Frank Catalanotto is a recovering pediatric dentist, former president of American Dental Education Association, former dean of University of Florida College of Dentistry and current professor there. He has devoted most of past 12 years to access to care issues. He is a passionate believer in the value of adding dental therapy to the oral health care team. He believes that Dental Therapists are good for both patients and dentists.
VIDEO - DUwHF#978 - Frank Catalanotto
AUDIO - DUwHF #978 - Frank Catalanotto
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Howard: It is just a huge honor for me today to be podcast interviewing Frank Catalanotto DMD, Professor, Department of Community Dentistry and Behavior. Frank is a recovering pediatric dentist, former president of the American Dental Education Association, former dean of University of Florida College of Dentistry and current professor there. He has devoted most of the past twelve years to access to care issues. Here's a passionate believer in the value of adding dental therapy to the oral health care team. He believes that dental therapists are good for both patients and dentists.
So Frank, with your last name Catalanotto, I have to ask you. Are you Italian or Sicilian?
Frank: I am of Italian descent. My father's parents were born in Sicily and my mother's parents were born in Naples.
Howard: Is that right? Naples, Florida or Naples?
Frank: Naples, Italy.
Howard: Naples, Italy, wow. I also have to ask you since this is Dentistry Uncensored, a lot of Italians were offended by the HBO series, The Sopranos. Did that bother you?
Frank: Not at all. It was a TV show and they were playing a TV shows about other ethnic groups that have had bad criminal involvement so no, I wasn't offended by that at all.
Howard: And I tell everyone that not everyone can be perfect like the Irish.
Frank: Probably (inaudible 01:30) married to a wonderful woman of Irish descent.
Howard: Oh, right.
Frank. Now one thing I need to say that I wish you would have not mentioned my university affiliation so I have to say that the views I express are my own and do not reflect the official views of the University of Florida.
Howard: Yeah. Roger and the reason I'm so honored that you accepted my invitation to come on the show is because you are for something that is so many dentists are just so fearful of and they just think it's the downfall of dentistry and I've seen this rodeo before. I've been a dentist thirty years and I remember when hygienists were trying to get independent practice and it passed in Colorado and all of like seven hygienists did it, but you would've thought the sky was falling and now I see this rodeo again with dental therapists. What are your thoughts on that? You must know it's controversial to the American Dental Association and to organized dentistry and to dentists.
Frank: So it is very controversial, but let me also state that we believe in the opposition is coming primarily from leadership. We participated in a poll through the NIH funded practice-based research network which reaches out to about fifteen hundred dentists across the country, will allow their officers to be used for clinical research and in that poll 48% of them thought that dental therapy sounded just fine.
So I think there was fear mongering going on by the leadership of organized dentistry. Maybe it's a ploy to try and increase membership to show that they’re fighting for dentists, but the truth is dental therapy is great for patients, but it's also great for dentists as we're seeing in Minnesota.
Howard: Well explain what it is. I mean, I'm sure there's dentists in… about twenty... podcasters are young so probably 25% are still in school. The far majority, the vast majority under thirty were probably the two oldest guys that ever listened to a podcast in dentistry. Explain what it is.
Frank: So dental therapy is just another member of the oral healthcare professional team. They are trained. The educational requirements in the United States by the commission on dental accreditation are three years of education and during that education they are taught how to do restorations, they are taught how to do prevention, they get significant training in motivational interviewing to change patient's behavior. They can actually extract teeth also like, can extract primary teeth and permanent teeth that are very mobile, like have a mobility factor of at least three. They work under the general supervision of a dentist, which means that they can work in the office when the dentist is there or they can work out of the office or in the office when the dentist is not there.
They have been in use in fifty-four countries around the world for up to a hundred years and in the United States, they are up and running in Alaska and Minnesota. Legislation has passed in Vermont and Maine. Vermont will start their first educational program this fall and there was legislation pending in about twelve other states including your state of Arizona.
Howard: You're flying to Phoenix next Wednesday to testify Thursday.
Frank: To testify Thursday morning in front of one of the committees. I forget whether it's the House or the Senate. I do a lot of this for both the Pew Trust and the Kellogg Foundation which are the two national foundations that are promoting dental therapy.
Howard: Pew Trust and the Kellogg Foundation. Can you tell us what are those? Tell us a little story.
Frank: So the Kellogg Foundation actually comes out of a Kellogg breakfast cereal cooperation and it was founded many, many years ago by Mr. Kellogg, the original founder of the company. And they're very interesting because their mission focuses on social justice and racial equity and correcting healthcare disparities and that's why they got into this dental therapy business.
Howard: Social justice and what were the two?
Frank: Social justice and racial equity with a focus on healthcare disparities. And so that's why they were the first foundation in helping support the Catholic in Alaska and they worked in a couple of other states in the country.
The Pew Trust on the other hand, is very different but with the same goal. The Pew Trust is driven very much by data and evidence. So they look for evidence based policy solutions to a variety of problems. It could be education, it could be the environment, it could be healthcare and they had been in the dental care business for about ten years. They have supported community water fluoridation, they have big proponents of school-based sealants and then they had moved a significant amount of their efforts towards dental therapy because they believe the printed published evidence that dental therapists are safe and do high quality dentistry and can be effective in improving access, particularly for poor people but quite honestly for old people.
Howard: Well, maybe it's just my perception but it seems like every time I see something about Pew Trust, it's about the oceans, the trash in the oceans, the overfishing of the oceans. To me, it seems like they're really big into the oceans.
