Remembering 9/11

...not so sure...

In a previous post I mentioned how universal healthcare has been tested in the UK and in Massachusetts. We need change but not a goverment take-over of health care.

Invisalign Sets Quota, Infringes Patent

Align Technology, the parent company of Invisalign is in some hot water. It is estimated that 80% of current providers will not offer Invisalign next year. Infringing on the doctor-patient relationship, Align technology instituted a quota system effective June 1, 2009. The quota requires a minimum number of cases be submitted each year to continue as an Invisalign provider. They spin it as "proficiency" but it is certainly a quota.

Proficiency would best be maintained with a qualitative standard rather than a quantitative benchmark. For example, weeding out providers whose treatment outcomes are fair or poor rather than good or great would be a proficient measure. Clearly their wording is just "spin."

Limitations

Invisalign doesn't work for everyone. My dad and I have successfully been using Invisalign to straighten teeth while being extremely picky in case selection. My mentor has a background in the movement of teeth because he placed traditional braces for 15 years. Knowing the limitations of clear removable aligners, we limit our cases to the most predictable. We consequently have very good treatment outcomes.

In spite of limitations, Align Technology recently instituted a quota system. Limitations of Invisalign have been reported in recent studies from the American Journal of Orthodontics-Dentofacial Orthopedics (Jan. 2009). The study reports "the mean accuracy of tooth movement with Invisalign was 41%." The most accurate movement had a success rate of 47.1% and the least accurate movement was 29.6%. Clearly there are limitations.

Dentists Act

Dentists from across the country have been voicing concerns to each other and previously established advocacy groups. The American Dental Association and the Academy of General Dentistry have voiced their concerns to Align technology. The president of the AGD stated:

"The Academy of General Dentistry is very concerned about the imposition of case requirements by Align Technology. We have received many letters from our members stating their concern that a corporate entity is imposing proficiency requirements and moreover a minimum number of patient case starts without the science to substantiate their actions. We as an advocacy and educational organization for the general dentist are in the process of expressing our concerns with Align Technology and are pursuing possible further action regarding Align’s standing as a PACE approved CE provider."

Investors act

Investors have also reacted. Since the quota policy was effected on June 1, 2009, (the peak) the stock has dropped.

I am not willing to use a treatment modality when it is not in the patient's best interest just to keep some large corporation happy.

Point #1: Aligns quota system is ridiculous.

The fabrication process of Invisalign's clear aligners is quite amazing.

Unfortunately, the entire process infringes a valid patent originally filed in 2003 by Ormco Corporation. A jury ruled on the matter in the U.S. District Court for the Central District of California in late June. Align was found liable and their punishment was to be determined at a future date.

ORMCO Acts

A huge hit (-10%) came yesterday when Align Tech, gave an update on litigation involving the previous mentioned patent infringement. Ormco is going for the jugular. On July 13, Ormco filed to essentially stop all of Align's revenue producing activities (doctor certification, case activations, etc).

It will be interesting to see how this plays out. Watch for news after August 3rd and August 17th.

OTHER options

Luckily, for patients and dentists, there are other options that can accomplish the same outcome. Take Clear Correct for example. The add is a bit cheasy.

However, they got a lot of attention from providers, including myself, with this:

Welcome to Obamaland: I have seen your future and it doesn’t work

In a previous post¹ I mentioned my Spanish friend Blanca and her bout with infertility treatment, breast cancer, and reconstruction. I am so happy that she didn’t have to pay anything (aside from taxes). While universal healthcare works so well for some, we have to look at the big picture. We should not further burden our country with universal healthcare without looking at a few models. Take England and Massachusetts for example.

I recently learned about the UK’s National Health Service system through this book.² The clever title and cover, along with a summary that had me laughing audibly in the bookstore, made the purchase unavoidable, especially with all of the Obama hype.

As a Brit, Delingpole tells his personal experiences of terribly long wait times while in excruciating pain, terrible service, and a lower standard of care (increased MRSA, deaths). Working in healthcare I see patients everyday who put off necessary treatment due to insurance and finances. Although I wish more people could afford health care, universal government-run health care is not the answer.

