Is Need or Demand the Driving Force for a New Texas Dental School?

Michael W. Davis, DDS

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On September 6, 2016, the Texas Tech University Health Sciences Center (TTUHSC) announced that it will be opening the Woody L. Hunt School of Dental Medicine (WLHSODM) in El Paso, Texas, in 2021. The TTUHSC cited the lack of dentists in El Paso County and an inability to attract dentists to this low-income region as reasons for the launch.

Also, explained TTUHSC system regent Rick Francis, “We have 2,000 employees and 600 students who are getting an education they couldn’t have gotten 15 years ago. And those 2,000 jobs are good, high-paying jobs.”

Since the announcement, debate has emerged about whether or not this school is truly needed and what may be really driving its development. 

Texas Dental Association 

“It is the policy of the Texas Dental Association (TDA) to support the mission of state funded university-based dental schools, which is to educate students to serve their patients and communities and continue to grow in skill and knowledge over their lifetime in practice,” reported the TDA in May 2017.

“With the creation of any new dental school, the historical legislative support, including financial support, should be maintained for the existing dental schools in Texas,” the TDA continued in its statement.

The TDA approved this seemingly obtuse and cryptic policy nearly a year after TTUHSC announced its plans for the new dental school. Questions have surfaced. Were rank-and-file member doctors of the TDA fully informed and engaged in the process? Were these dentists able to express their approval, concerns, or misgivings? Or, was approval of this new dental program conducted by an elite few and in relative secrecy?

Meanwhile, the Texas Academy of General Dentistry (TAGD) is taking a similarly neutral approach.

Texas AGD is happily supporting all Texas dental schools through our FellowTrack education program for the Academy of General Dentistry (AGD) Student Chapters, and we will continue to do so,” said Francine A. Johannesen, executive director of the Texas AGD. “Currently, the TAGD has no established position regarding the addition of any dental schools in Texas.”

Concerned Dentists of Texas 

Two cofounding members of the Concerned Dentists of Texas (CDOT), Jackie Stanfield, DDS, and Debra Seznik, DDS, believe that Texas does not need another dental school. These doctors say that a new dental school would further burden Texas taxpayers and that the existing marketplace is already saturated with dentists. Too many dentists are already struggling to finance their astronomic student loan debts, they further note. 

In an op-ed for the Dallas News, they referenced a 2012 report of the Texas Higher Education Coordinating Board (TECB) noting that, at the time, Texas did not need another dental school. The doctors also referenced the saturation of dentists in Texas and the influx of more than 9,000 new dentist licensees into Texas from 2005 to 2015.

In 2012, the 2012 TECB reported, “The uneven distribution of dentists across urban and rural areas is likely the result of economic factors, including educational costs, debt loads, and practice costs.” It also recommended “that the state not establish a new dental school,” since instead of more dentists, Texas needed “a geographic redistribution of dentists.” 

During a Texas House of Representatives Subcommittee on Education hearing in February 2017, TTUHSC reported that El Paso needed 120 more dentists. However, Stanfield and Seznik questioned the expenditure of $79 million dollars for potentially 120 new dentists for El Paso.

Stanfield and Seznik also brought up the issue of dental tourism for the El Paso population. Many are being served for their dental needs in Ciudad Juarez, Mexico, which is just across the river. Juarez also maintains a dental school immediately across the border.

The doctors further addressed viable solutions for underserved populations. One answer was enhanced funding for the Dental Education Loan Repayment Program, which would incentivize recent graduates to practice in areas of need. They also encouraged the expansion of state and federal dental public health programs. 

Additional offered solutions included increasing the enrollment at existing Texas dental programs and expanding externships to third and fourth year dental students to serve in disadvantaged regions. Local challenged communities could benefit from added dental services, and students could be exposed to populations that they might elect to serve after graduation, Stanfield and Seznik said.

“A fourth dental school in El Paso has been in consideration since 2011, when the Texas Legislature authorized the Texas Higher Education Coordinating Board to study the issue. Their 2012 Reports recommends that ‘Texas not open a new school,’ and the supply of dentists has only significantly increased,” CDOT said in an official statement to Dentistry Today.

“Texas dentists were knowingly kept in the dark by the very organization (Texas Dental Association) that is supposed to represent the rank and file. As we have stated previously, an open, fact-driven debate on this issue is imperative,” CDOT continued.    

“This is not an issue of Texas A&M versus Texas Tech as some have implied, but rather of Texas patients who deserve the best of dentistry and transparency,” CDOT said. “For the Texas taxpayer who should not be picking up the bill for something that is not wanted, nor needed. And lastly for Texas dentists where far too many struggle to pay back crushing student loans in a state where finding a position is nearly impossible. We ask, ‘Where do you stand?’”

CDOT is currently seeking signatures on an online petition to stop the proposed El Paso dental school.

Dr. Richard Black

Richard Black, DDS, MS, is the first dean of WLHSODM. A past president of the TDA, he also is an ADA trustee for the 15th District.  

“The state of Texas has three high-performing dental schools in Dallas, San Antonio, and Houston, but their graduates are not relocating to West Texas at a rate that is adequate to relieve the shortage faced by our region. Statistically, the majority (75%) of Texas dental school graduates establish practices near their professional schools. The facts speak for themselves!” Black said.

“Over the past 10 years, Texas dental school graduates practicing in West Texas or in the upper Rio Grande have been on the decline. Since 2007, only 22 dentists or 0.9% of the state’s total graduates have chosen to establish their practices in West Texas, and only another 22 in the Upper Rio Grande region,” said Black.

“The shortage of dentists is expected to worsen over the next decade. By 2025, when the first class of the Woody L. Hunt School of Dental Medicine graduates, 45% of the state’s general dentist workforce will be at or past retirement age!” he continued.