Frank: So that's what you hear about it if you listen to a national public radio. You'll probably hear the Pew Trust referred to ten times during a day, but they cover a wide variety of areas; it's way more than the environment. Again, like I said, it can be education, it could be poverty, it could be healthcare, more global health issues and they still have dental health as an area where they could make a real impact. That's how they choose to make their decisions and the dental team in Washington headquarters is about fifteen people. They devote a lot of effort to this activity.
Howard: When you said the therapist three years of education, is that three years at a high school three years or is it like hygiene school which is two years where they have to do two years?
Frank: It is after high school, basically and if you are already a dental hygienist or let's say, an expanded function dental assistant, you can get some prior credit so you could probably get the training in about a year and a half. The Alaska program, just to clarify, is two full calendar years but the coding standards are three academic years so six semesters spread over three years. That's why Alaska we do it in two years because they go full-time. Yes, it’s post high school.
Very analogous to physician's assistance. The difference is that a physician assistant has to have a bachelor's degree first, but the total clinical training for a physician assistant is no more than two years in some states, three years in another. Very analogous to what a dental therapist can do.
If you look at the skillset of the physician assistant, they're doing—well, I should say one of the scare terms used by dentists in opposing dental therapy is irreversible surgical procedures. That means cutting your cavity or your tooth out or extracting the tooth. Well, you want to look at the list of irreversible surgical procedure that a physician’s assistant can do with just two to three years of education? It's enormous. Bone marrow biopsy samples, a variety of things like that that are certainly irreversible surgical procedures so it's a scare tactic.
You have to look at the evidence. One of the things I say to opponents and I look at them right in the eye and I say this, “I understand how you feel, but can you show me any evidence to support your fear or your concern about the quality and safety at what they do?” and then I just sit back and be quiet because I know what the answer is. No, there is no evidence to support.
Hell, even the American Dental Association Council on Scientific Affairs said that the quality of work done by a dental therapist is equal to, equal to that of a dentist and they interviewed (inaudible 10:19) at the time of their report and every report that we're getting now out of Alaska and Minnesota, shows safety, quality and effectiveness and improving access for underserved people.
Howard: Again, you and I remember Bob Barkley. Do you remember Bob Barkley?
Frank: Yeah, I do.
Howard: And he was the first dentist. By the way, we got a VCR tape from Omer Reed. I kept telling my listeners, I feel so sorry for so many of the most important people in dental history that never got digitized and made it to YouTube because they're gone. So I was asking my listeners if you have any old tapes that some of these legends and Omer Reed found a VCR tape about Barkley and of course, I don't have the VCR player, but Ryan's going to take it to a place and make it digital and we're going to load it up on YouTube because when he was going around the country, he was trying to promote dental hygienist and it was the same mechanism.
People are like, “Well, first of all, who's got time for that? I'm booked out two months in advance doing immediate dentures and you want me to do this?” And then he had to look at them in the eye. He said, “Do you want your granddaughter to have an immediate denture?” This hygienist going to try to prevent and then he went down in a plane crash. Wasn’t it up by Minnesota or something? A lot of amazing rock stars and dentists went down early in a plane crash. And then when expanded duty function assistants came out, it was the same thing. This was going to destroy dentistry and Arizona just passed that.
Frank: Even dental hygienist, they are still fighting allowing them to do what they're trained and able to do. If you look at the southeast United States in terms of the issue of general supervision of dental hygienists, the southeast United States is a black hole. Only Florida, two, three years ago got general supervision of dental hygienists allowed. Only two years ago, you could get the ability of dental hygienists to do local anesthesia. I mean if it's safe in all these other states, why isn’t it safe in Florida or Mississippi or Alabama? I constantly hear about struggles in other states to help improve access by expanded scope for dental hygienists and the resistance that occurs. It's very disappointing of my profession.
Howard: I think one of the most disappointing things in the profession that a hygienist has four years of college. In the healthcare arena, she'd be a registered nurse or he'd be registered nurse yet they're not allowed to give flu shots or HPV vaccines. Neither is the doctor of dental surgery. That blows my mind.
I mean, HPV. Australia is the first country on earth to declare that their HPV is gone. Their vaccination program, I think they declared it with what was the cervical cancer, uterine cancer and to see the onslaught rising of oropharyngeal cancer and to see all these hygienists and dentists handcuffed behind their back. Yet I could walk over to Walgreens or CVC and get a flu shot by someone with nine months of training yet a hygienist is talking to grandma and grandpa about gingivitis and in the next six months or when she sees them again after the flu season eight thousand to thirty-eight thousands Americans will die from the flu. And why are you looking for gingivitis when the flu season - and in fact, we even had a dentist on DentalTown. A dentist, I think it was in Alabama, died this year of the flu and he was a total class act, a healthy guy. I mean this is just you would not think he would die from the flu and so it blows my mind.
When you're talking about access to care, I believe Tennessee is the first state to allow hygienists or dentists, you got to be a doctor of dental surgery to keep up with the pharmacy tech at Walgreens. I can't believe that it's just not standard of care that dentists are given the flu shot and the HPV vaccine, they say it needs to be in the child by twelve. I guess that if you catch HPV, 99% of the body takes care of it, but if it does turn into a neoplasm it’s about eight years later and that should be very high on the agenda for dentistry.
Frank: The HPV is a really interesting place. So I do some work with colleagues at the University of South Florida and I'm trying to get dentist more motivated to counsel patients about HPV vaccine. Not even giving the vaccine but just and it's very, very difficult because it's a very touchy area and a very sensitive area to talk to parents of children about a disease that's transmitted by sexual behavior and unsafe sexual behavior and the need to get the vaccine, whether it'd be by the dentist at some point in the future or by the physician, but dentists are really wanting to do that is what the research has been finding and that's part of the attitude that we've got to change. I mean, dentists have to learn to start to recognize they are part of the healthcare system and the healthcare team and we can't keep this isolationist silo mentality that we have right now.
You look at the data coming out from the insurance companies and others about the relationship between periodontal disease and diabetes and cardiovascular disease. It's pretty unequivocal at this point about that relationship and we need to do a better job of talking to our medical colleagues and educating them. They need to understand this better, but we're not alone in this health business. If we are, maybe we should just be a cosmetologist or something, but oral health is health and dentists need to realize that and do everything we can as a profession to help people get better access.
It's hard because according to the ADA, cost is the major factor that keeps patients away and I want to go back to all therapists, that's what dental therapists can do that can help reduce the cost of delivering care to patients and they're doing that in Minnesota today for oral patients. In Alaska, it's limited to the Native American indigenous folks. But in Minnesota, they’re in private practices, they’re in FQHCs, they’re in hospitals, they’re in for-profit corporate groups, they’re in not-for-profit corporate groups delivering care across the state.
Howard: Who was the executive director of the ADA back in the day? I think you started like ten years ago?
Frank: Harold Hildebrand. There’s a quote that I use from him from the seventies and he was one of the most respected executive directors of the ADA.
Howard: What was his last name?
Frank: Harold Hildebrand. And his quote, I'm going to have to paraphrase it for you, was that the New Zealand dental nurse program which was being tried out in Kentucky and Massachusetts was probably the best thing that could happen to American children in the history of dentistry and yet this American Dental Association stopped those studies at the Forsyth Dental Center, I forget where it was in Kentucky, stopped it cold.
Howard: And why do you think it was?
Frank: Again, it's fear. It's fear and look, we dentists have had a monopoly on healthcare. An absolute monopoly on healthcare; the truth is we control who gets on the state boards of dentistry. The PAC money helps control legislative control over the monopoly, but when we’re are leaving a hundred and ninety million people in United States without access to dental care last year, this has got to stop. We have to be part of solutions. We can't stay in there and be opposing everything. I can give you so many examples.
When I arrived at the University of Florida in 1995, one of the first things that I wanted to do was get our dental students out of the building from Gainesville to work in FQHCs, working alongside dentists in FQHCs and the Florida Dental Association tried to stop me from doing this. It was going to cause competition for dentists. Eighty dental students spending six weeks in community-based sites. Please, give me a break. That's not going to cause competition down there and they tried to stop this and the only way they were stopped, what they were doing was the president of the university and the vice president stood by me a 100% and then the Federal Trade Commission came in and stopped the dental association from stopping our dental school from opening up these community-based sites with our students.
I mean, that attitude just has to stop when a hundred and ninety-one million people didn't get care. It has the stop when a hundred people had died in the last decade for a preventable dental infection. When last year in Florida, a hundred and sixty-six thousand visits to hospital emergency departments for a preventable dental problem. Or also, a professional can have a monopoly? No, I don't think so.
Howard: It's interesting because I'm in Phoenix, Arizona where the city is about a million, but the metro is 3.8 million. On Sunday, if you get hit by a car and break your leg, the ambulance is there, they take you to a fully-staffed twenty-four-hour a day, but if you broke your tooth, you're completely out of luck on a Sunday. I mean, there is no access to care on Saturdays and Sundays in almost every town in America is almost zilch.
Frank: What you have to do is then go to a hospital emergency room and for roughly about a 1,000 dollars to 1,500 dollars depending on the city and state, you're going to be given some pain medication and an antibiotic and you're going to be told to go see a dentist tomorrow. Again, that doesn't work. If you couldn't find or afford a dentist today, you're not going to find or afford one tomorrow and so this is system of high costs and I’ll also admit, poor oral health literacy for many in the public, it's not just costs. It has to stop and there are lots of solutions for this.
The American Dental Association has proposed this community dental health coordinator and I can see how that can work for safety net settings; I still don't understand how that will work in private practice. But they are basically patient navigators helping drive patients to go seek dental care but that still don’t affect the issue of cost in dental care history.
Howard: The independent practicing hygienists, I believe there's only like seven in all of Colorado. When I lecture, the dentists love it because she's in some small town of a thousand. She didn't go buy land and buildings and started a dental office, she just took her dining room table out and put a dental chair and she does the hygiene and then when she sees something, she writes a referral and then that patient drives to the next bigger town. Those dentists love it. They’re sending her cookies and cupcakes for her referrals, it's kind of amazing.
Also, Arizona just passed the expanded duty function assistant which almost made me thirty years ago go back home to Wichita, Kansas instead of Arizona because the dentists in Kansas loved it. They would have three tiers of operative to go and they'd num, num, num, drill, drill, drill and then the ADF phase would do it and I would always say to them, “Well, do you think they do a good job?” You know what they'd say to me? “Are you kidding me? They do it better because they get a block off an hour for one filling.” I would be in there trying to rush three fillings in one hour and since they take the time, it looks like a piece of artwork. And so my buddies in Kansas said the expanded duty function assistants are actually better.
I'm starting to wonder if the majority of these dental therapists will actually end up working in dental offices so the hygienists are doing the cleaning which the dentist doesn't want to do and the dental therapist could be doing the operative which the dentist really doesn't want to do. I mean, come on after you've done ten thousand fillings, do you really want to do another filling? Do you really want to do another cleaning? Do you see that?
