to expand the patient base for student clinics—and faculty practice plans—may encounter opposition from community practitioners. For both dental schools and private dentists, the future may bring more significant competitive threats as those health plans that cover dental services extend selective contracting or employment arrangements to dental care (Bradford, 1992; Keefe, 1994).

As noted above, academic health centers face major challenges from health care restructuring, challenges that differ from community to community depending on the specifics of state policies and local health care markets. Individually and collectively, they are still developing strategies to deal with ongoing and anticipated changes in health system organization and financing. Some are likely to fare better than others, either because their environment is less hostile or because their adaptive strategies are superior.

Not surprisingly, the committee's site visits made clear that dental schools face different environments that relate in part to the size, competitiveness, and other characteristics of their community and in part to the directions being set by university or academic health center leaders. Some institutions have indicated that all components of the academic health center, including the dental school, must become more patient oriented and efficient to survive in a more competitive health care system. This may put additional pressure on dental schools to adopt the comprehensive, faculty-based models of clinical education described in Chapter 4. Faculty practice plans that incorporate care by predoctoral students may, however, not be attractive to health plans that include only a limited set of health care providers.

Community Service

During the 1970s, many dental schools developed community dentistry departments or programs that provided clinical experiences in community health settings for most dental students. Funding for these programs came from federal government initiatives such as the Model Cities program and Public Health Service grants. The elimination of these federal programs coupled with reductions in other sources of dental school revenues led many schools to discontinue or limit off-site clinical opportunities for students. Another disincentive is that schools forgo fee income when students are off-site rather than providing services in the dental school clinic. Reduced student and faculty involvement in the larger community increases the isolation of the dental school.

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