Value Based Care Heated Discussion Leads to Editorial Authors Publishing Clarification

Dentistry in General Presents ADA officials and members debate JADA editorial, Medical Loss Ratio (1).mp4: Video automatically transcribed by Sonix

Dentistry in General Presents ADA officials and members debate JADA editorial , Medical Loss Ratio (1).mp4: this mp4 video file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Bob Dee, DDS, Moderator:
Hello, everyone. It's Bob Dee for Dig TV. I've wanted to thank everyone who's here today. I appreciate your effort and your service to the profession. I'm going to go through a couple of housekeeping things very fast because we started a little late today. I'm going to be. I apologize in advance. I'm going to be looking at my notes because I feel like this is really, really important and I don't want to miss anything. So I want to make sure I, I basically cover everything that we tend to cover. I'm going to go over the format so everyone is, you know, familiar with it. This episode will be in our Facebook group and our YouTube channel and other social media outlets that may be posted. The reason we're meeting today is. You know, we are having, you know, Dr. Cohlmia and Dr. Rizkallah prominent dentists here. We want to make sure current former and future ADA members to hear what the ADA is doing. Applaud them. And criticize them for things that they're not doing. This we're trying to accomplish this by having two members from the ADA, two representatives from the ADA, and then we will have the two prominent dentists that were involved in many aspects of organized dentistry participate. Social media is an important part of communication these days, and I want to make sure that everybody hears everyone here. As far as your role in helping the profession.

Bob Dee, DDS, Moderator:
It's maybe challenging, but I believe it's a fair forum. So let's start. I want to start by introducing everyone. Dr. Ray Cohlmia currently serving as executive director of the American Dental Association. He graduated with Doctor of Dental Surgery Degree from University of Oklahoma in 1988. He was in practice private practice for 27 years with his father and brother. While also holding a faculty appointment at the College of Dentistry. He served as an assistant dean for clinical operations from 2013 to 2015 and was appointed as dean of University of Oklahoma College of Dentistry from 2015 to 2021 and concurrently remained in the private practice during that time. Dr. Cohlmia has served as a delegate to the American Dental Association and 12th District Trustee from 2015 to 2019. Along with his involvement and leadership in academia, he has served in many capacities including presidentses at the local and state level, served on many national councils, committees and task forces for the American Dental Association, as well as many other dental organizations. Welcome, sir.

Bob Dee, DDS, Moderator:
We have Marco Vujicic, PhD. Marko currently serves as the chief economist and vice president of the Health Policy Institute at the American Dental Association. He is recognized thought, he's a recognized thought leader in health care policy as it relates to dental care. He has published extensively in peer reviewed journals such as Health Affairs, The New England Journal of Medicine, and his team's work is regularly cited by CNN, The New York Times and Wall Street Journal and Fox News and many other media outlets. Previously, he was senior economist with the World Bank in Washington, DC, where he focused on health systems reform in developing countries. Welcome, sir.

Bob Dee, DDS, Moderator:
Then we have Dr. David Leader, who is a general dentist with 25 years of private practice ownership experience. He has a master's degree in public health. Dr. Leader is a 2017 Health Policy Institute Fellow of the American Dental Association and Tufts University School of Dental Medicine and worked under the guidance of Marco who is also on this panel. Dr. Leader is currently a full time associate professor at Tufts University School of Dental Medicine, where he is director of Emergency Clinic, co-director of the Master's in Public Health Dual Degree Program. Doctor Leader has served in many capacities in organized dentistry, including Chair of the Dental Practice and Benefits Committee and chair of the Peer Review Committee of the Massachusetts Dental Society. Welcome, sir.

Bob Dee, DDS, Moderator:
Dr. Mo Rizkallah is an orthodontist and has been in private practice for 22 years. He was a valedictorian of his biology program, his business administration program, and his dental school program. Dr. Rizkallah is currently the president of the American Alliance on Dental Insurance Quality, as well as president of the Medicaid Orthodontist of Massachusetts Association. Dr. Rizkallah is well known as the author of the Massachusetts Question Two the First Dental Loss Ratio Law in the Nation. And he was recently awarded the 2023 American Dental Association Presidential citation for revolutionizing dental insurance and was recently named Person of the Year 2022 by Dentistry Today. Welcome, sir. Wow. I need a breather, guys.

Mouhab Rizkallah, DDS Mass Prop 2:
You did great. Bob. Thank you.

Bob Dee, DDS, Moderator:
That was the formalities.The way we're going to do this today is that we're going to have basically three parts to this. We're going to invite one member from each group, which means the ADA representatives and the ADA member representatives to characterize the ADA from their own perspective, focusing on positives and negatives. The second part will be question and answers. And the format is going to be that I'm going to give everyone five minutes to answer. As far as your team and then we can discuss it for ten minutes. I have a timer here set up for 30s before your time is over, so you can just wrap up and we can move on. And then the part three would be in the closing. I want to find out about each group thinks and how they describe what our what is our 5 to 10 year plan. What specifics can you explain to us? Without further ado, let's start. I want to, I want someone from each group and you guys can choose. Characterize. I think Dr. Cohlmia would be good for this. Characterize the ADA from the perspective of focusing on positives and negatives. And you have seven minutes, sir.

