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The Veterans' Administration's dental facilities and equipment are adequate, but in need of modernization. Outmoded equipment is gradually being replaced and further progress is being made as funding permits. Included in this program are newly designed operatories, featuring modern cabinetry, instrument panels, and contour chairs, that are being installed to facilitate the practice of sit-down team dentistry now being taught in all dental schools.

This critical assessment of the current status of the Veterans Administration Dental Service is presented primarily to serve as a basis on which this committee can make a projection of immediate and long-range objectives. In my belief, such considerations should be made in the expectation that they cannot only contribute to improved care of patients, but help establish new directions that will permit the VA health care system to utilize its existing affiliations with the country's dental schools and other educational institutions to make a maximum contribution to expanding its own available dental services and in helping to solve the country's critical dental health care needs.

Senator CRANSTON. Thank you very, very much, Doctor. I know that you are universally recognized as among the outstanding leaders in dental education and knowlege in our country, and it was particularly helpful to have you with us.

I have quite a few questions I want to ask you, but I want to declare a 2-minute recess so I can see a legislator from California who has to see me. I will be right back.

(Whereupon, a short recess was taken.]
Senator CRANSTON. The hearing will now resume.

Doctor, do you have an estimate of the funding needed to provide the level of dental care you believe is needed currently in VA facilities?

Dr. ROBINSON. No, but I can supply the information for the record, Senator.

[Dr. Robinson subsequently supplied the following information :] Dental care for hospitalized veterans is not identified as a line item in the budget. From my personal experience as a consultant at several VA hospitals, I believe that at least a 25 percent to 35 percent increase in facilities and personnel would be needed to reach the level of dental care I feel to be adequate. I would suggest that the committee might obtain more detailed information in dollars from the Administrator.

Senator CRANSTON. Would you also specifically indicate how much new staff would be needed, and how much new equipment, and how much of this patient care load could be met through supervised utilization of these students in training as dental assistants and dental hygienists?

Dr. ROBINSON. I will have to furnish that information for you, too. [Dr. Robinson subsequently supplied the following information:]

In order to plan an adequate number of dental students in training at hospitals and helping to provide additional care, there is need for at least six operatories in every hospital participating with dental schools in this program. In larger hospitals and schools as many as 20 operatories could be used to advantage. There would be need for auxiliary personnel and supervision. The supervision could be a joint budgeting responsibility of the Va hospital and the affiliated school. Some may feel that the productivity of the students would be so low and the cost of supervision so high that they might offset each other. Our experience in our community hospital does not support this concept.

Senator CRANSTON. Do you feel that the VA has shortages in the dental field currently?

Dr. ROBINSON. Yes, I do. They have been training their own people through the career residency program, and have been able to train large numbers of them. It is relatively recent that the program got underway, but they have a very high retention factor.

Senator CRANSTON. Do you have any idea of the estimated number of dental schools that could effectively expand their programs if funds became available next year for implementation of Public Law 92-541 ?

Dr. ROBINSON. I could not think of one that could not expand its program if funds were available.

Senator CRANSTON. You think every school could !
Dr. ROBINSON. I think everyone could.

Senator CRANSTON. Isn't one of the major problems in expanding enrollment the lack of chairs for teaching purposes which the VA can help make available?

Dr. ROBINSON. That's true. I might point out that in our own instance, we are affiliated with the Veterans' Administration Hosnital in Kansas City and in Leavenworth, Kans., and partially with Topeka and Wichita. There are not adequate chairs for our students who work there.

On the other hand, the Jackson County Public Hospital recently added 22 chairs to their hospital, and these are manned everyday, 5 days a week by dental students, which certainly expands their treatment program at a very minimal expense.

Senator CRANSTON. How much leadtime do dental schools require to develop such expanded programs?

Dr. ROBINSON. I think most of them have them on blueprints and could have them going within 1 year.

Senator CRANSTON. You recommend that the funds allocated to dental research be increased. Do you have an estimate of the amount of additional funds that could be effectively utilized ?