Frank: Let me tell you about the experiences in Minnesota. So remember, this is the state where the dental association vigorously opposed dental therapy. So they had roughly eighty graduates of the dental (unclear 23:55) programs in Minnesota. I believe it's about twenty-five or so of the therapists are now working in private practices. The private practices are doing a social good because at least 50% of the therapist's patients have to be Medicaid, but you know what else is happening? Exactly what you just said, the dentists are actually making a higher profit on their practice. One, they're not making it off the sweat of the brow of the therapist. They’re making it because the therapist is doing the less dollar-producing simple restorations and the dentist is now free to work at the top of his or her scope of practice. That means crowns, that means dentures, that means bridges, that means implants, that means cosmetic dentistry; all the things that are more high-end.
So in Minnesota we're having a social good, more Medicaid patients being seen, we're having happier dentists and in particular, so we have educational tours in Minnesota where we bring people in to see dental therapy in action. The ending speaker at the last meeting was a world dentist, a young dentist, working in a rural part of Minnesota where he has no specialists to refer to. What is he doing? He now has two dental therapists in his office. He's flying around the country to seek courses, learning new skills, he is practicing at the top of his scope of practice; his therapists are doing the routine work. In Minnesota, a lot of them are dual-trained so they're both the hygienist and dental therapist so they're doing essentially what you said and they are working in Minnesota. They are seeing Medicaid patients. They are helping the dentist expand their practices and the dentist is working at the top of his or her scope.
Howard: And in Minnesota, what is the equivalent pay of like a dental assistant versus an expanded duty function assistant versus a hygienist versus a dental therapist?
Frank: So from what I understand, it’s a little more than a dental hygienist. So it's in the vicinity of about $60,000 but for a new dentist going out into practice, the starting salary might be a hundred and twenty to a hundred and thirty. If they're going to work for FQHC for example, a safety net clinic, that means that they can hire two therapists for the price of one dentist and expand their reach. And the other way they work in FQHC and safety net situations is they take portable equipment and go out to schools. Howard, they go out to nursing homes.
There is a wonderful case study that I can share with you. Apple Tree Dental, famous not-for-profit. I'm sure you've heard about them in Minnesota. Michael Helgeson is the CEO of that organization. They send their dental therapists to a VA nursing home to provide dental care to those patients and they can take care of about 70% of their own health needs of fragile nursing home patients safely and effectively. Think about that. They can go into schools. Instead of asking Mom or Dad who is in the hourly job at Walmart or McDonald’s to take time off to bring the child to the dentist they can get their dental care in their schools as part of the school day. What a great way to bring care to people who need it.
Howard: So you're a pediatric dentist and you're coming to Arizona where we have one of the most famous pediatric dentists on earth, Jeanette McLean who was doing silver diamine fluoride. She made the New York times but that is probably the only controversy amongst pediatric dentists. Some love it, some try it don't care for it. Jeanette McLean loves it. What is your views on that?
Frank: So I think silver diamine fluoride is wonderful. It has lots of applications and uses. I’m not in practice anymore so I don't want to mislead anybody. But from my conversations with people of the pediatric dentistry department, with other folks in my department who have studied it and researched this and talk about it, it is very good and very effective.
There’s a couple of pediatric dentist in Florida who have been using it right from the beginning. (unclear 28:40) the distributor actually elevate oral health in southeast Florida and they are saying it's significantly cutting down. They're going to the operating room. It’s even significantly cutting down on their sedation cases and they're able to hold those kids until they are a more manageable age.
So based on everything I've seen and read and people I've spoken to, I think it is another great tool. Is it the only solution? Of course, not just like dental therapists are not the only solution to helping people. But yeah, I think it's absolutely terrific.
Howard: I'm the New York Times also did an article. You said Apple Tree Dental so on Twitter, they're @AppleTreeDental and I'm retweeting their last two tweets so my homeys listening can find these guys. But they also had retweeted how dental inequality hurts Americans as printed in the New York Times. Did you see that article and what were your thoughts on that article?
Frank: My thoughts are it's absolutely correct. We should not have this inequality. We should not have one group of haves and one group of have nots. Everyone deserves access to quality healthcare and very specifically, dental care because and again, I'll just give you a couple of examples. We now have five or six published studies that show that kids with poor oral health don't perform as well in school and my response to that is how do you get out of poverty if you’re poor? You get out of poverty by education and hard work and if one in five kids in a town has a toothache, how are those kids going to learn? Well. So yeah, I mean I think inequality is bad and perpetuates more inequality as one gets older. So I am all for any kind of evidence-based solutions that can improve access to healthcare and quality dental care.
Howard: The American Dental Association, you got to give it to them, they’ve got the who would you say the best quarterback in the NFL is? It's who's that guy for the Patriots?
Frank: Oh yeah, I'm blocking on it. My wife would know immediately; she loves (inaudible 31:09).
Howard: They’re economists. Marko Vujicic, I mean he was from the World Health Organization. He was from Brussels. I mean, this might be the number one healthcare economist in the world.
Frank: Marko is absolutely terrific. I have met him personally and know him. I think he's absolutely terrific.
31.30 Howard: Because what I love about economists is they never have a dog in the fight. They’re emotionaless. I mean, they make accountants look emotional. They just look at the number. They don’t talk about would have, should have, could have, right and wrong; they just say this is it. He talks a lot... his last article in JADA “our dental care system.”
Frank: It was a great piece, his last article.
Howard: What’s that?
Frank: It was really a great piece, his last article.
Howard: Talk about it and Marko because if you want to argue with Marko, he's going to show you data from fifty different countries. I mean, this guy knows the economic research. Tell them about Marko and this article, what you think of his article and Marko.
