Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice.

FRAMING HEALTH MATTERS

Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice Richard J. Manski, DDS, MBA, PhD, Diane Hoffmann, JD, MS, and Virginia Rowthorn, JD

In recent years, advocates for increasing access to medical and oral health care have argued for expanding the scope of practice of dentists and physicians. Although this idea may have merit, significant legal and other barriers stand in the way of allowing dentists to do more primary health care, physicians to do more oral health care, and both professions to collaborate. State practice acts, standards of care, and professional school curricula all support the historical separation between the 2 professions. Current laws do not contemplate working across professional boundaries, leaving providers who try vulnerable to legal penalties. Here we examine the legal, regulatory, and training barriers to dental and medical professionals performing services outside their traditional scope of practice. (Am J Public Health. 2015;105:1755–1762. doi:10. 2105/AJPH.2015.302654)

Recent scholarship and advocacy on improving access to medical care and dental care in the United States have focused on expanding the scope of practice of advanced-practice nurses and allied health professionals, allowing them to do more clinical care. Until recently, however, little attention has been given to expanding the scope of practice of dentists to do more primary health care or of physicians to do more oral health care.1---4 Notwithstanding the public health advantages of expanding the roles of dentists and physicians, state practice acts, standards of care, and professional school curricula are all designed to support the historical separation between the 2 professions. Here we examine the legal, regulatory, and training barriers to dental and medical professionals performing services outside their traditional bailiwicks and recommend ways to expand roles for medical and dental providers to improve access to oral health care and overall health care in the United States.

BACKGROUND The motivation to increase the role of physicians and other medical providers in providing oral health services is driven primarily by limited access to dental care in the United States, particularly among certain populations.5 Although the aggregate number of

dentists in the United States may be sufficient to meet the oral health needs of the US population, according to the Pew Charitable Trust, 2 factors contribute to inadequate access to dental care for certain groups, especially for children: (1) an uneven geographical distribution of dentists nationwide that leaves individuals in some rural and inner-city communities with an inadequate supply of dentists and (2) the relatively small number of dentists who participate in the Medicaid program.6 Special populations such as the elderly, people with disabilities, individuals with HIV/ AIDS, and institutionalized people face significant barriers to obtaining dental care.5,7 According to the US Department of Health and Human Services Health Resources and Services Administration, it would take nearly 9500 additional dental practitioners to meet the current oral health care needs of our nation,8 but dental schools are graduating fewer dentists than would be required to replace those who retire each year.9,10 Lack of access to dental care among poor children is of particular concern to advocates, because of the importance of establishing good oral health at an early age. Nationally, only 20% to 30% of children aged 2 to 5 years are seen by a dentist yearly,11 and many children with access to dental care through Medicaid are unable to receive treatment because of

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a shortage of pediatric dentists and of dentists who accept Medicaid patients, because of low reimbursement rates.11 This shortage was highlighted by the well-documented case of Deamonte Driver, a 12-year-old African American boy from Prince George’s County, Maryland, who died in 2007 from a brain infection caused by an abscessed tooth.12 His death spurred officials in Maryland and across the country to make dental care more available to low-income children. Nonetheless, significant gaps remain in dental services to children in the United States. The passage of the Patient Protection and Affordable Care Act (ACA), which contains several provisions targeted at improving oral health, has also increased awareness of the need for more oral health care providers. Perhaps the most important of the act’s provisions is a requirement that most health plans cover a set of essential health benefits, including pediatric oral care.13 Pediatric oral care must also be covered by basic health plans14 and plans available to most people eligible for Medicaid under the new Medicaid expansion.13 In addition, the ACA prohibits insurers from imposing cost sharing on some preventive oral health services, including oral health risk assessments and fluoride supplements for children whose water source does not contain fluoride.13 An estimated 8.7 million children will gain access to comprehensive dental benefits by 2018 through the ACA, a 15% increase since 2010.15 This increase in new beneficiaries of dental coverage will be split evenly between Medicaid, health insurance exchanges, and employer-sponsored insurance.13 Although the added coverage will reduce the number of children without dental benefits by about 55% relative to 2010 levels, the impact of the ACA on adult dental care will be mixed.13 An estimated 17.7 million adults will gain some level of dental benefits in 2018, but nearly all of the projected increase will be from

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expanded Medicaid coverage.13 Although some adults (4.5 million) will gain extensive Medicaid dental benefits, three quarters of the estimated increase in adults with dental benefits will occur in states that provide only limited or emergency dental services to adults enrolled in Medicaid.13 Because adult dental benefits are not mandated under Medicaid, they are vulnerable to future budget cuts. Also, only a small number of adults (800 000) are expected to gain private dental benefits on the exchanges.13,16 Adults who previously received their dental insurance through their employer will have less coverage under the ACA, some experts predict, because insurers are not required to offer adult dental coverage and adults are not required to purchase it when it is offered.16 Overall, the ACA is expected to result in a substantial increase in the number of children with dental coverage and a small decrease in the number of adults covered by dental benefits relative to 2010 levels.16 Increased overall coverage and subsequent increased demand for dental care services, especially among children, will further aggravate the current problem of access to oral health care and further strain the current dental workforce.

PHYSICIANS PROVIDING ORAL HEALTH SERVICES The well-documented and ongoing crisis in access to dental care in the United States has prompted some prominent medical and public health organizations to call for physicians and other nondental health care providers to provide some oral health care services.2,5,17,18 For example, the 2011 Institute of Medicine report, Improving Access for Oral Health for the Vulnerable and Underserved, recommended that the Health Resources and Services Administration convene key stakeholders to develop a core set of dental competencies for nondental health professions to be incorporated into certification, testing, and accreditation requirements.5 A core assumption of the project, as expressed in a 2014 report, is that “[o]ral health and systemic health are interrelated in that overall health includes oral health.”2(p8) There is good reason to lean on the medical field to improve access to oral health care. Physicians see and treat young children much

more frequently than dentists do.11 One study found that the use of ambulatory health care in a physician’s office during the first year of life and from 1 to 4 years is 78% and 84.1%, respectively.11 The use of dental care provided by a dentist for these same age groups is 0% and 19.2%, respectively.11 Efforts to incorporate some oral health care into the primary care setting have been promoted and advanced by health care providers and state Medicaid programs. For instance, the US Preventive Services Task Force released a draft recommendation in 2013 that primary care providers be trained to provide fluoride varnish in an effort to prevent dental caries in young children.3 As of 2009, 34 state Medicaid programs provided reimbursement to physician primary care providers for providing preventive oral health care services to children.4 These included the application of fluoride varnish,19 caregiver education, risk assessment, and oral examination and screening.4 Several dental and health care organizations are also recommending that oral health be included in a patient’s medical home to fully integrate oral health care into overall health care.20---23 A recent report by the Dentaquest Foundation set forth a continuum of possible collaboration and integration models, which range from dental and medical practices operating separately in separate locations to integrated practices operating in the same location.24 One of these models, the Early Childhood Oral Health program, would incorporate oral health care into the primary care setting for a Medicaid population. Under this approach, primary medical care providers would screen patients for dental conditions and refer them to on-site dental professionals. The model would be funded by the increase in dental revenue that would result from referrals of children of all ages from pediatricians and family practices to the dental clinic, and the dental professionals would reimburse the medical side of the practice for the referrals.

DENTISTS PROVIDING MEDICAL SERVICES In just the same way that physicians are making incremental inroads into care that has traditionally been provided by dental professionals, dentists are already helping

