Under fire

Graduate dental education threatened by federal ruling

A new federal regulation "could stab graduate dental education right in the heart," says Dr. David Russell, associate dean of clinical affairs at Tufts School of Dental Medicine.

The regulation, due to take affect in October, would eliminate federal financial support for postgraduate dental specialty programs and also impact those in most need of oral health care, including the uninsured and the underinsured. The new regulation also will affect postdoctoral training in podiatry, pharmacy and family medicine.

Dr. David Russell © Mark Morelli

Tufts School of Dental Medicine became part of the federal program last year after negotiating a Graduate Medical Education (GME) agreement with Hallmark HealthSystems. (GME funds must be associated with a teaching hospital.)

The GME program provides postgraduate stipends to students who have graduated from accredited dental schools in the United States, Puerto Rico or Canada. At Tufts, 46 postgraduate students last year were eligible for stipends. This fall, 55 postgraduate students are eligible for the $27,800 to $30,000 annual stipends.

A loss of services
If that support is eliminated, the impact on care at Tufts dental clinics is not clear. However, according to the American Dental Education Association (ADEA), postdoctoral dental residents nationally provide roughly $27 million in uncompensated care each year.

For dental medicine, the new rule would mean the elimination of about 356,000 patient visits a year, 500 residency positions and 153 faculty positions, according to ADEA, which notes that 1,700 students nationwide are eligible for the stipends.

The new rule insists that Graduate Medical Education contracts between a hospital and a non-hospital residency program must have existed since the residency program was initiated to be eligible for the federal funds. Very few such contracts existed before 1997, when Congress made it attractive for hospitals to get involved in off-site residency training programs.

Grassroots appeal
ADEA and several other organizations issued an urgent call to action when the new regulation was announced in May by the Centers for Medicaid and Medicare Services (CMS) of the U.S. Department of Health and Human Services in response to alleged abuses in the program.

Russell was among those recruited by the ADEA. He rushed to Washington, D.C., on less than a day's notice and spent three days helping to educate people he had worked with in the office of U.S. Sen. Orrin Hatch, R-Utah, where he served as a Robert Wood Johnson Health Policy Fellow in 1999-2000. Hatch is a senior Republican on the Senate Finance Committee.

"We were able to raise the collective consciousness among senators' health aides, who met to mark up the Medicare reform bill that was headed for the Senate Finance Committee," says Russell.

That bill would cancel out the new regulation, Russell said. Although the same language did not make it into the House bill, the House Appropriations Committee did challenge the new regulation in an addendum to its budget bill. The final fate of legislation that would overturn the regulation probably will be decided later this year in a joint House-Senate conference committee.

The impact at Tufts
"This CMS' rule is completely contrary to congressional intent," says Patricia Campbell, the dental school's executive associate dean, who negotiated Tufts' GME agreement with Hallmark HealthSystems. It also would be a "significant negative" for Tufts, she adds.

"The program already has helped us increase by 25 percent the number of American-trained dentists in our graduate programs. It's increased the quality of our postgraduate students and also has allowed many of our own students to seek graduate training in dentistry," Campbell says.

"I've been very impressed with the effectiveness of grassroots advocacy with this issue," says Jack Bresch, director of ADEA's Center for Public Policy and Advocacy. "I found a real can-do attitude, a feeling of 'tell me what to do and I'll do it.' "

He says that enthusiasm to help was widespread and definitely had an impact—an impact that may well be needed again if the regulation is to be rescinded or overridden by Congress.