Delingpole provided a very insightful perspective into government-run healthcare system:

• 95 billion pounds (£) are spent each year for their NHS (more than defense or education).
• NHS is the largest world employer after the Chinese army and Indian State Railway.
• Headline: [Foreign] visitor seeks heart transplant at British taxpayer’s expense That is a $100,000 procedure. Annual estimate of “health tourism” at 50-200£ million pounds.
• It is estimated that 15% of yearly cancer or stroke fatalities in Britain would survive if treated in any other European country.
• NHS responsible for 40,000 patient deaths per year.
• 55% of senior doctors pay for private medical insurance, avoiding exposure to NHS treatment.

Delingpole sums up Britain’s healthcare with this statement: “The service so costly it eats up the biggest part of your tax dollar, but so terrible that even in your hour of greatest need, you’d rather walk barefoot across hot coals then ever have to use it.”

Clearly there are glaring defects in the NHS of the UK. Our population is five times the population in the UK. If it didn’t work over there…maybe Massachusetts has done better. Apparently not.

Massachusetts in Suit Over Cost of Universal Care

The New York Times reports on Boston Medical Center, facing a $38 million deficit this year, its first loss in five years, and projecting a $100 million loss next year. The cause: Universal Healthcare.

“The central charge in the suit is that the state has siphoned money away from Boston Medical to help pay the considerable cost of insuring all but a small percentage of residents. Three years after the law’s passage, Massachusetts has the country’s lowest percentage of uninsured residents: 2.6 percent, compared with a national average of 15 percent. “The magnitude of the loss here can’t be solved on the program-cutting or expense-cutting side,” Mr. Traylor said. Professor Parmet said the hospital’s dissatisfaction with the new law should be a warning to Congress that “insurance alone doesn’t solve the problems” of the health care system. In fact, she said, it might exacerbate the financial problems of safety-net hospitals in the short term.”³

It sounds like it is not working in Massachusets either. What exactly are we looking at? Last year Obama estimated universal healthcare "will cost between $50-$65 billion a year when fully phased in."⁴ Delingpole assures it will cost at least 10 times that. Recently, we have seen cost estimates of $1.5 trillion over ten years.⁵

It is estimated that the “health care bill would increase the federal deficit by $239 billion over the next 10 years.”⁶
“Coming to America to feast on this cornucopia of freebies is the world. One million to 2 million immigrants, legal and illegal, arrive every year. They come with fewer skills and less education than Americans, and consume more tax dollars than they contribute by three to one.”⁷

We’d like to say that we are the most innovative nation in the world, that we can make a government run healthcare system work, that we can provide insurance for all Americans. We invented the television after all. The internet, the zipper, the microwave, even radiocarbon dating. However, there is one thing in common with all of the innovative inventions and success stories: free market capitalism.

Charge has been given to the government to run quite a few things including education and legislation, of course. We have seen what government run education has given us (which I don’t really blame the government except that they’ve given into a minority group of lefties who ruined for the rest of us. That will be a different topic.) Legislation? How about passing a 1071 page $790 Billion bill without reading it. Sure, I bet the government is up to the task of creating and managing a universal health care plan. Right….

1. http://theworldaccordingtojohnp.blogspot.com/2009/07/ever-want-to-punch-someone-in-face.html

2. http://www.amazon.com/dp/1596985887/?tag=googhydr-20&hvadid=2637583131&ref=pd_sl_63pinvwdg_e

3. http://www.nytimes.com/2009/07/16/us/16hospital.html?_r=3

4. http://www.salon.com/news/feature/2008/02/21/healthcare/

5. http://www.politico.com/news/stories/0709/25104.html#ixzz0LkytuL9m

6. http://www.foxnews.com/politics/first100days/2009/03/18/universal-health-care-cost-trillion/

7. http://www.wnd.com/index.php?fa=PAGE.view&pageId=104226

selling out…

I was in the 7^th grade. I walked into Blockbuster music and saw along the back wall a big blue album cover with four white dudes on the cover. Intrigued, I approached the listening station and listened to the entire cd. I begged my mom to get if for me which she did.

