The Delivery of Oral Healthcare Through Chain Store Pharmacies
Edward F. Rossomando, DDS, PhD, MS
Since the publication of Oral Health in America: A Report of the Surgeon General, the issue of inadequate oral healthcare for a significant segment of the US population has been framed as a problem of access.1 For most, the term access evokes the metaphor of opening a door. Similarly, a lack of access suggests a locked door. When used to describe the current situation with regard to oral healthcare, access takes on a pejorative connotation. The phrase lack of access may suggest an image of a truculent dentist, standing at the door of his or her office, arms akimbo, blocking entry. Such a connotation polarizes the debate.
Psychologists speak of reframing this conceptualization as a technique to incite behavioral changes. In the case of oral healthcare, reframing is accomplished by substituting the word delivery for access. Thus, to enhance access to oral health care, maybe we should focus on exploring mechanisms for the delivery of oral health care to all segments of our population—rich and poor, urban and rural.
This substitution of delivery for access also enables the focus to shift from the patients to dentists. This does more than add piquancy to the debate, as illustrated using the US Postal Service as an example. Without exception, we speak of the mail as being “delivered” by the post office—not of the mail being “accessed.” The lack of oral healthcare may reflect the absence of a delivery mechanism.
Delivery of Oral Healthcare in US
In the US, oral healthcare is delivered by dentists and dentist-supervised auxiliary personal. According to the US Bureau of Labor Statistics’ Occupational Outlook Handbook, only 150,000 dentists in the US treat a population of more than 300 million.2 Of the 150,000 dental professionals, 128,000 are general dentists, translating into one dentist for every 2344 people. In the 1970s and 1980s, the average number of persons per dentist was 2194. As most of these dentists practice in metropolitan centers, it is delivery of oral healthcare to rural areas that becomes the problem. Many efforts by the federal government to encourage dentists to locate in traditionally underserved areas have been unsuccessful. For example, the Indian Health Service, responsible for providing healthcare such as dental care to Native American populations, has been unable to fill all positions.3
In addition to disparities with geographic distribution, the number of dentists in the US is declining. An estimated 6000 dentists retire each year while the number of dental school graduates is constant at roughly 4500 students annually. This deficit will become more challenging as the baby boomer generation ages, creating greater numbers of people in need of complex dental procedures. Current estimates predict that by 2050, the number of Americans older than 65 will increase by 147%.4
However, oral healthcare can be provided by allied health personnel. For example, a recent American Dental Association (ADA) report recommended expanding duties for allied personnel, such as dental hygienists, provided that the ADA and the American Dental Hygienists’ Association could determine a standardization of duties. The ADA report also suggested training in the use of new technologies could enhance productivity, allowing a dental office to treat more patients and perhaps lower costs.5
Even if the dental provider workforce were to increase, it is doubtful that the needs of the ever expanding US population can be met. In part, this is because any additional dental providers are unlikely to practice in rural settings. Previous experience suggests they would continue to choose metropolitan areas. Clearly, another approach is needed to deliver oral healthcare to the rural population.
The Chain Store Model for Delivery of Healthcare
Since 2006 MinuteClinic, which operates inside CVS drugstores in New York and other areas, has emerged to deliver routine medical care. At these facilities, nurse practitioners prescribe medications, including antibiotics, certain creams, and cough syrups, and administer vaccines.6 The Convenient Care Association, which operates and owns MinuteClinic, expects the number of facilities to double in 2008.6
Initially, providing medical treatment without a physician caused alarm within the medical profession. However, concerns were alleviated when MinuteClinic and organized medicine agreed on parameters for clinic operations. Nurse practitioners provide only treatments for which they are licensed. If the symptoms are more complicated, the patient is referred to an emergency room or a physician.
MinuteClinic improves delivery by bringing consumers as close to healthcare as their nearest chain store pharmacy. However, these facilities serve other benefits as well. Many have argued that uninsured persons with acute illnesses significantly strain the healthcare system. Because hospitals must treat all patients entering the emergency room regardless of the prospect of reimbursement, the uninsured have placed a significant financial burden on federally funded programs and hospitals, as well as raising insurance premiums. Facilities such as MinuteClinic may alleviate such pressures by providing delivery of routine healthcare to the uninsured.