Raymond Cohlmia, DDS, ADA Executive Director:
Thank you so much, Bob. It's great to be here. Appreciate the opportunity. You know, the American Dental Association is doing some incredible things right now, but we have to be realistic of what's happening around us. We have generational shifts in the workforce. We have patient expectations that are dramatically changing. We're having a difficulty achieving personnel. There's technological innovations and there's changes in dental practice that are happening each and every day. And it's not the American Dental Association's job only to promote the profession and members, but is to bring to them the information that they need to to make decisions. It's important for them to know what the trends, what's happening out there. Many times in the years past, we've closed our eyes. We act like nothing even happened and the shift occurs right. I want to make sure that the ADA makes things happen instead of turns around and says what happens. Now as we continue to look at these challenging things. And there are so many things coming down the pipe of what we're doing here, because if I look at all of our different things right now, I will tell you what we've done at the ADA is focus and create what we call our member groups and our customer groups. What are those customer groups? Well, it's really five specific areas. It's our public professional area. It's our direct to dentist, which is our members. Everything that we do is supporting the member. It's the tripartite, the local, national and state. Again, something very critical in order for our advocacy for representation, because literally, you know, Bob, life can change with the stroke of a pen.

Raymond Cohlmia, DDS, ADA Executive Director:
It can literally change with a stroke of a pen. The next thing is our business products and portfolio, making sure that we provide our members the tools and the information and the products and services that they need to make the decisions. And the last group is our enterprise or internal. That's what supports all these operations. Now, what the ADA has done is in a positive mode, is begin to focus on our goals, is to begin to focus on what you need to become successful in your practice. And one of the things that you have to be successful in your practices is information is to know what's out there, to know what's going on. Because if not, your practice and your way of life could change in a moment's notice without you knowing. Again you may wake up and say what happens. That's the whole purpose of the public professional area, is to provide the information out there, good or bad. You know, Doctor Vujicic and I, we spend a lot of time together and I said, your job is to provide me with information that sometimes I don't want to hear, but I need to hear. It's your job to provide me with information that is happening on the outside that our members need to make decisions and determine where they want to take the path. I don't create policy. I don't create procedure. I don't create any of this business. What I'm waiting for is for the profession. You all tell me what you want to do and how you want to move.

Raymond Cohlmia, DDS, ADA Executive Director:
Now, you said it's interesting because we talk about different sites. We're talking about 200,000 dentists plus. And trust me, they all have their own opinion on where things should go and how it should happen. And there's no way, especially today's world with the traditional generation, baby boomer generation, millennials, Generation X and the Z's and the coming Alphas, they all perceive things in a different fashion and what they're looking for in the profession. It is our responsibility, the American Dental Association, to provide that. By doing so with these customer groups and these member groups focusing on what their needs are, not what our past has been. Many times we have built our process has been based upon what I call twatty, the way we've always done it. Incidentally, those are the six most deadly words to any organization or business otherwise. We all know that we're all business individuals. What you did 10-15 years ago will not apply and will not succeed 10 or 15 years from now. We have to stay ahead of the curve. The question is, is there's a lot of information out there. We're here to discuss today multiple aspects of the American Dental Association. But the bottom line is, is I'm working for an organization to become the disruptors instead of the disrupted. And in other words, we're going to make things happen instead of say what happens. And it takes each and every one of our voices to come. I will tell you one thing in response to this information.

Raymond Cohlmia, DDS, ADA Executive Director:
I love it because I now know people are reading the data. I know that. I know people. It's great we're getting information out there again, good or bad, but everybody needs to hear every aspect of it to make the decisions to decide where they want the profession to go. I'm excited for the future of American Dental Association. You're seeing changes now like you've never seen before. We have a digital interface. We're developing apps. We're going to do more things that is customer-member content specifically designed to support the member. Why? To help them become better professionals, which changes people's lives. Our new mission statement is we make people healthy. And we know what goes with that statement is a whole lot of other factors that come into play too as well. But if we believe and we make people healthy, then indeed we should start doing that. The world's in the palm of our hand of what we decide to do, Bob, And it's up to us, but it's up to your American Dental Association, and it's their responsibility and our responsibility to provide the information that they need to hear. That may not necessarily want to hear, but they need to hear to understand what's happening, because consumer disruption, business dynamics is happening awfully fast on the outside. The business generation now is 18 months. Your business has to do something different every 18 months in order to stay on top. We've fallen behind in some areas. We're catching back up. You're going to see incredible things with your American Dental Association.

Bob Dee, DDS, Moderator:
Thank you very much, Ray. We have some time left. I want to mention here for the audience and for you guys, as you guys all know, am a loud mouth, and I have a lot of opinions, but today I am only playing the role of the moderator. I will not be giving my opinion. I will listen to all of you. I will be writing an editorial on this subject. But at this time I'm just the moderator. I want to turn the mic to Dr. Rizkallah and Dr. Dave Leader. You guys, same question. Characterize the ADA from the perspective of focusing on positives and negatives, please.

Mouhab Rizkallah, DDS Mass Prop 2:
Dave, if you don't mind, can I start by fielding this? Thank you. Let me. Let me just say, if I'm understanding you correctly, you're asking us to characterize the ADA both on positives and negatives. Right? Now, I don't want to even propose that we're going to go bashing here because there are so many positives to things things to say, but there are negative things to say. And I want to just make sure that Dr. Cohlmia had a full opportunity if he didn't realize maybe because we were quick on this. Dr. Cohimia, did you want to talk about any negatives that you also are aware of at the ADA? Before I go into this.

