The Monday evening meeting (January 28th) at Bluefield College concerning the pending dental school was both informative and thought provoking. As the current President of the Virginia Dental Association, a long-time resident of Virginia and someone who has always been an advocate of finding ways to increase access to oral healthcare, I felt compelled to provide both my professional and personal points of view related to the plans in Tazewell County.
First and foremost, it is important that all parties be congratulated for their tremendous efforts and spirit of cooperation it has taken to get to this phase of the dental school project. It is a testament to the will of the people and the strong leadership of elected officials in Southwest Virginia to rally behind such a noble and vast undertaking as the opening of a brand new dental school from ground zero. This letter is not meant to necessarily throw cold water on those plans, but rather to challenge residents, city officials and the entire community to make sure their goals align squarely with the financial resources needed for such a projecte and that the expected outcomes of a dental school in Tazewell are fully attainable within a reasonable period of time.
I have a personal experience that makes me either qualified or biased in evaluating the Tazewell County project as I was a student at Oral Roberts University School of Dentistry from 1979-1983. The school opened in 1978 and I enjoyed an excellent education as the University built a modest dental clinic of less than 20 treatment operatories in a business complex much like Bluefield College is proposing to do. My school was very well funded at the outset and had tremendous amounts of fanfare for the first couple years, but as operating debt mounted and challenges began to overwhelm the school’s well-meaning and dedicated staff, the school abruptly closed in 1986. Of the approximately 100 graduates over those 8 years, only 12 remained in Tulsa, Oklahoma. Most left the area during this time due to the economic downturn in the oil industry-not dissimilar to the challenges southwest Virginia is facing on the coal front. With that background, I felt a responsibility to pose some key questions for all stakeholders to consider.
Should a Dental School Be a Driver for Economic Development? Tazewell County administrator, Jim Spencer, recently said “We are glad to see that this unique partnership between Bluefield College and Tazewell County is moving forward. It is a great example of what can be done when officials are working together toward a common goal of creating new economic development and growth”. I greatly admire his enthusiasm and passion, but as a dentist for over 30 years, I believe that when the focus of any dental school revolves around income production, the profession and ultimately patient care is in big trouble. Quality dental programs are vital for our citizens’ health and the reputation for that quality and rigor often takes decades to build while requiring an extraordinary financial commitment to sustain the infrastructure while the brand grows and crystalizes among various constituencies. In my humble opinion, a dental school is not an econmic engine for growth. The notion that having a dental school in an area will be a boon to the number of providers does not always play itself out, especially in more rural areas. Why? The reasons are many but again finances drive the outcome – in this case, the personal finances of a graduating dental student.
Will Student Indebtedness Drive Graduates to Suburban Areas? Dental students are far and away some of the most expensive students to educate. As a group they accumulate an ever-increasing amount of educational debt (I have been told that it costs the VCU School of Dentistry at least $85,000 per year to educate a dental student). Oral Roberts had a vision that dental graduates from his university would provide dental care for people internationally while also serving as missionaries. This was a noble goal; however, dental school debt made this financially impossible for most of the graduates. The lesson for the Bluefield College project is simply to do the necessary research and deep analysis on whether graduates will stay in the southwest part of Virginia without solid economic incentives that don’t typically flow from treating the underserved and Medicaid markets.
Will a Brand New School in a Beautiful, but Rural Area, be Able to Compete as Competition is Fierce and Getting Fiercer? At a time when traditional dental schools in our country are faced with a multitude of challenges to their survival, new dental schools are cropping up at an alarming rate. Student tuition funds most of the operating budget for these new schools and therefore the onus of each school’s financial success rests on the shoulders of the students. There must be a ceiling to tuition costs and students must know when to walk away from educational options that have high risk implications. If it proves necessary to do so, will Bluefield College be prepared to begin the search for international dental students who are able to pay the inevitable soaring dental tuition necessary to keep the school financially solvent? It is instructive to remember Georgetown University and eight other dental schools closed in the 1980s and 90s due to an eerily similar imbalance of supply and demand we are facing today.
