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In Search of the Underserved

East Carolina University’s new dental school was sold on a dubious basis.

By Duke Cheston

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December 13, 2010

This coming August, the latest installment of North Carolina’s ongoing experiment in social engineering through health care education will be officially underway. East Carolina University’s new dental school will admit its first class of students.

The school will cost nearly $100 million to build, with an additional $11.5 million in recurring funds every year from state taxpayers. This rather large investment is supposed to enable North Carolinians in some of the state’s more remote rural areas—the “underserved”—to see a dentist more easily. Taking a deeper look, however, one wonders if the need to improve “access” is really all that urgent.

At first glance, the proposal for the new dental school seems reasonable enough. Some people in our state have to travel further to see a dentist than others. If you look at the map below from a 2005 report by the North Carolina Institute of Medicine, it’s clear that dentists are not distributed evenly on a county-by-county per capita basis. Four counties don’t even have a single dentist. Moreover, thirty-three out of North Carolina’s hundred counties “saw a decline in dentists per capita from 1996 to 2005,” according to the 2007 North Carolina House bill that started funding for ECU’s dental school (and was later incorporated into the main budget). So why not do something to help our state’s most dentist-deprived citizens?

The trouble is that these “underserved” citizens, at whose altar our state politicians sacrifice so generously, are somewhat difficult to find in reality. It’s almost as is if no one has even looked for them. For instance, Trenton, North Carolina, is at the center of dentist-free Jones County, one of four such counties in the state that are referred to in the bill. A quick Google Maps search for a “dentist near Trenton, NC” reveals ten dentists within 30 minutes of driving time, which is approximately the time it takes me to drive to my dentist in highly over-served Wake County. Put another way, the maximum possible benefit that the 200 or so citizens of Trenton, North Carolina, one of the most underserved areas in the state, could get from ECU’s new dental school is less than a half hour of driving time.

A quick phone call to Julie Kerr, receptionist at Warren & Miller Family Dentistry in New Bern, just outside of the perilously “underserved” Jones County, further reveals the silliness of fretting about the lack of dentists in Jones County.  Warren & Miller see a fair number of patients from Jones, Kerr said, but they are far from being swamped by an influx of residents from the neighboring county. “There are lots of dentists in New Bern for people from Jones County,” she said. A brief look at the amount of work that went into the practice’s stylish website confirms that they are still, in fact, looking for more patients. If Jones County citizens’ teeth are rotten, it’s not from want of nearby dentists.

Thus the inclusion of Jones County in the list of the “underserved” by the advocates of the new dental school undermines the whole concept of dentally “underserved” North Carolinians. True, there are some remote areas a bit farther from a dentist. But the longest travel time to a dentist in North Carolina I was able to find was in the aptly named town of Last Chance, out east in dentist-free Hyde County near Lake Mattamuskeet.  According to Google Maps, it takes 54 minutes to reach the dental offices of David H. Elliott II from Last Chance.

Rhett White, city manager of Columbia, North Carolina, in dentist-free Tyrrell County, told me that the problem of distance, which doesn’t seem that considerable, is sometimes compounded by the lack of dentists willing to accept Medicaid patients.  This means that poor people have to travel somewhat further to see a dentist. This is a problem, but one that results primarily from the problems inherent to Medicaid and not from a lack of dentists.

Furthermore, there is significant reason to doubt that efforts at placing dentists in remote areas will be successful—in any case, not on a large scale.

In order to produce dentists who will voluntarily locate in lesser-served areas, East Carolina’s new dental school will take a multi-pronged approach. First, it will selectively recruit students from rural and underserved areas in the hope that they will wish to eventually return to those places.

Once in school, students will be prepared to “fulfill leadership roles in these communities” and will receive “curricular experiences designed to help them succeed as general dentists and as small business operators in the often economically challenging environment of rural counties.” According to the ECU School of Dental Medicine (SoDM) website, the school will “emphasize the diagnostic role of the general dentist” since specialists are harder to come by in rural areas. Rural dentists, therefore, should be better able to diagnose patients they might otherwise refer to specialists in a more convenient setting. Finally, ECU SoDM students will go through a “capstone learning experience” involving “extended immersion in a dental clinic located in a rural community away from the ECU campus.”

This is all very well and good and may eventually have some impact. ECU’s Brody School of Medicine, for instance, tries something similar (i.e. targeting rural areas) and has a 28 percent “success” rate of getting doctors to practice in rural areas. That is a higher percentage (but still smaller total number) than UNC-Chapel Hill’s medical school. The impact, however, as at Brody, will be limited by the huge incentives against working in remote areas. Given that dentists typically serve constituencies of several thousand people, it is difficult to imagine a dentist moving to Trenton (population ~200) when he or she could stay in New Bern and serve the people from both New Bern and Trenton. Besides, a new dental school won’t fix the problems with Medicaid reimbursement that prevent some dentists from treating the remote poor.

Moreover, the idea that North Carolina needs more dentists in general has not been sufficiently established. The aforementioned House Bill 1293, which initiated funding for the new school and was incorporated into the 2007 budget, lists our state’s overall dentist per capita rank—47th—as a reason for the new school, but that isn’t the same as demonstrating a genuine shortage. The Joint Plan for Dentistry, which helped justify creating the new dental school, notes that “Only 9 out of 100 NC counties meet or exceed the national average of dentists per capita,” another somewhat misleading benchmark that doesn’t demonstrate a dentist shortage, either.

Finally, even if it is conceded that North Carolina needs more dentists, a new dental school is not the best way of going about increasing the supply. According to the American Dental Association, it would be more economically efficient to simply increase the enrollment at the dental school we already have. In a 2005 report, the ADA calculated that economic efficiency of dental schools tends to increase up to a total enrollment of about 1300 students. By comparison, ECU’s new dental school is expected to enroll 50 students per class (200 students total when at capacity) and UNC-Chapel Hill’s dental school is planning to increase enrollment to 100 students per class (400 in school at once). If the ADA is correct, then we are wasting a substantial amount of money by building a new low-capacity school when it would be prudent to simply increase the capacity of the existing one.

Alas, it appears too late to stop the dental school from being built. As you can see from the live streaming 24-hour video feed of the construction site, there’s already a big hole in the ground and a number of large colorful machines moving about on site. What’s more, tens of millions of dollars worth of loans (in the form of COPs, bonds that aren’t voted on by the public) have been taken out, and it’s hard to get that kind of toothpaste back in the tube.

But what the legislature, the UNC system, and any other governmental entity can do is to consider more carefully next time the rationale of such massive spending programs. No dentist shortage (or “maldistribution,” whatever that means) has been demonstrated, but we’re trying to solve the apparent shortage in a very inefficient way, anyway. This doesn’t need to happen a second time.

Groucho Marx famously said, “Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." Is there a greater example of this than the idea of “underserved areas” and ECU’s new dental school?

 


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