Raymond Cohlmia, DDS, ADA Executive Director:
Oh, I'm always thought about very negative things. I know there's several negative things going on. I, I learned I listen very clearly. I understand what's going on and everybody's always going to find a negative aspect. I certainly hope the positives outweigh the negatives by far, but the negatives shape who we are and define who we're going to be. So I listen to negatives each and every day, to be honest with you.

Mouhab Rizkallah, DDS Mass Prop 2:
But the question is the question is in terms of credibility for our conversation here, you know, we want to get into some meaningful, meaningful conversation. For meaningful conversation to happen, you know, we want ... we're members, you know, I'm a member. Dave is a member. And we represent today we represent 166 000 plus members and non-members that the ADA represents, even if they're not members, which I'll go into. But, you know, are there any things that concern you at the ADA? Is what I'm really saying. Any specific things, Dr. Cohlmia?

Raymond Cohlmia, DDS, ADA Executive Director:
I'm not gonna, I don't think that's a fair question to me because I'm balancing five different levels. I'm looking at multiple aspects. You know, when we look from the professional side to the public side to the dentist, tripartite side to the business side. There's multiple things that I'm looking at across the board. I don't look at to me as negatives. I look at it as opportunities to improve. I'm well aware of multiple things like that. If there's a specific area you would like to talk about, I'm certainly listening.

Mouhab Rizkallah, DDS Mass Prop 2:
Great. And I don't mean to put you on the spot. I really mean just for, you know.

Raymond Cohlmia, DDS, ADA Executive Director:
I mean, I'm addressing so many different things right now. I mean, did a basic five year business plan for the board of trustees and was talking nonstop for almost 5.5 hours.

Mouhab Rizkallah, DDS Mass Prop 2:
I understand.

Raymond Cohlmia, DDS, ADA Executive Director:
So many aspects of the ADA. Your question is so diverse that I, I don't think I can narrow in one particular scope. So you pick a subject, we'll go from there.

Bob Dee, DDS, Moderator:
Yeah, maybe we can. Maybe we can address that after you speak, Doctor Rizkallah. And maybe you can bring up some things and I'm going to start your time now. Doctor Rizkallah.

Mouhab Rizkallah, DDS Mass Prop 2:
Great, Great. Thank you So. I just was jotting down some notes as Dr. Cohlmia was speaking and let me just say. every dentist in this country should be an ADA member, in my strong opinion. Okay. Because. Because I actually think we should have a certain faith in the ADA with where they're at right now. Okay. There does come a point in any organization where you lose complete faith. That's not where we are. We're actually a powerful organization right now. And I have convinced many people to become ADA members. And I have indicated to many people that being an American Dental Association member doesn't mean you pay dues. Effectively, even if you are not paying dues and you are not a member, you are representative, you're represented by this organization because this is the recognized organization in our country. Okay. So those people who take a position of I'm not going to pay any dues anymore, I'm frustrated with the ADA. That is not a position of power. It's actually disempowering. You disempower yourself to have a voice anymore and you're not you're not really helping the problem. The real answer to solving this to solving problems is paying your dues and not blindly delegating. That's key. Okay, So we have to pay our dues and we have to communicate what we want the ADA to do. So the ADA is in fact a representative of every dentist. The question really is, are they an advocate for every dentist? See, they're are different questions. Okay. And I would say the answer is yes and no. There are aspects that they are wonderful advocates and there are areas that are the negatives that Bob you're pointing out here, that you want to point us to point out that really they do have some weaknesses.

Mouhab Rizkallah, DDS Mass Prop 2:
So the real question then becomes, okay, if there's yes and no, their advocate, but not some not all the time. Then the question is how do we make it all the time? How do we make it always yes, they're always an advocate. And that's where you have hard conversations, okay. That are honest and meaningful conversations. So I do hear people say, "but the ADA doesn't care. They don't want to hear what you have to say." And I actually I don't believe that. I actually think the ADA does care. And I, I have been an ADA member since I was back in ASDA, so going back 26 years. Okay. And I believe the ADA has many good people. I believe Ray is a good person. I believe one of the people I love the most at at the ADA is is Linda, Linda Edgar, the incoming president of the ADA. Wonderful person. And I think the ADA is a powerful force. I actually think the ADA is the potentially most powerful professional organization in this country. How do I know that? Look at what we did with question two when the ADA plugged in. We did amazing things. But the ADA is not as nimble as we would like it to be, but it's it's this big mothership that has these different components to it. But when that mothership takes all of its power and puts its laser on something. Man, it can do amazing things.

Mouhab Rizkallah, DDS Mass Prop 2:
So I respect the ADA, but I also want to describe the ADA in a in a certain way. Characterizing the ADA is like characterizing a flowering tree, so to speak. Okay. You have to cultivate that tree. You have to water it. You have to fertilize it. You also have to prune it. Okay. Sometimes that sounds a little painful, but that's what it is. And if anyone knows anything about pruning a flowering tree, if you prune it properly, you get what? You get more flowers. That's cool. Okay. And you're cutting back dead branches and you're, and judicious pruning accomplishes really great tasks. So what are the flowers that the ADA has right now? It has flowers. Okay. ADA is is doing great in noncovered services in many states. Assignment of benefits, leasing, virtual credit cards, prior authorization, retroactive denials. They supported $5 million toward the medical loss ratio in Massachusetts. That's great. Okay. But the ADA also has some rotten wood and it's got to get pruned back. That's just a fact. Okay. And I would say that those areas that I could pick out two areas of rotten wood, I would say it's their branch called the Health Policy Institute and their branch called the Dental Quality Alliance. The Health Policy Institute is actually what brought us here today. The Health Policy Institute just put out the most repugnant article pushing capitation plans for those who don't know what that means. That's population based payments instead of procedure based payments to take over dentistry.

