Reflections on the 'New' Environment

For much of the 20th century, dentistry was looked upon as a cottage industry. The 1990s have seen considerable change to that image, and recent developments suggest that dentistry, not unlike its relatives in the health care arena, has been undergoing considerable transformation as the 21st century appears on the horizon.

While recent surveys of dental practice will show that the majority of dentists still function in solo practice settings, increasing numbers of dentists are functioning as employees or in multidentist modes of practice. Managed care and other contract plans and dental management service organizations are among the forces that have been reshaping the dental practice environment that at one time was labeled "private" dental practice. Solo practitioners who have valued their autonomy and privacy often agonize over the changes in the practice environment that have been stimulated by regulatory agencies and third parties. At the same time, a criticism frequently leveled at private practice is that is has resulted in isolation for many practitioners.

A positive force in the reduction of the isolation has been the increased access to information and communication resources. The individual practitioner can have immediate access to new information and an additional method of patient communication through the Internet. ADA Online and CDA Online offer invaluable information resources for dentists, as do other health care information-oriented web sites designed for dentists. At the same time, web sites that are accessible to the general public challenge the independent practitioner to stay current with information resources that educate the dental consumer at levels never before possible. While we have not had access to data showing the utilization level by dentists of the new technologies, there is a suspicion here that dentist interest in using online resources (as a group) may lag behind that of other groups of small business owners. From several sources, we know that many physicians use e-mail to communicate with patients on a daily basis. With time, we expect dentists to increase their reliance on Internet resources, which will further distance practitioners from the negatives attributable to the isolation of the solo practice environment.

Two recent events may have significance as we consider what further changes might affect the dental environment in the first decade of the 21st century. We refer to the American Medical Association's decision to form a national collective bargaining unit and the American Dental Association's support of a proposed Quality Health Care Coalition Act (HR 1304), which was introduced this spring.

The differences between medicine and dentistry have been frequently documented, although the environmental factors influencing health care in general tend to be similar in the two professions. In the instance of the recent AMA action, the increasing numbers of patient care physicians who now serve as institutional employees (slightly more than one quarter) was a major factor influencing the decision. While the dental environment has not yet changed as significantly as the medical environment (there is less HMO activity and fewer employees in dentistry), there has been a frustration in dentistry for many years with the intrusions from outside that might be more readily addressed and eased if dentists were to have greater freedom to discuss and negotiate fees. Without the pressures brought forth by a large employee population in dentistry, it would appear that our profession will not be considering a collective bargaining unit any time soon, which leads us directly to the other recent activity of note.

The American Dental Association was supporting HR 1304 as of mid-July. This bill, which was introduced by California Rep. Tom Campbell, would relax antitrust laws and allow self-employed health professionals to negotiate contracts collectively with health plans. While some association members are undoubtedly critical of support for such an activity because they view it as a further erosion of professionalism, the ADA believes that successful legislation could reverse current antitrust laws that have been unfairly preventing health care providers from discussing fee information when negotiating with health plans. The threat of antitrust violation has compromised the efforts of professionals to achieve better plans that benefit patients.

The ADA House has taken positions of support for antitrust reform for more than two decades. In June of this year, the state of Texas implemented the first state law granting health professionals the right to jointly negotiate fees and terms of health plan contracts. These activities illustrate the ever-changing nature of the environment for professional practice. While threatening to some, the increasing notion that professionals can and must work more closely together to bring about the desired level of care is nonetheless a positive, progressive step. In the past and present, the threat of antitrust violation and a practice concept that has nurtured isolation have probably minimized the influence that the organized professions have had on health care decisions.

A few months ago, we were reminded of a reality that we often take for granted. This reality was that the 20th century has seen some truly remarkable advancements. A vehicle that emphasized that point to us was a film tracing man's first efforts to fly, starting with the Wright Brothers in the first few years of this century. By the mid-1980s, we had seen development of the highly advanced Stealth B2 bomber and ventures into space that could not have been imagined in 1900. The aforementioned information technology explosion and the dentistry-specific technologies of recent years have brought similar exceptional possibilities for change to the dental profession. The changes in the dental environment in the 1980s and '90s have clearly moved the profession out of the cottage industry environment in which it existed in 1900 and the better part of this century. And, as we look into the future, the possibilities for professional networking and communication are largely untapped and infinite. The new generation of dentists brings a higher level of computer literacy that will lead in a few short years to a new curiosity and, thus, to a higher level of utilization of information technology in dentistry than has been possible heretofore.

Add to all of these extraordinary advancements the potential for future legislative change and technological advancement, and the independent dental practitioner of the future will no longer face the isolation that often occurred in the "old" environment for dental practice that is familiar to many practitioners who are still active today.