Dr. ROBINSON. Again, I will have to get that figure for you in an

exact way;

[Dr. Robinson subsequently supplied the following information:] I believe that a graduated increase in dental research funding over the next 5 years could allow recruitment of qualified scient and development of cooperative programs with dental schools. By 1978 the amount allocated for research in oral disease and its prevention should be at least 8 percent of the total VA research budget.

Senator CRANSTON. You were a member of the Advisory Council on Dentistry that reported to the Medical Director of the VA, and made several recommendations that would strengthen and expand the VA dental services provided veterans. I found that a very interesting series of recommendations. I would like to run through the main ones, and if you have any comments or expansion on any of these, I would be very interested in hearing them. If you can advise of any action or response made to the suggestions of the council, by the Administrator, I would be very interested in that. The main recommendations were, (a) that the VA develop a dental

а health system for ambulatory patients in conjunction with those being provided for other medical services.

Has anything happened on that, thus far!

Dr. ROBINSON. To the best of my knowledge, that has not been activated, as yet. There presently are legal barriers to expansion, but if S. 59 becomes law, dental care for ambulatory patients could be greatly expanded.

Senator CRANSTON. Then, (b) that the VA set an immediate priority for the full utilization of auxiliaries in its facilities to increase the efficiency, practicability and economy of its dental services, and that staffing patterns be developed to assure that by 1975 the team approach to dental health care is fully operational in all VA dental services.

Any action?

Dr. ROBINSON. Lack of funds has impeded action. And, I would like to point out, Senator, that this is one of the most important areas because, again, it would reduce the cost of care, expand the utilization of the dentists, and rather than having a 1-to-1 ratio—we don't even have now—of assistants to dentists, we should have 2-to-1 and a hygienist with every dentist. This forms a team that can operate in a much .more economical fashion. And, it's funds that have prevented this, not personnel. A start has been made but progress is slow. The TEAM program is now in operation in some 10 dental schools. At least in the VA hospitals affiliated with those schools the team approach could be utilized, but it would require renovation of dental facilities in those hospitals.

Senator CRANSTON. Recommendation (c) was that the VA immediately establish recruitment and training programs for dental auxiliaries, with special emphasis on veterans with experience as dental auxiliaries during their military service.

Dr. ROBINSON. Again, lack of funding. There are places ready to go, and they just need funding. The VA has tried on-the-job training for veterans, but I do not believe that is the answer, for these veterans have had practical experience in the service. I believe they need special programs for "retreading” them and upgrading their background knowledge.

Senator CRANSTON. Recommendation (d) was that support be provided to the Dental Service for immediately expanding its research and development activities, and that those activities be directed toward the solution of oral and related health problems that are most prevalent in the patients in the VA system but which have direct applicability to the private sector.

Dr. ROBINSON. This has not yet been done. Again, here is a matter of it being economically more feasible to carry out research and prevention rather than care of disease after it has occurred.

Senator CRANSTON. In each of these cases where you come back with almost that universal answer, “no funds, no action,” could you supply for the record the funds you think are required to get action?

Dr. ROBINSON. Again, I would like to put that in the record.

Senator CRANSTON. Further, it was recommended (e) that a strong public and professional educational program be implemented to educate the public about the mission, activities and potentials of the VA Dental Service.

Dr. ROBINSON. The report of the advisory council has been published and the VA personnel have appeared before some organizations but in my opinion this is almost totally inadequate and is not the strong program the council members envisioned.

Senator CRANSTON. Same reason?


Dr. ROBINSON. Funding.

Senator CRANSTON. It was recommended that the VA Dental Service immediately embark on a series of studies and demonstrations to develop and test new ways of providing care to patients and to improve the use of dental manpower facilities.

Dr. ROBINSON. Again, this would require funds.

Senator CRANSTON. Finally, the Council suggested that its membership be more representative of all aspects of dentistry and be more integrated with other areas of health care facilities.

Dr. ROBINSON. The Council has been dissolved because of the restrictions on councils within the Federal Government.

Senator CRANSTON. Why is that necessary?

Dr. ROBINSON. I understood it was because they would have to get Executive permission to have the Advisory Council as such, and this would be difficult. This is only what I know as a civilian on this particular question.

Senator CRANSTON. How valuable is the Council, and what do you think of that action?