“The current dental schools in Texas are located on the I-35 corridor and eastern third of the state, while Texas’ oral health disparities that pose risks to overall health are most concentrated in its rural and border regions. The rural regions of the state have lower rates of dental visits compared to urban areas,” said Black.

“Most importantly, the WLHSOM will be accepting only highly qualified undergraduate students. But this institution is going to preferentially admit qualified and culturally competent students from the West Texas regions. It will then give our fast growing and productive part of the state a fighting chance to keep our own, well-trained professionals in the area because they have trained close to home,” Black said. “The people of West Texas deserve it!”

Texas Tech Health Sciences Center in El Paso 

In a recent editorial also for the Dallas News, Black and TTUHSC president Richard A. Lange , MD, MBA, described the need for dental professionals in underserved West Texas. 

“Both West Texas and El Paso have been designated as Dental Health Professional Shortage Areas by the US Health Resources and Services Administration. While the entire state lingers below the nation’s average ratio of dentists to citizens, West Texas and the border region face the highest shortage of dentists in Texas,” they wrote.

“Over the past 10 years, the number of Texas dental school graduates practicing in West Texas or in the Upper Rio Grande have been on the decline. In 2017, of 304 Texas dental school graduates, only one chose to practice in West Texas and only two opened practices in the Upper Rio Grande,” they continued. 

“Previous attempts to resolve the regional disparities by increasing class sizes at the existing dental schools and offering a dental loan repayment program have been ineffective in addressing the shortage of dentists in West Texas and border regions. Admissions to the three existing dental schools have increased 27% over the past 15 years, with no improvement in the shortage of dentists in West Texas,” they said.

Need Versus Demand

Certain economic facts face modern dentists, unlike previous generations. First, approximately 12% of a dentist’s monthly income is dedicated to student loan repayment. Second, on average, dentists require 15 years to repay student debt. And third, dentists’ median loan balance is $236,739. 

Confusion also exists in differentiating between the concepts of medical “need” versus medical “demand.” This then equates into compounded misunderstandings about medical “shortages.” 

Jeffers et al note that a “basic difficulty lies in the failure of economists and health professionals to fully communicate when using their own respective terminologies. The concepts to which these terms refer are quite different but are often interpreted through usage as meaning the same thing.” 

The authors further note that the “fact that the two terms are often used interchangeably further adds to confusion and lack of understanding concerning the differences in the phenomena to which the concepts ‘need’ and ‘demand’ relate.”   

Furthermore, they say, “The notion that ‘health is a right not a privilege’ may be good moral ethics, but it is not sufficient justification for making an all-out economic effort to provide all the medical services that society needs.”

Jeffers and his coauthors conclude that “‘health is purchasable,’ meaning that somebody has to pay for it, individually or collectively, at the expense of foregoing the current or future consumption of other things. Everything has its price—however ethically desirable it may be.”

The largest employer of dentists in El Paso is Kool Smiles Dental, which operates six separate dental clinics. This dental service organization recently settled with the US Department of Justice and the State of Texas for $23.9 million for alleged dental Medicaid fraud. 

These sorts of employment venues may be ethically problematic for recent dental graduates. Yet they may represent one of the very few employment options in an economically challenged demographic, and one highly dependent upon dental Medicaid.

Just because a given demographic has a medical need for dental services, that in no way may relate to a viable economic demand for those same services. Similarly, farmers in Third World nations may desperately need tractors and cultivation equipment. Unfortunately, there may exist no feasible financial means to acquire such farm equipment, especially on farms with low production due to poor soils, inadequate water, or destructive farming practices. Need and demand are not the same.

If West Texas truly has a dentist shortage for the economic demand (not need), why wouldn’t market forces correct the issue in short order? Is the current dentist “shortage” really a matter of need or demand

Undoubtedly, a dental school in El Paso would be a positive boon to the local economy. Numerous jobs and spinoff positions would be generated in the region, which was largely overlooked during the economic expansion in Texas over the past decade. It would also represent a local institution of deep community pride. 

However, one must consider potential unintended consequences. Possible negatives include unfavorable local (and national) employment options for dentists such as corporate Medicaid mills, the consequences of excessive student debt, and the fiscal necessity of graduates forced to relocate to another region or state. 

Conclusion

Each doctor I interviewed sincerely desires the very best for Texas and Texas dentistry. There are no villains, only heroes, regardless of their differing views. It’s often difficult for a non-Texan to fully appreciate how deeply state pride and love runs in this vast state. 

The TDA’s motto is “The voice of dentistry in Texas.” One may wish in retrospect that organized dentistry had more fully operated with transparency in the process of developing the new dental school. It might have been favorable to bring the different sides together early in the concept phase to prevent perceptions of secrecy and duplicity. 

Creighton University, which operates a private dental school program in Omaha, Nebraska, recently expanded and improved its healthcare facilities. This includes increasing its dental class size from 85 to 115 students. Yet few would seriously anticipate a dent in the dentist shortage in rural western Nebraska from this effort.

Graduates will locate to communities where they may reasonably expect to earn a living and pay down a mountain of student debt. Is this elevation in output of graduating dentists at all a reflection of social need or economic demand? Or, is this simply another example of unfettered growth of the dental education-industrial complex?

Today, we have two camps in Texas seemingly in intractable opposition. Each group has wonderful intentions, although at loggerheads. Earlier in the process, it might have been helpful to find common ground and compromised solutions, with each side respecting the other’s perspectives. I sincerely hope the distrust can be healed, especially between such esteemed and valued professionals. 

Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa 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 at mwdavisdds@comcast.net or smilesofsantafe.com.

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