' bottom line, dentists would be lobbying against it rather than for it. Fluoridation campaigns give the illusion that organized dentistry gave a hoot about people who can't afford them.
The truth is that after 60 years of water fluoridation, tooth decay is a national epidemic and so is fluoride overdose symptoms - dental fluorosis, or discolored teeth - which now afflict up to 48% of US school children. Covering those fluorosed teeth has created a new way for dentists to make big bucks off the weathier patients which enables them to ignore low-income Americans on Medicaid and those without insurance.
Also the ADA has created a multi-billion international market for fluoride products. Their ADA seal of approval is on almost anything that has fluoride in it. Those company pay back the ADA in grants, advertising, equipment, etc. The ADA uses corporate money to lobby our legislators to get laws passed that benefit themselves - not us.
Posted by: nyscof at May 2, 2008 5:14:28 AM
It may come a shock, but the AMA has nothing to do with regulating the supply of physicians. Anyone is free to start a medical school, and the accreditation process does not involve the AMA. Physician licenses are issued by th
e states with no input from the AMA. The Flexner Report was a sad commentary on the condition of medical practice in this country and spurred many reforms to put the marginal practitioners out of business. For a look at what it was like before these reforms, see http://www.amazon.com/Charlatan-Americas-Dangerous-Huckster-Flimflam/dp/0307339882/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1209731653&sr=8-1
Yes, there is a problem with access to adequate medical and dental care in remote rural areas such as parts of Alaska, and allowing paraprofessionals such as dental therapists and nurse practitioners to work independently in these areas may be a reasonable solution. But don't carry it too far - do you really want to allow Dr. Quack to treat brain tumors with herbal remedies?
Posted by: Ned at May 2, 2008 8:45:44 AM
The ADA and AMA have always struck me as (perhaps well-intentioned) cartels. Yes, in the past the US was flooded with quacks and charlatans; but the simple and non-coercive solution is to establish reliable, independent mechanisms for rating doctors and dentists. [A diploma from a good medical school is the most obvious example.] If I can't afford a Cadillac doctor, shouldn't I have the right to go to a nurse practitioner at my local drugstore? Or even an herbalist (so long as he doesn't make fraudulent claims?)
Here's an anecdote and question. My grandfather was a country doctor, and most of his patients were poor farmers who didn't have health insurance. Sometimes he was paid in squirrels or potatoes. His practice was a small (and very successful) business; there was no HMO telling him to spend only three minutes with each patient, so he could take the time to listen and observe and get the diagnosis right.
Could a doctor do that today? As far as I know there is no place where an uninsured person can simply pay for a visit to a doctor's office. But it might solve the problem someone mentioned earlier of low reimbursement costs making it hard to be a low-cost provider.
Posted by: src at May 2, 2008 10:13:22 AM
A lot of people who comment here know something about economics but nothing about health policy. I, on the other hand, know a lot about health policy and little about economics. Ned is right, everyone else's comments about the AMA acting as a cartel are at least 30 years out of date. In addition, there isn't any evidence that increasing the supply of physicians brings down health care costs. In fact, the evidence runs in the other direction; increasing numbers of docs means health care costs go up. The only exception to this rule is that having more general practitioners rather than specialists gives better overall results while keeping costs down.
On the other hand, there is nothing good I can say about the ADA. There is a vast cultural difference between dentists and physicians which I can summarize by saying one is a very well paying trade and the other is a profession. The Med Schools try to inculcate some ethical code of conduct which includes, at least in theory, some obligation to treat the ill even when they may not be able to pay for treatment. Dentists don't have any such obligation in theory or practice which leads to crap like their lawsuit to block the Dental Health Aides in AK.
Nurse Practitioners and Physician Assistants are now well-established and the AMA didn't stand in their way with nearly the ferocity that the ADA has used to prevent hygienists from being able to practice independently or to try to kill the AK program. There's a movement by hygienists to license Advanced Practice Hygienists who would be able to practice independently. See http://www.adha.org/news/04212008-adhp-mn.htm for an example. This kind of thing would do more to make dental care available to the underserved than opening more dental schools ever would.
Posted by: SteveH at May 2, 2008 12:53:16 PM
This can happen in currently regulated and third-party payer system: "increasing numbers of docs means health care costs go up"
But, only state and federal government stand in the way of allowing up to, say, 5,000 trained doctors, nurses, and dentists per year receive visas to work in the U.S..
Certified medical and dental schools in other countries would quickly expand, and medical and dental services would improve as well in the countries doctors are from (a recent empirical study found this).
Wal-Mart, Walgreens, and other firms would likely hire these new dentists and doctors, and provide services as low cost (to draw in customers, for example).
