What are the prospects for better dental care in the rapidly changing medical care scene?

This paper presents current trends and predicts some possible developments with emphasis on prepayment group practice.

DENTAL CARE IN THE EVOLVING MEDICAL CARE SCENE

Frederick D. Mott, M.D., F.A.P.H.A.

ALTHOUGH I have not been too close to problems of public health dentistry in recent years, the problems of dental care are not completely strange to me. Back in the days of the federal Farm Security Administration, in the late thirties and early forties, we were privileged to undertake some pioneering in prepaid dental service. At one time we had dozens of dental care prepayment plans in operation over the United States comprising about 200,000 low income farm people; all of these plans were voluntary and had been developed in cooperation with the dental profession. I was also in charge for a time of the rather vigorous effort to provide dental care to agricultural migrants through the use of mobile dental units as well as through arrangements with dentists practicing near the migratory labor camps. In the Province of Saskatchewan after the war we had, as an important part of our activity in the Department of Public Health, an extensive program of dental care for social assistance beneficiaries, and a reasonably complete program of care for children in two of the rural health regions. -Currently, I am serving in a program of medical and hospital care that has had to postpone entry into dental prepayment, and I am afraid this is all too often the story. However, our members constantly ask when they will be able to get dental care on a prepaid basis, and
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I imagine therefore it will be our next benefit, and this, too, is-I believethe story of dental care today. I wish to review briefly what seems to me to be some of the trends in medical care today and where they lead us. The outstanding trend is the constant broadening of the horizons of the medical sciences. I need not dwell on this. The field of dentistry is no exception in the picture of constant change. Rapidly advancing science is accompanied by a greater and greater degree of specialization, and this has its unfortunate aspects in the compartmentalization of medicine and dentistry-a trend which I understand dentistry is happily resisting. In any event, with this picture of constant change the whole concept of what constitutes good care is inevitably changing from year to year and this points up the dangers of professional isolation under circumstances in which the professional person cannot keep up with the advances in his own field. These advances also have a price tag and we constantly face rising costs-not simply because of more complex services and not of course simply due to inflation-but due to a considerable extent because people are demanding and receiving a greater volume of service. I note that the increase in dental fees, by the way, is somewhat less than the average rise in medical care costs,
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but even so, the expenditures of the American people for dental care now exceed two billion dollars. While we are keenly aware of the distinction between demand and need, there is no question but that we are observing a constantly increasing demand for more adequate health care. This seems to be related to a whole series of factors, among them such factors as rising incomes, better education, urbanization, and the growth of prepayment for health services. Perhaps most clearly heard is the voice of labor in this demand for broader services, particularly through prepayment. And we may remind ourselves that we have this increasing demand in the face of a diminishing supply of physicians and dentists. These trends point up some of today's needed actions. There is clearly a need to increase the availability of health services and here one of our tasks is to reach the disadvantaged groups-rural people, those of low income, the unemployed, and the elderly. Dental care illustrates one of our largest and most serious gaps today in the provision of services. I must say that I find it shocking that only 40 per cent of our people get dental care in a given year, that we have some seven hundred million unfilled cavities and that the number is rising, and that we have some twentytwo million edentulous people and that this number may also be rising. There is also a need for the coordination of services to bring some order into today's rather chaotic and compartmentalized situation. As Dr. Baumgartner has said, "Health is a many splintered thing." There is a place for some practical coordination and there is need for us to foster patterns that will promote continuity of responsibility for care for people, care by a personal physician and care by a personal dentist. Still another need, as we face down162

