Michael W. Davis, DDS, discusses failings of our current medical model and why dentistry should avoid those same traps.
Q: How is our medical model of patient healthcare delivery failing?
A: Formerly, patients could depend on the doctor/patient relationship (a legal contract). Physicians held their patients’ interests foremost. Outside entities in prior times were not lawfully permitted to dictate or direct patient care, especially without the knowledge and consent of the patient (the disadvantaged party in the doctor/patient contract).
Q: How does that happen?
A: In large part, physicians no longer own or control their clinics and practices. Large corporate entities, often in the portfolios of private equity investment firms, beneficially own medical practices, clinics, and hospitals. One or more figurehead owner-physicians may be retained as regulatory nominee owners, but they usually lack any true majority ownership. The real control is in the hands of fiscal “bean counters” whose primary objective is not the optimization of patient healthcare but maximizing quarterly profits for investors.
Q: How is the beneficial ownership of practices by unlicensed entities specifically manifested?
A: The physician’s time with any given patient will be restricted or eliminated, as doctors present “excessive” overhead labor costs. Lesser-trained auxiliaries (nurse practitioners, licensed practical nurses, registered nurses, physician assistants, etc) will assume roles formerly taken by physicians. Some auxiliaries provide adequate patient care, while others deliver care outside their skills or credentialing. All are theoretically under the supervision of a licensed physician who usually lacks real control or authority over the subordinate.
Specialist referrals and laboratory selection will be limited to those most beneficial to the company’s financial bottom line (in-house specialists and company-controlled labs, termed “patient steerage”). Patient scheduling is often overbooked to promote optimal income production, regardless of patient and staff frustration or inconvenience. Even as the healthcare company’s overhead costs are reduced and production is maximized, fees will increase because competition will be diminished or eliminated in a given market.
Such a healthcare firm boasts its overwhelming size as benefiting the marketplace with superior “economy of scale.” In reality, this “economy of scale” primarily serves only the investors.
Q: Has the mindset changed from the past?
A: Today, physicians aren’t usually vested owners in smaller groups or solo practices. They are employees of big businesses. They do not answer so much to patient needs but to the directives of their unlicensed corporate bosses. Increasingly, physicians are unionizing. Some bring legal actions against large corporate ownership. Some have filed complaints with labor boards for alleged employee workplace violations. Many retire early or change careers. Studies are also pointing to increasing depression, burnout, and suicide for physicians. This has all lead to physician shortages in primary care medicine, internal medicine, general practice, and numbers of specialties. These shortages are projected to increase into the next decade as our population ages and the need for physician care elevates.
The solution presented by the medical education-industrial complex is to expand applicants to medical school and build more medical schools. Few actually address the underlying issues with the destruction of the doctor/patient relationship by corporate-directed healthcare.
In the early 1950s, approximately 75% of all practicing physicians were American Medical Association (AMA) members. By 2012, AMA membership fell to 20% or fewer physicians. A reported 10% falloff in membership came immediately following the AMA’s support for the Affordable Care Act (ACA). There’s a great deal of physician frustration over the AMA’s timidity to address serious concerns affecting physicians and the delivery of patient care.
Q: Are there examples where dentistry has followed medicine’s example?
A: Where dentistry has followed the medical model, we have witnessed serious problems. Today, increasing numbers of dentists work as employees (associates) or “owner-dentists” (with very little control) for dental service organizations (DSOs). The doctor/patient relationship has been intruded upon by outside business interests without the knowledge or consent of patients. Dentists often lack control over patient scheduling, specialist selection, laboratory selection, supply and equipment selection, options for care delivery, adequate staffing, staffing that is answerable to the doctor, production quotas, etc. Patients and doctors suffer as a result.
The profession has allowed the dental education-industrial complex to expand, and excessive numbers of dental graduates are pumped out. Income levels of dental graduates seem highly prized when examining the surface. Yet, when student debt/income ratios are appraised, dentistry ranks near the bottom of all careers. Debt loads are so exorbitant that many recent grads will be forced to repay loans over 20 to 25 years, and some will never repay their student debt.
Recently, Michigan and Arizona have passed legislation authorizing the lawful practice of dental therapists. No serious-minded person would expect these auxiliaries to actually work under a doctor’s direct supervision if working for the DSO industry. Furthermore, in a free-market economy, one would be disingenuous to claim dental therapists would limit their services exclusively to remote, underserved demographics. The US Federal Trade Commission and lobbyist influence of the DSO industry would never permit employee restriction long-term.
Q: Can organized dentistry steer clear of medicine’s decline?
A: We have already seen membership losses with the ADA, modeling the AMA. Dental groups must assume a greater role in confronting abuses of the insurance industry, corporate healthcare, the dental education-industrial complex, and government. Far more attention to these matters is required if dentistry isn’t to go the way of medicine.
Dr. Davis practices general dentistry in Santa Fe. He assists as an expert witness in dental fraud and malpractice legal cases. He can be reached at email@example.com or at the website smilesofsantafe.com.