The Year in Review

By Brian L. Blomster

The unavoidable metal-on-concrete whack of a pile driver doing its work next to CDA headquarters as winter fell on California offered what might be a fitting metaphor for the just-finished year.

Even as its pounding shook the surrounding landscape, work on the foundation of Esquire Plaza -- a project in which CDA through The Dentists Insurance Company has financial interest -- has been necessary preparation for building something bigger, better.

And for CDA, 1997's trials and triumphs provided plenty of opportunity for growth. The association got some big wins in the Legislature and took a couple of punches in court. A longtime leader in the organization called it quits, and the new executive director who had been on board little more than a year chose to leave. Victory came in a long-disputed issue before the Board of Dental Examiners, but the fate of two extensively debated subjects -- direct reimbursement and continued competency assessment -- remained high in the association's policy-making consciousness.

Elsewhere, Western Dental Plan was slapped with a huge fine and other sanctions, and Denti-Cal fraud fired concern up and down the state.

But, despite the questionable intentions of a Reader's Digest article, dentists and dentistry continued to enjoy an esteemed place among the country's professionals, even as they worked to maintain a degree of control in an atmosphere fogged with concerns about access to care, fair compensation and the proliferation of underfunded capitated programs.

Politics, regulation and the vexations of being a highly visible target for the occasional critical dart could not slow progress within the profession. The association added muscle to its frame by creating positions for a director of Information Technology and a director of Special Projects, the former charged with turning a sagging system into a high-powered tool, the latter bringing a well-trained ear to the long-heard call for access for the state's underserved populations.

The industry enjoyed a bit of a jolt when the federal Food and Drug Administration approved marketing a laser for use on hard tissue procedures.

No, it was not a year without an occasional discouraging word, but shouts for achievement, progress and plain good dentistry left 1997 with an echo worth listening to.

Transition Continues

As sometimes happens in corporate America, when change comes, it comes in stages. CDA is facing another such stage as a search begins to find a new executive director.

In July 1996, Kenneth L. Zakariasen, DDS, came out of academia to replace Dale F. Redig, DDS, who had been the association's top staff person since 1978. Zakariasen brought in a philosophy that depended heavily on giving executive staff members the power and flexibility to make decisions and pursue projects that previously had been under tight control by the executive director's office.

But by late summer of 1997, although CDA's Executive Committee embraced the concept of staff empowerment, differences in management style and association direction led Zakariasen to resign.

CDA President Eugene Sekiguchi, DDS, accepted an interim appointment by the Executive Committee to replace Zakariasen, and he subsequently appointed a search committee, which may bring forward candidates for the permanent position by March.

"We will continue to move forward," Sekiguchi vowed.

Other significant change visited the association's Sacramento headquarters. Hoping to close a technology gap and improve the capabilities of CDA and component societies, association leaders OK'd creating the position of director of Information Technology, a position filled by Valerian Szyntar. Szyntar immediately began rebuilding IT throughout CDA and its subsidiaries, beefing up his staff and laying the groundwork for a complete overhaul and upgrade.

Another need was met with creation of the position of director of Special Projects and filling the spot with Teran Gall, DDS. A practicing dentist, Gall is overseeing such ongoing concerns as direct reimbursement and continued competency assessment, while pouring energy into securing funding for fluoridation projects and access for underserved populations.

Goodbye, Dr. Gaynor

Never the retiring type, J. David Gaynor, DDS, refused to call it quits. Instead, he left CDA after an almost three-decade relationship as a volunteer and staff member to start a new career.

Leaving his post as president and executive director of The Dentists Company and The Dentists Company Insurance Services after 15 years, he joined MBNA America as a senior account executive in San Francisco. He had been a CDA trustee and was president of the association in 1980. Blunt and outspoken, Gaynor's legacy includes successful practice as a pediatric dentist, leadership in the fight to fluoridate California and start-up -- from scratch -- of TDC and TDCIS.

Gaynor was succeeded as head of the two companies by Roger R. Kittredge, CPA, MBA, CDA's longtime chief financial officer. Laura Catchot, CPA, MBA, who had served as the association's comptroller under Kittredge, was appointed as CFO.

Taking the Lead

1997 was the year CDA changed the way it played politics, and the result was a string of legislative successes and the prospect for more good things to come.