Mouhab Rizkallah, DDS Mass Prop 2:
They're saying that has to be the complete future, 100% future of dentistry, capitation plans, the Dental Quality Alliance. So that's a rotten wood area that needs to get pruned back. And we're going to talk about it today. Okay. And then the second area that is that branch needs to be pruned back is the Dental Quality Alliance. Great formative idea that turned into something that doesn't make any sense. And you know, when I say it doesn't make any sense, I'm saying the ADA has a group called the Dental Quality Alliance. You would think that means they're sort of defining quality. But who is the incoming president of Dental Quality Alliance? Actually, a representative from Delta Dental. Delta Dental of Massachusetts. Dr. Linda Vidone is going to be chairing the Dental Quality Alliance in the upcoming year. That is a conflict of interest. And that person should not be using an ADA platform saying, I am the chairman of the Dental Quality Alliance at the ADA and therefore she can sort of manipulate the word quality as if Delta Dental knows anything about quality other than virtue signaling quality. So all that to say, you know, I think there's so much going on at the ADA that's so wonderful, we should all be members and also we should be genuine in our appreciation and honest and genuine in our critiques so that our flowering tree is as flowering as it can be. But let me yield to David. David, do you have any points on you want to add to that?

David Leader, DDS, Tufts University:
Yes.

Bob Dee, DDS, Moderator:
So I'm sorry, we have we only have 45 seconds, so please wrap up.

David Leader, DDS, Tufts University:
I. So I just want to point out a couple of things. The ADA is great when they are on the side of dentists. The ADA is a problem when they cede that responsibility to non dentists, to the insurance industry or when there is an appearance of the ADA being too close with the insurance industry. And this is what Mo and I are going to be talking about.

Bob Dee, DDS, Moderator:
Thank you very much. I appreciate it. This kind of is a nice segue into our second part, which would be, the question and answer. Our first question is about that article that Marco has written. Dr. Rizkallah posted these in many groups, including mine. And there have been discussions left and right. So I want to... as a dentist, as someone who is still working full time, after reading that article, I was disappointed. I want to know, is this what we expect to come out of the ADA? I know I said I'm not going to interject my own opinion, but that's a little bit of snippet of what I think. But what I want to do is what do you sense dentists around the nation feel about this ADA? People like me, you know. Do you think it was appropriate? I want to actually start with Dr. Rizkallah and Dr. Leader? What do you guys think? I mean, is this something that bothered you? I know how Dr. Mo thinks. I haven't talked to Dr. Leader. But it really, I don't know. It made me uncomfortable. Not because the findings were there, but the way the tone of the article was. And we've talked Ray and I have talked about the perception of what people think of the ADA. You know, you could mean something, but perception is very important. Dr. Mo, Dr. Leader, I want to give that to you guys. And we have five minutes.

Mouhab Rizkallah, DDS Mass Prop 2:
Thank you. You know, Dr. Leader and I anticipated you asking this question, obviously, because that's what and he I'm actually going to field that one as well. And initially. Okay. But it may take it may take all the time. I'd like to actually share my screen. Can I do that? Do you guys see my screen?

Bob Dee, DDS, Moderator:
Okay. Yes, there it is.

Mouhab Rizkallah, DDS Mass Prop 2:
Okay, great. So I want to start by saying for those who are seeing that article and sort of potentially dismissing that article as if it is just, you know, an ADA economist speaking about dentistry and it doesn't mean anything. I want to I want to clarify that. So Marco is yes, he's the chief economist of the ADA, but he's also the vice president of the Health Policy Institute, which is actually the highest person at the Health Policy Institute, which is a branch the of our flowering tree, the ADA. And I'd like to - this is the landing page of the Health Policy Institute. And I'd like to point out their mission. Their mission is to provide an ongoing basis policy knowledge related to critical issues in the dental care system. In order to do what? Inform strategic decision making within and outside the ADA. They're basically trying to steer strategy. Through through innovative knowledge generation, synthesis and dissemination, the Health Policy Institute aims to be a thought leader and the premier source for credible data and research on critical issues facing the dental care system. And its vision is to be the leading think tank on the US dental care system. Okay, so anybody reading that article that is saying, you know, it's not a meaningful article, it doesn't mean anything, Actually, that's not true. The the Health Policy Institute is meant to direct the ADA. Okay.

Mouhab Rizkallah, DDS Mass Prop 2:
Now, with that in mind, I want to go right to the article and let's actually start at the end of the article to sort of see the conclusions and then back into what it's saying. Looking at this area here. Okay. The second, the second, the last paragraph before the conclusion. Zooming out, I'm going to actually, I'm gonna actually blow out myself in here. Okay. In the highlight if you are a provider reading this, this is written by Marco, okay? And he's writing "If you are a provider reading this and thinking this is a terrible idea, we need to stop this. I can't control people's health or feeling really uncomfortable or angry. You're not alone". So he's expecting us to get angry. Okay. "The value based care care movement is disruptive, especially to providers. Nevertheless, there is a consensus around its inevitability. There is no turning back on this journey". What we're talking about here is Marco is writing an article that's basically saying the the the profession of dentistry in the United States needs to leave fee for service and enter a full value based care, which is capitation, capitation plans. We've been there before. Okay. And read the conclusion. Value based care, which is again, it's just a euphemism. It's just a repackaging of the word capitation. "Value based care in dentistry is an approach that prioritizes the patient's needs and preferences, aims to achieve optimal oral and overall health outcomes".

