Interview with Dr. Jay W. Friedman
by: Michael Davis DDS
December 17, 2013
Dr. Jay W. Friedman has had a significant impact on the oral health of the public. His commitment to public health has spanned seven decades from the 1950s to the present. He pioneered in the development of quality standards for dental care, group practice, and dental insurance. An accomplished clinician, he has been a consultant to a number of state and national organizations. Notable are Dr. Friedman's remarkable contributions in leading the challenge against the prophylactic extraction of third molars, as well as advocating for adding dental therapists to the oral health work force.
Dr. Friedman earned his Doctor of Dental Surgery degree from Columbia University in 1948. Subsequently, he practiced general dentistry in Farmingdale, New York from 1948-1954, including two years in the U.S. Air Force Dental Corps. In 1955, Dr. Friedman became the director of an innovative group practice dental cooperative in Seattle, Washington, which served as a prelude to his pursuit of a life in public health. He received his MPH in 1962 at the University of Michigan, followed by an NIH Fellowship. Friedman then moved to Los Angeles, California, becoming actively engaged in research, writing, consulting, and clinical practice. Between 1964 and 1977, he served as a researcher at the UCLA School of Public Health. His 1972 Guide for the Evaluation of Dental Care was distributed widely by the U.S. Public Health Service; it set the standard for monitoring dental practice. In 1974, he co-edited, with Jerge, Marshall and Schoen, Group Practice and the Future of Dental Care. In 2002, he reissued a revised edition of his Consumer Reports Book, “The Intelligent Consumer’s Complete Guide to Dental Health.” In 2012, he received the John W. Knutson Distinguished Service Award in Dental Public Health from the Oral Health Section of the American Public Health Association.
Dr. Davis: Dr. Friedman I’m honored to interview you, both because of your work to advance public health dentistry over the years, but very specifically your efforts to reduce the routine removal of asymptomatic third molars (wisdom teeth). Extraction of these asymptomatic teeth most often generated no patient benefits. All the while, patient risks of morbidity and mortality were elevated, especially injury to the jaw nerves causing numbness of the lip and tongue, jaw fractures, post-operative infections, and the potential risks from sedation. A number of young adults faced serious clinical injury, inclusive of untimely death. Dr. Friedman, I’m not overstating, that your work to educate our dental profession actually saved many lives. In the face of your work, you were highly criticized by elements of the oral surgery community, whose potential income was threatened. Regardless, you took the high road, in advancing the dental profession, in service of the public welfare.
Dr. Davis: Dr. Friedman, in recent years we’ve seen advancement of corporate owned and managed dental clinics. These private equity backed dental clinics have a fiduciary responsibility, to place the interests of shareholders to the fore, and generate profits. By contrast, doctors have both an ethical and legal responsibility, to place the patient’s interests to the fore. The conflict of interest seems obvious. Would you like to elaborate?
Dr. Friedman: It is not only excessive third molar extractions that should concern us. They are just one part of a pattern of what I call FUN (Functionally Unnecessary) treatment, which may be physically and fiscally harmful to the individual and exploitive of public funds. It applies to the whole gamut of dentistry, including unnecessary x-rays, cleanings, fillings, crowns, replacement of missing teeth, and the array of “cosmetic dentistry.” Nonetheless, I believe the majority of dentists are well-intentioned and provide care they believe is in the best interest of their patients. That they―we―are not immune to FUN treatment is due in part to deficiencies in our education and the need to generate money to pay rent, utilities, supplies, salaries, and our own income.
Corporate owned dental clinics and private dental practices share the same objective, which is the generation of profits. In a capitalistic system, corporate shareholders benefit as if their investment produces the profit rather than the workers who perform the service. In a private practice, at least the dentist is part of the workforce. He or she may share some of the “profits” by awarding bonuses to auxiliary staff. In many private practices, the staff is given incentives to generate income and a bonus in the same manner as the corporate practice. So in that respect, I do not see a big difference between the two systems.
The ethical and legal responsibilities of a health provider are the same, whether in a for-profit private or corporate practice or a non-profit community health center. We do not know if the abuse is worse in a corporate setting than in private practices, anecdotal reports notwithstanding. But we have good reason to believe it is widespread throughout the “dental industry.” And, whether we like it or not, corporate practice, including the spreading “retail clinics,” is increasing. Whether we like it or not, they are providing care―much of it necessary and good care―to a portion of the population that cannot afford the high price of private practice.