How Financially Sustainable is the Model Over the Mid-Long Term? Most of all I would hate to see the taxpayers of Tazewell County fund a project in excess of $13 million that, based on history, could be short lived. At a time when most of us are tightening our belts, we must take a more critical look at where tax money is being spent – balancing risk and reward. In fact, UVA at Wise received substantial bond backing from the Commonwealth just a few years back to build a ‘satellite’ dental school near the fairgrounds with the understanding that they would need to only find the investor capital for operating funds – that project nevertheless has been shelved and not one dime of state funds spent. One must ask why that was the case after being given “free money”. We need to find out the specifics of that decision and utilize any of the information available to us from UVA at Wise to analyze the feasibility in Tazewell County.
What in the University of Virginia Study Should be Considered? You may recall that a study was done by Wanchek, Rephann, and Shobe (Weldon Cooper Center for Public Service) for UVA at Wise in 2011, regarding the possibility of opening a dental school in the area. It is instructive on a number of fronts and probably the quote that gave me the most concern was, “Furthermore, simply increasing the number of providers in the region is unlikely to be sufficient to increase use of dental services in underserved areas.” A few other quotes (with my summary in italics) from that study should also be considered before moving forward:
- Demand for Dental Services is Low Due to Lack of Funds to Pay Providers. “The primary constraining factor on the regional availability of [dental] services is inadequate demand due to low incomes and lack of dental insurance. Furthermore, simply increasing the number of providers in the region is unlikely to be sufficient to increase use of dental services in underserved areas. Regions with higher ratios of dentists to population do not generally show higher dental service utilization levels among lower income individuals.”
- The Recently Implemented Dental Hygiene Protocol is Working Well. “Early childhood and school-based programs have seen a greater volume relative to elsewhere in Virginia, in part because of a pilot protocol allowing dental hygienists in schools and clinics more latitude to practice preventive care without the direct oversight of a dentist.”
- Graduates Settle Down Where they Can Make a Living. “Where dentists settle within the U.S. depends in large part on the opportunities to operate a profitable practice and hence on the income and population characteristics of the region.”
- Recruitment of Faculty Would Be a Major Challenge. “The Southwest region’s remote, rural location will complicate faculty recruitment. Faculty recruitment may be a formidable challenge, particularly for two-earner families where occupational matches in a rural region can be more challenging than for larger metro areas with larger and more diverse labor markets.
- Southwest Virginia is An Attractive Place for All Kinds of Businesses but is a Dental School One of Those? “Because of the region’s relatively low population density and longer travel distances, it could be more challenging to attract patients than it would be in a more urban environment, particularly during certain times of the day and seasons of the year. This implies additional recruitment, marketing and transportation costs along with the possibility of lower average utilization rates…It is clear, however, that establishing a dental school at such a remote, rural location may present unique and formidable financial and managerial challenges.”
Again, the goal of my raising these concerns is not to be a naysayer on the vision, but rather to ensure history does not repeat itself as dental schools have closed across the country (and from my very personal, and somewhat painful, experience over 30 years ago in the Sooner State). Mine is a cautionary tale and the hardworking folks in southwest Virginia need to make sure a dental school and the significant resources it is going to take away from other potential projects will be highly successful over the long-term. They deserve nothing less. With that in mind I would urge the Bluefield College Dental School planning group to take a closer look at the UVA Report and work together to answer some of the questions posed above. As a dentist and business owner, I wholeheartedly recognize no business plan is perfect and doubts will always remain when starting any venture, but let’s make sure before taxpayers jump into this type of investment that our expectations are firmly rooted in facts and rigorous analysis. I know the Virginia Dental Association and the dedicated, loyal dental practitioners stand ready to help and provide any help necessary to make the best decision possible.
Other links of interest: