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Has the ADA Ever Mentioned Quality Control?

About My Tell-All Book?

By D. Kellus Pruitt DDS

One day, I’m going to write a tell-all book about quality control dentistry …  But, for all I’ve been told, it might be fiction.

The Quality Mandate 

Here’s something I find entertaining about the “quality” reporting mandate that was quietly written into HIPAA about the time President Clinton amended the 1966 Freedom of Information Act – making doctors’ records no longer proprietary business information. The 1996 HIPAA Rule is modular, and around every corner, we’ve learned there is an exploding surprise that was slipped into a thick bill long ago. The bolus technique of passing difficult legislation is not unlike the way the 2000 page healthcare reform bill was handled. It gets crap through the system too quick to be read, understood and debated by principals in healthcare who aren’t paying attention anyway. It’s a rule-making policy that simply favors stakeholders rather than doctors and patients. Depending on the campaign contributions, silliness can catch fire like a Madoff investment.

Dental Quality Compliance 

I don’t know about physicians, but dentists have never been warned about the quality control part of compliance. Now that it’s an integral part of healthcare reform’s imaginary funding, it’s a sure bet that no ADA official is willing to discuss the egregious blunder even anonymously.

ADA Department of Informatics

Soon enough, ADA members will learn about the clandestine quality control efforts of the ADA Department of Informatics – the brainchild of former ADA Sr. Vice President Dr. John Luther, who I hear is no longer part of the organization. Although I’m a persistent, nosey outsider peeking into a secretive not-for-profit organization (?), from what I can tell, the ADA’s interest in quality control began about 6 years ago following a visit to the ADA Headquarters by Newt Gingrich – which evidently favored the ADA Department of Dental Informatics with federal funding to replace dependence on finicky members’ dues. Had ADA members who were busy treating dental patients actually known the directions the ADA took the ADA’s mission statement for easy money, Dr. Luther’s career with the organization would have been even shorter.

Anonymous ADA Leaders 

Knowing that anonymous ADA leaders’ blunders no longer stay hidden forever, don’t you find the shyness of today’s dental leaders amusing? Don’t you just know the trusting early-adopters of interoperable eDRs will be pissed off when they discover that long ago, the ADA could have warned them about ambitious stakeholders’ plans for the profession?


Who’s going to break the sweet news to dues-paying members before CMS, insurers, and quality control consultants (today’s dental insurance consultants), are granted a back door to HIPAA-compliant dentists’ interoperable computers allowing access for real-time quality control authorities, as well as fraud, HIPAA, FTC and other inspectors working on commission? It’s a dark tale.


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8 Responses

  1. According to an ongoing poll on DR.Oogle Blog, more than half of dental patients believe dentists recommend unnecessary procedures to boost their profits.


    I don’t know about you, but I think that’s pitiful, but probably accurate.

    Darrel K. Pruitt DDS


  2. Dental Therapists could freeze in Alaska

    In the two years of dental education that dental therapists miss compared to fully-licensed dentists, what subjects do you suppose were deemed unimportant by stakeholders? Nobody is saying.

    “‘That model is not the solution’” by Craig Palmer’s was posted yesterday on ADA News and features a well-written letter voicing meaningful arguments against the cruelty of allowing inadequately trained dental therapists to perform oral surgery on the inconvenient poor in Alaska.


    Dr. Olga Gonzalez intended for her letter to be read at a focus group meeting convened by Moderators Etc., Inc. – which invited her to attend. She writes:

    “I do not subscribe to the premise that inferior care is better than no care at all. I believe the patient population with access to care issues, is also the population with limited economic resources, limited educational attainment, and more compromised medical histories. These are the most vulnerable patients, the poor, uneducated, disabled, and elderly. It boggles my mind that we should consider having this most vulnerable population treated by the least qualified provider, a dental therapist.”

    Unfortunately, the Chicago dentist was unable to attend the meeting due to a prior engagement, and Moderators Etc failed to present the dentist’s letter as entrusted. Once again, Doc, our side of the story was left out of yet another important discussion concerning our profession. Why oh why does the ADA not have a functioning Facebook? How could modern transparency possibly harm Americans more than misinformed focus groups?

