Amer­i­can den­tal lobby bares its teeth on care laws

Northwest Arkansas Democrat-Gazette - - MUTUAL FUNDS - MARY JOR­DAN

AU­GUSTA, Maine — Lit­tle in pol­i­tics has sur­prised Richard Mal­aby as much as the power of den­tists.

For years, lo­cal den­tists held four Christ­mas par­ties at Mal­aby’s 19th-cen­tury coun­try inn in the pic­turesque town of Han­cock. But in 2014, Mal­aby, a Repub­li­can law­maker in the Maine Leg­is­la­ture, voted to cre­ate a new type of den­tal provider to per­form ba­sic ser­vices in poor and ru­ral ar­eas.

The Maine Den­tal As­so­ci­a­tion, which op­posed the bill, was fu­ri­ous. And the den­tists took their Christ­mas par­ties else­where, cost­ing Mal­aby $6,000 that De­cem­ber and ev­ery Yule­tide since.

Among the gen­eral pub­lic, den­tists tend to have a Nor­man Rock­well ap­peal — solo prac­ti­tion­ers who clean your teeth, tell your kids to cut down on the candy, and put their seal of ap­proval on a range of minty tooth­pastes and mouth­washes. But law­mak­ers from Maine to Alaska see a dif­fer­ent side of den­tists and their lobby, the Amer­i­can Den­tal As­so­ci­a­tion, de­scrib­ing a po­lit­i­cal force so uni­fied, so re­lent­less and so thor­oughly wo­ven into Amer­i­can com­mu­ni­ties that its clout ri­vals that of the gun lobby.

“I put their power right up there with the [Na­tional Ri­fle As­so­ci­a­tion],” Mal­aby said. “Den­tists do ev­ery­thing they can to pro­tect their in­ter­ests, and they have money.”

As the cost of den­tal care rises be­yond the reach of mil­lions of Amer­i­cans, the den­tal lobby is com­ing un­der in­creas­ing scru­tiny. Crit­ics say the Amer­i­can Den­tal As­so­ci­a­tion has worked to scut­tle com­pe­ti­tion that could im­prove ac­cess to den­tal care in un­der­served ar­eas and make rou­tine check­ups and fill­ings more af­ford­able.

The Fed­eral Trade Com­mis­sion has bat­tled den­tists in state af­ter state over an­ti­com­pet­i­tive con­duct. In 2007, the FTC suc­cess­fully set­tled a com­plaint over a South Carolina den­tal board re­quire­ment that den­tists ex­am­ine chil­dren in school clin­ics be­fore hy­gien­ists can clean their teeth, adding greatly to the cost. In 2015, the FTC won a Supreme Court rul­ing against the North Carolina den­tal board, which tried to block teeth-whiten­ing busi­nesses from oper­at­ing in malls.

This year, the FTC pub­licly com­mented on a grow­ing cam­paign to im­prove ac­cess to den­tal care by cre­at­ing a cat­e­gory of mi­dlevel prac­ti­tion­ers, or “den­tal ther­a­pists,” to pro­vide some rou­tine ser­vices. In a let­ter to the Ohio law­mak­ers con­sid­er­ing such a mea­sure, FTC of­fi­cials said ther­a­pists “could ben­e­fit con­sumers by in­creas­ing choice, com­pe­ti­tion, and ac­cess to care, es­pe­cially for the un­der­served.”

More than a dozen states are con­sid­er­ing sim­i­lar pro­pos­als, de­spite fierce re­sis­tance from the Amer­i­can Den­tal As­so­ci­a­tion and its state af­fil­i­ates. Dur­ing the Maine de­bate, so many den­tists flooded the State­house in Au­gusta that be­sieged law­mak­ers taped up signs declar­ing their of­fices a “Den­tal Free Zone.”

The den­tists had a unique way to get around the block­ade: the reg­u­lar checkup. While the bill was pend­ing, some law­mak­ers found them­selves get­ting an ear­ful when they stretched out and opened wide for an oral exam.

“I’m cer­tainly a cap­tive au­di­ence when I am in the den­tal chair,” said Brian Lan­g­ley, a Repub­li­can state se­na­tor in Maine who also got calls from four other den­tists in his district and ended up sid­ing with them.

The bill es­tab­lish­ing a new provider type ul­ti­mately passed, but “it was bru­tal, very bru­tal,” re­called David Burns, a Repub­li­can state se­na­tor who re­tired af­ter sup­port­ing the mea­sure. Af­ter­ward, Burns said, he got a call from his den­tist, who vowed never to treat him again, say­ing, “This re­la­tion­ship is over.”

Most of the 200,000 den­tists in Amer­ica work solo, in of­fices that are es­sen­tially small busi­nesses. They are known for pro­ject­ing a re­mark­ably uni­fied voice on mat­ters re­lat­ing to their liveli­hood. The Amer­i­can Den­tal As­so­ci­a­tion says 64 per­cent of den­tists be­long to the as­so­ci­a­tion. By com­par­i­son, only 25 per­cent of physi­cians be­long to the Amer­i­can Med­i­cal As­so­ci­a­tion.

