The Federal Trade Commission filed a comment on a state law in Georgia to expand the scope of practice for dental hygienists:
The comment, submitted by staff of the FTC’s Office of Policy Planning, Bureau of Competition and Bureau of Economics, says that that Georgia House Bill 684 “would likely enhance competition in the provision of preventive dental care services and thereby benefit Georgia consumers, particularly underserved populations with limited access to preventive care.”
Under current Georgia law, dental hygienists generally must work under the direct supervision of a licensed dentist, which means a dentist must be physically present at the location where the services are being provided. As a result, dental hygienists may be unable to provide care in locations, often rural or underserved areas, where dentists are scarce or unavailable….
HB 684 would broaden the settings where direct supervision is not required, aligning Georgia’s supervision requirement with those in most other states. The FTC staff comment concludes that fewer restrictions likely would enhance competition in the provision of preventive dental care services and expand access to care, especially for Georgia’s most vulnerable populations.
This is not sexy, this is not lucrative, this is not the way political programs are built as the slogan “Minor administrative changes to marginally increase competition by redefining scope of service delivery laws when do we want them —NOW” does not fit on a bumper sticker.
However these are the types of gains that need to be made to reduce the guild power of high end medical providers. Most of the people, most of the time, don’t need high end care. Their basic needs can be met by trained individuals who are not over-trained. Part of the training, of course, needs to be on the recognition of situations which are above the current level of training and therefore the patient needs to go up the ladder of care. But basic dental services, basic primary care services, basic preventative services can often be performed perfectly adequately at the master or bachelor level clinician level instead of a doctorate level clinician level. Those rules are overwhelmingly determined at the state level, so that is where the long slow slog of reform needs to come.
Punchy
Therefore, I can say with great confidence that this bill will not pass the GA leggy. No chance angry white dudes are going to pay 100% of all the dental, ortho, and periodontal (not to mention, gold teeth) work of all the Blahs in GA, which is exactly what will happen once Boortz and Limbaugh convince them of so.
Tom Levenson
This kind of thing is really important. TMI anecdote from my past: I needed a deep scaling (just as horrible as it sounds) and the periodontist/dentist in the practice I used wasn’t available in any kind of a timely way. So they asked me if I were OK with an upqualified hygienist doing the procedure, which I was. She did a perfectly good job, and the procedure was done with a single person (as opposed to the more expensive periodontist plus assistant).
The bill was exactly the same — which did have an impact on my pocketbook, as my dental insurance did not cover the whole procedure by a fair margin. If I knew then what I needed to know then, I might have argued the bill — but in any event, it’s really true that there is a fair amount of room in the system to expand the range of providers.
Yeah. I said TMI up front. You got no cause for complaint.
PS — as an experience, deep scaling is worse than gum surgery. I know…
p.a.
Off topic: 1/1/16 63°, providence ri just saw a honeybee in my yard. Just barely flying, but still…
FlipYrWhig
I really really really want the Democratic candidates to hatch plans about expanding access to primary care. This is something that should be right in the Bernie Sanders wheelhouse: community health centers. And I’d like to learn about Hillary Clinton’s plans too. I want a focus on _public health_. All the flash and fuss over single payer strikes me as much less pressing than this, an immediate problem that can be addressed to show that the government can write new rules that help people’s lives in tangible ways. Democrats can craft a whole story that enfolds items like Remote Area Medical, combating infectious diseases, and Flint.
Steve in the ATL
Slippery slope–next thing you know, paralegals will be operating without attorneys and half of the BJ commentariat will be unemployed.
Why do you want my children to starve to death? Or not attend private colleges and spend summers in Europe and drive German (not VW) cars? What did I ever do to you?
Richard Mayhew
@Steve in the ATL: Bullshit— I estimate it is only a third of the commeteriat — a third is academics of various sorts, and a third is the rest :)
p.a.
@Steve in the ATL: @Richard Mayhew: We don’t want to deny all those things, we want to expand those possibilities to all.
Mnemosyne
A true dental hygienist (as opposed to a dental assistant) has the equivalent education as a registered nurse, so they should in theory be able to do a lot of the basic dental care (like cleanings and x-rays) without needing close supervision any more than an RN would for equivalent care.
Totally random question: is there a dental hygienist certificate equivalent to a nurse practitioner?
Weirdly, my dentist has decided to go without a hygienist in his current office and does all of the cleanings himself. It seems to work out fine.
Feathers
Absolutely this. Read an excellent commentary on the wretched and inexcusable state of dental care for the poor in the US, long ago, on paper and before the internet. The blame was placed squarely on the lack of a nurse practitioner level of caregiver, who would be capable of running freestanding clinics in the community. Lowering the cost of preventative visits for everyone would have huge society-wide benefits, not only in terms of health, but the employability of those with bad teeth in a service economy.
But it is always blocked by the dentists.
Richard – curious. One of the best dental plans I had (mid 90s) called for you to get cleanings every six months. If you did that and got the work done that the dentist recommended, everything was covered 100%. If you didn’t get your regular cleanings, what they reimbursed dropped substantially. Are those plans still around and I just haven’t been offered one, or were they an actuarial failure? Sorry if this is too far off your path.
Richard Mayhew
@Feathers: That sounds like a good plan but it is way outside of my area of knowledge to say anything about them besides “I need to read about it”
Steve in the ATL
@Richard Mayhew: I forgot the holiday basket painting contingent. I hope their work doesn’t get moved overseas!