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patients with some medical concerns typically addressed by physicians. Although the public health forces behind enhancing the medical services provided by dentists are not as strong as those pushing to include oral health care services in the medical office, there is a movement to recognize the systemic health training and capabilities of dentists, and surveys reveal support among patients and physicians for enhanced medical care in the dental setting.25 This is particularly true for health conditions that are principally or initially manifested in the oral cavity. In the interest of improving the health care system’s ability to provide early diagnosis for certain health problems, many public health officials support the role of dentists in screening, diagnosis, and even treatment of certain medical conditions.26---28 Examples include sleep apnea, diabetes, hypertension, oral cancer, and HIV. Sleep apnea is a condition normally treated by sleep physicians with the use of a standard continuous positive airway pressure machine, but in the past 2 decades, dentists have become more involved in the treatment of sleep apnea.29---31 Up to 50% of sleep apnea patients are unable to use the airway machine successfully, which has given rise to the growing field of dental sleep medicine and the use of oral appliance therapy (OAT). OAT uses an oral appliance (similar to a mouth guard) that is selected and fitted by a dentist to help keep a patient’s airways unobstructed. Dentists are advised by the American Academy of Dental Sleep Medicine to assist in the screening of patients who might be suffering from sleep apnea and to work closely with a physician who can diagnose sleep-disordered breathing and refer the patient to receive OAT from a dentist.32,33 Diabetes, hypertension, and oral cancer are other conditions that dentists can help detect and treat. All have a link to oral health care but often have other, more systemic symptoms. People with diabetes are at higher risk than others for gum disease (periodontal disease), which can ultimately result in tooth loss.34 Patients with diabetes are also more prone to infections because the disease compromises their immune system, causing them to be more susceptible to oral infections.34 Dentists also play an important role in

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helping to identify patients suffering from high blood pressure, because blood pressure values must be obtained prior to certain dental procedures that require anesthesia.35,36 Some high blood pressure medications cause oral health problems.37 Dentists have long been actively involved in screening and diagnosing patients for oral cancer.38 They refer patients with symptoms of oral cancer to their primary care provider or to an oral surgeon or oncologist. A more recent foray of dentists into the medical field is in the area of HIV testing. The first health care professionals to come across visible signs that a person is HIV positive are often dentists and dental hygienists.39 Oral symptoms are typically the first symptom of HIV infection and may signal clinical progression of the disease.40 With the advent of easy-to-use and rapid noninvasive saliva, blood, or plasma screening tools, such as the OraQuick Advance Rapid HIV-1/2 Antibody Test, dentists can easily screen patients for HIV.40 Some researchers recommend screening high-risk patients for HIV/AIDS as part of their dental care; others recommend providing HIV/AIDS screening to all dental patients unless they opt out.39 Researchers who analyzed data from the 2005 National Health Interview Survey found that an estimated 3.6 million Americans reported that they were at significant HIV risk yet had never been tested for the disease.39 Three quarters of this group had seen a dentist in the previous 2 years, indicating that the dental office represents an opportunity to identify seropositive individuals and link them to care.39 Some dentists and dental school clinics are already moving ahead with screening of patients for HIV/ AIDS.41

BARRIERS TO PRACTICE EXPANSION The movement to expand the practice of dentists and physicians and find areas of overlap is growing, but some hurdles must be overcome. For many reasons—historical, medical, and cultural—the dental and medical professions seldom collaborate and do not venture into one another’s traditional practice territory. These historical barriers have been formalized through state laws and regulations governing

licensure, scope of practice, and professional education.

Scope of Practice A fundamental barrier to practice expansion is the existence of state professional practice acts. Regulation of health professionals has typically been left to the individual 50 states, and each state regulates health care professionals who practice in that state through practice acts, which are statutes passed by state legislatures that define the scope of practice of a profession within the jurisdiction, outline licensing requirements for the profession, and establish penalties for violations. Physicians and dentists operate under different practice acts. Although practice acts vary state by state, typically all applicants for licensure must meet 2 basic requirements: graduate from an accredited professional school and pass a written examination. Dentists must also pass a clinical examination. Practice acts also create boards composed of practitioners and consumers. Boards are charged with licensing, regulating, and disciplining professionals within the scope of the applicable practice act. A primary purpose of a state practice act is to ensure that only licensed practitioners perform the defined tasks of a particular profession, to protect the public from unprofessional, improper, unlawful, fraudulent, or incompetent practice. Although statutory language varies from state to state, as would be expected, dental practice acts typically limit the scope of practice of a dentist to procedures in the oral cavity involving teeth, gums, and jaws.42,43 Each state also has a medical practice act that defines the practice of medicine and delegates the authority to enforce the law to a state medical board. Practice acts typically define medicine as engaging, with or without compensation, in medical diagnosis, healing, treatment, or surgery.44 Medical practice acts can be thought of as umbrella acts, allowing physicians to perform many functions that are permitted under other practice acts, such as nursing, dentistry, and chiropractic. These other areas of practice are essentially carveouts from the practice of medicine. No legislature has formalized a prohibition against physicians performing oral health services, although in 13 states (Alabama, Colorado, Delaware, Kansas, Kentucky, Maine,


