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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: access to care, professional ethics
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Abstract |
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The commission proposed four guiding principles with respect to formulating a series of positions on access to oral health care:
My activities in chairing this commission, my concerns about why oral health professionals may not be adequately responding to the lack of access to oral health care for certain populations, and these four guiding principles were key factors that stimulated my efforts to bring about this workshop.
I would now like to present a few more details about how I approached this topic of the ethics of access to oral health care. While there is no legal right to health care in the United States, many commission members, and I think many participants in this workshop, would agree that there is a natural right to health care for all members of society. In addition, I think we would all agree that health care for the underserved and indigent is a societal problem that must be addressed by the public at large. But we must ask this question: How have the dental professions dealt with this crisis? That is, how are we as health care professionals responding to the challenges of access to oral health care?
While a later article in this issue will clearly address some of the data supporting the contention that there is a real problem in access to oral health care, especially for some populations, I would like to offer just two reports. First, the findings of the U.S. surgeon general’s report on oral health clearly demonstrate disparities in access to and levels of oral health.4 Second, the U.S. Health Resources and Services Administration reported that there were 1,895 designated Health Professional Shortage Areas requiring a total of 8,000 dentists in 2002, with more than 40 million people living in these areas; this is an increase from 792 shortage areas in need of 1,400 dentists in 1993.5 These two observations sound like a crisis in access to oral health care to me.
We can look for some answers in the recent Future of Dentistry report published by the American Dental Association (ADA).6 Consider the following quotation from this report: "Dentistry is known and celebrated for its high ethical standards and awareness of its social responsibilities and public trust. Whatever actions the profession takes in response to future challenges, that trust must be maintained. To do so, the profession must find ways to provide for those in need, regardless of their financial wherewithal or the challenges they present." With that statement as a framework, I want to touch on some solutions proposed in this report for addressing the access to care challenge.
Several reports suggest that dentists are, generally speaking, not seeing Medicaid patients for a variety of reasons.7–11 The ADA Future of Dentistry report suggests that one solution is to improve reimbursement rates and decrease administrative burdens. However, the U.S. General Accounting Office reports that the results of past efforts in several states to increase Medicaid fees have been marginal at best in terms of improving access.12 Fortunately, more recent reports from several states suggest that this mechanism may produce some improvement in dentist participation rates in Medicaid.13,14
The ADA Future of Dentistry report also discusses the issue of philanthropic care. However, while dentists provided about $1.3 billion in uncompensated care in 1998, this was only 2.4 percent of total dental expenditures compared to a rate of 5 percent of total physician expenditures.15 In addition, recent data from the American Dental Association demonstrate that while dentists’ mean net income increased approximately 35 percent from 1996 to 1999, free dental care provided by dentists decreased 6.6 percent and discounted dental care decreased about 10 percent.16,17 These data may suggest that dentists could do a better job in providing dental care to the underserved, but, to be fair, the demographics and large number of underserved and low numbers of dentists suggest that dentists simply could not handle the entire burden of the underserved with current practice models.
A third recommendation in the ADA Future of Dentistry report focuses on increased advocacy. However, a look at the past track record of advocacy suggests that our profession could do more here. A recent report suggests that a consistent theme of dentistry related to access to care issues is a "lack of effective advocacy."18 David Nash recently reviewed over thirty-five years of organized dentistry’s opposition to proposals to develop alternative delivery systems including alternative providers.19 Witness the tremendous effort by organized dentistry to block the dental therapist program for the Indian Health Service; trying to influence the text of federal laws allowing self-governance of the Indian tribes is serious business. These activities appear self-serving to many and do not present a good public relations image for the profession. On the other hand, the good news to me is that recent ADA leadership clearly has a focus on access as demonstrated by the Give Kids A Smile program and increased federal and state advocacy. These efforts must continue and must be expanded.