Under an aggressive new philosophy coming from the Council on Legislation and Government Relations Director Liz Snow, CDA saw six bills it sponsored or supported signed into law by Gov. Pete Wilson, addressing a range of issues important to dentistry and the public's health.

Among notable victories were bills involving uniform educational standards for foreign-trained dentists and proper diagnosis for new patients. Both issues had long occupied the association's attention.

Coalition building and compromise were keystones for success, but even more important was the association's new-found ability and desire to help set the legislative agenda rather than react to bills put forward by others.

"We made a conscious effort to be proactive rather than reacting to someone else's legislation," said William J., Emmerson, DDS, chairman of the Council on Legislation.

Grassroots participation also received credit for CDA's showing at the Capitol.

"Dentists were involved locally," Snow said. "They were engaged from the beginning of the process. Legislators saw that these had support from our members and that it all wasn't just coming from association headquarters. ... Lawmakers saw the faces of our membership."

BDE Strikes Definition

The California Board of Dental Examiners struck from its infection control regulations a definition for "surgical procedures," a move that met with wide CDA approval.

The definition -- "entries into normally sterile areas of the body" -- had been taken to mean anything from extensive work on soft or hard tissue to an injection.

Laboring under that definition, dentists had been required to use sterile techniques for many procedures that they would not have otherwise. Supporters of eliminating the definition say that move allows dentists to use their professional judgment in determining when to use sterile gloves and/or coolants and irrigants.

"It makes treatment more effective, since it lets the doctor decide when the extra precautions should be used," Sekiguchi said, adding that the real issue was that the definition did nothing to further patient safety.

BDE President Peter C. Hartmann, DDS, said his board's action helps clarify when dentists need to use sterile irrigants and coolants and ultimately improves infection control regulations.

"It streamlines it somewhat," he said.

Judith R. Babcock, CDA's director of Dental Affairs, who has been involved in the association's support of eliminating the definition for years, was pleased.

"We've gone from no regulations to regulations that were really onerous and cumbersome to regulations that were clearer," she said. "These regulations are reasonable, providing for patient and office staff safety while not unduly burdening the dentist."

Court Sides with FTC

The Federal Trade Commission won the latest round in its legal fight with CDA when the Ninth Circuit Court of Appeals in October supported the FTC's determination that the association's restrictions on advertising constitute an illegal restraint of trade.

The court also affirmed that the FTC has jurisdiction in the matter.

The long-running dispute will end up before the Ninth Circuit Court en banc -- before the entire court -- if CDA's petition for rehearing is granted. The most recent ruling was before a three-judge panel from the court and favored the FTC 2-1.

If the Ninth Circuit Court again rules against CDA, the association will appeal to the U.S. Supreme Court.

In its review of the FTC's ruling that the advertising limitations appearing in CDA's Code of Ethics are illegal, the appeals court found that "The advertising rules of the CDA, as applied to truthful and nondeceptive advertisements, violate Section One of the Sherman (Antitrust) Act and Section Five of the Federal Trade Commission Act."

The appellate court agreed with the FTC that CDA's guidelines not only restrict false and misleading advertising, but could also restrict truthful and nondeceptive advertising for such things as money-back guarantees, special offers on dental procedures, senior citizen discounts and discounts for new patients.

The court also ruled that the FTC has jurisdiction over some nonprofit entities, a point CDA continues to dispute.

"CDA is firm in its conviction that the FTC lacks the authority to regulate nonprofit entities and that the Ninth Circuit ruling violates a fundamental congressional limit on FTC jurisdiction," said CDA legal counsel Raoul Renaud.

State Gets Tougher on Denti-Cal Fraud

A California law prohibiting dentists from offering inducements for referral of Denti-Cal patients gained widespread attention and continues to affect unprincipled practitioners as well as dentists who aren't well-versed in the statutory restrictions.

Of greatest concern to law enforcement are dentists who reward third parties for rounding up people eligible for Denti-Cal benefits and bringing them to their offices. The third parties -- often called "cappers" -- are paid a flat fee or by the head and promise that the dentist will give Denti-Cal beneficiaries anything from cash to items such as sneakers or even toasters.