Maryland, Mississippi, Nebraska, Nevada, Ohio, Tennessee, and Virginia), dental practice acts prohibit a physician from practicing dentistry as a specialty without a dental license. Because medical practice acts do not exclude oral health services, it is clear that, under current law, physicians can administer treatments and services that have historically been provided by dentists as long as the state dental practice act does not specifically prohibit physicians from performing them. Some dental practice statutes explicitly allow physicians to extract teeth, although at least 1 that allows this practice also stipulates that a physician cannot create or restore lost or missing teeth.45 In an example of this broad understanding of what it means to practice medicine, Maine, a state with a severe shortage of dentists, since 2005 has allowed the Maine Dartmouth Family Practice Residency to train primary care doctors to extract teeth and perform other basic dental procedures. Similarly, the University of New Mexico School of Medicine runs a yearlong residency program for dentists, and medical residents are allowed to participate to learn basic dentistry. Scope of practice is a significant barrier to practice expansion, because professionals who practice outside their scope of practice risk criminal prosecution and monetary penalties. When a licensing board becomes aware that an unlicensed individual is performing services that are within its purview, it can investigate and if necessary charge the individual with unauthorized practice. Boards can also take action against a licensed provider who performs services not authorized by the provider’s license. Because the unauthorized practice of medicine or dentistry can result in a criminal sanction or significant monetary penalty, health care providers are generally careful to work with patients within their state’s defined scope of practice and may be wary of practice expansion unless scope-of-practice issues are resolved. Although medical and dental practice acts are generally clear in what they allow professionals to do in the daily course of business, in some areas, such as medical emergencies and patient screening, practice acts are less explicit. Dentists are trained to provide emergency medical treatment of a range of medical emergencies in the dental office, and most states



require that dental offices have a medical emergency plan in place.46 By allowing and expecting dentists to provide emergency care, state statutes recognize the ability of dentists to take part, at least to some degree, in medical care that goes beyond the oral cavity. In the absence of this assumption, dentists would have to practice in or near hospitals where physician-provided emergency care was available. The emergency conditions that dentists are trained to manage include d

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airway obstruction; asthma, bronchospasm, and chronic obstructive pulmonary disease; cardiac arrest; cerebrovascular accidents and transient ischemic attacks; chest pain, angina, and acute myocardial infarction; and heart failure and pulmonary edema.47

All 50 states have some form of Good Samaritan law that protects individuals and health care providers who provide good-faith emergency assistance when proper emergency care is not available.48 Many state Good Samaritan laws specifically include dentists in the category of health care providers who are protected by the law when they provide aid to strangers. Some Good Samaritan statutes that do not mention dentistry include it implicitly by providing protection from liability to all licensed health care professionals. Dentists have also been recruited for emergency preparedness and vaccine administration.49 These laws represent implicit recognition of the broad health care skills of dentists. Although state practice acts are largely intended to protect the public from incompetent health care providers, they also serve to protect the economic interests of health professionals.50,51 Historically, dental and physician boards have pursued several cases against allied and other health care providers for the unauthorized practice of medicine or dentistry, but relatively few cases have been brought by medical boards against dentists,52 and, as would be expected, even fewer by dental boards against physicians, for unauthorized practice.53,54 Current issues raising concerns for some medical boards are the use by dentists of Botox and dermal fillers to treat maxillofacial trauma or dental and orofacial problems and

pain or for cosmetic purposes and what types of cosmetic surgery oral and maxillofacial dental surgeons can perform.55 Perhaps medical boards have paid less attention to dentists than to other professional groups encroaching on physicians’ scope of practice because dentists have not aggressively attempted to enter into medical practice areas. To the extent that dentists try to change scope-of-practice laws to allow them to undertake more general health care, they may be assisted by previous efforts of such groups as advanced-practice nurses, who have made significant inroads into expanding their scope of practice at the state level and have also gained the support of the Federal Trade Commission, which recently suggested that state legislators consider the anticompetitive effects of proposals to limit the scope of practice of these highly educated nurses.56,57