    To consumers, a confident dentist’s work looks easy. And without the benefit of Dr. Gonzalez’s input, I assume Moderator Etc’s audience is still conveniently clueless about the economics of providing intricate handwork to exacting tolerances in sensitive mouths… and above all, providing the dentistry safely.

    Without including value as a variable in the discount equation, a focus group could be easily misled by unaccountable stakeholders’ promises that just seem too good to be true. Why is Alaska in a race to the bottom in quality of dentalcare for the poor?

    According to Becky Bohrer, writing for the Associated Press two weeks ago, “Resource-rich Alaska took in nearly $1.9 billion more than expected last fiscal year thanks largely to high oil prices and ended the fiscal year with an estimated $260 million surplus, an amount equal to nearly 4 percent of its general fund.”


    Nicaragua, Honduras and Guatemala are each doing much worse than Alaska, yet their laws don’t allow unlicensed dentists to perform oral surgery on their citizens. Why can’t Alaska take care of its poor in an affordable, humane manner instead of permitting scared high school graduates in the middle of nowhere extract large portions of teeth?

    Dr. Gonzalez told the ADA News: “I wrote the letter because I felt that with regard to the access to care problem, if anyone has something to say about it, it should be a dentist. That model is not the solution. There are too many chances for something to go wrong.”

    She says in the letter: “I recall treating a patient with developmental disabilities. In the course of preparing the patient’s tooth for a restoration, I detected a change in color, of the lips and gingival tissue. Immediately, I reacted and turned the patient on her side, suctioned her mouth, and was successful in getting her to start breathing again.”

    Dr. Gonzalez’s story grabbed my attention because I too have witnessed a similar emergency while on a dental mission in Nicaragua. An eight year old disabled dental patient with numerous dental problems became unresponsive during treatment. At one point, his life depended on quick, confident action by our members to get his heart beating before transporting him to a hospital in the bed of a pick-up. Fortunately, the child survived.

    The routine stuff in dentistry is easy when one is given adequate time to do the tedious work. It’s when rare, unexpected complications arise that the speed and quality of decisions based on medical knowledge separate the confident from the half-trained – who are more likely to freeze.

    A fireman’s knowledge of combustion is irrelevant until something important is burning.

    If the ADA had a functioning Facebook instead of an obscure, read-only website, I promise Dr. Gonzalez’s important message would have reached more than the ADA’s usual 46 readers without depending on my help. But I don’t mind.

    D. Kellus Pruitt DDS


  3. Access to Dental Care
    [A National Scandal?]

    With all of the attention paid to health reform, Medicaid and Medicare, one area of clinical need largely has been ignored: dentistry. Lack of access to this critical service is widespread, and the results can be devastating for both children and adults.

    Many programs are trying to fill the gap, but the challenge is daunting.


    Darrell – Is this really true?



  4. Jack Dillenberg DDS – The most dangerous dental school employee in the free world

    Thanks, Mary

    Emily Friedman’s description of the dental industry is the most balanced I have ever read – meaning she included a dangerously uninformed stakeholder’s opinion that I hope all Americans find viscerally disagreeable.

    The Dean of the Arizona School of Dentistry at A.T. Stull University in Arizona, Jack Dillenberg DDS, reached way beyond his expertise in dentistry, as well as liberty, when he confidently recommended a slippery solution to access to dental care. I hope alumni will remember Dean Dillenberg’s words long after his resignation:

    “We have to refuse to allow states to opt out of the adult dental benefit under Medicaid. I also believe that every dentist who has a license must take a minimum number of Medicaid patients into his or her practice to keep that license. Even if he or she went to a private school, if there were any public support of any kind for him or her or the school, this should be a mandate. The federal government should make the states require dentists to treat at least a low number of Medicaid patients.”

    Upon reading this, it suddenly occurred to me that there should also be a federal mandate forcing dental school deans to work at least a low number of weeks for the state for no pay.