Frank: So I mean, one of the things that he says is that compared to a lot of other countries, cost is the major factor that is keeping folks from dental care in the United States. So one of his fundamental premises is that we need to expand access in this country via whatever way we can do it and that's one of his four recommendations.
One of his other recommendations is that we need to become part of a healthcare system where you cannot stand in isolation as a profession and he’s said this in numerous pieces over the last number of years that he has been working for the American Dental Association.
One of the things he said is that we've got to have better metrics. We've got to have better ways to measure what we do. And again, I'm going to point out another negative here, but what has prevented us from getting good measures and outcome measures in dentistry is the lack of diagnostic codes and who has been the opponent of diagnostic codes for all but the last couple of years and that’s the American Dental Association.
And then the fourth thing that he says is that we've got to change how we deliver care so that all members of the team are practicing at the top of their scope of practice. Now, he did not say dental therapists in that fourth recommendation, but I can read dental therapy right in that. So we've got the dentist, we’ve got the dental therapists, we've got the dental hygienist, we've got the expanded function dental assistant all working at the top of their scope of practice. We have got to reform the healthcare delivery system and that was his fourth message in that most recent article.
Howard: Well, one of the strangest things about dentistry and why a lot of people think a dentist isn't a doctor... like people have told me several times in the last fifty years, “Well, dentists? That's not a real doctor.” I always say, “Well, Dr. Pepper wasn’t a real doctor and neither was Dr. Dre or Dr. Seuss.” But urban legend has it that the medical schools wanted beds and that they actually started dental schools simply because they wanted chairs. Dr. John M. Harris started the world's first dental school in Bainbridge, Ohio and helped to establish dentistry in the health profession. It opened on a 21st February 1828 and today is a dental museum. The first dental college was Baltimore College of Dental Surgery which opened in 1840.
The reason I don't like the separation of dentistry and MD program is because when you go to other systems like the old Soviet Union system, dentistry is all surgery. You work in an operatory and I noticed that in the Soviet era, back when I got out of school, if a dentist, say he lost an eye and now he has 2D or he lost a hand or she was injured, she could just immediately go be a physician because probably half of all physicians never do eye hand surgery. They’re mostly running tests and talking to patients. So those disabled dentists can go be dermatologists or do a residency in something else immediately, whereas dentists can't do dentistry anymore. I mean, you literally got to start back at square one to go be a dermatologist.
Frank: Become a consultant for an insurance company or an expert in malpractice cases, but you're right, there's not a lot that you can really do. But it's not just Russia that you mentioned; most of Europe traditionally had a system that was medically-based for dentistry. You became a physician first and then you went on to dental care. Now that has changed drastically over the last twenty or thirty years and it's much more like our Western system where we are separate.
I don't have a big problem or concern about the separation of the education. My problem stems from the separation of the practice and why wasn't dentistry in Medicare in the sixties when Medicare started opposition of the American Dental Association and now we're left out of it. People start to retire at sixty-five, they had dental insurance and they find out there is no dental insurance in Medicare. Now I'm happy to see that there is an effort going on nationally and the American education is part of that effort to try and bring a dental benefit into Medicare. That really pleases me and I'm proud of the profession for being part that activity.
Howard: Vujicic one of my top favorite economists, but my other one, and maybe my most favorite, I shouldn't say that I don't want it to get back to Vujicic. But if there's anyone that he competes with, it's got to be Dr. Regina Herzlinger a doctorate of business administration, healthcare economist, Harvard University. And she makes a valid point that one of the biggest problems with Medicare, Medicaid is that they say this is the fee and this is the only fee you can take. So then you have access to care issues because a lot of doctors aren't making a low cost Chevy, they're making a little more expensive Pontiac or Buick or olds or Cadillac and like everyone would take Medicaid or Medicare if they came into your office and said, okay well Medicare will pay seventy-five dollars for this filling, but we charge a hundred and fifty. Here's the list of all six thousand dentists in Arizona; the ones with stars by him will take his fee.”
But humans are capable of making very complex businesses decisions. They purchase cars and there's a variety of price points but it's kind of like government says, “Oh no, if you're poor you can only have a used car” and when they raise their hand and say, “Well, can I apply that used car for a brand new Chevy?” The answer is no. And Delta goes to great deals. Like if you go out of network, they'll stop mailing the money to the dentist, they'll start mailing it to the patient just knowing that that will go south and a lot of them were cash the check and spin it.
So sometimes to me, it takes out innovation, it takes out the poor people's ability to decide for “I'm going to cut back spending on eating out at restaurants or other discretionary income to get a better, a more expensive filling. Maybe this guy does a tooth colored and the Medicaid clinic does an amalgam.” So it seems like it has more to do with power and control instead of subsidizing your consumer choice to go out there and buy what you're intelligent enough to make your own decision.
Frank: I don't know enough about the background of what you were just saying, but it’s very clear to me that Medicaid fees are low because it’s not a priority within state governments where Medicaid decisions are made. I mean, thank heavens that it's mandated for children by the feds because they play a large portion of that. In many states, we don't have an adult benefit. Certainly in this political world, I don't see any opportunity that we’re going to be able to raise Medicaid fees.
Medicare, on the other hand, I think it was a different situation. Medicare does work hard to provide innovative solutions. I remember my eye doctor saying to me, he said, “Frank, I may not be happy with the dollar amount I’m receiving for your eye (unclear 40:17), but I know that check’s going to be there next week with very little paperwork.” I mean, that's one of the beauties of Medicare; the least costly insurance company in the United States in terms of administrative overhead. It's simple to use and I think that's one of the things that I liked about the Affordable Care Act, to be quite honest with you, was an approach towards more innovation, controlling costs. It had its flaws and I certainly recognize that, but it was started dealing with this issue and we spend more per capita in this country, twice as much as the next closest country and we have health outcomes that rank in the twenties. Why is that? Our system is out of control. It's driven by the wrong incentives. It's not driven by keeping you and I healthy.
Imagine if a dentist were under pressure to keep my mouth healthy with me in partnership, what that might do. If I got paid as some programs now do in the northwest and in Minnesota, if I got paid partially on the procedures that I do, but also on my patient's health outcomes. I didn't mention that when I mentioned Marko’s most recent paper, that was one (unclear 41:46). We've got to change the incentive system.
Howard: Well, first of all, in the Affordable Healthcare Act, I thought it was extremely bizarre that they rolled it out at the state level of Medicaid as opposed to the Medicare because like when I saw so many people in Arizona in my practice that were up against Obamacare, I'd say, “Well right here on your chart, you have access, you're pregnant, you're a woman, you're unemployed and who's paying for all your prenatal care?” and they say, “Well, that's access.” And I say, “Well, that’s the Affordable Healthcare Act. That's Obamacare. So you want all that taken away?” And she'd say, “No, not at all” and I said, “Well, you just told me you hate Obamacare and you don't think they should.” So the branding for as far as business, I mean all these people in fifty different states getting these benefits under fifty different names is in my opinion and a half of them didn't even know that was Obamacare their part of healthcare.
But back to subsidies. Again, when the federal government subsidizes corn farmers for ethanol, whatever they don’t set the price. They don't say, “Oh, we're going to give you corn subsidies and you have to sell your corn at a dollar a bushel,” Then two-thirds of the farmer and say, “Well, I can't do this.” Well, that's what they do with healthcare. They say, “Well, here's Medicaid, here's a subsidy for cleaning, filling exam, an x-ray for Medicaid for the poor.” And Medicare doesn't cover it for the elderly, but that's all they do. They say, “Here's the subsidy and we're going to set the price.”
Historically, like the greatest city in America, New York City, they had an error where to make apartments affordable, they started setting rent prices. So what did they do? They stopped all rental construction. It was a disaster and all the economists agree that when you set the price, you kill the industry. And I think the Medicaid I mean California had a deal where they raise the prices of their Medicaid for dentistry and they were shocked that a whole bunch more dentists took it. And it's like, well, if you just set it to the subsidy, well everyone would take it. But again, there's still set on 1970s rent control policy.
One other thing I want to say about another policy that I think is very misguided and that is I'm from Kansas and when you go to Kansas, Ohio, Nebraska, North and South Dakota, 10% of the counties don't even have a dentist. They don't realize that the deans are still filling the class based on if you got straight A's in math and geometry and calculus and physics, which I've never used in my thirty years of being a dentist. But if you want a kid to go to that farm town of five thousand, guess what you’ve got to do? You’ve got to accept a kid in that town of five thousand. you can’t accept a kid from Kansas City and then be shocked when he doesn't go to the small town in western Kansas. But that kid in western Kansas doesn't get in because he doesn't have A’s in geometry.
Frank: We have sort of figured that out in dental education, thanks to the leadership of the American Dental Education Association and most admissions processes at most dental schools today use a holistic admissions process where it's not just grades. So they’re trying to get that rural kid as well as the inner city applicant, they’re trying to get diversity in the applicant pool and the graduates of dental schools. We've got a long way to go, we’re not yet approaching what I call equity within reflecting the population in this country, but we're getting a lot better at it than we used to and that’s part of dental therapy that’s so interesting.
So in dental therapy in Alaska, I'll start with that as an example. You’ve got to understand the cultural issues in Alaska of the Native American people and they recruit students from these remote populations and what do they do when they graduate? They go back or they'll work in a hub city like Bethel, which is not a big town, but it's got one or two paved roads and an airport an I've been there. They fly out on Monday mornings, the remote village of four hundred people is hours away and you're only going to get there by plane. What we're seeing in Minnesota is dental therapists are working in rural communities; they are going where they are needed.
Howard: I did something in Alaska that all my Alaskan dental friends have never done. My Dad wanted to go fishing in Alaska. So me, Dad, brother Pau flew into Fairbank. We drove down to Homer, went halibut fishing for a few days. Then we were on the Kenai Peninsula, went salmon fishing, it was during the king salmon run so I think it's like June or July or something like that. Anyway, we got all done and we decided that we wanted to go see the Arctic Ocean.
So we drove up to Mount McKinley and then I think that I forgot that most northern Fairbank’s the last big city with a highway and we're sitting at the Waffle House and we said, “Well, we want to drive to Pedro Bay” and the guy starts laughing. He goes, “You can't drive to Pedro Bay.” He says, “The only road is the Alaskan pipeline access road and it's private property,” and me and Dad looked at him. We said, “Well, what happens if we drive the Alaskan pipeline access road to Pedro Bay?” We said, “I mean, are we going to get arrested or a ticket or?” He goes, “Dude, I've only seen the sheriff on that road once a year.”
So me, my Dad and Paul drove from that northern most city all the way to Pedro Bay and we went over Bricks range and saw the reindeer herd of like twenty-five. I mean, when we pulled up into Pedro Bay, those guys were laughing so hard because we were so dumb. We assumed there'd be a Holiday Inn or a Hilton, a Waffle House and they called us lower forty-eight. They felt so sorry for how dumb we were and we were on a once in a lifetime vacation that they let us sleep in their barracks. They refueled our car for free, filled up we had like five-gallon gas cans in the back of the SUV; they took really good care of us. That was an amazing trip. But do you remember Jack Dillenberg when he was dean of the ATSU-ASDOH?
