Inside Dentistry
February 2010
Volume 6, Issue 2

A Conversation with Dr. James Bramson

Joining the editorial board of Inside Dentistry, the dental visionary sits down for a one-on-one interview. Here’s what he had to say.

This month, Inside Dentistry introduces a series of interviews with some of the people who have made—and continue to make—a significant difference in dentistry. With the diversity of their contributions to the profession, as well as the depth and breadth of their expertise, these key opinion leaders will surprise, inform, and hopefully inspire our readers. They all have one thing in common: they think differently.

Inside Dentistry is pleased and proud to announce the addition of Dr. James Bramson to its distinguished Editorial Board. One of the most-recognized figures in the dental profession today, Dr. Bramson is president of Bramson&Company, a strategic healthcare consulting firm. He is also serving as executive vice president of industry relations for Dentra. A former general practitioner, and the Ninth Hillenbrand Fellow to the American Dental Association, he has held positions as executive director of both the Massachusetts Dental Society and the ADA. The publishers and staff of Inside Dentistry are very excited to welcome Dr. Bramson, and by way of introduction to our readers, sat down for a candid conversation with this tireless oral healthcare advocate to glean his thoughts about the current and future states of the profession.

Many of our readers know of your high-profile position in dentistry over the past 8 years. Can you tell us a little more about your background and path into dentistry?

My father was editor and publisher of a weekly newspaper in the small town of Moville, Iowa, which has a population of 1,200. The town had one dentist, no physicians, and few other professionals. Dad wanted me to take over the paper, but instead, the town dentist happened to take me under his wing. At the ripe age of 8, I declared that I wanted to be a dentist, and once you start telling people that at age 8, you can’t go back! My goal at the time was to start my own practice, and run my own business because I saw the things in dentists that young people see as attractive—professional stature, flexibility in schedules, decent income, and the ability to make a difference in their community. After nearly 8 years of private practice, I was seeking a different level of engagement with the profession, and decided to start my administrative career.

What sectors of dentistry are you interacting with now?

I started a dental consulting business, and currently work with several corporate and non-profit clients whom I help on many different levels, including strategic go-to-market product development, organizational analysis, and the development of creative ideas to respond to the latest healthcare and professional market trends. I also serve as executive vice president of industry relations for Dentra, a Seattle-based provider of quality measurement solutions that support the enhancement of dental care through performance analytics and outcomes assessments. Dentra delivers analytical reports of patient satisfaction, practice patterns, quality measures, and business metrics. The company is relatively new, but OCS, its parent company, has more than 12 years of experience in providing similar data analysis for the home healthcare and hospice markets. Essentially, these companies leverage their informatics platforms and extensive databases to synthesize huge amounts of complex data into actionable, outcomes-friendly intelligence. I aligned with Dentra because health IT will be one of the main drivers in improving quality throughout the healthcare system.

Based on your experiences, what do you see as dentistry’s biggest challenges in the next 5 to 10 years for practitioners?

Einstein once said, “We don’t need to think more, we need to think differently.” That may be the way to approach some of our challenges, including the changing demography of the United States, measuring and assessing quality, the emergence of new social networking mechanisms, the scarcity of economic resources to pay for dental education, and the rising demand for healthcare.

The changing demography in our country and today’s disease patterns are often manifested in the lack of access to care issues. This is typically thought of in the context of the underserved and needy segments of the population, whose healthcare is often covered through some governmental program. But it plays out in the number and type of dentists, the overall dental workforce, social programs and their reimbursement, safety net and community health centers, programs for children, and the aging population—the list goes on and on.

Values-based purchasing or the “pay for performance” model is growing. The theory is a sound one: the best performers should be rewarded financially for their excellence. The rub comes in determining what excellent performance is, and how this is determined. That is part of the reason for the need for performance analytics and benchmarking because people want to be able to better assess outcomes and determine overall value. Hospital-based report cards are a good example of the populist movement to enhance access to information about the quality of care delivered by institutions or providers.