    Like other publicly supported academians with unrealistic, even socialist solutions to access problems in dentistry, Dr. Dillenberg would generously force dentists, including the students who pay his salary, to donate their labor for the common good in the land of the free. As I said, Dr. Jack Dillenberg is a dangerous man.

    For one thing, capriciously depriving as many as 170,000 small business owners of their right to be paid a fair wage for their labor hasn’t happened in the western hemisphere since Fidel Castro “liberated” Cuba fifty years ago. Ominously, Dr. Dillenberg encourages lawmakers to require dentists to treat “at least a low number” of Medicaid patients. “…at least?” Who’s job will it be to determine the minimum number? Will dental leaders with Dr. Dillenberg’s generosity ever be satisfied?

    Suppose the worst possible happens, and the Dillenberg Mandate quickly gains popularity as a “painless” way for states to save money on dentalcare for the poor – attracting politicians far and wide who can promise constituents even more free healthcare for other parts of their bodies. Where will the involuntary donations to the state stop?

    Let’s not overlook the interests of the most important people in dentistry – the nervous dental patients. Most realize that dentists’ intricate handwork performed in sensitive mouths of dental patients cannot be rushed without causing bad things to happen. As the minimum number Medicaid patients dentists must treat keeps rising, painful, careless mistakes will be made as dentists attempt to work too fast – just to have time to treat paying customers who keep the doors to the small business open.

    Since nobody else is yet capable of being transparent about the heavily discounted end of the dentistry market, let me put this bluntly and get it over with: How well will poor children, who have no choice, be treated by rushed dentists who are frustrated because they must pay for the child’s dental problems due to a cruel mandate thought up by a former dental school dean? How many poor children will become scared away from dentists the rest of their lives. How many will instill their fear of dentists into their children as well? How much pain can one dentist cause?

    It’s immoral to force dentists to choose between working too fast or bankruptcy.

    D. Kellus Pruitt DDS


  5. CIO of NCQA replies again

    Finally, a public discussion about HIPAA, EHRs and dentistry.

    Rick Moore, Chief Information Officer (CIO) at the National Committee for Quality Assurance (NCQA) responded again in defense of HIPAA and EDRs. His response on the Linkedin group can be read here:


    I countered:

    Rick, you said in one paragraph, “The goal of HIPAA is not protect patient’s from “identity theft” — it’s to provide for information exchange and appropriate handling of PHI. However, I can certainly understand how someone that is not informed might think that ‘identity theft’ is the purpose of HIPAA.”

    Then in the next paragraph, you say, “The goal of HIPAA is to set in place appropriate protections of protected health information to avoid inappropriate use and/or unnecessary exposure/risk of PHI.”

    Once again, you got me. HIPAA is far more complicated than this dentist is capable of understanding.

    Compared to the gold standard of paper dental records, EHRs are both more costly and dangerous. What’s more, the lousy fit is undoubtedly true in far more medical disciplines than I suppose EHR stakeholders can yet afford to acknowledge. Trust me, Rick. It’s true by a long shot.

    As a matter of fact, in November, the CEO of CR Foundation – a well-respected dental research company – lost his job over spreading an unfounded rumor in a Dentistry iQ article that dentists can expect a “high return on investment” from EDRs. He was unable to produce evidence to support his claim when a dentist publicly challenged it. His blind enthusiasm and bias turned into a huge embarrassment for the Utah business which depends on the trust of providers. Nevertheless, he was ultimately held accountable for his words, and was replaced by Dr. Gordon Christensen, the co-founder of the foundation. I have to say, that kind of accountability is hard to find in the HIT industry.

    As for the liabilities of EHRs, besides the life-and-death danger I’ve already mentioned concerning imperceptively altered medical histories, if a dentist’s computer is stolen in a burglary, and the dentist does everything expected of him by HIPAA/HITECH, simply notifying his or her former patients can easily bankrupt the practice even before the HIPAA fines. The Ponemon Institute estimates the loss to be $200 per patient identity – $50 for the notifications and $150 for the lost reputation in the community.