hill trends in the supply of physicians and dentists, is that we conserve our resources through organization and the economies that organization can bring. Part of this task is to increase professional productivity to the limit through the use of well trained auxiliary personnel. These steps are needed now, no matter what new schools are on the drawing boards or what new student loan programs are in the minds of our congressmen. This is a time for fresh thinking, for new approaches, for carefully thoughtout experimentation. Many of us in the medical care field see real hope in the growing group health plan movement. Some four million persons are now getting physicians' services, and an increasing number are getting dental services, through plans characterized by the provision of comprehensive care, with emphasis on prevention, reasonable cost, attention to quality-typically through the pattern of group practiceand with a reflection of the consumer interest. Some of these so-called direct service plans linking group practice with prepayment are well known. There is the Kaiser-Permanente program on the West Coast with its own network of hospitals and group centers, serving upwards of 800,000 people. There is the HIP program in New York City, wi1fi services rendered through personal physicians and specialists in 32 medical groups. The most interesting of these groups, I believe, is the Rip Van Winkle Clinic in upstate New York, and not least because several dentists are an integral part of the medical care team. The Group Health Association in Washington, D. C., is another of these plans, known for its dental group and parallel dental prepayment plan. Group Health Cooperative of Puget Sound in Seattle is another with a parallel dental care plan expecting to undertake prepayment at any time. We all know of the popular and successful dental servVOL. 52, NO. 7. A.J.P.H.

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ice provided at the Labor Health Institute in St. Louis. There are many other labor health plans in operation and quite a few have ventured into prepaid dental care. These plans are showing results. They are proving that quite comprehensive care can be made available at a supportable cost. They are showing that something can be done about quality. They are beginning to show measurable results in terms of improved health. The youngest of these group health plans is the one with which I am associated in Detroit, the Community Health Association. Our program, which has now been in operation almost a year, was sponsored initially by the United Auto Workers, but they had the wisdom to promote the establishment of a community plan with a broadly representative community board of directors. Our members are enjoying virtually comprehensive medical and hospital care and it will not be long before we turn our attention to dental care. Services are rendered by personal physicians and specialists organized as a full-time medical group based in a community hospital in the heart of the city, and neighborhood medical group centers are being built in outlying parts of the city. The membership of our youthful organization comprises some 7,500 persons, but we anticipate substantial growth in the coming weeks as each plant of the Big Three of the automotive industry undertakes complete re-enrollment of its employees with the CHA an option as a result of recent collective bargaining. I submit that these group health plans are in tune with the times. They are meeting the demand for comprehensive services. They are controlling spiraling costs in a way that seems impossible in fee-for-service medicine and fee-forservice dentistry. They are in tune with the constantly changing technology of medicine and dentistry for they provide a means whereby professional
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workers can keep up with advances in their fields, they effect coordination of services, and through the availability of personal physicians and personal dentists backed up by teams of specialists, and without the barrier of dollars, they promote continuity of responsibility for care of the individual. These plans also conserve our limited resources and, finally, they recognize the legitimate interests of consumers in over-all policy matters. Are these plans the only answer? Of course they are not. But I believe their growth is a very healthy thing. Patterns of quality, with insistence on standards, will have an important influence as we move inevitably toward universal coverage programs. In the meantime, the competition afforded by these plans will push other voluntary plans, such as Blue Cross, Blue Shield, and the dental service corporations, into broader coverage and greater recognition of the public interest. These moves in the direction of introducing organization in health services are, I believe, significant for dentistry, although dentistry has traditionally been very much a solo form of enterprise. However, it seems to me that the advantages of the group practice of dentistry are just about as compelling as those of group medical practice. Beyond that, logic-and the implications of technological change-and the hard facts of rising costs-point to more and more groupings of health workers in coordinated teams, teams that comprise dentists as well as physicians, teams that are geared to offering broad health services to the community. To a considerable extent, we may see these teams built around community hospitals, but I do not believe this will necessarily become the predominant pattern. Hopefully, we shall see increasing emphasis over the coming years on keeping people well, keeping them on their feet and moving, with use
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of the hospital bed largely a sign of failure. In any event, whether groupings of professional health people are hospitalcentered or not, one would hope to see dentists general practitioners and specialists-as integral parts of such groupings. Both medicine and dentistry would be the stronger by pooling their skills and judgment without geographic barriers. While organized labor and consumer groups are throwing increasing support to the group practice-prepayment movement, we shall undoubtedly see the steady growth of dental prepayment in its various other forms in the coming years. Many segments of labor have achieved much in terms of medical and hospital benefits and I sense that dental care is very likely to be next on labor's agenda. Fortunately, there has been a good deal of experimentation in prepayment for dental care and while the number of people covered is relatively very small, there is certainly healthy variety in the various efforts to edge into this important field of prepaid
service. I cannot speak for labor, but I would

confidently predict greater labor support for service programs than for insurance company plans. Parenthetically, does profit have a place in health? I choose to think not. Unions like the UAW, with headquarters here in Detroit, furnish very powerful support to Blue Cross and Blue Shield across the country in what is apparently emerging as a life and death struggle between the Blue plans and the commercial insurance industry. Perhaps there are some "ifs" here. My guess is that labor will support the dental service corporations to the extent that they reflect the public interest in their operating policies, in representation on their governing boards, and in the degree of self-discipline exercised by the participating profession. One might expect
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that enlightened management would have similar interests. But do we have the whole answer to meeting urgent dental needs in voluntary dental care insurance? The answer is clearly no! Let me touch briefly on three or four points in relation to what seems to me to be the attitude of labor and consumer groups. First, fluoridation of community water supplies. The backing of the AFL-CIO for action seems to be allout and very vigorous at the national level, despite the flow of abusive letters which I am told is being received. I would look for increasing local support and believe it will often be decisive in this show-down struggle. The whole cause of education in dental health will be advanced through this campaign of organized labor for fluoridation, holding promise of increasing support for worth-while health education and prevention activities. Another vital task for which labor and organized consumer support is assured is the tremendous and costly task of doubling educational facilities for dentists and auxiliary workers, assuring adequate financial support for these new and expanded schools, and stepping up the number of candidates for training through generous scholarships and loan funds-goals that cannot conceivably be attained without a substantial degree of federal financing. Steadily expanding research in the causes of dental disease will also command broad support, if leaders in public health and dentistry will speak out and fight for the priority this deserves. Finally, a word about the elderly and about our youth. The level of dental care among the aged is shockingly low. I see no particular prospect of raising this level appreciably within the lifetimes of millions of persons over age 65 except through a system of financing geared to the Social Security mechanism. It is quite reasonable to predict
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that hospital care for the elderly will be so financed within the next two years. It seems equally reasonable to me that the program will then be extended by stages to meet the other urgent health needs of elderly persons, including dental care. As for our youth, the Commission on the Survey of Dentistry has not come up with a brand new idea in calling for an incremental care program for children, with local, state, and federal sup-

port, but they have spoken out in clear and explicit terms. The proposal makes sense. It would hardly be exaggerating to say that such a program would be a godsend. Properly explained to the American people, it would command overwhelming support. And through its operation over the years, we could sweep away much of the deadening public apathy that is holding dentistry back from making its greatest contribution to our national health.

Dr. Mott is executive director, Community Health Association, Detroit, Mich. This paper was presented before the Dental Health Section of the American Public Health Association at the Eighty-Ninth Annual Meeting in Detroit, Mich., November 15, 1961.

National Tuberculosis Association Fellowships

The American Thoracic Society, medical section of the National Tuberculosis Association, provides fellowships for the graduate education of investigators and teachers in the field of respiratory diseases and tuberculosis. The following types are offered: Research Fellowships, both predoctoral and postdoctoral; Teaching Fellowships; and Edward Livingston Trudeau Fellowships, offered to young physicians who have completed their hospital residency training and are now ready to assume responsibility for medical school teaching programs. Each applicant must have been accepted by the head of the department under whom he expects to work for the next academic year in a medical center or hospital in this country. All applications must be submitted by November 1. Further particulars from Director of Medical Education, American Thoracic Society, 1790 Broadway, New York 19, N. Y.

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