We know how to limit the abuses―the fraud, the FUN treatment―by means of regulation and, especially, oversight. Unfortunately, we lack the interest, the authority and the support to do so.
[Many of these issues are discussed in a paper we published some years ago:
Friedman JW and Atchison KA. The standard of care: an ethical responsibility of public health dentistry. J Pub Health Dent. 1993; 53(3):165-9.]
Dr. Davis: Your efforts in public health dentistry have advanced the concepts, which save the public from needless dental care. This saves taxpayers money through Medicaid expenditures, as well as direct expenditures from the public. On the emotional level, patients are spared from excessive or needless dental treatments. In having done many hundreds of patient chart audits, as you’ve done, I’ve seen a disturbing pattern of gross over-treatment of pediatric dental patients with steel crowns and pulpotomies (baby root canals). I’ve seen this troubling and systematic treatment pattern, from interstate corporate Medicaid mills, as well as smaller unethical dental clinics. What are your findings, and can you offer some possible solutions?
Dr. Friedman: Some years ago, I became involved in the administration of a state Medicaid program with the intent to “contain costs.” It soon became apparent that a popular pediatric dentist was hospitalizing virtually all of his very young patients for “roundhouse” stainless steel crowns. I asked him to submit pretreatment radiographs (2 BWs plus anterior PA’s – a maximum of 4 films―or photographs―that could be taken in the hospital operating room prior to treatment) along with the claim statement. At first the pediatric dentist refused. When he finally submitted pretreatment x-rays, it was obvious that most of the stainless steel crowns were unnecessary.
Meanwhile he appealed to the state dental association, claiming I was demanding anesthetizing his patients for pretreatment x-rays as a separate procedure for preauthorization. He was an obvious liar and a cheat, which I pointed out to the Peer Review Committee that was also attended by some state Medicaid administrators. (Not the smartest thing to say in a gun-toting state.) Needless to say, the pediatric dentist was supported by the Peer Review Committee. But why would the Medicaid functionaries support him, knowing that he was exploiting the fund shamelessly? The reason: the pediatric dentist was one of only a very few in the state willing to treat Medicaid patients. The Medicaid people feared that if the pediatric dentist dropped out of the program, there would be no one to take care of these young kids? The fact that he was abusing many of them was not sufficient reason to insist on legitimate oversight. The upshot: Shoot the messenger. It was not the first time it happened to me. Fortunately, at least for me, I had some lives to spare.
As you indicate in your question, this is “a disturbing pattern” that is not unique to pediatric dentists. The best solution is for administrators of commercial dental insurance plans and Medicaid, to require evidence-based documentation of need, not for every case but for those involving extensive treatment.
Dr. Davis: We currently have a dental Medicaid system in chaos and crisis. The majority of licensed dentists in any given state decline Medicaid participation. Those who are Medicaid credentialed, in the private sector, too frequently are abusing and defrauding the program. Regulatory oversight seems abysmal. In fact, regulators at both the state and federal levels seem to frequently enable Medicaid abusers, with “wrist-slap” sanctions, all to keep the broken system afloat. Taxpayers, who want to have a viable safety-net program for disadvantaged children, are cheated. Disadvantaged kids are getting hurt. What suggestions and possible solutions can you offer, to assist the nation’s dental Medicaid program?
Dr. Friedman: If we really want to care for disadvantaged children, we have to consider better ways of bringing oral health care to children who cannot access private practices, free clinics or community health centers. With respect to health care, children are essentially non-ambulatory. They must have someone with the desire, time, money and means to take them to health care providers. Since many children lack that caregiver, they will not receive preventive and curative health care, even if it is free. If there is no one to bring these children to dental care, then dental care must be brought to them in schools, preferably by salaried dental therapists whose competency has been well documented.
There are over 14,000 dental therapists in 54 countries, including New Zealand, Great Britain, Australia and Canada. They have recently been introduced in Alaska and Minnesota to serve underserved populations, with more states likely to follow. Priority should be given to children and the most effective utilization is in school-based programs where over 90% of the children can be served efficiently and economically.
Dr. Davis: Under the new Affordable Care Act, estimates for child eligibility for dental care are to expand by 25-33%, over current Medicaid numbers. If what we experience is an expansion of our current failing Medicaid system, I’m very worried. What are your thoughts on this, as well as the Affordable Care Act generally, as it relates to dentistry?