The Amer­i­can Den­tal As­so­ci­a­tion agrees that too many Amer­i­cans are get­ting in­ad­e­quate den­tal care. They ar­gue that the an­swer is not the cre­ation of “lesser trained” ther­a­pists, but more gov­ern­ment fund­ing and “com­mu­nity den­tal health care co­or­di­na­tors” to ed­u­cate peo­ple and get them to a den­tist.

“Den­tistry has a fun­da­men­tal be­lief that den­tists should be the only ones to do sur­gi­cal, ir­re­versible pro­ce­dures,” said Michael Graham, se­nior vice pres­i­dent of the Amer­i­can Den­tal As­so­ci­a­tion’s Divi­sion of Gov­ern­ment and Pub­lic Af­fairs. “A lot of things can hap­pen when you cut into a tooth.”

Oth­ers ar­gue that the Amer­i­can model of den­tistry is badly in need of in­no­va­tion and com­pe­ti­tion. The Pew Char­i­ta­ble Trusts and other foun­da­tions ad­vo­cate ther­a­pists as a way to im­prove ac­cess and af­ford­abil­ity.

Ther­a­pists cost less to train than den­tists do, and states set the rules gov­ern­ing their train­ing and scope of prac­tice. Sup­port­ers say the idea is for the ther­a­pists to work in con­cert with a li­censed den­tist but be more mo­bile, vis­it­ing peo­ple in nurs­ing homes and un­der­served ru­ral ar­eas to per­form ba­sic oral ex­ams and fill and pull some teeth.

They would also treat peo­ple on Med­i­caid, the gov­ern­ment health care pro­gram for the poor. Two-thirds of li­censed den­tists do not ac­cept Med­i­caid, and hos­pi­tal emer­gency rooms are swamped with peo­ple with ne­glected teeth.

“Ther­a­pists are not a sil­ver bul­let but a sig­nif­i­cant way to be­gin ad­dress­ing the prob­lem,” said John Grant, di­rec­tor of the Pew Char­i­ta­ble Trusts’ den­tal cam­paign.

Louis Sul­li­van, a physi­cian who served as sec­re­tary of health and hu­man ser­vices un­der Pres­i­dent Ge­orge H.W. Bush, said den­tists’ op­po­si­tion to ther­a­pists is largely about money.

“They think den­tal ther­a­pists will be com­pet­ing against them and there­fore will com­pro­mise their in­come,” he said.

Sul­li­van noted that doc­tors strongly op­posed the cre­ation of nurse prac­ti­tion­ers in the 1970s. Now doc­tors — and the health care sys­tem — can’t live with­out them, he said.

As in the nurse-doc­tor bat­tle, there is a gen­der fac­tor: More than 95 per­cent of den­tal hy­gien­ists are fe­male. As a group, they sup­port the idea of ther­a­pists and, with ad­di­tional train­ing, could join their ranks. Cur­rently, hy­gien­ists work in small of­fices with li­censed den­tists, 70 per­cent of whom are male.

Den­tistry has “been an old boys’ club,” said Ruth Ball­weg, a pro­fes­sor and physi­cian as­sis­tant at the Univer­sity of Wash­ing­ton School of Medicine who has been in­volved in the fight for den­tal ther­a­pists. “But the model is chang­ing.”

More than 50 coun­tries, from Canada to New Zealand, have den­tal ther­a­pists. Alaska Na­tive tribal ar­eas first in­tro­duced den­tal ther­a­pists to the United States in 2004. Since then, Min­nesota, Maine and Ver­mont have ap­proved them. Ohio, Kansas, Mas­sachusetts, North Dakota and sev­eral other states are now con­tem­plat­ing their au­tho­riza­tion.

The Amer­i­can Den­tal As­so­ci­a­tion has spent mil­lions of dol­lars try­ing to block the bills. It also filed mul­ti­ple law­suits try­ing with­out suc­cess to stop the Alaska pro­gram.

“They went af­ter th­ese Alaskan ther­a­pists like they were ISIS. It was em­bar­rass­ing,” said Jack Dil­len­berg, a den­tist who has taught at the Har­vard School of Den­tal Medicine.

Dil­len­berg vis­ited the Alaska pro­gram, where ther­a­pists work­ing in con­sul­ta­tion with a li­censed den­tist — some­times by telemedicine — visit is­lands, re­mote vil­lages and other un­der­served ar­eas.

“I thought they were awesome,” said Dil­len­berg, one of few den­tists to pub­licly sup­port the ther­a­pist idea.

Of two dozen den­tists in­ter­viewed, a hand­ful said they liked the idea, with some ar­gu­ing that the ex­is­tence of ther­a­pists would let them con­cen­trate on more com­pli­cated pro­ce­dures. An­other pro­po­nent, Maine den­tist Aatif An­sari, posted pro-ther­a­pist com­ments on Face­book dur­ing the 2014 de­bate. He got ham­mered by his col­leagues.

“It was very ag­gres­sive. Folks were up­set,” An­sari said. “They said things like, ‘How could you? I spend this many years in school and how could you let some­one with in­fe­rior train­ing do this work?”

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