    Believe it or not, my patients rarely ask me for copies of their dental records, and when they do, I hand them the information they want as paper copies of their records, as well as their x-rays. They don’t even have to sign any HIPAA forms. What could be more convenient than that? And you have to admit EHRs simply cannot match the safety of paper records. It’s the gold standard.

    As for you having to switch dentists twice in 4 years because of new preferred provider lists, I’m sorry to hear that. As a professional who understands dentistry far better than HIPAA, I should warn you that almost a decade ago, Delta Dental data-mined several years of claims and discovered that “Changing dentists causes fillings.” Have you experienced that phenomenon?

    Since you are CIO of the National Committee of Quality Assessment, perhaps you could persuade your colleagues to investigate whether patients who stay with the same dentist for a decade or so have better luck with their teeth than those who receive consistent care in only 12 month stretches – and from dentistry’s lowest bidders and no quality control.

    You’re in the quality assessment business. Off the top of your head, would you say that customers who are free to go elsewhere, but nevertheless choose to remain with the same dentist, enjoy higher or lower quality care than those who must move their records to a new preferred provider every couple of years?

    The concept has been called a “dental home.”

    D. Kellus Pruitt DDS


  6. Mandated EDRs?

    Q = Are EHRs mandated or not, ADA News?

    “If you are going to do something stupid again and again, then do it with enthusiasm” – Colette, French writer (1873–1954)

    Almost a decade after President Bush made the executive order that all health records will be digital by 2014, dentistry’s leaders appear to be still undecided whether dentists caught secretly using paper dental records will risk federal punishment. In the last 6 months, they’ve changed their minds twice.

    September, 2008:

    “The electronic health record may not be the result of changes of our choice. They are going to be mandated. No one is going to ask, ‘Do you want to do this?’ No, it’s going to be, ‘You have to do this.’” – ADA President-elect Dr. John Findley in interview for ADA News.


    January, 2012:

    “Dentists and their employees may have heard rumors of federal mandates requiring dentists to adopt electronic health records (EHRs), or implement ‘paperless’ offices by 2014. Another rumor implies that dentists must be able to create and transmit digital radiographs (which are important EHR capabilities) by 2014. There are no such mandates or deadlines for dentists who do not submit claims to Medicare, or who do not see large numbers of Medicaid patients.” – ADA News article.


    May, 2012:

    “Dentistry has joined a growing list of domains, including cardiology, eye care, patient care devices, radiation oncology, anatomic pathology and several others, in preparing for the legally mandated transition from paper records to electronic health records.” – ADA News article


    So which ADA message should dentists believe the most? The majority opinion? If “legally mandated” mentioned in the May article by staff writer Jean Williams means that dentists can actually read the law, including how HHS intends to enforce paperless practices, is there a link to that information?

    If reliability is out of the question, Colette suggests enthusiasm is the next best thing.

    D. Kellus Pruitt DDS


  7. The ADA’s Dental Quality Alliance – Quality control, cost control or simple tyranny?

    “The ADA was asked in 2008 by CMS to be the lead agency in forming the DQA, with an initial charge of creating programmatic measures for children’s dental Medicaid plans. It is comprised of multiple stakeholders from across the oral health community who are committed to development of consensus based measures.” (See “DQA accepting proposals to test measures” by ADA reporter Kelly Soderlund, ADA News, August 13, 2012).


    Actually, in the 2008 address to the ADA House of Delegates, HHS Secretary Michael Leavitt put it much more bluntly than Soderlund leads dentists to believe: “If you don’t get a handle on quality control my MBAs will.”

    The government official’s threat to US citizens reminds me of a quote by Thomas Jefferson: “When governments fear the people, there is liberty. When the people fear the government, there is tyranny.” Not unexpectedly, our spineless ADA leaders capitulated to DQA cost control measures as quietly as they surrendered my profession to HIPAA and EHR vendors – once more favoring stakeholders over dues-paying members, the Hippocratic Oath and the ADA mission.