Dr. Friedman: We have a great capacity in this country for taking a good idea and making it worse. The Affordable Care Act is an acknowledged compromise between those who advocate a Single Payer system as in Canada and those who oppose any national health care system. At best, it is considered a beginning that will improve over time. But its basic flaw is continuation of the fee-for-service system that invites―that insures―over treatment and excessive cost. No one in his right mind would design a health care system that pays a doctor, or any health care provider, only when he or she operates.
The only countries that have provided adequate dental care for all its children utilize dental therapists primarily in school-based facilities. The success of this model that originated in New Zealand ninety years ago is well documented. Dental therapists can be trained in 2-years post-secondary school. Nearly eight dental therapists can be trained for the cost of one dentist. Four dental therapists can be trained in the time it takes to produce one dentist. And in terms of salaries, two or three dental therapists could be employed in place of a single dentist. Anyone who thinks producing more dentists without changing the health care system is the cure for our neglected populations is delusional.
Dr. Davis: Our recent dental university graduates are today facing student loan debts, often exceeding $300,000. These loans are never dischargeable in a legal bankruptcy. The young doctor must repay the loan. In the face of this debt burden, many of these junior colleagues are opting for employment in corporate clinical venues, many or most of which operate from unethical business practices. This may seem to be the only means of student loan repayment. What are your ideas, to turn this situation around?
Dr. Friedman: We should develop loan forgiveness programs such as required public service in public health clinics and FQHCs (community health centers), military service, etc. We should promote non-profit group practice based on capitation and salaried remuneration that could employ new graduates in training environments similar to an internship. And, we should develop real quality assurance surveillance systems with teeth, e.g., graduated sanctions for substandard practices. This would require training auditors to review records and procedures to assure that minimum standards of care are being observed. No surveillance system is perfect, but no system at all is what guarantees the worst abuses not only in corporate practice but in any practice.
We are not looking for perfection. What we should be concerned with is “adequacy,” defined as “sufficient for the purpose.” Easy to say, of course, but we have made progress over the years in sterilization, patient records, radiation hygiene. Now we have to concentrate on protecting the patient from excessive and abusive care. We might start by eliminating CE course in “Building Your Practice, Increasing your Bottom Line. Planting Implants Galore.” It’s not only unethical corporate practice that should concern us. It should be any unethical practice.
There is nothing inherently wrong with a recent graduate working for a corporate practice or retail clinic. Our responsibility is to assure that every practice adheres to a basic standard of decency.
Dr. Davis: You have been a prominent advocate for the dental therapist program, to help with our nation’s “access to care” issues. By contrast, I have advocated against this program, because of concerns over Medicaid mills, interstate corporate and otherwise, misusing dental therapists, as they often have unlicensed dental assistants in providing dental hygiene services. Dental regulation for unlawful practice of dentistry often consists of a sanctioning “wrist-slap”, then a return to business-as-usual (unlawful actions). Because the needs of many of our citizens are so great, and often unmet, I’m very willing to keep an open mind on the topic of dental therapists. Please give your perspectives on dental therapy programs, and how they are workable for the best interest of the public.
Dr. Friedman: I share your concerns about the potential misuse of dental therapists. But I am more concerned that the most neglected part of our population―poor and minority children―will continue to be neglected if dental therapists are taken over by the private sector. In Minnesota, the dental therapists can be employed by private dentists if at least 50% of the therapists’ patients are Medicaid recipients. Thus, the private practitioner can also have them treat their more affluent patients to their own advantage and profit. It would be much better to employ them in public health clinics where 100% of the patients would qualify as poor and underserved. And it would be best if they were placed in schools where all the kids would have ready access to good dental care.
`If the American Dental Association and state components had any sense, they would promote school based programs that we know work effectively. After all, many―perhaps most―dentists don’t want these kids in their offices anyway. If the ADA wants to prevent dental therapists from competing with dentists, from being exploited by corporate practices and “Medicaid Mills,” how better to protect its members and the public than to restrict and control the deployment of dental therapists in school-based programs, particularly in poor and underserved inner cities and rural areas.
Dental therapists are here to stay. Sooner or (probably) later we will have them in all states. But it will take years, decades, before we will have enough dental therapists to care for our neglected children. Perhaps then, when all the kids have access to good dental care, they should be allowed employment in the private sector.
Dr. Davis: In conclusion, I want to thank Dr. Friedman for his time and effort in this interview. Dr. Friedman doesn’t have a product to sell or market. His time is freely given to advance the dental profession, and serve the public welfare. I thank Dr. Jay W. Friedman for his service.