Mouhab Rizkallah, DDS Mass Prop 2:
No, it doesn't. No practitioner believes that. Let us bring it a step closer. So some people are saying that he's opining, he's not opining, he's leading. And if you go then back up into really the content of it, He's saying just to the beginning, okay, value is a measure of the benefits obtained relative to the cost incurred. Because I'm short on time, I just want to say value is not the sacrosanct component of what dentistry is. Quality is. And in certain instances, value and quality are actually in tension. Okay? You can get value when you're buying, you're buying a product. But when you're talking about services and in particular quality services, I would ask, I would I would challenge anyone to fill in the blank of this sentence. The concept that you can get quality blank If you provide cost coverage and reasonable profit, you can get quality what? Roof, housing, car, dentistry? But the idea of saying you can get value in blank is not actually the right question. Okay, let's move down. Let's move down here. And my point in that in that fill in the blank idea is basically that that quality is something that requires cost coverage and reasonable profit. And that's what every industry needs to be able to provide quality. Anybody who thinks otherwise is actually working in a fantasy land. That's the only way you're going to get to quality. .

Bob Dee, DDS, Moderator:
Thank you, Dr. Rizkallah. We're going to move on.

Mouhab Rizkallah, DDS Mass Prop 2:
You're going to give me a 30 seconds.

Bob Dee, DDS, Moderator:
30 seconds to wrap up, please.

Mouhab Rizkallah, DDS Mass Prop 2:
Okay. So here's here's what it says in his in his diagram. It says, fee for service. No link to quality and value, meaning we have to go to the far right category for population based payment. But let me tell you something. Fee for service has a link to quality and value. It's called consumer choice. Consumers pick who they want based on the quality that they perceive, and it's individual tailored to them. So anybody who is categorizing, as Marco has here, that Category one fee for service has no link to quality and value is actually living in a fantasy land. That's actually how we purchase in consumer behavior.

Bob Dee, DDS, Moderator:
Thank you for your comments. I'd like to turn the mic to the other side. I think maybe Dr. Vukusic wants to defend his article. Is that okay by you, Dr. Cohlmia?

Marco Vujicic, PH.D., ADA Chief Economist:
So, look, he point is to have discussions like this, like Bob, that's exactly why you pulled this together. So all these viewpoints, they're all valid. This is very important to talk about. And there is strong opinion and there's strong emotion. And you're seeing that here. This is all good. To me, the point of what my group does and again, we're not clinicians. We operate at 30,000ft. And the role of my team and me is to look out into the world what's happening in broader trends, in consumerism, in patient mindsets, in practice models in the payer models, in health care more broadly, and trying to bring important things about the future to be discussed in dentistry. Dr. Rizkallah, I have no say in policy. You are absolutely right. I put out something that obviously hit nerves. It's meant to stimulate discussion, but I am calling the world as I see it. And the fact is this is one of those big trends. Whatever our opinion, the five of us here are leadership. I'm being very blunt. Whatever our opinion about these issues, there are things happening in the world that are very disruptive that are not going to go away. And one of them is this.

Marco Vujicic, PH.D., ADA Chief Economist:
Now, Dr. Rizkallah, we've been very clear in that article about all the landmines and how this is fraught with challenges and how we're nowhere near ready. And look, if the tone was we need to do this now, let's go. My bad in how we wrote the article, I'll take full accountability for that. It was not meant to give that type of the ADA is all in on this tomorrow. Let's go. It was meant to say, this is coming. It's a long term journey. It's fraught with challenges. In health care we learn more about what doesn't work versus what does. But this is not going away. And if you want to thrive in this, here are some things you need to sort out and think about. So I'll take accountability for a tone that wasn't right. Fair enough. That's good feedback. But we're not going to shy away from saying these are things that are coming and they are big and they are going to reshape dentistry. And our leadership in the ADA, you all said, Right, that's what Ray is trying to do. Get our board, get our volunteers, get our different groups saying, okay, how do we lead the profession through this? So I like that we're having this discussion.

Marco Vujicic, PH.D., ADA Chief Economist:
You have opinions, each of you, there's other opinions, others have talked about, this is all good. The question is, you know, what do we do next? And that's more kind of for our leadership to kind of sort through. But Dr. Rizkallah, I mean, this issue is not going away. So the point of that article was to say these are the things to consider. This is how providers should prepare. And again, if I was over prescriptive in tone, my bad, I take accountability for that different editing needed. But again, things that make us uncomfortable to me are good and there's so much that is reshaking this profession up right now that is monumental change. That is not going to go away simply because we don't like it. So I think the challenge becomes what do we do? And this is where input from everybody is needed. I love what Dr. Rizkallah and Dr. Leader said. Like, the point is to voice this within the ADA. Now whatever. If you feel it shouldn't be the role of us to put out uncomfortable information, that's a whole different debate. But that's kind of the charge we've been given. So I don't know. Ray, anything you want to add?