Every song was an instant hit for me. I had just discovered how to enjoy music the previous year when the messages in many of the Beatles love songs adequately voice my crush for another girl in the sixth grade.

Weezer had similar yet crunchier melodies that were very catchy. They were just what I needed for the 7^th grade. A couple years later when they finally came out with another album my taste in music had evolved a bit more. Again, I headed to Blockbuster music to listen to he 2^nd album. I didn’t hear the same melodies. The connections I had with the first album were nowhere to be found. I listened to 30-40 seconds of each song and put the cd back down. I later read in Rolling Stone magazine that Weezer had broken up.

I was disappointed as I had been hoping for a third-album-redemption.

Finally in the Summer 2001, I saw the green album available in some music store by NikeTown in Huntington Beach, listened to a few songs. When I got to the 4^th song, I knew Weezer was back. Since then I have enjoyed every album, with Maladriot being my least favorite. This is not about my enthusiasm for Weezer or their music. This is about “selling out.” What does that even mean?

People talk about musicians and bands “selling out.” It’s this horrible thing that a band does that just makes them “not cool” anymore. It is changing their music or core values or whatever to sell more music and make more money.

I don’t really get how anyone can label a band a “sell out.” How do you know they sold out? Musicians are people who are constantly changing just like we are. How can you expect their music to stay the same? Musicians have to put food on the table just like we do. Is it because he has a mustache now? Is it because the records went platinum?

Some people like to discover music and then abandon it when it becomes mainstream because they don’t want to affiliate with “people like that.” If the music goes mainstream it is because the musician sold out. I disagree.

Maybe a couple examples of sell-outs are Green Day and MXPX. Many people have said that Green Day sold out. From big time punk to mainstream focusing on “teenage girls” with love stories and plays? (Haven’t they always been trying to impress the girls?) MxPx shortened their name from Magnified Plaid and toned down their Christian content of the songs from their original album Pokinatcha. Their subsequent albums were also toned down and mellowed out. Did they sell out?

How many songs are written and recorded before the 10 or 12 are put on a final album? Why only those 10-12 songs? What is the strategy? Why not release all of the songs? You could say that they are now with Rivers solo stuff. Now, is that selling out or the opposite of selling out? Wouldn’t selling out just be putting out the best songs that are going to make the most money? Clearly some of the songs on these extra albums are not the best.

If music is good, it will become popular. Popularity should not be construed as selling out.

then again... i am just a sell out.

Ever Want to Punch Someone in the Face?

Have you ever met somebody who just knows they are right? And no matter what you tell them, they won't budge or concede?

The other day I had a new patient come in. He asked where I served my mission to which I replied. Spain, Bilbao mission. He said, "oh Spain.... that is a poor country." I am really an agreeable person.but I could not help myself. I had to disagree with him even at the risk of poor business practice. "Actually it's not," I said. He told me that I must have been in the wrong places.... I interrupted him asking him if he had ever been to Spain. "No, but my brother was there for three months. He just got back. "

"Spain is not a poor country. It is kinda 3rd-world-Europe, I told him. But everyone has running water and electricity. A stark contrast with this village high up in the Andes mountains of Peru.

It was pretty bad in the 60's 70's and even into the 80's, but they are in the EU and they don't have a dictator anymore."

I told him about my friend Blanca who was having trouble getting pregnant and underwent in vitro, TWICE before successfully giving birth to a beautiful little girl, then found out seven months later that she has breast cancer. She had double radical mastectomy, chemo, had the cancer go into remission. Now she has had reconstructive surgery. FREE. $0 out of pocket. All paid for, didn't cost her a dime. Socialized health care. I don't know how a poor country can afford that.

Towards the end of all of my debating points he said, well, they aren't the big empire that they were in the 19th century. Hmmmm. YA THINK? I gave him that but he still insisted that Spain is a poor country. I had to leave the room or I was going to sock him.



I lived in Spain for 2 years and had just been back a couple months ago to see friends. You won't really find unpaved roads or mass transit via golf carts like you would in San Pedro, Belize. You could probably get some people, happy to save a few Euros, lined up for free dental care. Good luck getting permission from the Spanish government to enter the country for such a purpose. Spain has a high standard of living and they take care of their own fairly well.

