For the past seven years I have been a special appointment of Marin Health and Human Service (HHS) to the County Dental Clinic, focused on clinical oversight, quality assessment and quality improvement. During this time we have made many improvements in the scope, quality, and delivery of care in the clinic.
Before the current HHS administration took over, we had a close relationship to Marin HHS with quarterly meetings to discuss needs, progress in the clinic, and budgetary items. Since Dr. Grant Colfax arrived as new director of HHS, there has been zero communication with the dental clinic. HHS has no knowledge of the services provided by County Dental, and has not involved the clinic in any planning process or asked them for any advice.
Both County Administrator Matt Hymel and Dr. Colfax presented a vision of the dental clinic being integrated with Marin Community Clinics (MCC) at the Kerner Blvd location. They spoke of it as being an easy transition at the county budget hearings in June. Their premise was that the consolidation of clinical sites with MCC would allow greater efficiency, medical screening, fewer hospital admissions, etc.
Despite the administration's vision of the need for an integrated clinical site for all services, extremely few of county dental's patients do not have a primary care physician or specialized care when they need it. Now we are told that the clinic will not be closed or moved, but the management will be under the direction of the chief dental officer for MCC, Dr. Connie Kadera. We have also been assured that the transition is not about quality, so why the necessity to change management?
Any consolidation with Marin Community Clinics will result in a serious loss of services to the community. They have primarily treated children due to the enhanced revenue stream they get for pediatric patients. MCC bills by encounter rather than fee for service, and that encourages maximizing the number of appointments each day and minimizing the number of services provided. MCC refers all new adult patients to the County Clinic, and they do not provide many oral surgery procedures, few emergency services, few root canals, few partial dentures, and no fixed bridgework.Many of these procedures are referred to County Dental Clinic.
If you call Marin Community Clinics for a new patient adult or emergency appointment you will be told to call the County Dental Clinic. County Clinics have consistently demonstrated in past decades the commitment, dedication, compassion, and competence to deal with adult patients. We have treated 14,000 patients of record since 2010 with a sliding fee schedule based on federal poverty guidelines; 87% of those are over 21 years of age, and 52% are over the age of 40. Many of these patients suffer mutilated dentition from premature tooth loss, rampant caries, or end stage periodontal disease.They need stabilization and management by dentists experienced in comprehensive care.
Many of our patients have Medi-Cal as their only source of treatment. Procedures we provided during calendar 2016 include 1,811 examinations, 992 prophylaxis, 180 crowns, 95 root canals, 168 dentures, 114 partial dentures, innumerable periodontal treatments, and 1,563 oral surgery procedures of varying difficulty. The clinic may see as many as 10 emergency or walk-in patients daily in addition to those appointments already scheduled.Much of this treatment, including the emergency treatment, is for patients told to go to the County Clinic from MCC because they are unable to provide the services.
Every emergency patient is seen the same day at the County Clinic, and we refuse treatment to no one.
Marin County Dental employs talented auxiliaries with advanced education and skills (RDAEF and RDAEF2) that are licensed to perform procedures that dentists would otherwise have to do. This allows our dentists to deal with patients requiring additional time because of disability, anxiety, or mental health disorders.There are no corresponding positions at MCC, and these talented individuals will become unemployed or suffer severe salary cutbacks and their skills will be lost. Our RDA’s, RDAEF’s, and RDAEF2’s and support staff share approximately 170 cumulative years of experience. The five dentists working at County in suite C as of June 30 shared 105 years of cumulative experience.We employ a hygienist that has been with the County 32 years and does the majority of our non-surgical periodontal therapy and prophylaxis, and she will not be transferable to MCC.
County Clinic is the number one choice of UCSF dental students that want a public health clinic to rotate through during their junior and senior years because of the number and variety of the procedures they participate in. UCSF recently terminated their ex-tern agreement with MCC because students could not complete their requirements during their rotations.
Prior to any feasibility studies, any public hearings, or any vote by the Board of Supervisors, Marin County Health and Human Services is callously and surreptitiously eroding the morale, structure and vitality of the County Clinic.
During employee meetings with Human Resources, county dental staff is told that they must sign up to be employed by Marin Community Clinics, or they must look elsewhere for employment. MCC is already soliciting “transition” teams. They have hired away one of our dentists that was concerned about her future.We are now down two dentists, causing additional stress and forcing other clinicians to volunteer to fill empty slots in the schedule. We cannot fill these positions due to the controversy over the clinic’s fate.
Subsequent to my opposition to the takeover, my contract to continue oversight and quality control was not renewed. The program director is not a dentist and has little knowledge of dental procedures. I no longer have access to county emails and patient records, and patients I was treating have been deprived of continuity of care.
The clinic now must operate without support, oversight or quality control.Marin Health and Human Services said that I declined to sign a new contract. I asked for a new contract to continue to help the clinic during these difficult times, a contract that was cancellable at any time without cause.
During any transition and beyond, many adults in the community will suffer from a diminution in adult services and dislocation of the site, which is close to public transportation.
Make no mistake, the County Clinic will eventually be moved to the Kerner location.
My concern is the preservation of the County Clinic, and to maintain its quality care and commitment to helping the least fortunate as it has for many decades.Marin is such a rich county that it can afford the small subsidy that is required to keep the clinic open.The estimated shortfall for the county dental clinics and the medical specialty clinics is .53% of the 2016-17 budget of Marin Health and Human Services and .18% of the total Marin County budget. At the same time HHS is increasing its planning and administration budget by 17.6% over the same period.
This type of planning we do not need. What is more important for the county to spend its money on?
There are ongoing meetings with county supervisors who have heard primarily from county administrators and HHS regarding the proposal.There is a state required Beilensen Hearing on September 12 in the Civic Center Supervisor Chambers.
Please voice your opposition to this proposal.
County Dental is the alternative for the mother that is concerned that her three year old child will be subjected to physical restraints during four appointments necessary at MCC for four fillings.
It is the alternative for the combative child who was referred by MCC for treatment under general anesthesia to a specialty clinic, but was successfully treated in our clinic.
It is the alternative for the adult missing a single anterior tooth who would like a fixed bridge.
It is the alternative for the periodontal patient who would like to maintain a few teeth as anchors for a transitional partial denture, and would like to find a way to pay for it.
It is the alternative for the patient on social security who wants to save an infected bicuspid from extraction by doing root canal therapy at a sliding scale that he can afford.
Write or phone the supervisors. Tell them to restore the confidence and morale of the staff and maintain the independence and autonomy of County Dental. They provide a real alternative of patient based care delivery for the most needy in our county that needs to be continued.
Yours for better dental health,
Michael Aaronson, DDS
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