Raymond Cohlmia, DDS, ADA Executive Director:
No, that's exactly it. You know this if you read it, there's a lot of factors that have to be addressed. I mean, this is something that's not going to happen overnight by any means. But I believe it brings about an awareness to determine where you want to take the profession, what you want to do. And that's what I'm waiting to hear from. I'm waiting to hear from each and every one of you all. Okay. Give me a direction. I'm not making a decision on where the profession is going. That's your job. My job is to fill out the business side and to make sure you are successful for your members and what you want to do. But we have to have a landscape of things happening out there in the world. As I said to you earlier, that's exactly it. You know, Bob, his job is to find information that may not want to hear, but I got to hear. And agree that maybe the tone was incorrect. Yeah, I got that. But was the information did it bring about an awareness for us to make a decision on where we're going to go? And that's the purpose of what we're trying to do now.

Bob Dee, DDS, Moderator:
Thank you very much for everyone for staying on time. We have ten minutes to discuss this issue, but I'm going to break the first rule. I'm going to give my opinion here. I just can't. I can't you know, this is the purpose of this. And I am now an ADA member. Although I believe what Marco has done is a good information. But as a dentist, I'm looking at this and I'm like, I don't want the ADA to be putting this out for me. I want you to tell me how to fight it. When I listen to Marco talking.

Marco Vujicic, PH.D., ADA Chief Economist:
Yes.

Bob Dee, DDS, Moderator:
You're basically waving the white flag that this is coming. This is not coming. And I would love to actually invite Marco to debate this with him. This is not coming. This is not coming to dentistry. And I'm and I have my opinions on it. But let's forget that we have ten minutes and I'm going to stop people exactly at the ten minutes. So, David, go ahead and start.

David Leader, DDS, Tufts University:
I'm actually a little bit prepared for this exact question. So, Marco, I, I read your paper. I was a little disappointed, you know, like you said in the tone and I was kind of curious because back in 2016 and I hate to be pulling things out of your history, but I mean, it is in writing. It is in print. You wrote, Why are payment rates to dentists declining in most states? And at the end of that paper, you said the lack of research stems from a lack of data. You're talking about payment rates provided to dentists through private dental plans are going down. There's considerable variation across states. The small number, a small number of states had large increases in payment rates. But you said that because there's no MLR in dentistry, in dental insurance, that we don't have the information that the medical insurers are giving us. Then I found a paper by Finocchio, I don't know if you know this one. Medical loss ratios for California's Dental Insurance Plans Assessing Consumer Value and Policy Solutions. Are you familiar with that paper? Yeah. Okay, great. So in this paper they point out that they call the value based plans HMO plans. But the HMO is the same as a DMO or or a capitation plan or a value based plan. And they show that the insurance companies that are using these these HMO plans have a much lower MLR than insurance companies that use any other type of plan.

Mouhab Rizkallah, DDS Mass Prop 2:
Meaning that the value based plan actually makes more money for dental insurance companies.

David Leader, DDS, Tufts University:
Right. The insurance companies have a bigger profit and on average, 40% profit, 40% over. And so anyway, I was wondering why you didn't, you know, knowing about this, you didn't bring this up in that paper because it seems salient?

Marco Vujicic, PH.D., ADA Chief Economist:
Well, HMO is not the same as VBC. So that's one misperception. And you're both echoing it. This is not a return to the 80s of capitation plans. Right. So the the value based care movement, a core tenet of this go around is accountability metrics. So an old model in the 80s was, Here's some money. Manage the patients. We walk away. Providers have incentives to not provide care, keep money, et cetera. The idea here is if you're going to do any sort of capitation, it should be risk adjusted to account for the population's needs. And there should be accountability, accountability metrics on the back end right performance metrics that reward better health and better health outcomes. So it's not relevant, David, for this discussion. And look on these issues like you're all just raising why this is problematic and why there's a high failure likelihood and even what Bob said, right? So as a provider reading this, you're like, I don't. Okay, you said it's not inevitable. But again, my opinion is, it is. And when you look at the trajectory over time, we're seeing more, I guess, steps towards this type of model, then steps away from it, let's say. In the article we highlighted that. But fair enough. I mean, some people may think it's not inevitable. Again, I'm giving my take, right? I'm looking at what's happening. I'm giving my take on where we're going. I do fundamentally think it's a 30 year journey, not a two year journey. And I do think it is inevitable.

Mouhab Rizkallah, DDS Mass Prop 2:
I have to jump in here. And, you know, let's let's just take a moment here to look at look...

Marco Vujicic, PH.D., ADA Chief Economist:
Can I finish my thought first on this and let you on this just to respond to David. That's why those things weren't weren't included. And on the MLR thing, look, we'll have another discussion about that. But part of the challenge in any sort of movement towards accountability and quality and outcomes, David, you're hitting on it, is the lack of data and reporting by insurers. That's part of what Dr. Rizkallah, I'm sure was one of the motivations. But I mean, it is an unregulated field, right? And insurance in dentistry is not true insurance. And the MLR type of reforms are trying to bring that type of accountability to payers. Right, Right. So okay, go ahead.

Mouhab Rizkallah, DDS Mass Prop 2:
So, so let me let me say a couple of things. The first thing is value based care, value based dentistry is in fact capitation. The idea that they are not capitation I mean looking right at the screen here...

Marco Vujicic, PH.D., ADA Chief Economist:
You're saying HMO. So that's different than we're talking about.

Mouhab Rizkallah, DDS Mass Prop 2:
We're talking about value based care here. Okay. Population based payment is is exactly in the box here per member per month payments. That's the problem with your paper. Now, looking at looking further down at the paper. When you hang...