The 1980s: The Franchise Dentistry Era
In 1980 David Slater predicted that his company, Omnidentix, would grow to 25 centers in 3 years and double each year thereafter. By 1985 Omnidentix was bankrupt.7 In fact, by 1986, 11 of the 12 major dental franchises would cease franchising, reorganize, or declare Chapter 11 bankruptcy. Many dental professionals found cause for celebration in the demise of what was at the time named “franchise dentistry,” “department store dentistry,” and “strip mall dentistry.” Regardless of whether this demise brought joy or sorrow, the franchise dentistry model’s quick collapse was quite shocking.8 After all, it was only in 1979 that a headline in the Wall Street Journal declared: “Department Store Dentists, Lawyers Win Acceptance Despite Criticism from Peers.” In that same year, a headline in Dental Economics heralded “The Birth of Franchise Dentistry.”8
Some consider the 1977 US Supreme Court decision that enabled professional advertising to be the genesis for franchise dentistry. Following a complaint made to the Federal Trade Commission that the ADA was unjustly prohibiting dental practices from advertising, the ADA agreed “not to restrict or declare unethical truthful advertising by dentists, pending the final outcome of the Federal Trade Commission’s case against the American Medical Association involving the same issue.”9 Once unbarred, direct mailings, news-letters, and newspaper advertisements became widespread. Telephone directories became littered with ads offering availability of on-call dentists 7 days a week, often at reduced rates. Frequently, such prices were made possible through the use of allied professionals such as hygienists or dental technicians because of the lower cost of their services. Many thought this race to the bottom would cause “fear [toward] the adverse effect on the public image of the profession, unrealistic public expectations, more lawsuits, and eventually increased government intervention.”9
One lure of franchise dentistry stemmed from the immense overhead that private dental practitioners face. One dentist in the 1980s said dental franchise could reduce overhead by allowing a practice to be “open twice as much as the traditional private practice, [therefore] you could treat more patients and consequently spread your overhead over more hours. Through bulk purchasing, they could give you the best prices on equipment and supplies, thus reducing your overhead even further.”9
In reality, expanded hours increased labor costs astronomically. Additionally, because dental franchises operated within shopping malls and thus were committed to strict lease agreements, they were required to be open during slow hours and seasons.
Byzantine management practices, high licensing costs, and immense overhead are perceived as the causes for the demise of franchise dentistry in the 1980s.8,9 Most importantly, a key failure for dental franchising was its marketing strategy—lower costs for patients. With lower costs, patients perceived dental franchises delivered inexpert treatment. Adding to this perception of “low quality,” dental franchises operated often in strip malls and shopping centers. Dental franchises were unable to overcome the inaccurate public perception. In the 1980s, one dentist wrote, “With the widespread prevalence of health and dental insurance, there may be little incentive for consumers to consider price.”9 It was believed that the trend of expanding dental services coverage exhibited in the 1970s—increasing more than 2% per year—would continue throughout the 1980s.
The reality was startlingly different. In the 1990s insurance premiums began to increase, at times quadruple the rate of inflation. Many Americans had little choice but to opt out when faced with out-of-pocket dental procedures offered at private practices. As a result, dental franchises lost market share and eventually closed.
Given the current insurance situation, some think it is time to resurrect the idea of franchise dentistry in a new format—chain store dentistry. The modified concept reflects the new home for the endeavor. Rather than being housed in a stand-alone store front, these modernized ventures would be in chain stores, such as pharmacies or even discount department stores.
Chain Store Pharmacies to Deliver Oral Healthcare
While it is unclear if the MinuteClinic’s model will be successful, the idea of using chain stores as delivery sites for medical and, by extension, oral healthcare remains worthy of consideration for several reasons. First, the number of dentists in the US is unlikely to keep pace with the increasing US population. Second, the technology and products for providing oral healthcare have improved to the extent that an ADA report stated that technology can lower operating costs and allow for less skilled personnel to treat patients effectively.5 Third, advances in diagnostics and therapeutics should enable hygienists, dental assistants, and dental therapists to offer some state- and federally-approved services to patients at a lower operating cost than could be provided in the dental office. Taken together, these observations, along with the recognition by Americans that oral healthcare is important for overall health, suggest that it is appropriate to continue considering the feasibility of the chain store for the delivery of certain dental services.
1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. http://www.surgeongeneral.gov/library/oralhealth. Accessed December 2008.
2. US Bureau of Labor Statistics Office of Occupational Statistics and Employment Projections. US Bureau of Labor Statistics Occupational Outlook Handbook. Washington, DC; 2006.
3. Indian Health Service. The Federal Health Program for American Indian and Alaska Natives. Public health dentistry—creating access for the underserved. An interview with RADM Christopher G. Halliday, Chief Dental Officer, USPHS. HIS Impressions. http://www.ihs.gov/medicalprograms/dental/index.cfm?module=news&option=04_03_p1. Accessed December 2008.
4. US Census Bureau. Population Estimates. Washington, DC: 2002.
5. American Dental Association. Future of Dentistry. Today’s Vision: Tomorrow’s Reality. Chicago, IL: American Dental Association Health Policy Resources Center; 2001.
6. Hughes JV. The nurse practitioner will see you now. New York Times. February 4, 2007. http://query.nytimes.com/gst/fullpage.html?res=9D04E0D9153FF937A35751C0A9619C8B63. Accessed December 2008.
7. Cassiani J. Viewpoint: why dental franchises fail. Dental Economics. 1987;19-20.
8. Yavner SB, Yavner DL, Douglass CW. The failure of the dental franchise industry. J Dent Pract Adm. 1988;5(1)21-24.
9. Waldman HB. The reaction of the dental profession to changes in the 1970s. Am J Public Health. 1980;70(6):619-624.
About the Author
Edward F. Rossomando, DDS, PhD, MS
University of Connecticut School of Dental Medicine
Center for Research and Education in Technology Evaluation