That is the extreme end, but even dentists who offer rebates or discounts are operating outside the law. The state Business and Professions Code prohibits any form of rebates, commissions or discounts for patient referrals.

So, even a dentist who sends a favored patient flowers for referring another patient for treatment is violating the code.

Therein lies part of the problem, and that is, many dentists are unaware of the strictures they work within relative to referrals.

But the state's biggest concern is for those who are trying to grab a bigger chunk of the Denti-Cal pie and are willing to pay for the chance.

"People who have participated in this have told us they've received running shoes, blenders, toasters and other items," said Ann Kensey of Delta Dental's Surveillance and Utilization Review Department. Delta Dental administers the state's Denti-Cal program.

Law enforcement officials say the problem is growing.

"We have witnesses complaining that people are being solicited for this scheme and picked up from the San Joaquin Valley area as far north as Fresno and taken to Los Angeles," said Victor Telles, a state Attorney General investigator supervisor.

Ann Emery, coordinator of CDA's Council on Dental Care, said that although the Denti-Cal fraud is troubling, relatively few dentists are participating.

"Based on the information we have, it appears that a small percentage of providers are participating in this illegal activity, and they are targeting a particularly vulnerable population -- Hispanic Denti-Cal patients -- where language is a barrier," she said.

Beam Us Up

A much-anticipated step into the future occurred to the cheers of some and restraint of others when the Food and Drug Administration approved for marketing a laser for use on hard tissue in adults.

Available for several years for use on soft tissue, the latest advancement gives lasers new credibility as an effective tool. With a price tag of about $39,000, it also gives its producer a nifty payoff.

While the new tool's applications are limited to very specific types of procedures, it is a step toward lasers that someday may be used for root canal surgery and cutting and shaping of bone, according to Colette Cozean, chair and chief executive officer for Premier Laser Systems Inc., the laser's maker.

The laser approved for marketing is called the Centauri Er:YAG, which stands for erbium, yttrium, aluminum and garnet. Erbium is the crystal that generates the wavelength, while yttrium, aluminum and garnet are metals and crystals that help control the laser beam. The handpiece looks like a standard dental drill and uses water or air to cool and clean the tooth during treatment.

Richard T. Hansen, DMD, is a UCLA faculty member who participated in clinical tests on the laser. He said test results and other patient studies "underscore the fact that a laser for hard-tissue procedure writes a new page in dental history."

"I believe it's a development patients have been waiting for, especially considering the public's familiarity with the success of medical lasers," Hansen said.

He also listed benefits for practitioners.

"We can pinpoint and excise diseased hard tissue with great precision, preserving the tooth's overall integrity," Hansen said. "We can eliminate nonproductive time spent during the day waiting for anesthesia to take effect, and we find the laser ideal for the newer tooth-colored restorative materials dentists increasingly use."

Long Year for Direct Reimbursement and Continued Competency

Two programs that have been scrutinized, retooled, criticized, picked over, lionized and, ultimately, dusted off and told to keep going continue to search for their places in the hearts and minds of the association's leadership and members.

Direct reimbursement, which supporters say preserves the idea and practice of fee-for-service dentistry and helps maintain the dentist-patient relationship, was given new marching orders by CDA trustees during their March meeting. A resolution that would have pumped another $150,000 into the program was defeated, ending a study being conducted for the association by the consulting firm of Johnson & Higgins. A report presented by Johnson & Higgins representatives indicated that to gain a greater share of the market, DR would have to undergo modifications that trustees rejected.

Some discussion called for the DR program to be terminated. But, instead, trustees instructed the Direct Reimbursement Committee to place new emphasis on CDA staff working directly with employers in an attempt to gain a greater market share.

The 1997 CDA House of Delegates in December was to consider a resolution restructuring the association's DR program to reflect the new direction.

"Regardless of your personal feelings about the amount spent on DR promotion in California or the use of CDA staff resources, it should be realized that this is the best dental benefit option that assures complete freedom of choice for patients and practitioners alike, while making the best use of the dental care dollar," wrote DR Committee Chairman Russell E. Chang, DDS, in June.

Delegates at the House also were to consider the latest version of voluntary continued competency assessment presented by the ad hoc committee that has pursued the issue.

Renamed "QUIL3" -- Quality Improvement through Lifelong Learning -- the program is a result of assessment of field tests at both Scientific Sessions and ongoing give and take between the committee and the Board of Trustees.