Standard of Care Practice acts are not the only legal framework under which dentists and physicians provide care. For clinical and legal reasons, health care providers must also meet the standard of care for their profession. From the clinical perspective, the standard of care is the care that is appropriate in a given situation according to clinical practice guidelines, scientific evidence, and other practice standards. From a legal perspective, the standard of care expected of a health care professional is the care that an ordinary, prudent professional with the same training and experience would provide under the same or similar circumstances.58 To prevail in a medical malpractice case, a plaintiff must prove that a health care provider failed to meet the standard of care—in other words, provided care that was below what would be expected of a similar practitioner confronted by the same situation. The standard of care is a critical concept in the discussion of dentists and physicians and their respective scopes of practice. Even if a medical practice act were broad enough to allow a physician to perform a certain dental procedure, the physician would have to be able to perform that procedure at the standard of care expected of others performing the same procedure. A physician who performed a dental procedure but lacked the requisite ability


and harmed the patient could be found negligent in a malpractice case. Therefore, alongside statutory or regulatory strategies to expand the work of health care providers beyond their traditional boundaries must come proper training to ensure that providers are able to meet the appropriate standard of care for their new role.

Dental and Medical School Curricula Professional training is designed to prepare students to pass licensing examinations and to meet the standard of care when they move into practice. If dentists and physicians are to perform tasks historically practiced by each other’s professions, dental schools and medical schools will have to modify their curricula to reflect the expansion of both professions. Although some changes will be necessary, current medical and dental school curricula already have some overlap. A 2005 study that compared competencies across 3 major health professions (dentistry, nursing, and medicine) found significant overlap in training.59 In the case of medicine and dentistry, the study found a 25.4% partial or total overlap between 63 dental competencies and 30 medical learning objectives. Curricular overlap and joint learning between professions is common in countries where professional studies start at the undergraduate level. In many European countries, dental students learn alongside medical students for part of their education.60,61 In Hungary, for example, dental students spend the first 2 years of their studies with medical students, giving them a broader foundation in nondental health care. In addition to recognizing the advantages of a shared curriculum, some dental educators and public health leaders advocate expanding the dental school curriculum to include more clinical training in the delivery of primary health care. New Models of Dental Education, a 2006 study by the Macy Foundation, funded in part by a grant from the National Institute of Dental and Craniofacial Research, convened experts to examine issues related to the dental curriculum.62 The resulting report delineated opportunities for expanding the concept of diagnosis in the dental office as a means to identify a host of oral and systemic disorders. The report concluded that this process would need to begin with changes to the dental school



curriculum and clinical education to ensure that dentists d d

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can diagnose oral diseases, with new technology and computer-based programs to augment decision-making; have knowledge of systemic diseases that modify oral diseases; can diagnose systemic diseases that can be affected by oral diseases; and can conduct health care screening and interventions in the dental office.

Some dental educators have suggested that dentists be called oral physicians. Donald Giddon, a professor at the Harvard School of Dentistry, urges the use of this term to acknowledge that dentists have general knowledge of the structure and function of the entire body, along with their special expertise in the oral cavity.63,64 He also argues for the expansion of dentists’ primary care functions to meet public health needs not addressed by other providers. However, he acknowledges structural issues that need to be resolved first, including that dentists may be unwilling to provide services for which they may be trained but which the public does not want them to perform and that patients may not want to compensate them for services not ordinarily expected of dentists. Although more study is needed about the public’s comfort level with dentists providing health care not related to the oral cavity, in at least 1 survey, a majority of respondents supported the concept of medical screening in a dental setting and expressed willingness both to undergo screening tests and to discuss their results with a dental team.25 Conversely, other groups are recommending more oral health training for physicians and other health care providers.65 In response to the Institute of Medicine’s recommendation, the Health Resources and Services Administration developed the Integration of Oral Health and Primary Care Practice initiative in 2011, which published a starter set of 5 domains representing core clinical competencies for physicians in the area of oral health: d

