RALEIGH — Many North Carolinians, especially in rural areas, suffer from lack of dental care. Would a $100 million new dental school at East Carolina University provide it? The General Assembly is pondering that question.
Although the proposed ECU dental school has significant political support, its future is uncertain. In 2006, the legislature gave ECU $3 million to plan the school. But the governor has proposed that funds for building it go into a bond issue, to be presented to the voters in November.
The House and Senate are still developing their budgets. On May 3, appropriations subcommittees proposed only $1 million for the dental school’s professional staff and $2.5 million for capital planning.
The school’s proponents stress that the school would be unique, designed from the ground up as a school that would reach out to rural, underserved populations. It would include 10 rural clinics partly staffed by fourth-year dental students. It would recruit students eager and willing to working in underserved areas.
A dental school at ECU would be “a step in the right direction,” said Burlington, N.C., dentist Steven D. Slott, because it would educate more dentists while also providing care for patients in the rural and underserved parts of the state. Slott’s practice serves primarily rural and Medicaid patients.
Not so fast, critics say. Many factors, from poor education to low Medicaid reimbursement, prevent people from getting dental care. Ten clinics scattered around the state would not make much of a dent, and whether graduates would actually serve those communities is an open question, the critics say.
“It will not address the problem,” said Ernest Goodson, an orthodontist in Fayetteville who has worked as a public health dentist. “The real issue is the maldistribution of dentists.” It’s impossible, he said, to keep a dental practice going in an underserved area, and a new school won’t change that. “A new school would be wasting a whole lot of money.”
Deciding who is right is difficult because there are few impartial commentators.
Lining up in favor of the dental school are the persuasive vice chancellor of oral health at ECU, D. Gregory Chadwick, who would head the school, the UNC general administration, which is also seeking state funds to expand the UNC-Chapel Hill dental school, and powerful eastern N.C. legislators. The most outspoken opponents are dentists.
Both groups reflect relatively narrow interests, rather than an objective assessment of the pros and cons for N.C. taxpayers, who would shoulder a big economic burden. The university system has asked the legislature for $87 million over the next two years to build the ECU school. Operating costs are expected to be an additional $15.6 million each year, although not all those funds would come from state appropriations. The university also wants $96 million to expand the dental school at Chapel Hill.
Regional support for the school reflects hopes that it will improve the economy of eastern North Carolina, as well as the health of the population. In contrast, many dentists are skeptical about the school, citing the high costs and uncertainty about its effectiveness. These dentists could have a lot to lose if ECU graduates set up private practice in the big cities, rather than go to rural areas. This would increase competition among dentists, who already report that their incomes are static.
So far, taxpayers’ and free market groups have been largely silent. At a meeting in March of the House appropriations subcommittee on capital, however, several legislators raised questions about the ambitious plans of UNC. The system wants hundreds of millions of dollars from the legislature for capital investments over the next decade, including the dental school expansions and a $244 million research campus in Chapel Hill known as Carolina North.
Background
The history of the idea of building a new school of dentistry is short. As recently as 2002, a study commission reported to the UNC general administration that a school at ECU was not warranted. The reasons cited were the high cost, a pending national shortage of dental faculty, the lag time before the first class would graduate, concern that there weren’t enough qualified N.C. students for two schools, and, most important, the report said, doubt that a new school would increase dental care to populations in rural and underserved areas.
Nor did a series of reports on access to dental care beginning in 1999 recommend a new dental school; it wasn’t until the 2005 update that a report even mentioned that a new school was under consideration. The reports, issued by the N.C. Institute of Medicine, made recommendations for increasing access to dental care ranging from raising the Medicaid reimbursement rates for dental services to requiring dental-student recipients of state financial aid to serve low-income patients. Medicaid pays private dentists 60 percent or less of market prices. The reports did not recommend a new dental school.
Even in late 2005, an article by the former dean of the UNC-Chapel Hill School of Dentistry, John W. Stamm, discussing an emerging shortage of dentists in the state, did not recommend a new dental school. He noted that the American Dental Association says that schools with fewer than 800 students tend to be inefficient. Chapel Hill has about 320 students and ECU would have 200.
The picture changed suddenly in March 2006. An advisory committee at ECU, appointed by ECU Vice Chancellor Michael Lewis, resoundingly endorsed a new dental school at ECU. The committee of outside experts “unanimously and enthusiastically” supported such a school.
Before the month ended, the UNC system itself was on board, with a cooperative plan that included a new oral sciences building at Chapel Hill. The Board of Governors approved the plan April 11, 2006, just in time to request and obtain from the legislature $7 million in planning funds to get the process going.
The Issues
The chief argument for the ECU dental school is that this one will be “different.” Unlike the dental school at Chapel Hill, which emphasizes specialized research, it will focus on “the education of general dentists to provide dental care and health policy leadership to North Carolina communities that have limited health resources and few other dentists, particularly specialists.” (The quote comes from the official plan presented to the UNC general administration Sept. 29, 2006.)
Fourth-year students will experience an “extended immersion in a dental clinic located in a rural community away from the ECU campus.” The 10 community-based clinics around the state are part of the school’s capital investment. Student recruitment will “target residents from rural and underserved areas who demonstrate a strong personal commitment to serving rural North Carolina as health care providers.”
The goals are ambitious, but major questions remain. Would fourth-year students’ immersion in the new clinics have a big impact on both dental care and the students’ “real-life” education? More critically, would graduates end up reaching “rural” and “underserved” populations?
Supporters point to the Brody School of Medicine at ECU. Founded in 1974, it emphasizes primary care, especially in underserved areas of North Carolina. According to the Sept. 29, 2006, plan, “More than 28 percent of BSOM graduates practice in rural North Carolina, which is over 50 percent more than the other publicly-funded medical school in the state.” Since the medical school at Chapel Hill graduates four times as many students, however, the actual number of BSOM graduates in rural North Carolina is smaller than the number of graduates of Chapel Hill.
Even if this percentage held true for dental students from ECU, it must be asked whether a 28 percent “success” rate would justify the costs of the school. It suggests that some anxious dentists might be right — most graduates would end up in cities. This might be good for consumers, but not for rural ones.
The ratio of dentists to population in North Carolina is lower than the national average — 4.4 dentists per 10,000 people, compared with the national average of 6 per 10,000, according to the Cecil G. Sheps Center for Health Services Research. The number of dentists has been growing, however. One reason appears to be a 2003 law that allows out-of-state dentists to obtain a license based on “credentials,” not on the state licensure exam. Thus, changes outside education, such as easier licensing rules and higher Medicaid reimbursement, might have a bigger impact on access to dental care than graduating more dentists.
But such changes might never come about without a new dental school. Slott, who supports the school at ECU, said he is tired of promises to do something about underserved populations. Such promises emerge when there is talk of a new dental school, but disappear when the talk goes away, he said.