Marco Vujicic, PH.D., ADA Chief Economist:
On, I'll stop you. What do you mean that's a problem with the paper? I'm simply outlining what..,

Mouhab Rizkallah, DDS Mass Prop 2:
That's what. I'm saying. That's what I'm saying is our problem as members.

Marco Vujicic, PH.D., ADA Chief Economist:
Okay.

Mouhab Rizkallah, DDS Mass Prop 2:
Your paper is the idea that you're saying we want a you're proposing a per member per month destiny.

Marco Vujicic, PH.D., ADA Chief Economist:
I want to be very clear. I'm not proposing we go to some model A or B, I'm saying the world is moving from the left to the right.

Mouhab Rizkallah, DDS Mass Prop 2:
Okay. So let me let me just. Okay, so that's that's actually I'm getting a little off point here. Look at your conclusion. The last word. Let us bring it a step closer.

Marco Vujicic, PH.D., ADA Chief Economist:
Okay. Fair enough. No, I meant to give an uplifting. This is going it's happening. Let's make it positive for patients.

Mouhab Rizkallah, DDS Mass Prop 2:
That's fine.

Mouhab Rizkallah, DDS Mass Prop 2:
I don't want, don't want to lose time on my point.

Marco Vujicic, PH.D., ADA Chief Economist:
You keep bringing it up. But I want to say fair enough I won't, I take that feedback. The tone should have been different. Fair enough. .

Mouhab Rizkallah, DDS Mass Prop 2:
Let me get to my points here, though. At the bottom here, it says under the FFS model, the problem is that quality measures in dentistry are simply measures of appropriate service provision. Wait, that's a problem. The problem is that quality measures in dentistry are simply measures of appropriate service provision. That's not a problem. That's actually correct. And then it goes on to say quality measures are not focused on oral health outcomes or technical evaluations of the procedure, which is likely what providers think are of in terms of quality. You're saying us, as providers, we think technical evaluations of the procedure is quality, is our evaluation of quality. You're making it seem like we don't know what quality really is. Where we actually do understand what it is. It's not, we're not techs, we are doctors. We are, we are, we screen, we educate, we prevent, we diagnose, we treat and we deal with patients on their individual real social problems and accommodate to their problems at their socioeconomic level, their familial problems. The idea here that you're saying we think quality is technical evaluations. No, no, we are we are caregivers. We are not techs. But moving on here, the bottom here, it says several dental benefit plans are exploring VBC initiatives with an explicit goal of improving and oral health outcomes. And then you point to Liberty Dental Plan, Delta Dental of Massachusetts. And you basically say, at the end, these are the ones we want to follow. And then what you do is you say...

Marco Vujicic, PH.D., ADA Chief Economist:
I don't say that. I just want to clarify. I don't say that. I say this is what's happening in the world. Here are a few examples.

Mouhab Rizkallah, DDS Mass Prop 2:
And then you and... Then on your LinkedIn page, you're calling out the Eric Mortlach. He's the CEO of Delta Dental of Massachusetts, Ameren Schott, Who is Liberty. Liberty. Alicia Hightower, who is Medical Delta. And you're basically saying, hey, what do you say here? We highlight special innovations in the field, so have a look. You're not saying we're just predicting. You're saying we're going to take them there. That's what you're saying. I consider this to be a serious conflict of interest. But I want to actually say one more thing and then I'll shut up for a for a little bit. The idea here of what is actually our future and how do we get there is central to this conversation. This is not just a complaining conversation. How do we stop that arrow from going from Category one to Category four? Here is how. We change the paradigm from dental insurance companies make more by spending less on patient care to dental insurance companies spend making dental insurance companies make more by spending more on patient care. From dental insurance companies make more by spending less to dental insurance companies nake more by spending more on patient care. How do you do this? It's a medical loss ratio. Federal. The medical loss ratio only allows dental insurance companies to profit or make more when they care for more patients. That's how it works. So when you say at the end "this is inevitable, this is where we are going. Yes, we are. Let's take a step further. Embrace it." That's your advice? What I'm saying is not only do I agree with Bob that that's not our future. I am saying we are, we have a solution and it's a medical loss ratio. And if you want to ask the question of how do people feel about that, what do people want? Let me show you the results in Massachusetts, 2022 Massachusetts ballot results. Question one That's not us. They got a 52% vote. Question three. That's not us. They got a 55% vote. Question four. That's not us. That's a 53% vote. Look at the oranges, that's who who won. The people want a medical loss ratio. They don't want value based care. They want quality care.

Marco Vujicic, PH.D., ADA Chief Economist:
And that's incorrect as well. If you look at polling of the public and you ask them, would you like your providers in dentistry to be rewarded somehow for outcomes or to have some type of links to value, the vast majority say yes. So it's not true that the public doesn't want. I'm not doubting that.

Mouhab Rizkallah, DDS Mass Prop 2:
That's a false question. Einstein said 90% of getting to the right answer is asking the right question. If you ask anybody, would you like, you know, and just you form it in a way that sounds good, they're going to say great. But if you form it in a way that says, would you like to do this so that dental insurance companies actually take more of your money, less goes actually into your mouth because you're provider would buy better products, would would be able to pay their employees better all of these different things that provide more boutique like quality. If you, if you structure the question in a way that says would you like to do that at the cost of being able to enable empower your provider toward quality? If you ask that question. You get an answer.

Marco Vujicic, PH.D., ADA Chief Economist:
We can debate. I don't have...

Mouhab Rizkallah, DDS Mass Prop 2:
In fact that is what orange on this screen. This screen is patients saying, I want less to go to my insurance company. I want more to go to me. That's what they're saying.

