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APPENDIX 2 INDIVIDUAL COMMITTEE MEMBERS ' COMMENTS ON THE REPORT Alvin L. Morris, D. D. S ., Ph.D. University of Pennsylvania While I approve the report and its conclusion, there are two areas with which I am sufficiently concerned that comments appear in order. In the committee's zeal for providing basic preventive and educa- tional services in or through the nation's school systems, it has produced a report that will be interpreted by'many as recommending an exclusion of the private sector, or more specifically the dental practitioners of the nation, from participation in the delivery of Priority One services: prevention for children and adolescents. The report recommends, "however, no payment would be provided by public insurance programs for such services outside the school based program. In my opinion, that recommendation is basically flawed for the following reasons. 1. Regardless of how dental services are provided and financed, ultimately the nation will be dependent upon the dental profession to make a national dental health care program a reality. To exclude preventive services for children and adolescents from the practice of dentistry under a national plan would have unfortunate consequences It would use the power of funding mechanisms to reorient dental prac- tice away from the current emphasis on prevention in which the pro- fession takes justifiable pride. In the presence of a school based preventive program, patients should be provided the choice of re- ceiving preventive services from dentists in the community. Under the national plan, reimbursement for such services should be at the per capita cost level of providing school based services. 2. The recommendation ignores the reality that not all school systems will introduce preventive dentistry programs regardless of how a national health plan is written. Some school boards and ad- ministrators will opt not to put forth the effort to implement such programs. Some will have other priorities for their efforts. In some communities the anti-fluoridationists will influence what occurs. In such communities, dental practitioners will be the only source of preventive services for children. 2-1

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3. The recommendation appears in conflict with one appearing later in the committee report that states "alternative prepaid delivery systems and capitation reimbursement systems be made an integral part of a dental health program under national health insurance." I believe that the delivery of preventive services by practicing dentists should be an available alternative to school based programs. I do agree that the school based approach is the preferred alternative. My second area of concern is the absence of emergency services under Priority One. While acknowledging potential difficulties in administering such a benefit, I do not accept them as insurmountable. The case for including emergency services can be made adequately, in my opinion, on the basis of the alleviation of suffering. However, another compelling argument can be mounted. If the reduction of tooth loss is a primary goal of preventive dentistry, treating dental pain, including mild pain, is a preventive service of highest order. Con- sistent with the committee's emphasis on prevention and for humanitarian reasons, emergency services should be included in Priority One. Comment has concurrence of: I. Lawrence Kerr, D.D.S. President, American Dental Association Private Practitioner Harold Hillenbrand, D.D.S Executive Director Emeritus American Dental Association 2-2 *

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COMMENT Owe E. Reinhardt, Ph.D. Professor of Economics and Public Affairs Princeton University Thanks mainly to the untiring efforts of the committee's staff, led by Chester Douglass, and to the patient and able chairing of the committee by Dorothy Rice, this report now stands as a solid contri- bution to policy analysis in the area of dental care. I concur in the findings of the report and endorse its recommendations as far as they go. There are two issues, however, that might have been examined more thoroughly in the report: (1) the issue bf health-manpower substi- tution in dentistry and (2) the structure of the market for dental care. Both issues bear directly on the quality and cost of dental care and thus on the problem of access to dental care. Both issues also touch upon such delicate matters as the quality of dental care, professional prerogatives, and professional incomes, and it is unlikely that a com- mittee as diverse as ours would have reached a consensus on those issues. I would be remiss in my social responsibility as an economist, however, were I to endorse the report without further comments on them. Indeed, to do so might be viewed by my peers as "economic malpractice." For the busy reader, the arguments to be woven further on in this comment can be distilled into ten succinct propositions and three recor;~- mendations. These may strike the reader as provocative. For that reason I have gone to unusual length to amplify them in additional Sections II to V.* Proposition 1 Our current statutes governing the assignment of tasks among the various members of the dental-care team are probably too conservative. Experience in other countries suggest that in the United States the delegation of tasks from relatively expensive dentist manpower to less expensive non-dentist manpower could be pushed beyond currently permissible limits without impairing the quality of dental care. *Available from Office of Communications at the Institute address on p. ii. Request "Reinhardt Cogent" and send $~.25 to cover duplica- tion and postage. 2-3

