Yesterday (May 18, 2016), I had a new experience, I flew across the country to attend a conference and after the first session and brief discussions with several leaders, flew back to Beaumont on the same day. I did not leave angry but realized that if I stayed, I would be disruptive.  I was there at the invitation of someone I greatly respect and did not want to embarrass or disappoint that person, so my only option was to leave. 

I will not identify the conference or the leaders as my goal is to explain my objection to what I heard and to think about how to solve the dental healthcare problems which were to be addressed.  My goal is not to embarrass anyone and I am reasonably certain that the leaders of the conference are not interested in hearing a contrary opinion. 

The remarkable thing is that I totally agree with the goals of this conference and I even understand the rationale of their approach. However, I do think that their philosophy and rationale are counter productive.  The stated goals are:

1. Eradicate dental disease in children
2. Incorporate oral health into the primary education system
3. Include an adult dental benefit in publically funded health coverage
4. Build a comprehensive national oral health measurement system
5. Integrate oral health into person-centered healthcare 
6. Improve the public perception of the value of oral health to overall health

SETMA’s Commitment to Dental Care

When I was asked to attend this conference, I responded with the following explanation of my commitment to dental care and health:

1. SETMA, my practice, tracks dental care in patients with diabetes because those who get annual teeth cleaning have better diabetes control
2. Spends the largest amount from The SETMA Foundation for extensive dental care.  The funding for the Foundation comes totally from contributions by the Partners of SETMA.
3. SETMA has extensive evidence of the value of dental care for overall health.  Seven years ago, we asked a dentist for the cost of properly repairing a patient’s teeth. He said $10,400.  We asked him to make a $4,000 contribution to our Foundation and we would pay him $10,400 for her care.  In the years prior, she had been hospitalized 10 times, was on 9 medications, had poorly controlled diabetes and was getting sicker. After the dental restoration, she has not been hospitalized once and is on one medication.
4. Screens pediatric patients for dental health.

It is SETMA’s contention that if Medicare and all insurance companies pay for screening, preventive maintenance and restorative dental care that the return on investment would be significant.

My Life-Long Support of Dental Care for All

When I was a college sophomore in 1962, a boy in my dorm had totally rotten teeth. I went to a dentist and arranged a total extraction and dentures which I would pay for by working the following summer. I was 18 years old.  There was another student who agreed to pay for half of the dental work.  When we returned from the summer vacation and I had paid my half, he said that he was not going to keep his commitment.  I had to be at school two weeks before the cafeteria opened so I had money for two weeks of food.  It was exactly half the cost of the dental work.  I gave it to the dentist and fasted for two weeks.  The debt was paid, the boy's life was changed forever and I received a great blessing.  And I had my first experience with the joy and the discipline of giving to others.

What Offended Me at this Conference’s Initial Presentation?

Through my 43-year medical career, I have known that there are identifiable differences in care received by various groups or populations of patients.  Sometimes those groups are identified by ethnicity and the differences, which almost always represent lower quality of care, are referred to as “Ethnic Disparities”.  When these disparities are recognized, it is possible to design treatment programs which can mitigate or hopefully eliminate them.  Due to the use of business intelligence, statistic analysis, and health data informatics, SETMA has been able to demonstrate the elimination of ethnic disparities in diabetes and hypertension treatment.  SETMA’s approach to healthcare is defined in our Model of Care.  (See: The SETMA Way - SETMA's Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change)  This model includes personal and personalized care for individuals and population-health-methods for groups or panels of patients.

SETMA is accredited as a Patient-Centered Medical Home (PC-MH) by all four national organizations that provide such (see:  Accreditations - SETMA's Accreditation, NCQA, AAAHC, TMF Health Quality Institute, URAC and Joint Commission).  SETMA has also been involved with Medicare Advantage and its predecessor organizations for 20 years.  We know and practice the Triple Aim defined by the Institute for Healthcare Improvement and we support and participate in Alternative Models of Care (AMC) to that end.

In the introductory session at this conference, the discussion was not about defining the problem of dental care and designing a solution.  It was about who is to blame.  Terms like “health equity” and “social justice” were used to explain our current dental health.  It was even said, “White people get dental care,” implying that the absence of dental care among other groups could have a race basis.   

“Social Justice” and “Health Equity,” while popular and familiar terms are not healthcare terms; they are political terms.  The vocabulary of the presentation sounded like a training program for a Community Organizer group and the spirit was like a cheer leader among people who shared a common belief. The presentation was given by a liberal, qua progressive, qua socialist who, rather than promoting a solution, placed responsibility for the solution, not upon the individual, but upon society.  The presentation was well rehearsed and well presented and had obviously been practiced before. 

Also, I had heard it before.  If “social justice” is the solution, then it must be to undo the result of “social injustice,” and it was implied that the solution to the problem was to find who is to blame, and that it might actually be “white people.”  After all, if they are absorbing all the resources, there is no balance or equity in the distribution of those resources.

I will soon be 73 years old.  My personal experience with dental health came through my father and mother.  I grew up in a lower, middle class home.  70 years ago, in my family, there was not a great deal of money,  Nevertheless, my father, who lost all of his teeth at age 30 due to poor dental care, made sure that his children and wife had excellent dental care. It was a choice he made.  He did not use alcohol.  He did not have a fancy car.  He lived in company housing and he grew most of our food.  But, he provided for our dental care.  He did not expect society to provide it.

Repeatedly, it was said that “we,” implying government, society and “white people” are responsible for providing dental care to everyone.  Here is where it got curious.  PC-MH was touted as the model of care for the future.  Terms familiar to those of us involved in PC-MH, like “patient activation” and “patient engagement” were used.  Unfortunately, it was never stated that these terms refer to personal participation and personal responsibility for one’s own health and dental care.

Everyone understands that some people need help, but it should be help, not societal assumption of full responsibility for all healthcare.  Seven years ago, SETMA formed a Foundation and the partners of SETMA have given $500,000 a year to that foundation in order to have funds to help our patients who cannot afford their care.  In the following section of SETMA’s website (www.jameslhollymd.com), you can read some of our stories which illustrate the above.  (See:  Medical Home - The Story and the Ideals) (For more detail see: Your Life Your Health - Medical Home Series Two: Part XVIII - Introduction to SETMA’s 2009, 2010 and 2011 Series of Articles on Medical Home  and for the update of this story see:  Your Life Your Health - Patient Centered Medical Home Poster Child: An Update after Five Years of Treatment in a Medical Home)) 

We have continued this even though due to the 20% CMS reduction in Medicare Advantage reimbursement and the Affordable Care Act’s “tax” to our IPA of $1,500,000 annually to be increased this year to $1,700,000 resulted in a revenue decrease such that some of the partners of SETMA have not been paid since December 3, 2015.  Yet, we still support our employees and patients without any decrease in their benefits.  We are taking steps to respond to this pressure, but none of those steps are taken at the expense of the quality of care our patients receive.