The committee calls the program put before delegates an "education-based, voluntary, self-administered program designed to assist the participating dentist in assessing his or her skill, knowledge and judgment in a contemporary dental environment."

The assessment can be done in privacy, and no in-office audits are part of the program.

Committee Chairman Steven Schonfeld, DDS, said in May that "CDA is acting to do something that (organized dentistry) can live with."

The program is needed, he said, to help ward off state-mandated testing and to give legislators direction and a blueprint from which to work if they decide state oversight of continued competency testing is necessary.

State Nails Western Dental

In an 11th-hour settlement between California's Department of Corporations and Western Dental Services, the Orange County-based dental HMO agreed to pay a $1.7 million fine.

The June 30 settlement was reached just one hour before a hearing during which a Superior Court judge would have decided the fate of Western Dental. In addition to the fine, the largest ever levied against a health plan by the DOC, the settlement called for appointment of joint monitors and required implementation of 23 corrective actions.

The settlement stemmed from a lawsuit filed by the DOC against Western citing 27 areas needing corrective action, ranging from quality assurance and accessibility to plan administration and organization.

Originally, the DOC sought a fine of $3 million.

"We are content that a settlement has been reached between the DOC and Western Dental," said CDA President Eugene Sekiguchi, DDS. "Although the penalty is lower than the original proposed fine, this is a step in the right direction to ensure quality dental care for Western Dental patients and consumers in California."

Magazine Article Takes Shot at Dentistry

Gaining its share of publicity but faltering under its own paucity of sound research, an article published in Reader's Digest questioning the integrity of dentistry was more smoke and noise that bombshell.

The story was based on visits by its author to 50 dentists in 28 states. To select the dentists, the author consulted the Yellow Pages. He wrote that examinations of his dental condition conducted by the various dentists resulted in proposed treatments that ranged in cost from about $500 to nearly $30,000.

The author's conclusion was that dentistry is being driven in large part by dentists trying to push more expensive treatments rather than address a patient's real needs.

CDA offered a positive message in response, saying that the author's methodology was rudimentary and unscientific but that the story raised the valid question of how best to choose one's dentist. The association emphasized accepted ways to select a dentist; the Dental Bill of Rights; how to determine quality dental care; and reasons why diagnosis, treatment options and dental costs vary.

From the Ground Up

Work began in June on a project that will turn a pair of old theaters and an empty, weed-covered lot into a wellspring of economic opportunities for CDA.

Construction of Esquire Plaza, an ambitious development next door to CDA headquarters in Sacramento, eventually will produce a 22-story Class A office building and an IMAX theater. The Dentists Insurance Company, one of CDA's for-profit subsidiaries, is investing $9.7 million in the project. TDIC will be the owner in a limited liability company.

"This is a way to continue to diversify our asset base," said TDIC Chairman Bruce Valentine, DDS. "TDIC investments are heavy in stocks and bonds but only a little in real estate. This allows us to take a more diversified approach to our investing."

Mike Brassil, TDIC's chief financial officer, said the company expects "steady long-term asset growth" and further strengthening of the company's investment portfolio. TDIC's chief executive officer, Frederick E. Knauss, said the development "is an investment like any other TDIC makes," although the projected 10-year rate of return of 17 percent makes it even more attractive.

Honors

The contributions of two California lawmakers who were instrumental in CDA's success at the Capitol in 1997 were recognized by the association in September.

Sen. Jim Brulte, R-Rancho Cucamonga, and Assemblyman Fred Keeley, D-Santa Cruz, were the first recipients of the George F. Baker Award.

Baker, who died in May, had been an active CDA volunteer and member of the Board of Trustees. He helped develop and was a charter member of CalDPAC, helping CDA move squarely into the realm of influencing state politics on behalf of its members.

Brulte was honored for authoring and helping to get passed into law SB 1014, which placed into statute the requirement that an examination, diagnosis and treatment plan be completed before treatment is provided to patients.

Keeley was recognized for authoring AB 1116, which is meant to ensure uniform standards for dental licensure.

"Honoring both a Republican and a Democrat this year, we believe (reflects) the bipartisan nature of Dr. Baker's legislative networking," Sekiguchi said.