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Proposition 2 In assessing the merits of any new type of health manpower, such as extended-function dental nurses or physician extenders, it is not enough to inquire whether this manpower is needed to meet a shortage of den- tists or physicians. From society's viewpoint, the deployment of expanded-function dental nurses, for example, might be desirable even if there were an ample supply of dentists. After assuring themselves on the issue of quality, the consumers' essential next question is what impact the new type of manpower will have on the prices of health services. Another way of looking at the matter is to inquire what set of economic lifestyles consumers are willing to support by their use of health ser- vices: predominantly the elevated economic lifestyles of physicians and dentists, or relatively more of the less elevated lifestyles of lower- skilled health workers. Proposition 3 In an era of relatively flush health-care budgets, such as the 1970s, the question raised in Proposition 2 might be academic. In the highly constrained budget environment of the 1980s, the question becomes increasingly important and will therefore be raised more often in debates on health policy. Proposition 4 The quality of the care dispensed by a dental-care system has two distinct dimensions: 1. 2. the technical quality of the services actually delivered by the system (the microquality); and the percentage of the population adequately served by the system (the macroquality). By international standards, the American dental-care system probably deserves a high grade on its microquality and a low grade on its macro- quality (as is susggested by the "substantial unmet need for dental care" identified by the conmittee). Proposition 5 Even if it were demonstrable that more extensive task delegation within dental care might, in some instances, lower the microquality of dental care--a result not to be taken for granted--society might, nevertheless countenance or even actively seek a trade-off of micro- for macroquality to serve a greater number of persons without having to allocate greater financial resources. 2-4

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Proposition 6 Trade-offs such as that alluded to in Proposition 5 have important consequences for individual consumers. As a general principle de- cisions on them should not, therefore, be left mainly in the hands of health professionals (or of economists, for that matter). Where feasi- ble, consumers should be offered ample opportunity to tradeoff dollars for quality in dental care. This freedom of choice should be offered consumers at least so long as our society refuses to make dental care of homogeneous quality accessible to all citizens, regardless of ability to pay, perhaps through a comprehensive universal dental care program of the type adopted by some nations in Europe. Proposition 7 Current statutory restrictions on task delegation in dental care serve to enforce an economic structure that hampers the ability of market forces to constrain dental care prices and expenditures. Proposition 8 Not only do the current statutes on task delegation in health care unduly limit the consumer's options--leaving some consumers priced out of adequate health care altogehter--but also these statutes favor physicians an dentists in the distribution of the economic opportunities offered by the health-care sector. In particular, these statues reserve the right to professional entrepreneurship mainly to physicians and dentists, forcing the other members of the health-care team into administrative and economic dependence on the licensed pro- fessional entrepreneurs. Probably unintentionally, but quite effective- ly nevertheless, the arrangement has limited the enterpreneurial possi- bilities for women and members of minorities, who have traditionally been underrepresented in the ranks of the professional entrepreneurs and overrepresented among those relegated by the statues to the sub- ordinate ranks of salaried health workers. Thus one may question our current licensure laws in health care not only on grounds of economic efficiency, but also on grounds of fairness. Proposition 9 Although there are compelling technical reasons for governmental restrictions on the practice of medicine and dentistry, economists increasingly have come to believe that our current licensure laws are being urged on society as much to protect the economic position of particular health care providers as to assure consumers of effective 2-5

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qualtiy control 1/. Economists have come to take this view partly because of the health professions' rather selective and seemingly self-contradictory objections to alternative means of quality assurance, such as strict, periodic relicensure rather than one-time licensure for life. The nine propositions suggest the following recommendations: Recommendation 1 Because the United States is unlikely soon to make adequate dental care available to all Americans through a national dental insurance or dental care plan, policymakers should critically review the existing statutes on licensure in dentistry and explore ways to make added dental services available at lower prices through bolder delegation of tasks from dentists ot non-dentists, especially to expanded-function dental auxiliaries and nurses. Recommendation 2 Because the cost savings from more extensive task delegation in dental care are more likely to flow through to consumers in a highly competitive market structure, every effort should be made to main- tain and to heighten competitive pressures in the dental care market. This strategy might include experimentation with an expanding of the right to independent entrepreneurship--from dentists alone to dental hygienists, to expanded-function dental auxiliaries and nurses, and to denturists. Recommendation 3 To preserve competition in the market for dental care, any public dental care progran--such as the school-based program recommended by the committee--should be subject to vigorous and fair competition from the private sector. This principle, for example, suggests a voucher system for the proposed school-based program Under this system, parents who prefer to have their children treated in a pri- vate practice would be entitled, for every child, to an annual, non- transferable voucher equal to the average annual pre-capita costs experienced by the relevant school-based program. Without such a voucher system, the public program would have an unfair advantage over the private sector. For a succinct statement and analysis of this thesis, see Paul J. Feldstein, Health Care Economics (1979), Chapter 9 on "The Political Economy of Health Care." 2-6