Dr. ROBINSON. I think the report speaks for itself, and I think it would be very valuable to be able to continue this Council.

Senator CRANSTON. Has the medical counterpart been abolished, SMAG?

Dr. ROBINSON. SMAG has not yet been abolished.
Senator CRANSTON. Is it going to be abolished !
Dr. ROBINSON. To the best of my knowledge, it is not.
Senator CRANSTON. Does it have any dental representation ?

Dr. Robinson. It has had a dental representative, and I understand there is an appointment of a new dental representative pending.

Senator CRANSTON. Is that adequate? Dr. Robinson. It would not replace the Dental Advisory Council. If there is no replacement of the advisory council in dentistry, I think there should be two or three dentists on SMAG to represent the various sectors, the practicing sector, the educational sector and the research sector.

Senator CRANSTON. Would you give this further thought and a recommendation on how many representatives of the dental community should be on SMAG, should the Dental Advisory Council not be reestablished ?

Dr. ROBINSON. I think three would be a minimum to adequately represent these three areas.

Senator CRANSTON. We will print the full report of the Council in the hearing record at the conclusion of your testimony.

Over the last 3 fiscal years, one recurring problem has been a growing backlog of Vietnam veterans' needs for dental care under the VA fee-dental program.

What is the status of that backlog at this point ?

Dr. ROBINSON. I would have to get that from the Assistant Medical Director for Dentistry for the record.

Senator CRANSTON. Is there adequate provision of funds in the fiscal 1974 budget for fee-dental care?

Dr. ROBINSON. I don't believe there is, if there is any additional demand for dental care.

Senator CRANSTON. What kind of problems occur when a veteran has to wait 6 months to receive dental care under the fee program?


Dr. ROBINSON. The disease has advanced to the stage where rather than having a relatively early lesion to treat and preserving the teeth, he may lose his teeth and get into the situation of need for further, expensive treatment.

Senator CRANSTON. Could you give us an estimate on the adequacy of funding for fee dental in the budget?

Dr. ROBINSON. I believe that in the absence of additional benefits the amount budgeted may be adequate.

Senator CRANSTON. I have to go to the floor for a vote. Would you mind waiting? I will be back as quickly as possible, because I do have a few more questions.

Dr. ROBINSON. Certainly.
Senator CRANSTON. We stand in recess.
[Whereupon, a short recess was taken.]
Senator CRANSTON. The hearing will reconvene.
I apologize for the delay.

Doctor, regarding your comments on Public Law 92–541, I regret the exclusion from subchapter I, of the establishment of new dental schools. The original Senate-passed bill, S. 2219, which I authored in the last Congress, did provide authorization for the establishment of new dental and other health training schools, as well as medical schools.

Unfortunately, the House insisted on limiting the new school provisions in the subchapter I of the bill to medical schools, which I think is an unfortunate decision.

However, I would like to point out that the $50 million authorized to be appropriated annually to carry out subchapters II, III, and IV, providing for the expansion of existing training at affiliated institutions, is available for expenditure, if appropriated, at the VA's discretion, to carry out activities under any of the subchapters.

The legislative authority in subchapter III, which does cover dental schools, is equally as broad as the authority in subchapter II, which covers only expansion of medical schools. Thus, there is no cause for concern in terms of expansion of training at dental schools being fully authorized by Public Law 92-541.

In my opening statement, I said I was interested in finding where savings could be made in present budget items as well as where more money is needed. If we could get our attentions and efforts on places where we could make some savings, it might help us then get funds for programs that so definitely need them.

Where would you recommend that we cut the fiscal 1974 budget, if you can make any such recommendation, for, first, the Department of Medicine and Surgery, and, second, other VA programs, and, third, the rest of the Federal budget!

Dr. ROBINSON. That's a little broad. I think we can save money. I'm certainly not going to suggest cutting the budget. We can produce care more effectively by better utilization of auxiliaries, and this would mean putting money into the utilization of auxiliaries. As I pointed out in my testimony, the team approach, where dentists, dental assistants and dental hygienists work together is a much more economical method of dental practice than the method used in the past.

The second one, which would save a great deal of money, and I think practically no expense, would be the use of qualified dental students,


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