Undoubtedly, there exists a great deal of need for dental care within our society. This includes disadvantaged children, disabled persons, impoverished elders, chronic drug and alcohol abusers, those in our prison populations, homeless people, undocumented aliens, those with severe dental phobias, and people who place little value on or concern over dental services. It is a mistake to conflate the need for dental healthcare services with an economic demand for those services.
An early paper from the public health community published in 1971 made the distinction between an ethical medical need for care within a society and the demand for those services, which is an economic concept.1 Need and demand are 2 very different and distinct issues.
A relatively wealthy society can fund nearly any program it desires. Unfortunately, such a society cannot fund every program it desires. A viable fiscal demand for dental healthcare services must be in place, or those services will rarely reach patients, no matter how great the medical need. Any programs must be paid for.
Numerous industries exist in dentistry that benefit from misrepresentations by conflating dental need with demand. Such industries could not exist in a true free market economy, where consumers select winners and losers. Top-down government planning and large non-profit institutions, often with the best of intentions, have entrenched these largely wasteful and often destructive industries. Let’s take a look at 3 of these in this Viewpoint.
The Dental Education-Industrial Complex
The need for dental services in our nation has prompted the expansion of candidate admittance to existing dental schools and the opening of new programs. The federal government is complicit in this activity by allowing an almost limitless expansion of the student guarantee loan program. It’s seemingly irrelevant that graduate doctors struggle to repay student loan debt. Further compounding the problem is that most employment capacity for dentists is in regions of high dental need, but where there is little economic demand for healthcare.
One must question if education leaders are simply ignorant on concepts basic to economics or if they are acting upon ulterior, self-serving motivations. Despite the economic hardships and challenges faced by many recent dental school graduates, the numbers and sizes of dental education programs are expanding. Student loan debt is growing. New graduates struggle to find employment venues not enmeshed in an operational model of healthcare fraud, and/or run like a sweatshop mill, with little concern for patients’ interests. Not only do recent dental graduates suffer, so does ethical patient care.
The “Access to Care” Industry
Some of the most visible players in the “access to care” industry are nonprofit groups like Kellogg and Pew. I believe they truly care about our nation’s underserved populations. While their objectives seem noble, their means generate a host of negative, unintended consequences. Their earlier mission of expanding the number of graduating doctors in order to meet the needs of the disadvantaged has backfired. The cost of patient care hasn’t come down, in large part due to the drastically increasing cost of education and its related student loan debt.
For-profit “Medicaid mills” designed to serve the underprivileged have sprung up nationally. They rely heavily on staffing clinics with recent dental grads, as well as imposing production bonus and quota programs. These chain clinics are generally run by dental service organizations (DSOs), and beneficial ownership is usually in the hands of the private equity investment industry. Allegations of fraud, waste, and abuse abound from these clinics. Government and private civil legal actions against such facilities are also common. The resulting “Medicaid mill industry,” as an answer to the “access to care” problem, is a disturbing national disgrace.
Kellogg and Pew are currently promoting the dental therapist concept as their newest solution for “access to care.” We already witnessed the unintended consequence of how an excess capacity of graduating doctors was utilized in the DSO industry generally, and the Medicaid mill industry, specifically. I seriously doubt Kellogg or Pew forecasted this deleterious outcome. Why would dental therapists elect to remain employed for lesser income, in remote, underserved communities? We have already seen doctors leaving rural, destitute communities. Need doesn’t always equate to economic demand. The pattern is crystal clear. Yet, top-down planners firmly believe in the dental therapist solution for “access to care.” Kellogg and Pew lobby fiercely to this end. And, why wouldn’t the DSO industry scoop up cheap labor in sweatshop clinics via dental therapists, as they now do with the excess of dental school graduates? The isolated bubble of non-profits leads one to be distanced from economic realities.