Another challenge for the profession will be to understand and harness the power of social networking for professional discussions. For most dentists, this isn’t the first thing they think about, but as a cultural tool for communicating and connecting, it is going to be a force to reckon with. SERMO, a physician-based professional interactive network, is a good example of how these tools can facilitate discussion and lead to improved care, identify emerging issues, and mine the intellect of the group.

Finally, dental education is expensive, and financing it will continue to be a challenge. Privatization and commercialization of education, faculty shortages, aging facilities, and the inability to keep up with technology are all issues that will be challenging for the profession in order to educate the best and brightest new dentists. That’s why we should all support our dental schools and the efforts of the ADA Foundation under the Our Legacy, Our Future project.

What are dentistry’s biggest challenges in terms of workforce/policy issues?

Workforce is really an access issue, and scope of practice is ground zero in the debate. I think there will still be lots of pressure to expand permissible procedures for auxiliary staff, and provide less restrictive supervision requirements. Regardless of where you stand on mid-level providers, if healthcare reform passes and millions of Americans under 21 are newly covered for dental services, we are going to need lots of healthcare workers to deliver both the basic oral health education and preventive services that these newly covered people will need to avoid disease, and still attend to the huge unmet restorative needs of this group. Productivity gains through increased legal delegation and more efficient use of highly trained office support personnel is going to be one of the key ways that will help serve all these new patients. Our challenge is to look carefully at the scope of duties for various team members, and more closely connect education, duties, and supervision with those services that are needed most.

With challenges come opportunities. Flipping that last question around, what opportunities do you see ahead in the coming decade for practitioners in terms of clinical practice?

Patients will increasingly see dentists as more sophisticated healthcare providers as they prevent disease and deliver new treatments in a more therapeutically and pharmaceutically based fashion rather than primarily through a more mechanical approach, which has been our mainstay for decades.

What are the opportunities in terms of improving patients’ systemic conditions through oral health?

There have been exciting new findings about the association between oral disease and systemic disease. And because these findings lend evidence to a closer connection of oral health to overall health, they will clearly alter our relationships, perceptions, and interactions with the medical community, and drive a much closer collaboration between dentistry and medicine than in the past.

The opportunity here is for dentists to start seeing themselves in this larger context of a patient’s overall health. Right now, for example, dentists can play a huge role in oral cancer screening because the pay-off in early detection is enormous. As the profession learns more about these connections, dentistry’s credibility will elevate the prestige of the profession while positioning dentists as a much more integral part of the consumer’s overall healthcare.

Where does the profession stand in terms of curtailing caries as a widespread childhood disease or incorporating biological/biomimetic treatment advances?

This is one of the big areas where we are going to see lots of new science. And, most of it will probably be at the biological level. For example, fighting caries and periodontal disease with different biofilms instead of current therapies is pretty exciting. And biomimetic materials that more closely mimic the natural tooth form and function will be important. Can you imagine the day when tooth regeneration becomes the preferred treatment over placing an implant? The new wave will be a more diagnostic one, with new tools for assessing disease and preventing or reversing problems.

If you could change one thing about dentistry in the United States, what would it be?

This one is easy to answer. If I could wave a magic wand, I’d do away with the current system of clinical licensure examinations, and replace it with a single, standardized national clinical examination that eliminates the use of live patients. Each state could still provide the actual license, and have an exam about state jurisprudence issues, but they would all recognize a single clinical examination. This is a huge problem within the profession, and we ought to be able to solve it before someone from outside the profession gets involved.

In what ways do you see American dentists being able to effect changes in oral healthcare worldwide?

While more research is probably occurring in the United States than anywhere else, I am not sure it is just American dentists who are affecting the world. Oral care worldwide is certainly affecting American dentists, who are learning a lot from their international counterparts, and most respected scientific journals now have international editorial boards, and get submissions and publish papers from researchers from around the globe.