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risk assessment (to identify factors that affect oral health and overall health), oral health evaluation (to integrate subjective and objective findings of a focused oral

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health history, risk assessment, and clinical oral screening), preventive interventions (to recognize options and strategies to address oral health needs identified by a comprehensive risk assessment and health evaluation), communication and education (to communicate with and educate individuals and groups regarding the relationship between oral and systemic health, risk factors for oral health disorders, effect of nutrition on oral health, and preventive measures to mitigate risk on both individual and population levels), and interprofessional collaborative practice (to understand the relationship between oral and systemic health and collaborative measures to mitigate risk on both individual and population levels).2

The push to include oral health care in the overall practice of medicine is also happening on other fronts. A program at Northeastern University Bouvé College of Health Sciences, funded by the DentaQuest Foundation, is building oral care training into nursing, pharmacy, and physician assistant degree programs to integrate oral health care into comprehensive health care and ensure the “involvement of all health care professionals in oral health promotion and disease prevention.”66 To remove barriers to practice enhancement of both physicians and dentists, changes will need to be made—almost simultaneously—to practice acts and medical and dental curricula.

PUSHING THE LEGAL BOUNDARIES OF SCOPE OF PRACTICE Many believe that dentists should take a greater role in screening for certain medical conditions, such as cardiovascular disease and other chronic diseases, and, according to at least 1 national study, they would be willing to do so.67 Because such screening is not addressed in the medical practice acts, arguably it is not the unauthorized practice of medicine and is a potential area for expansion by dentists. Scope-of-practice and standard-of-care requirements stand in the way of expanding the roles of physicians and dentists, particularly those of dentists. The principal barriers to dentists expanding their scope of practice are


state dental and medical practice acts. Although state practice acts clearly prohibit dentists from diagnosing or treating medical conditions, exceptions are made in some situations, such as emergencies. Strong arguments can be made for expanding the exceptions beyond emergencies to allow dentists to do more diagnosis and treatment in health professional shortage areas if a physician is not available. Examples of conditions for which such allowances may especially make sense are diabetes and hypertension. Generally, dentists can only treat specific diabetic conditions that affect the teeth, gums, and overall oral health of a patient. Under current state practice act language, only a physician can diagnose and treat diabetes beyond its oral manifestations. Similarly, current law in most states allows only physicians to diagnose high blood pressure and prescribe treatment even in a medical manpower shortage area. We might want to allow dentists to diagnose and treat certain conditions even in regions where physicians are not in short supply. For example, we may want to permit dentists to diagnose and treat sleep-disordered breathing. Although providing OAT clearly falls under the dental scope of practice (the making and fitting of the oral appliance is considered part of the practice of prosthodontics, a subspecialty of dentistry recognized by the American Dental Association that is taught in most dental schools), dentists must be cautious in providing this service because the practice of dentistry does not extend to the actual diagnosis of the condition. Sleep-disordered breathing is considered a medical disease and thus must be diagnosed by a physician. For patients to be able to receive treatment with OAT from a dentist, they must first secure a letter of medical necessity from their diagnosing physician to submit to the medical insurers. Some state licensing bodies have gone as far as to forbid dentists to diagnose and test patients for sleep-disordered breathing. Therefore, under the language of current state practice acts, dentists are disallowed from diagnosing and treating this condition without the collaboration of a physician and must restrict their practice to implementing OAT. In the case of physicians performing more tasks in the oral health realm, state practice acts are less of a barrier. As long as a physician does



not hold himself out as a specialist in dentistry in states that make this distinction, physician practice acts are broad enough to allow physicians to diagnose and treat all systems in the human body. The primary barrier physicians would face if they expanded their practice would be meeting the appropriate standard of care for oral health procedures. Adhering to the standard of care requires appropriate training at the professional school level or through certification programs. For instance, when Maryland initiated its Mouths Matter program, under which medical practitioners can provide fluoride varnish applications to Medicaid patients, the state created a training course and certificate program, adapted from a training manual developed by the American Academy of Pediatrics.68