    Dr. Christopher Smiley, DQA chair, tells ADA News: “Quality measurement has been present for some time in medical care and it’s evolving in oral health care. This is going to impact not only public pay programs such as dental Medicaid and federal Children’s Health Insurance Programs but it will likely extend into private pay benefit plans through regulations of the health care exchanges.” Must American dentists fight against ambitious ADA bureaucrats in addition to the other self-serving stakeholders they invite to interfere with doctor-patient relationships?

    When the ADA-approved online report cards appear, dentists will be identified by voluntary but permanent NPI numbers which were promoted by ADA leaders and Delta Dental. It will be interesting to compare stakeholders’ favorite dentists with patients’ favorites as listed on doctoroogle.com.

    Doc, who would you really prefer to determine your value to society – patients you have pleased for years, or “multiple stakeholders” armed with your dental claims and a national report card? Since dental patient’s opinions have already been discarded as unreliable by the DQA, how do you feel about Dr. Smiley, Delta Dental and Leavitt’s MBAs determining your pay scale instead of the free market?

    I cannot think of a quicker way for the American Dental Association to become even more hated by a growing number of American dentists. What a disappointment to the profession.

    D. Kellus Pruitt DDS


  8. Meaningful, patriotic busywork

    Is Meaningful Use of EDRs just meaningless busywork? The ADA’s silence shouts yes indeed!

    Doc, do you know what data HHS demands that dentists collect and document to prove Meaningful Use of the certified electronic dental records (that dentists pay for)? I watch the EDR industry closely and I still haven’t a clue.

    The ADA’s notoriously unreliable advice concerning EDRs – including recent serial reversals of opinion whether they are required by law (which they are not) – has permanently damaged the organization’s credibility with dentists. That’s why very few paid attention to ADA President Dr. Robert Faiella’s recommendation last month that we purchase certified electronic dental records so that like physicians, dentists also can participate in the HHS’s “Meaningful Use.”


    “Along the way we are making sure we are involved in the certification of compliant systems, developing standards specific to dentistry, educating our members as the process moves along, and keeping liaison relationships with other standards organizations so we have input as things develop. Certification is an important piece, and assures the standard will lead to interoperability.” Why, Dr. Faiella?

    If the ADA President and other dentalcare stakeholders in academia are developing specific Meaningful Use standards for practicing dentists to adopt, and if they are also “educating members” about their work, why is there is still nobody a dentist can to turn to who can describe Stage 1 and Stage 2 requirements?

    So what do physicians, who certainly need EHRs more than dentists, think of Meaningful Use? Dr. Annie Marie Valinoti, an internist in private practice in Bergen County, N.J., posted her opinion in the Wall Street Journal last week: “Physician, Steel Thyself for Electronic Records – Who’s got time to listen to patients when the government demands ‘meaningful’ data entry?”


    “At first I thought EMR sounded like a good idea. Then our practice started using one.

    Tasks that once took seconds to perform on paper now require multistepped points and clicks through a maze of menus. Checking patients into the office is an odyssey involving scanners and the collection of demographic data—their race, their preferred language, and so much more—required by Medicare to prove that we are achieving ‘meaningful use’ of our EMR. What ‘meaningful use’ means no one knows for sure, but our manual on how to achieve it is 150 pages long.” Is that what you want in your practice, Doc?

    Less than a week ago, Accenture reported that according to their recent study, “More than half of doctors (53 percent) cited electronic medical record requirements as a main reason for leaving private practice.” It’s time to wake up, Doc.


    Outside the impenetrable walls of ADA Headquarters, it’s common knowledge that EHRs are a huge disappointment. With no added efficiency, they have already increased medical costs substantially, including the waste of billions in taxpayers’ stimulus dollars. Americans have been had. And if truth be told, I imagine the waste privately embarrasses even the undaunted Dr. Robert Faiella, who nevertheless continues to bravely promote Meaningful Use in spite of nonsense blossoming all around him. I’d like to think the man is driven by heart-felt patriotism, because it sure isn’t the Hippocratic Oath.

    The instant Dr. Faiella reveals dentists’ Meaningful Use requirements, the busywork will prove that ambitious stakeholders have wasted millions of dollars serving their own interests rather than dental patients’.

    D. Kellus Pruitt DDS


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