Immigration restrictions protect professional monopoly associations just as trade restrictions protect monopoly producers of goods.
Posted by: Greg Rehmke at May 2, 2008 1:19:12 PM
"Could a doctor do that today? As far as I know there is no place where an uninsured person can simply pay for a visit to a doctor's office."
Most health care providers, including physicians, dentists and hospitals, are delighted to take payment in cash and will often offer a discount for such. If nothing else, it saves them billing and collection costs. Try it sometime.
Posted by: Ned at May 2, 2008 1:27:22 PM
It is in some ways sad to see dentistry began to fall. Society should be brushing their teeth unless people want to resort back to the past when most people did not clean their teeth for months. Maybe the gov should look in to this situatuion. I agree that dentist should just be dentist and not therapist. Healthcare for most families provide coverage cost that allow them to continue to have clean teeth. A good idea would be to lower the cost of dental product in stores to allow those who cannot afford to actually go to the dentist. Or maybe the price to get our teeth cleaned should be lowered. Small problems like these are what waste people's time; the gov't should automatically fix the problem allowing more people to have cleaner teeth and worry about things like gas prices and what not.
Posted by: Zach Alexander at May 2, 2008 1:37:05 PM
"But, only state and federal government stand in the way of allowing up to, say, 5,000 trained doctors, nurses, and dentists per year receive visas to work in the U.S."
About one quarter of all physicians practicing in the US are foreign medical graduates. That's quite a lot. You might also consider how much other countries would want to open med schools, at considerable expense, just to provide care to US citizens. Why should they?
Here's an excerpt from a recent New England Journal of Med article:
"The total number of [medical] students remained essentially unchanged between 1980 and 2000 at about 16,000 graduates, whereas the U.S. population grew by about 71 million people. However, the number of licensed physicians increased substantially, because of the doubling of the number of graduates of schools of allopathic medicine before 1981, the robust expansion of colleges of osteopathic medicine, and a continuing flow of international medical graduates (IMGs), most of whom remain in the United States to practice after completion of their advanced training... The United States was able to maintain an adequate supply of physicians because the number of entry-level allopathic residency positions (24,085 in 2006) greatly exceeded the number of graduates of U.S. medical schools (15,925 in 2006). Because of this differential, teaching hospitals were able to employ thousands of IMGs each year to fill their advanced-training positions and to provide care to patients. As of 2005, IMGs represented 25.3% of all practicing physicians in the United States.8 In total, the number of active physicians grew from 453,165 (200 per 100,000 population) in 1980, to 601,237 (241.7 per 100,000) in 1990, to 783,852 (278.5 per 100,000) in 2000."
http://content.nejm.org/cgi/content/full/358/16/1741
It's clear physician supply hasn't been restrained, but it's also clear that med students follow the incentives which are to specialize, specialize, specialize. Specialists make lots more money. And they perform many more expensive procedures but, as I said above, the evidence doesn't show that improves the care provided. It simply costs more.
Posted by: SteveH at May 2, 2008 1:45:44 PM
It's not just the supply of physicians (and ceteris paribus increasing the supply will lower costs), it's the division of labor, which is highly regulated. Whether by the AMA, state boards, or whatever, the division of labor is highly regulated in favor of doctors. Procedures that could be competently handled by somebody with way less training than a doctor are forbidden by law from being done by anybody but a doctor, even if that only means the nurses do 99% of the work while the doctor spares a second to do the critical part, to satisfy the law.
Only a doctor or somebody who is a slave to the status quo could argue in favor of this system. What we need is to keep the licensing boards intact BUT make them only certifiers, and allow anybody to do anything, caveat emptor. Yes, there will be an adjustment period as consumers and providers manage to find the most efficient ways of doing things, and consumers will have to devote a smidge more time to finding qualified people if they do not want to rely on the more expensive licensed providers.
Licensed doctors and medical schools approved of all sorts of quackery in the past. Comparing a pre-modern era's unregulated medical care isn't quite fair. You might argue that strict licensing and regulation is necessary to protect the public--I for one disagree. But you cannot credibly build a case to demonstrate that a restriction on the supply of labor and a restriction on what services a given class of profession can produce ISN'T raising costs. And IMO, it's the reason why we have this epidemic of rising health care costs. Labor restrictions, and government-subsidies of the poor and aged passing on higher costs to paying customers.
Posted by: Jacob Oost at May 3, 2008 12:16:00 AM
More than capitalism and freedom, pure Mancur Olson (The Logic of Collective Action; The Rise and Decline of Nations; Power and Prosperity).
Posted by: Craig Glackman at May 3, 2008 6:26:08 AM
