THE EDITOR'S CORNER
A recent report of the Brookings Institution concluded that many well-intentioned social welfare programs did not succeed. The reason for failure was not lack of money, for huge amounts of money were pumped into these programs. They did not succeed because it was assumed that all that was necessary was to identify a problem, allocate funds, and the problem would be solved. It was not recognized that we lacked the "know-how" to solve certain problems. Under a slogan of "Don't just stand there. Do something." we forged ahead into programs that had little or no advance planning and little more to recommend them than a strong pressure group operating against a weak and ill-informed legislature.
What makes the Brookings report so timely is that we are on the verge of making another of these errors of commitment of our money rather than our brains. We are about to embark on a national health plan. The concept of a national health plan has great merit. But we have not made the kind of advance study and planning to give us any assurance that we know how to set up and conduct a national health plan. Medicaid and current health insurance programs do not offer that assurance.
In terms of dentistry, if you allocate funds to a dental health program and it turns out that $2 is allocated for a certain filling, under present conditions you are not going to be able to get much of a filling. If, on the other hand, you had experimented and tested with various ways of producing that service such as practice in groups, use of auxiliary technical personnel, increased efficiency, coupled with programs of prevention, education and research, you would then know what was the most favorable mode of delivery of various dental services, what level of quality to expect and what it would cost. You would know that a satisfactory filling of that kind was possible for $2 or $3 or $5 or whatever you determined. But now, you are turning your thinking around. You are planning what you want the service to be and how to deliver it at its most reasonable cost. You will have to determine what facilities will be best, what staff will be needed, how much training they should have. You actually have to build the facilities and train the staff before you offer the service, if it is going to operate according to your plan.
Therefore, even following advanced planning and testing, the implementation of a national health plan should not be done overnight. It should evolve with experience with larger and larger groups using the modes that seem to be succeeding. You first build the facilities. train the staff, determine the program and then test it on people in small groups. You modify according to your experience and as you expand facilities and staff, you offer the service to larger and larger groups.
Since you know what your costs are going to be and you know what your utilization rate will be, because you have tested this, you can know what the overall cost of your program will be. If you can pay the whole bill, then you have an optimum program. If you must limit your allocation, you do not do it by reducing the fee (this was established on a cost plus basis). Nor do you do it by reducing the quality (the standards of quality have been a basis of the plan of service). If you must limit your allocation, you limit your quantity (by adjusting the eligibility for the service).
If, on the other hand, you merely allocate a certain amount of money to a program loosely based on present methods of practice, either you will shortly run out of money or you will reduce the fee and/or the quality and/or the quantity of the service.
This brings up a point. We in the professions understandibly resist change. We like things as they are. Any suggestion which threatens to change our present practice status is generally greeted as heresy. Yet, we should consider the very real possibility that this very stubbornness on our part may serve to preserve practice as we know it in our lifetime and may destroy orthodontics as we have known it after we have departed the scene. I can't believe that we would knowingly let that happen Yet, the connection is this. Private practice modes that we now operate as solo practitioners, partnerships, and relatively small groups may not be the most economical way of delivering our service. If there are ways of delivering the high quality of orthodontic service for which we strive at a cost considerably lower than present cost--through more effective use of auxiliary personnel and more efficient practice methods--we should find out how, and now. When the Congress passes national health legislation it is too late. Attempting to use present modes of practice in a mass program cannot succeed. No one could afford it. You can predict that the fee and the quality and the quantity of the service would decline.
If there is a way of providing unlimited high quality orthodontic treatment, that must be our goal. Orthodontists, recognizing the approach of change, must guide that change or risk unwittingly being responsible for a service that will be satisfactory to neither the public nor the orthodontist. In a disorganized fashion, some progress is being made. Orthodontists are in the forefront of changing state dental practice acts to permit expanded use of auxiliary personnel. This seems to be a proper course and could lead to implementation of such a mode of practice within a national health program. But, these individual programs should be coordinated. They should be worked on, improved, subjected to some planning, further experimentation, evaluation. Perhaps there should be regional monthly symposia among practices of a certain staff size. It could lead to the development of regional plans for programs of prevention of orthodontic problems; education of the group itself, its staff, general dentists, the public, government officials; research projects on any of the aspects of the program, including working with private and government agencies on private and government study grants; and treatment of the largest number of cases that can be handled for the most reasonable cost that can be obtained.
Imagineering of this kind may even be turned to enjoyment and profit. But, beyond that, it should be done for the public good and so that this lovely specialty of ours shall endure in some semblance of the image that each of us has of it.