A business model largely overlooked in the access to care industry is Medicaid managed care organizations (MCOs). Medicaid MCOs are powerful and lucrative. Unlike a true insurance company, which places its shareholders’ money at risk, these companies only administer taxpayer money on Medicaid billings. Their percentage cut is usually in the neighborhood of 15% of Medicaid billables. Medicaid MCOs have been admonished by the US Health and Human Services Office of Inspector General as a weak model for serving the interests of taxpayers. Since it’s not the MCO’s money going out the door, they provide little to no oversight. They communicate too little with government oversight authorities. In fact, tax dollars expended for fraud, waste, and abuse actually elevate their revenue intake for program administration. The current legal case against the Xerox Corporation and its former dental Medicaid MCO in Texas is a prime example of this failed business model as a parasite upon government.
It’s in the economic interests of Medicaid MCOs to expand government spending for dental Medicaid. As government spending on Medicaid increases, MCOs expand their largesse. They will promote increasing adult and child dental Medicaid programs, lobby for government-sponsored dental care for the retired, espouse greater dental Medicaid fee schedule rates across the board, and oppose state work requirements for adult Medicaid beneficiaries.
Rick Perry, between serving 2 terms as Texas Governor and his current position as US Department of Energy Secretary, was a senior director at MCNA, a dental Medicaid MCO. The ADA’s current executive director, Dr. Kathleen O’Loughlin, formerly served as president and CEO of DentaQuest, the nation’s largest dental Medicaid MCO. Again, dental Medicaid MCOs retain leadership who command significant power and wealth. The MCO business is a significant factor in the access to care industry.
The Private Medicaid Mill Industry
Probably no entity does a better marketing spin conflating dental need with economic demand for dental services than the private Medicaid mill industry. Unfortunately, as elucidated in numerous government lawsuits, their methods of defrauding taxpayers are consistent. The old days of billing for services never rendered now often seem passé.
A classic favorite is to place excessive numbers of stainless steel crowns with poor fit on primary teeth with minimal-to-no dental decay or teeth that are nearly ready to exfoliate. Baby tooth root canals (pulpotomies) are an additional popular billing, regardless of patient need or benefit. Naturally, the parental informed consent process is highly remiss. Little consideration is given to the child’s stamina or maturity level in the delivery of extensive treatment. The goal is to maximize Medicaid production billing at any given patient visit.
The modern era of dental Medicaid fraud has progressed. Today, it’s common practice to see the placing of dental sealants and upcoding these to dental restorations. Four quadrants of restorative dental “services” can be delivered and billed at a single visit, with no need for anesthesia injections or patient discomfort. Massive “treatment” can be quickly rendered and billed out on primary teeth and permanent teeth. Patients do not hurt and have no out-of-pocket copayments, so they are pretty happy. The MCOs that handle administration are also pleased since their major stakeholders elevate dollars billed as Medicaid, which enhances MCO charges to the government. It’s seemingly only insignificant taxpayers and poor patients who are getting ripped off. The corruption of young doctors also seems to matter little.
When taxpayers hear the old refrain, “What about the poor children and the disadvantaged?” from any of these various groups, they should hold onto their wallets. For these vested concerns, it’s primarily about advancing the advocacy group’s own interests, not that of the poor or disadvantaged.
The 3 industries discussed in this piece, the dental education-industrial complex, the access to care industry, and the private dental Medicaid mill industry, are not isolated. These entities are connected and often feed off one another. They are also well represented by supportive leaders in government and organized dentistry. Each group supports each other’s interests, knowingly or unknowingly.
Conflating medical/dental need with an economic demand for dental care is an outrageous and yet pervasive misrepresentation. Reliance on top-down government leaders or the command decisions of non-profit industry grand poohbahs will result in failed programs, usually at taxpayer expense. The losers are patients, doctors, and taxpayers.
1. Jeffers JR, Bognanno MF, Bartlett JC. On the demand versus need for medical services and the concept of “shortage”. Am J Public Health. 1971;61:46-63.
Dr. Davis practices general dentistry in Santa Fe. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Sante Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached via email at firstname.lastname@example.org or at smilesofsantefe.com.
Disclosure: The author reports no disclosures.
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