John Comisi, DDS, MAGD.

• Why should "... dentists [be] included in the study as one of the alternative providers -- which they actually are ..."? This statement is interesting, since I always considered myself as THE principle provider of dental care, not an alternative, just as physicians are the principle provider of medical care. There are, in my opinion, auxiliaries to providing care that supplement and complement the care that is supervised and directed by the doctor (be it physician or dentist). Personally, I know that I work more effectively and efficiently because of these important and valuable team members, but I am the principle provider and not an alternative.

• If it is "so well-known" that dentists are the least able to provide care to the underserved, it would seem logical to provide the numerous list of references to back up his assertions.

• The diagnosis, interpretation, and implementation of care for patients need to have a responsible party involved in the process. Typically, this responsibility resides with the doctor. This is true in both the medical and dental models. The ultimate liability for improper care always comes to rest with the doctor. If the dental health aide therapist (DHAT) or dental therapists (DT) model is to be accepted, then that liability will then need to rest solely with those practitioners. It doesn't matter how many years of education any provider of care has -- there is a standard that must be met. If it is done by a doctor, hygienist, DHAT, or DT, the standard of care must be met, and the liability will be present in all situations.

• From a "business" perspective, the costs of business loans, rent, electricity, phone, equipment, supplies, etc. will be a constant. If the cost for running the business, ANY business, outweighs the income generated, the business just will not be able to stay viable and will no longer be able to serve the population it was intended.

• Of the modalities discussed -- private practice and community health centers -- only one of these requires personal risk. Community health centers are created and funded by the taxpayer base. This is the only way for these entities to exist, and in our current economic climate, is there really a long-term source of funding that is going to be available? Are private corporations going to become an integral part of the provision of healthcare? Is their bottom line going to be patient-focused or profit-focused?

• Medicaid reimbursement rates have not kept pace with the cost of doing business in dentistry. No business can afford to do business at a rate that will not enable it to stay in business. There is no appreciation in government for dentistry. They only see it as a "throw away" part of the medical model. There is no value to them, even though they claim to be concerned about the perceived lack of dental care provided. Yet not one of them wants to provide sufficient reimbursements to provide this care. I would suggest that they take a closer look at this. If you were to pay appropriate fees for the care rendered, do you truly believe that there would be a lack of providers?

Finally, as an ADA member, I believe they have provided insight to the mechanism of business and the problems that will likely arise when, and if, this midlevel provider system gets established. Thank you to the ADA!

John Comisi, DDS, MAGD, has been in private practice in Ithaca, NY, since 1983. He is a graduate of the Northwestern University Dental School and received his Bachelor of Science in Biology at Fordham University. He has lectured nationally and internationally, and has contributed to a variety of journals, including General Dentistry, Compendium of Continuing Dental Education, Dental Product Shopper, Dental Products Report, Oral Health Journal, and Inside Dentistry.

Dr. Comisi is a member of the ADA, Academy of General Dentistry, American Equilibration Society, International and American Associations of Dental Research, and National Dental Practice Based Research Network.

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