Frank: Well, I know Jack very well.
Howard: He was telling everybody that ten years ago, he was like, “Look, you're not going to accept a kid from Phoenix, Arizona and then he's going to go back and practice the rest of his life in the Navajo Indian reservation. If you want dentists in the Navajo Indian reservation, you’ve got to accept Navajos.” He understood more than anybody the holistic nature that 25% of Arizona’s Indian reservations and he set out full speed ahead to start getting rural kids, reservation kids to spread these dentists out and everybody called him a quack.
Frank: So Howard, let me tell you. So I’ve known Jack very well and a lot of us were skeptical when he started that and he proved us wrong. He proved us absolutely wrong and I will be the first to admit that. His numbers of what his students do after graduation is very different than other dental schools and he has sort of really figured it out. But again, I want to give credit. All the dental schools I've been working on this issue for quite a while, I don’t know if we've had the success that Jack has had. But yeah, I agree everything with you a 100%. He's done a wonderful job in Arizona and I hope that they continue to do what they're doing and they can still.
Howard: And when you accept a kid from UPMC dental school from Kansas City, she's got to have the plaza and the shopping and the dining and all this stuff, but that girl that you accept from a small town Kansas, that girl wants to be able to walk out in her backyard and shoot a rifle and she wants her kids to be able to ride a mini bike when they're five down a country road and they're just different people. And Jack understood that rural people don't want to live in Phoenix, Arizona. In fact, they hate it. They actually hate the big city.
Frank: One of my first trips for Kellogg a number of years ago was to go out to Kansas and meet with folks talking about dental therapy out there and I remember flying in and having to drive across the state and the first impression I got was I’m in the middle of nowhere. I went to, I forget the name of the university, but it was at the far end of the state and I met with folks who were saying exactly what you're saying. We have needs in rural Kansas that are different than in other areas, but it's the same crowd of them in Minnesota, it's the same problem in Florida. We all have little variations of that, but it's folks who will be willing to go back to those rural communities. Folks who are interested in taking care of underserved patients that we need more of those in dental school and we need a system that promotes that.
Howard: Yeah. I remember it was so hard raising my four boys because in the summers I'd send them back to Kansas, go spend two weeks on grandma's farm. Then they come back to Phoenix and they'd want to have the twenty-two rifles and the mini bikes and the motorcycles and I'm like, “Dude, you can't go out there and shoot twenty-twos in Phoenix, Arizona. We're all going to go to jail.” I actually questioned the lifestyle. I mean, so many times with my four boys, I thought to myself, “God, they would've been so much happier in rural America.”
Frank: (unclear 51:44). I mean, you just try to get the right balance for yourself and for your children. I mean, I lived in the middle of Manhattan for one year with two very small children, my wife and I, when doing some work at Rockefeller University, we loved it. We enjoyed it, but were we glad to go back to somewhat rural Connecticut. I went back to my position at the university there. You have to find a balance.
Howard: So just giving you a heads up. You're flying into where I'm at and live Phoenix, Arizona next Wednesday and the Arizona State Dental Association is emailing all their members of an alert to call your congressman for this hearing that they're trying to organize everybody to vote against it. You obviously probably know that that's what you're walking into. So what is your strategy when you talk to the legislators? What is your strategy when you talk to Kevin Earle, the Executive Director of the Arizona State Dental Association we’ve had on the show? Are you nervous about this or you’ve got butterflies in your stomach?
Frank: I’m not at all nervous about it because I've been doing this for ten years. So the very first thing you have to say to the legislators is look at the evidence, look at the evidence, look at the evidence. When they tell you they oppose dental therapy ask them to show you some data to support that. To be blunt, I have had conversations one-on-one. I wouldn't do this at a committee hearing about the influence of PAC money. We've got to face up to that reality and what I know I'm going to face in Arizona is one organization opposing it and about thirty to forty other organizations that are in support of dental therapy and so I will talk quite frankly at the committee hearing with the history of dental therapy, the current research results coming out of Alaska and Minnesota. So no, I'm not concerned at all.
Howard: So Alaska and Minnesota are doing this, you said Minnesota’s graduated eighty students and Vermont and Maine have approved it. So I figured there's kids in classes now they just haven't graduated yet?
Frank: It takes some time to get a program started. So Vermont has hired a program director, a dentist and they will probably accept their first class this fall. I'm actually going to be meeting her next week in Orlando and we’re actually going to have a panel discussion at the American Dental Education Association meeting next Saturday morning on the CODA accreditation requirements for dental therapy education.
Howard: Well, email her and CC me, Howard@DentalTown and tell her I want her to come on the show and it'd be a great one-two punch. You followed by her.
Frank: Well, actually what you want to get is you want to get someone. Her program hasn’t started yet; you really want to get somebody from the Minnesota or Alaska program. Dr. Mary Weller is the director of the Alaska program. She's been the director since the beginning of the program. She lived in rural Alaska. She now lives in Anchorage where the program is.
Howard: She’s a dentist, Dr. Mary Weller?
Frank: Dr. Mary Weller and then Dr. Karl Self, S-E-L-F, at the University of Minnesota and Dr. Colleen Brickel at two different programs in Minnesota, one based in the dental school and one based in a (unclear 55:30) program. I can send you those email addresses and names, Howard and I think they would make great guests for you.