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Opponents of proposals to increase competition in health care some- times argue that lack of consumer sovereignty alone makes a mockery of such proposals. How, they ask, can price competition possibly play a meaningful role in markets in which consumers receive services whose quality they cannot possibly assess and for which they may not even pay at point of service? This is, indeed, a troublesome question to which enconomists do not have consensus on an answer. I do not be- lieve, however, that the lack of consumer sovereignty is equally severe along the entire spectrum of health services from routine well-patient care to intensive acute care. Indeed, with all due respect for the dental profession, I would accompany my present missive on competition with Proposition 10 The degree of consumer sovereignty and the degree of cost- sharing by patients in the markets under discussion in this comment are likely to be such as to make the case for competi- tion compelling. I am not concerned in this comment with the delegation and compe- titive marketing of root canals or of similarly complex procedures. The focus is on much simpler routine procedures, such as prophylaxes and amalgam restorations of the sort now performed by dental nurses in New Zealand and Saskatchewan. Consumers purchase these services repeatedly and have ample occasion to exchange with acquaintances information about the perceived quality and the prices of such services rendered by particular providers in their community. After a decade of intense empirical research on health care markets, economists have come to the conclusion that for such routine primary care services competitive markets tend to work pretty much as would be predicted by classical economic theory. In the separately available amplification of these remarks, I begin with some exposition of the basic economics of health manpower substitution (Section II). Thereafter, in Section III, I comment on the technical feasibility of task delegation in dental care, illustrating my comments with some remarkable data on the performance of expanded- function dental nurses in the Canadian Province of Saskatchewan. In Section IV, the focus shifts to the market structure in dental care, in particular to the constraints imposed upon this structure by our licensure laws. Section V recommends proposed changes in the organi- zation of dental care in the United States. The comment concludes with Section VI. 2-7

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COMMENT Max H. Schoen, D.n.S., Dr. P.H. UCLA School of Dentistry I concur in the findings and recommendations contained in the Final Report of the Committee on the Study of Alternative Dental Care Provisions in a National Health Care Policy. However, although con- curring, I feel that the recommendations are not strong enough. In essence, the data show that the two major dental diseases, caries and periodontal disease, are chronic diseases which affect the vast majority of the population. With minor exceptions the effects are irreversible. Caries incidence peaks during adolescence and periodontal disease increases steadily as one ages. Both can either be prevented or controlled through the use of existing measures. Most caries can be prevented through the combined use of systemic fluoride, topical fluoride, sealants and dietary control. As stated in the report, these measures are best carried out through water fluoridation and mass therapy delivered at schools to virtually all children. However, the data also show that there is a considerable amount of untreated disease in the child population. Studies also have demonstrated that dental health education, unless tied to con- tinuing therapy, is of limited value at best. Therefore, I believe the recommended program would be strengthened considerably if it in- cluded school-based treatment for disease as well as prevention. Such public treatment programs should be instituted first in areas of greatest need, as evidenced by large percentages of untreated caries. Once the disease became less of a mass problem, the desira- bility of school-based treatment programs could be reconsidered, al- though a public treatment component should be retained to guarantee access to the underserved. While the figures for Denti-Cal (California's dental Medicaid program which uses private practice) are encouraging, they are far from optimal and still leave a large reservoir of unmet need. At present, there is no measure similar to water fluoridation which can be applied to the prevention and control of periodontal disease. However, studies have shown that the disease can be prevented or controlled by frequent prophylaxis which includes deep scaling, root planing and gingival curretage. I believe the only way this will be applied to the vast majority of our popula- taion is through organized programs, with a major public components 2 - 8