In trying to evaluate dentistry’s response to access issues, we can also look at the responses of some grassroots dentists to community-based dental education sponsored by dental schools. While dean of the University of Florida College of Dentistry from 1995 to 2002, I helped develop a series of community-based educational opportunities for dental students and residents in collaboration with local agencies such as community colleges, county health departments, and community college allied dental educational programs. The initial response of the local and state dental societies was very negative. To quote one newspaper article, "Dentists, UF college feuding over clinics; the dental association says UF is taking business from private dentists."20 More recently, in response to the University of Florida College of Dentistry’s Robert Wood Johnson Pipeline grant proposal to develop a student rotation in the local community college dental hygiene program to improve access to oral health care on the west side of town, the local dental society in Alachua County wrote to the president of the University of Florida expressing concerns about potential competition. "With an average of eighty senior dental students per year this would add up to 3,200 days per year of extramural experience, or essentially an equivalent influx of fifteen new dentists into the Gainesville area," he wrote. (There is no published reference for this letter, but interested readers may contact me for a copy.)
Please note that the vast majority of patients at the community college were low income and that dental students might be able to see about four to five patients per day. In my opinion, these kinds of negative actions do not reflect well on the profession.
One question we might ask at this point is this: What are some of the reasons we in the dental professions are not adequately responding to the access challenges? The following responses come to mind:
While each of these areas deserves attention and discussion, I would like to focus on the ethical framework question as that is what led to this workshop. There is a legitimate concern that practicing dentistry is a business: one must pay rent, pay for supplies, pay salaries to oneself and staff, etc. The long-term position of the American Dental Association is that oral health care is a commodity that must be viewed in normal market or business terms, i.e., demand and supply issues will determine fees, etc.
The ADEA commission report proposed an alternative perspective. First, oral health care should be treated differently from marketplace economies in "the good society" as described by Etzioni and others.21,22 Second, oral health care should be accessible to all members of society, and social and economic institutions of the society should be arranged to maximally benefit the worst off in society, as proposed by Rawls and others.23 Third, and this is most critical, health professionals have a moral obligation to provide care to the underserved and vulnerable, as described by Pellegrino and others.24,25
These three terms—"the good society," "social justice," and "moral responsibilities"—led me to review the ADA Principles of Ethics and Code of Professional Conduct.26 The code does not contain any language similar to concepts of the "good society" but does address the general principle of doing good. While the code does address the concept of justice, I would describe the usage as more legalistic than reflecting the values of social justice. Finally, there is little in the code that addresses moral responsibilities of health care professionals, though the code does address issues such as serving the community. In one sense, there should be no surprise about the lack of emphasis on these concepts in the code when one considers that the three dental textbooks in use in most dental schools today provide only a modest emphasis on issues surrounding professional monopoly, social or distributive justice, and access to care and very little discussion about the moral responsibilities of health care professionals to provide care for underserved groups. The good news is that ethical materials developed by the American College of Dentists do address some of these issues in more detail and they are a wonderful resource for all oral health care professionals.27
So now, I bring you what I call "The Challenge": Should/how can the profession reframe the dental code of ethics to reflect these principles related to the ethics of access to care? To initiate this discussion and bring together the participants for a workshop on these issues, the following steps occurred:
If we can initiate dialogue on ethical issues surrounding access to oral health care, and if we can alter the ethical framework of the profession over time, what do we want to see happen? There are several goals that we can identify at this time:
In closing, I want to make two additional points. The first is a sincere reminder that I and others do not believe that solving the access to oral health care crisis is the dental profession’s sole responsibility. It is clear to many of us that this is a societal problem of immense proportions, intertwined with general health care access, education, and oral health literacy of the public, employment, insurance, and a host of other societal factors. The dental professions will not solve these problems in isolation. Nevertheless, this access problem is "dentistry’s problem," at least from a public relations perspective. And dentistry can only address this negative image by taking a big leap forward in advocacy, and thus not be seen as resistant to or ignoring the problem.
Second, I wanted to give you a real life example of what the access to oral health care problem really means to patients. Gainesville, Florida, is home to more than 100,000 residents, has over 100 dentists in private practice, and also houses the University of Florida College of Dentistry. We have seven full-time pediatric dentists in our department and ten residents. We perform about six operating room/general anesthesia cases a week and over twenty sedations per week. Despite all that effort, there is approximately a nine- to eleven-month waiting list for a sedation or a general anesthesia procedure. Oral pain is no longer an emergency in our department; if your three-year-old is in pain from a tooth, we prescribe pain medication. Only infection, swelling, and elevated temperature will lead to an emergency appointment. We physically cannot accommodate any pain emergencies in our daily schedule. That is what lack of access means to patients, particularly Medicaid recipients and other underserved patients.
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