COLLABORATION BETWEEN DENTISTS AND PHYSICIANS In addition to efforts to allow dentists to do more medical care and physicians to do more oral health care, there has been a push to encourage collaboration between dentists and physicians, especially in the area of screening and diagnosis but also for treatment of certain conditions. In 2011, the US National Oral Health Alliance sponsored a leadership colloquium that brought together 125 participants from across the country to discuss the need for medical and dental collaboration in building a national commitment to optimal oral health for all Americans.69 Among the goals of the meeting were encouraging collaboration through interdisciplinary, cross-functional education; coordination of dental and medical delivery and financing systems; and integration of patient records. Little discussion has focused on the legal and regulatory implications of collaboration between dentists and other health care providers. Collaboration faces 2 potential legal barriers: corporate ownership laws and fraud and abuse laws that prohibit self-referrals and kickbacks in medical settings. Under most state laws, individuals may not own, manage, or conduct the business of a professional corporation unless they are licensed in that profession. In other words, only dentists can own or manage a dental practice, and only physicians can own physician practices. The reason is the historical

concept that learned professionals should regulate and manage their own professions. Because of the tax and liability benefits of corporate ownership, most states allow professional corporations—corporations owned by licensed members of the same profession. The most typical form of this corporate structure is the professional limited liability company, which is allowed in most states, although the exact requirements for incorporation vary from state to state. When conducting business in the area of health care, providers must navigate complex regulations that are designed to prevent fraud and abuse, such as the Stark law, which limits physician referrals if the physician (or an immediate family member) has a financial relationship with an entity,70 and the federal anti-kickback statute, a criminal law that prohibits the exchange of anything of value as an inducement to referral of federal health care program business.71 These fraud and abuse laws are designed to prevent physicians and hospitals from taking undue financial advantage of patients who are not in a position to question referrals as they might other consumer transactions. Collaborative models, as well intentioned as they may be, may conflict with fraud and abuse laws if they depend on referrals to providers who have a financial stake in the same entity. Other aspects of collaborative models may also run afoul of fraud and abuse law in ways their proponents may not be able to imagine.

About the Authors Richard J. Manski is with the Department of Dental Public Health, School of Dentistry; Diane Hoffmann and Virginia Rowthorn are with the Law and Health Care Program, Carey School of Law; and Virginia Rowthorn is also with the Global Health Interprofessional Council, University of Maryland, Baltimore. Correspondence should be sent to Richard J. Manski, DDS, MBA, PhD, Professor and Chief, Dental Public Health, University of Maryland School of Dentistry, 650 W Baltimore St, Room 2209, Baltimore, MD 21201 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted February 26, 2015.

Contributors R. J. Manski conceptualized the article, served as an expert on dental care, and participated in writing the article. D. Hoffmann and V. Rowthorn served as experts on health law and were significant contributors to writing the article.

Acknowledgments This article was supported by the University of Maryland School of Dentistry.

CONCLUSIONS To increase the ability of physicians and dentists to work beyond their current scopes of practice or to work collaboratively, more thought must be given to potential legal and regulatory barriers to practice expansion. The current legal framework does not contemplate working across professional boundaries, and doing so may leave professionals vulnerable to legal action and penalties. To move ahead on our recommendation that dentists be permitted to do more primary health care and that physicians perform more oral health care, states should allow the implementation of demonstration projects that would include such cross-disciplinary provision of services. An ideal demonstration project


would be initiated by a medical and dental school that were willing to collaborate to train medical students to deliver oral health care and dental students to provide primary care. This would require some changes to each school’s curriculum. Ideally, funding from a foundation or the federal government would enable the schools to accomplish this curricular change, and state legislatures would allow for exceptions to scope-of-practice limits that would permit such a demonstration project to take place. An effective project would increase access of the target population to both oral health care and medical services and improve that population’s oral and overall health. j

Human Participant Protection Institutional review board approval was not needed because no human participants were involved.

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