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Hygienists, functioning independently, can be located where people are: at their places of work, at the schools (where many already will be for the children's program) and at community health centers. Here too, the constant reinforcement of therapy appears to have a major beneficial impact upon personal oral hygiene or home care. This aspect of the program would be reinforced further by concurrent i elusion of that part of the recommendations urging treatment of existing disease and rehabilitation. _n- In order to be more effective, all of these components must be part of an organized public program. While I support a National Health Service as being the best way to deal with dental disease, I recognize it is unrealistic to propose its implementation and the phase-out of private practice at this time. But it is not truly unrealistic to have a comprehensive national dental program now, even if composed of a variety of components. The nature of the two major dental diseases cries out for such a coordinated approach. The study shows that total manpower is not a major problem, although there are difficulties with its distribution and the appropriate use of ancillary personnel. Total cost estimates, regardless of method of calculation, are not exorbitant and even then do not consider any saving from the prevention or control of disease. The problem is that an organized program with large public components is not politically expedient and I write this concurrence to point this out. A plan which would result in much less dental disease and the sequellae of disease in very few years could be phased in over a brief period of time if it were politically expedient. The committee's report, after describing how disease and consequent tooth loss can be minimized, does not follow through fully enough on the approporiate measures. Comment has concurrence of: Melvin A. Glasser, LL.D. United Auto Workers, International Union 2-9

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COMMENT Lois K. Cohen, Ph.D. Special Assistant to the Director National Institute of Dental Research While the report as it stands contributes to a general understand- ing of some of the available policy options, I personally feel that several significant aspects of past "evaluated" experience have been omitted from the analytic portions of the project. Consequently, op- tions which might reflect these considerations have not been presented. The research literature which assesses the outcome of oral health status among populations covered by various types of nationally de- veloped dental care delivery systems has not been comprehensively considered in this report. Policy issues raised in the volume, International Dental Care Delivery Systems (eds e J.I. Ingle and P. Blair' Cambridge' Mass: Ballinger Publishing Co., 1978), the product of an TOM forum to consider dental service policy alternatives, address several points of relevance to the current report. One of these re- lates to the family and the.organization of dental care systems. Systems which cover family units can be contrasted to systems which deliver care separately to children and their parents or other adults. Another issue suggests that there may be a culture of dentistry which could be more influential in its total effect than would any single component of that cultural fabric. No single variable, such as a school-based program in and of itself, can be the entire answer to the problem of unmet need in a given society. Rather it would appear that a constellation of factors which maximizes availability of care, access, appropriateness of the service package, and acceptability to consumers as well as providers ought to be considered. For want of a better term, this holistic approach in contrast to a segmented one could be subsumed under the rubric of a culture of dentistry. An additional point is that nowhere in the literature discussed in the volume on international care or elsewhere in the domestic literature, is there any evidence that dental emergencies when covered by a third- party program, are abused by "over-utilization." Family There is considerable literature on the importance of the family as a determinant of dental service utilization. In a recent review, A Decade of Dental Service Utilization: 1964-1974, (U.S. Dept. of Health and Human Services, HRA 80-56, 1980), family resource variables appear to act as enabling factors making utilization of services possible. The role of individual family members such as the mother, furthermore, has been shown to be significantly related to perceived need for care and actual visits to the dentists, in addition to the employment of optional personal oral hygiene practices--such as toothbrushing (e.g. Rayner, J.F. "Socioeconomic Status and Factors 2-10

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Influencing the Dental Health Practices of Mothers," American Journal of Public Health, 60, July 1970; Metz, A.S. and Richards, L.G. "Children's Preventive Dental Visits: Influencing Factors," Journal of the American College of Dentists, October 1967; Lambert, C., Freeman, H.E., et.al. The Clinic Habit, New Haven, Connecticut College and University Press, 1967~. This literature seems to parallel findings from-the study of the utilization of other ytpes of health services, reinforcing the strong relationship between the child's behavior and that of the mother or relevant "social others." While this literature was discussed in committee deliberation, its failure to be included in the Final Report is reflected in the committee's ultimate recommenda- tions. A school-based preventive program for children which omits significant links to the family ignores one of the most prominent sets of findings emerging from the health services and social science literature of the past fifteen or more years. There are several ways to enhance a school-based program so that it might efficiently link itself to the family. One way is to assure that services for children could be provided in the same setting and/ or by the same provider as is the case for other family members. The fact that 110,000 or more dentists in this country predominantly provide care in the private sector suggests that links to the pri- vate sector would seem sociologically more sound than would severing private practitioners from the reimbursement scheme as proposed under "Priority One." The committee did consider reimbursing the private practitioner at the rate which would be applicable for the same service delivered in the school setting. That proposal, ultimately rejected in the final report, still stands as one viable option for establishing a link with the family's usual custom of receiving care. Another option is to include some services for adults in the same setting and by the same type of practitioner as is provided for children. Emergency service is one category of services which could be utilized creatively to form a transitional link between children and parents and other adult role-models. Culture of Dentistry The mystery of why tooth loss patterns do not always bear a close relationship to oral disease rates suggests that much more is happening in the interaction between consumers and providers of dental services than merely the expected delivery of "appropriate" services. Consumers can and do demand extractions in some cultures. Providers extract more teeth than perhaps are war- ranted in some situations. The flavor of expected behaviors noted by voluminous social survey data obtained from public samples as well as professional samples suggests that the U.S. ought not ignore the multi-factorial nature of oral health utilization, let alone oral health status. Planning service delivery, no doubt, is an imperfect 2-11

