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Charles Arlinghaus: Expanding dental care by reducing regulations

November 05. 2013 4:26PM

There are some dental services that the government will allow only dentists to do that could be performed efficiently and less expensively by less advanced dental professionals. While virtually everyone in dentistry agrees with that assessment, they disagree quite a bit over which services should be restricted and which opened to more providers. They also disagree on whether the more open market should be limited to certain counties, and whether the protection of current business models is a good excuse for government restrictions.

The Legislature is considering a bill to create a middle level of practice somewhere between the more advanced dentist and the less advanced dental hygienist. The exact scope of practice of a hygienist differs from state to state. New Hampshire's hygienists have more responsibilities than those in some others states, but they are not allowed to practice independently.

Generally speaking, in almost every state hygienists push for more independence and the ability to do more things. They are almost always opposed by dentists, who would quite naturally prefer that many things be limited strictly to those licensed as dentists. This is the natural economic interest of most health providers. You are generally opposed to others being allowed to encroach on your turf.

The proposal is more complicated than allowing hygienists to also fill cavities. Following an example in Minnesota, legislators would create a new category of provider halfway between the requirements for hygienists and those for dentists. Minnesota calls its mid-level job a dental therapist. In New Hampshire, the title would be hygienist-practitioner, but the job would be very different from a current hygienist.

The name is meant to evoke the now-accepted but formerly controversial term "nurse practitioner." At one time, many doctors opposed allowing nurse practitioners to prescribe medicine or do some of the less complicated things that had been limited to just licensed doctors.

But nurses won the battle to create a more advanced middle level of service. Today, most of us have been to see a nurse practitioner at one time or another. For most things, it's just like seeing a doctor. But for some more complicated things you probably want to see the M.D.

Advocates for the new dental category are focused on access to care and the supposed inadequacy of the network of dentists in New Hampshire. I think that is short-sighted. If the only reason to allow a mid-level of practice is because of shortages here or there, the government would have to get in the business of estimating dental business capacity, deciding on appropriate length of travel, and deciding on whether transportation subsidies are a good business decision.

The whole proposal could be mooted by deciding if the recently created public health hygienist effectively obviates the government's planning needs.

If, on the other hand, some procedures like filling basic cavities are perfectly appropriate to be performed by a professional with a middle level of training, there would be no need to limit the geographic practice area of that professional. The government effectively would be deciding whether a licensing monopoly for cavity work, for example, was justified.

What we know today is that everyone involved in dentistry agrees that there are services that we limit today to dentists that we don't need to. Even dentists have suggested expanding the number of things that other professionals can do. The disagreement is over where to draw the line. Quite naturally, given the potential impact on their business, dentists have a more limited view of what services should be opened to competition.

The dentist will want to agree to have today's hygienists do just a few more things than they do today, but not many and only in limited circumstances. This is essentially the newly established public health hygienist. They are also generally opposed to hygienists or other professionals working independently.

For policymakers, barriers on the provision of service should be avoided whenever possible. If a service can be provided safely, but less expensively with a somewhat less advanced credential, that barrier to care should be eliminated. That the more expensive option has unused capacity is not a reason to avoid less expensive care.

The only good excuse for erecting licensing barriers is safety. But today we all agree that many more advanced services could be safely provided by a mid-level professional. The Legislature can and should create a new mid-level practice and should limit its scope only through safety concerns not by geography or practice protection.

Charles M. Arlinghaus is president of the Josiah Bartlett Center for Public Policy, a free-market think tank in Concord.

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