How significant do you believe managed practice organizations will become, and will this trend change the delivery of dental services as we know them today?

There is an emerging generation that very few have been paying much attention to—those born between 1982 and 2002, the so-called millennial. This age cohort is different from many of us in the workforce today. They collaborate differently, interact in a more grassroots or bottom-up manner, are very technologically savvy, like to work in teams, and seem to want, or expect, different things from their work. All in all, that will put a different face on the profession as they choose where and how they want to deliver care to the public. This new student base may not all want to be solo or small-group private practitioners when they get out of school. There are lots of predictions about new models of dental practices that will emerge, with one being a growing number of employee dentists in large dental offices, and I see that trend already beginning to take off.

These large, corporate dental groups often view themselves as being on the cutting edge of how dentistry is delivered, along with significant internal knowledge about how to market dentistry, how to use data and systems to understand their business models, and they have the fiscal resources to heavily invest in new technology. They may provide their own continuing education and other benefits to their employed dentists. In short, these organizations may be putting together a model that is quite attractive for today’s new graduates.

How do you think healthcare reform will impact dentistry? What do you think will drive dentistry’s participation and/or resistance to joining in healthcare reform?

Well, if the activities out of the House and Senate ever come together, it looks like dental coverage for children will be included in the reform. Dentistry has made great strides in researching the associations between oral disease and systemic disease, and we’ve said you cannot be healthy without oral health. So, I find it hard to see how you would or could uncouple them now. So, yes, healthcare reform will significantly change the perceptions of dental care delivery in this country.

Care financing is probably the biggest challenge in the federal programs for increasing access. With reimbursement rates at about the 15th to 30th percentile in many state Medicaid programs, it is not hard to understand why dentists believe they cannot participate if they hope to survive in their practices. It will be important that, under healthcare reform, rates for these programs be set at a market level sufficient to attract providers, but I’m not holding my breath on that one.

As medicine and dentistry try to come together, what changes—if any—do you envision in reimbursement policies for dentists?

I would hope that if medicine and dentistry do come closer together, patients get better care as a result. Reimbursement ought not to be the main reason for a closer relationship. As we learn more about oral–systemic connections, dental and medical plans will probably keep changing their coverage accordingly to offer better health outcomes. Beyond that, I don’t see a business reason to actually merge the two health plans for a patient—they can be sold and underwritten separately. There will be some problems in managing the plans with those services that seem to cross over. Salivary diagnostics is an example of an information-gathering service that both physicians and dentists can use. So, which plan covers those costs?

Where do you see yourself within the scope of dentistry 10 years from now?

Ten years is an awfully long time and, over that period, no one really knows. I intend to contribute to the profession as a thought-leader, help in strategic professional opportunities with organizations that enhance the delivery of dental care, and bring, if possible, energy and insight to advisory, non-profit, or perhaps even a corporate board, as a way to give back to the profession I love.

About Dr. Bramson

James B. Bramson, DDS, is a 1979 graduate of the University of Iowa College of Dentistry. Through the course of his career, he has been a private practitioner, a clinical instructor, and a published author who has written and lectured extensively on such topics as the changing dental marketplace, risk management, recordkeeping, dental office ergonomics, infection control and liability, dental practice sales, team management, as well as a wide variety of clinical topics.

In 1986, he was awarded the American Dental Association’s prestigious Hillenbrand Fellowship in Dental Administration. The year-long internship gave Dr. Bramson practical experience in various aspects of dental administration, allowing him to develop his expertise in national dental policy that has made him one of the best-known dental policy advocates in the profession today.

In addition to various positions he held with the ADA throughout the 1990s and his role as the executive director from 2001 to 2008, Dr. Bramson also served as the executive director of the 4,500-member Massachusetts Dental Society from 1997 to 2001. He is currently the president of Bramson&Company, a strategic healthcare consulting company, and the executive vice president of industry relations for Dentra, a provider of quality measurement solutions. He can be reached at j.bramson@comcast.net.

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