Ruviana
@Richard Mayhew: I think a third is coders and IT jockeys.
Frank Wilhoit
All that is being proposed here is a shift of power from one guild to another; and the only result will be a degradation of the standard of care. Guild power is in principle harmful, but in practice it is the only mechanism of quality control.
Richard Mayhew
@Frank Wilhoit: That is an extraordinarily strong statement :
Can you please provider cites and studies that are not sponsored by the AMA or ADA
Feathers
@Richard Mayhew: Thanks. I was just curious. I tend to procrastinate on things, so this really got me to make sure I got my regular cleanings. Also, it seemed a good level of requiring “wellness” behaviors. It didn’t intrude into my day-to-day life, was actually beneficial, etc.
Mnemosyne
@Frank Wilhoit:
So dental hygienist and registered nurse guilds are by definition inferior and more corrupt than the ADA and AMA? Any particular evidence for that?
Richard Mayhew
@Frank Wilhoit: also please respond to the recent findings on how concentrated and correlated future malpractice awards are with past malpractice payments
El Caganer
My dentist is the only doctor in his office; he’s got about 8 or 9 hygienists who do all of the standard work. At the end of each visit, he takes a look for himself and they tell him if they have any additional concerns that he should address. I’ve never had anything but top-shelf service from everybody there.
Steve in the ATL
@El Caganer: @El Caganer: I have always been under the impression that dentists (and orthodontists) make their money through this sort of leverage. Same in certain areas of law (immigration, consumer bankruptcy, insurance defense) where you have flunkies do most of the work at much lower cost.
Kay
@FlipYrWhig:
I wanted to do public community health centers for ordinary care and then refer (and insure) more complex problems for health care “reform”, but no one would listen to me :)
I feel okay recommending them because I used one once for a pregnancy and it was a really good fit for me. They were ahead of the curve on the whole “treat the whole patient” idea, IMO. I liked having a “team” where the doctor was really a minor player- I didn’t see her that much.
catclub
@p.a.: Further off topic. You seem to be living a month in the past.
Proust lived years in the past, so keep it up.
@Tom Levenson:
After years of apparently not quite good enough cleaning, they did the hygienist water pick/gun on all may teeth.
Each time after, fewer teeth needed that treatment, soon, none did. If there is something worse than the water gun, I don’t want it.
KithKanan
@Ruviana: I’m in that group and almost certainly not the only one.
Eric S.
@Ruviana:
Guilty as charged.
MomSense
@Tom Levenson:
Ugh to oral surgery. I just found out today that last year’s head on collision also destroyed one of my teeth although I didn’t know it until recently. I need to go to an endodontist, pay for it now, and fight with the at-fault insurance company to get reimbursed.
sigaba
@Richard Mayhew: I belong to a guild, we make sound effects for movies in Hollywood. Our sound effects are awesome.
There are people in Florida, Georgia and London who also make sound effects for movies. They don’t have a guild. Their sound effects are shite. When someone in London is making a big movie, they have to fly people from my guild out to London to do it.
Sample of one, confounding factors surely at play :)
(I think there must be some sort of mechanism at play where if you’re just a salaried employee and they can just fire you, everything fights to make you do the least amount of work possible, to not train anybody and to contribute nothing to the body of knowledge that makes your work better. Guilds have no interests but that.)
jl
@sigaba: I think medicine is a little different from sound effects. Different services are more easily separable.
Most people when they go in for a doctors appointment, get their vital signs done by tecns or an RN. They work for the doctor usually. Why? Why shouldn’t they act as independent professionals who bill for their services separately from the doctors consultation? (that is a hypothetical, not a loaded dig at doctors, maybe there is a good reason for it, I don’t know).
For people with chronic diseases who need frequent health screenings and medication adjustments, there are medication management clinics. Basically run by pharmacists. But usually state regulations mandate a doctor oversees it, and often an RN available. What does ‘oversee’ mean? What does ‘available’ mean? Should the doctor be there in person all the time and does s/he get to bill for every patient? That drives up costs, and why, the pharmacists knows more about how to adjust the drugs than the doctor for 95+ percent of the cases. Or should the doctor be on call, and can come when pharmacists sees something odd and thinks an MD consult is needed. The MD gets paid a hourly fee for being on call, and only gets to bill when a consult is needed. Or does the doc need to see some readout and a computer screen and check boxes that all is OK for every patient, and put in a small bill representing, supposedly, some value added for skimming a form and checking a box? The state standards run the gamut I think but I have not checked recently.
Most countries have a larger primary care force than the US, when you count up all the NPs, nurses, etc. Many countries separate their scientific medical professional organizations from economic interest group professional organizations, or at least more so than the US does, with the AMA, ADA, erc.
These issues need to be addressed to get cheaper primary care to more people. At current salaries and incomes, I don’t think it’s clear that US primary care docs and RNs are way overpaid compared to other countries, so it is an issue of increasing supply of services, while maintaining quality of care, and attempting to provide decent working conditions for health professionals (and they are not very decent in many ways, in some ways, IMHO, they are shocking and disgusting both for the professionals and in risk created for patients. The money suits treat their professional help as badly as the patients,whenever they can).
US specialists are very very highly paid by world standards and there is probably a different mix of issues for them.