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process. However, if we are aware that certain cultural factors appear to be important determinants of health service utilization and health status, then it would appear incumbent on us to try to integrate into our plans what appear to be logical and necessary elements to enhance optimum outcome. In this case, aside from linking the school population to family patterns of care, the American cultural expectation with regard to the delivery of quality oral health services is that private sector den- tistry is capable and, in fact, does fill that need on most occasions. To ignore the predominant mode of delivery in the first level of plan, in my view, is to ignore the prevailing supportive structures in the current cultural context. How much further we could advance toward the goal of better health for all, if we could use to advantage the incentives and strengths of the current system. Should changes in the system be necessary, evolutionary progress toward that end would seem to make more sense than any potentially disruptive approach, such as one which removes the private sector and places an entirely new school-based system in operation. Politically radical, the approach of "Priority One" does not seem to make for a sensible social strategy. An additional sociological point that I cannot resist stating relates to the gradual removal of responsibilities from the family to other social institutions, a process long in progress since the Industrial Revolution. The school has been a popular place to trans- fer such responsibilities and this institution has suffered attempting to accomplish their traditional educational tasks with the extra burdens of providing recreational, safety, health and other functions assigned to them. Recognizing this burden on the schools, it would seem logical to retain as much control as possible for health care in the family, if not for the reason that the family is already the pri- mary socialization influence on the child. I am not against school-based programs, but I feel uncomfortable pulling out from all the possible policy options available only one organizational model existing internationally, ignoring essential and critical links to existing supports in the culture, namely the family and the private sector of dentistry. In the quest for rapid solutions, we may fail, as the New Zealand lesson tries to teach us, to achieve long-term success--oral health for all which includes adults. New Zealand is now experimenting with rectifying problems it has with its fine school-based system by recently supplementing the school service with preventive technologies, by working closer with the private sector to correct deficiencies in the transition from school to private office care, and to make more compatible the existing separate modes of delivery for the different age groups in the population. 2-12

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Emergency Services Given the specific nature of the definition of dental emergencies, it would seem unlikely that abuse of these services would lead to the provision of comprehensive dental care. Moreover, there is nothing in the literature of which the committee is aware that would suggest abuse. On humanitarian grounds and in the absence of contradictory evidence, it would appear that the provision of emergency dental services would be appropriate. Linking minimal service pro- vision of this sort to the system which delivers care to children also could reinforce the idea of the maintenance of a similar delivery mode for all. Though a minor link, nonetheless, this could minimize yet another potential constraint or source of confusion created by hetero- geneous systems for different population groups. In summary, while I agree with much of the committee report, and am particularly delighted with the reliance on a "needs-based" approach to planning, I believe that all options were not considered sufficiently and that those related to a school-based program for children and emergency services could have been improved upon in the light of data from the dental health services and socio-dental research literature. 2-13

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Emergency Services Given the specific nature of the definition of dental emergencies, it would seem unlikely that abuse of these services would lead to the provision of comprehensive dental care. Moreover, there is nothing in the literature of which the committee is aware that would suggest abuse. On humanitarian grounds and in the absence of contradictory evidence, it would appear that the provision of emergency dental services would be appropriate. Linking minimal service pro- vision of this sort to the system which delivers care to children also could reinforce the idea of the maintenance of a similar delivery mode for all. Though a minor link, nonetheless, this could minimize yet another potential constraint or source of confusion created by hetero- geneous systems for different population groups. In summary, while I agree with much of the committee report, and am particularly delighted with the reliance on a "needs-based" approach to planning, I believe that all options were not considered sufficiently and that those related to a school-based program for children and emergency services could have been improved upon in the light of data from the dental health services and socio-dental research literature. 2-13