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competency than the outdated, unethical, extortion we are subjected to for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