Howard: Oh yeah, I mean my show is doing so good because it's Dentistry Uncensored. I don't want to talk about what everyone agrees on. I mean, you said the research showed that 48% of the dentists are for it, 52% of the dentists are against it. That makes me want to do ten shows on hit because that's where the ball is, that's where the action is. Just like I said, in pediatric dentistry, the issue of silver diamine fluoride. I don't really think the endodontist will have an issue. The issue in oral surgery is that in countries like Germany and Austria and Lincolnshire, they only pull about a third of the wisdom teeth that Americans oral surgeons pull. Americans oral surgeons extract wisdom teeth simply because they exist and the Germans and the Austrians, they like to look at research and they say a third of them don't cause a problem.
Frank: Yeah. So you're absolutely correct, the evidence does not support the mass removal of wisdom teeth that we see in this country and the oral surgery organizations have just avoided discussing that evidence. (unclear 56:46).
Howard: I feel abused by that system because just me and my five sisters don't have any tonsils or adenoids. Why? Because I was born in ‘62 and in the sixties and seventies, first time we got a sore throat. Guess what they did?
Frank: Well, I was born in ‘44 and same thing. I’m of that generation, we don't have tonsils.
Howard: I don’t know if we should be talking about this, they say you should never talk about religion, sex, politics or violence but now the circumcision issue is back up and now there's a lot of people saying that that's a cultural thing. What is your view on that?
Frank: I don't think it's a cultural thing, but I don't know. I mean, it's what we do in this country for the most part and it sounds like a reasonable thing to do.
Howard: It looks like a lot of insurances are going to stop paying for it because they're saying -
Frank: Oh, that’s interesting.
Howard: Yeah. A lot of the insurance are saying they're not paying for them anymore because there's no evidence that this removal of excess skin is an issue. But you're right, I don't think two dentists should be talking about circumcision, but it is an interesting thing how we're moving more to an evidence-based society and I would like to see the world surgeons really look - what I like is that the internet is really killing nationalism. I mean, like there's people listening to this show in all the countries and the Google search - by the way, if you Google search your name, I really like that video. The future now, Frank Catalanotto on YouTube.
58.20 Frank: Coming back out in June to Phoenix to speak to the state national organization that promoted that video. It's the future of dentistry symposium. Dr. Mark Cooper.
Howard: Absolutely, he's been on the show twice.
Frank; So I'm speaking to their DSOs, Dental Support Organizations. This is a group of smaller DSOs, not the larger type DSOs, to talk to them about the value of dental therapy. I’m really looking forward to that visit. Although, I'm not sure I want to be there in June because of the weather, but it's probably better than Florida.
Howard: You know it's funny, I was born in Kansas, went to Creighton in Omaha and dental school in Kansas City and you got to stay indoors when it's too damn cold and in the summer here, you got to stay indoors when it's too damn hot. I cannot believe that one time I missed my flight to go lecture because I went to the Sky Harbor airport and I think it was a hundred and twenty-six and the Boeing planes said, based on their design, they need the air to be under a hundred and eighteen. So we had to sit there in the terminal for four hours.
Frank: That is not the weather delay I would expect.
Howard: Oh my god, yeah and when you tell people that weather... and I've also left here in Phoenix to go lecture in Minneapolis, Saint Paul. It happened one time, was in the nineties, when I left Phoenix and got to Minneapolis, Saint Paul, it was one hundred degrees colder. I think it was like eighty-two in Phoenix and I forgot what it was the minus temperature there, but I couldn't believe that I traveled down a hundred degrees.
Well, I really, really admire you, mostly because most dentists don't want to stick their head up in anything controversial. It’s just so much easier to go with the flow and when people tell me they’re a pioneer in dentistry, I'd tell them to turn around and show me how many arrows are in their back and if you don't have any arrows in your back, you're not a pioneer. No one's trying to take you down. You never ruffled any feathers. You never tried to change the world. Gandhi’s quote was the best… Can you text me that Ghandi quote?
Frank: One of my friends said to me that as I take this battle forward in Florida, which we are doing right now, I will need to get someone to start my car every morning. Look, I have become a passionate supporter about the issue of access to care. The early part of my career I was probably like most other dentists even though I was in an academic career. I was doing my research, I was doing my practice, I was raising a family and I started to figure this out after working in the town of San Elizario for two weeks when I was at the University of Texas in San Antonio and starting to understand that there is a healthcare problem in this country and what I've later learned, it's a healthcare crisis, it’s not a problem and it isn’t just dental care, it's all healthcare and we better fix it and I want to be part of that solution.
Howard: Well, Gandhi said it best: First they ignore you, then they laugh at you, then they fight you, then you win. A lot of people don't realize that the biggest successes you've ever had is what's standing in your way that most. Like for instance, I think in the United States has an insane passport system. You can get a fake passport on eBay. You can go get passports anywhere. But when you go to countries that now started a passport system but they didn't have the passport bureaucracy, you go there and you put your hand on an iPad and then your other hand on the iPad, then you look in the deal and then it pulls up a picture of me and it says Howard Farran. I'm like god, that's a hell of a lot smarter system and you're supposedly a “third world country,” but that third world country doesn't have a legacy system that asks for it, like 911.
I mean, it's crazy. The last time I called 911, she's asking me for a description of the car wreck scene and I'm like, “I can FaceTime my eighty-year-old mother, why can't I FaceTime 911?” Because they built a system a gazillion years ago and they’ll be supporting it. What's embarrassing is a lot of these government legacy systems, the only reason the upgrade them is because no one makes the parts for them anymore. So they finally have to upgrade because they can't get any spares parts.
So but anyway, that was the fastest hour ever. Thank you so much for coming on the show and talking about such a controversial issue and best of luck and I sure hope you introduce me via email to the people from Alaska and Minnesota to talk about this and I hope you have a rocking hot fun time when you come here in Phoenix, Arizona.