Many immigrants literally from around the world immigrate to Spain. Europe, Asia, Africa, South America. I met immigrants from Nigeria who made enough money to cook me up a good meal of Pounded Yam and soup.
Do you think, the eating conditions would be that good in Benin City, Nigeria? (I'll let you know after I've been there. btw, You don't see any forks because with this typical Nigerian dish you dip the Yam's into the goat soup with your fingers.)

Spaniards are for the most part extremely well dressed. They even have shoes!

I went into some very poor neighborhoods and still the standard of living was much greater than what is found in poor countries. Running water, electricity, shelter, food, clothing. Basic necessities were met. The only beggars were Gypsies and drunks. I have been lucky enough to be in Mexico, Guatemala, Peru, Belize. On a Rich-Poor spectrum these lean much more towards poor on the spectrum then Spain. Spain really cannot even be compared with them except in a futbol match or historical perspective. You could always recount Spain's King Juan Carlos urging Venezuela's rambling president (read: dictator),

"¿Por que no te callas?" (Why don't you shut up!).

Other than diplomatic political meetings Spain is really in a different league than the "poor" countries of the world.

Spain is not a poor country. They are in a recession but they have the "ninth largest economy by nominal GDP, and high living standards (16th highest HDI)." That being said, unemployment recently hit a record high 17% and is thought to surpass 20%. What are Spaniards doing to find jobs? "Raquel Riojas, 26, from Malaga, spends ten hours a day surfing internet jobsites" In poor countries, people start selling fruit on the streets, doing manual labor, not surfing the internet.

Maybe it's just me who is biased and stubborn....

IF you are thinking about getting IMPLANTS

Today I read a news-blurb about implant placement by endodontists. It's from the Journal of Endodontics Volume 35, Issue 7, Pages 966-970 (July 2009) and discussed whether or not endodontists should be able to place implants.

Endodontics is derived from the Greek words endo (inside) and odons (tooth). WITHIN the tooth. Not around the tooth. Not where the tooth was. WITHIN the tooth. Let's keep it that way.

Great endodontists do some of the best, most complicated and tedious treatment that exists in dentistry. I do not think we should distract them from their focus of saving teeth.

If you are an endodontist, you get the 6 canal molars, Z-shaped canal systems, separated files, calcified canals, and probably some junk that the GP thought he could complete and gave in to his supplicating patient who did not want to see the specialist. These procedures arguably require the use of a microscope to be completed within the standard of care.

Currently, oral surgeons, periodontists, and general dentists can place implants. If I were an endodontist, I would want to place implants too. Implant placement is much quicker than doing a molar root canal. It is also much more profitable. Molar endo can bring in anywhere from $900-1600, give or take depending on where you live. Implant placement can bring in $1600-3,000 and can be completed in half the time.

I can't imagine that endodontists are doing so poorly that they are looking to increase their scope of practice beyond their training and what they were originally planning on doing. Their overhead is among the lowest in all of dentistry. They can generally have a smaller staff inventory and office space. I have heard overhead figures of 40%. It is a great specialty and they put a tremendous amount of effort and time in their training and work (the good ones).

Let's say endodontists start placing implants. That will change dentistry in several ways. Overall, I think the number of root canals completed will decrease. That may not be a bad change, as I have seen some fairly questionable teeth "saved" by endo residents. The specialist/GP relationship will be further hampered which will lead to less referrals and increased advertising by endodontists. The quality and difficulty of root canals treated will diminish as residents put forth less effort mastering the techniques of endodontics and more effort towards implantology.

If endodontists can place implants, should they be able to do extractions? Restore implants? Where will it end? Are we coming full circle back to General Dentist?

If I question whether my endodontist is going to place an implant on a patient that needs to be referred for a complicated endo, I am going to (1)NOT refer the patient, extract the tooth, and place the implant myself.

If you chose to specialize, you voluntarily limited your scope of practice to the specialty of your choice. Don't alienate your specialty by overextending your scope of practice. Enjoy the great advances occurring in endodontics.