Bob Dee, DDS, Moderator:
Gentlemen, we need to we need to move on from this subject. I'm going to move on. This is a five hour debate that we're going to have, and I hope it will happen at some point. I want to I want to invite everyone back. The question, the second question I have here is, should the members people like me, I know joined last night, but I consider myself a member. should my desires as a member be the goal of the ADA? Meaning? How do you guys determine what we want? And want to start with Dr. Cohlmia, and I think that's basically your job.

Raymond Cohlmia, DDS, ADA Executive Director:
This is not the goal of, this is not the goal of the ADA. The goal of the ADA is to inform you all and let you all make decisions on where you want to go. Our job is to provide information and we're waiting for you to have a directed decision. I've heard a lot about all the issues and the problems of what it won't work. What we need to hear is about solutions. Then let's define where you want to take this and what is achievable and what can actually fulfill what you believe the profession should go. What is realistic within our means? I understand that this article seems to be a hot article and if anything, if it brought attention to it, fine. If you want to go back to square one, great. Let's have a game plan. Let's show how we can do it. You know, MLR is a great thing. The American Dental Association backed that and worked and helped with Dr. Rizkallah led this. And he knows it's incredible what he's done. But is that going to change all? Is that going to stop everything that's happening on the outside? Is that really going to be an effective measure that's going to shut this down? That's the question you all have to decide. Is the outcome metrics really going to defeat where this is going? I mean, we can continue to monitor this for you. We can provide the information for you year after year after. And as Marco says, it's not going to happen in one year. This is a long term, but the data and the trend is pointing towards this direction.

Raymond Cohlmia, DDS, ADA Executive Director:
What do you want us to do? What define plans do you want us to do in order to turn the curve and turn it into a direction of where you believe the profession should do? Sometimes our job is to provide information again that you don't want to hear. Some of these things are hard to swallow. I deal with these things each and every day of things that we don't want to hear, but they have to be taken into reconciliation modes. The bottom line is this This is not the direction. This is not the policy. We are asking you all. Define what you want to do. And this is going to be a big subject for the board of trustees and for several operations, including the new Strategic Forecasting Committee. This is one of the things that's going to come their way. Fine, let's have a defined game plan, how we're going to win, and we will certainly support that. Our job is to support the member. Our job is to help them support the profession. And I'm not disagreeing with what you all are saying. Take in the fact that, yes, maybe the tone was incorrect. We give, you're right. You're right. It was. But does it raise an awareness on what we need to do to take a different track to achieve the profession of the future, the way you think it should be? That's the question I have. And that's where we are with the ADA.

Bob Dee, DDS, Moderator:
I appreciate that. I know you're not supposed to interrupt here. I am going to. As an ADA member. As a dentist. I expect these to be checked. I understand the ADA is now saying, Oh, yeah, the tone was wrong. Is the tone wrong? Dr. Cohlmia, or is this a deep rooted belief within the ADA to point us towards something that I didn't go to dental school to become?

Raymond Cohlmia, DDS, ADA Executive Director:
This is not a deep. This is nothing undermining. There's nothing about this. We are simply asking, you know, when we say for the profession and the members and the volunteers to lead, then lead, then let us know. Now, my question is, if we look at the perspective of the population, are we getting the same information? By the way, we've had several positive things about this article come out too. I mean there's there's been it's not just we're hearing the negative side. We got that. If it brings an awareness, Bob, for us to make a direction to change, to bring people together, to unite them, then so be it. Great thing. I'm sorry Marco didn't interrupt you.

Marco Vujicic, PH.D., ADA Chief Economist:
No, I was just going to say. But you know. Again, zooming out. Right. What I'm hearing and Bob wanted to ask you back, like, what is the angst about? Is it like, I don't like this world that's that I said is coming? Is that.

Bob Dee, DDS, Moderator:
So? I'm going to combine the 20 minutes on this issue so we can all discuss this. And I'm going to give time for Dr. Rizkallah and I'm breaking my own rule of being a moderator. I look at the ADA, even though the board, you know, we can't unionize, I look at the ADA to represent me.

Marco Vujicic, PH.D., ADA Chief Economist:
Your practice model?

Bob Dee, DDS, Moderator:
What I hear from every single dentist that I talk to. If that is not your perception, you guys kind of come out and tell me that you're just a reporting company. Okay. If I want the ADA to represent me, I want you to be in the streets and asking, What bothers you, Bob, as a dentist? What bothers you, Dr. Rizkallah, what bothers you? What I'm looking at is data after data after data. And I'm confused. I know Dr. Rizkallah and Dr. Leader are not confused, but I'm not that smart. I look at an article and I say, Oh my, where is this leadership taking me? Is this what I want? Now, again, it could it could be wrong. But I'm asking you guys to not just clarify. I want you to be straight to the point that I'm representing you. I am fighting for you. I understand these data. I, Marco, with all due respect, I don't even know why we have an economist in the ADA. I know you're a very capable person, and you're very smart. And I've read your papers. I'd love it as a person. But it just bothers me that I, not just me, many members, if you can look at through my group, they say "Oh, I don't feel like they represent me". And again, it could be a wrong perception. I want to give Marco a couple of minutes since I took your minutes to respond to that.

Marco Vujicic, PH.D., ADA Chief Economist:
So if, and Ray can talk more, we definitely ask dentists what their pain points are, what they need support with crystal clear. And Ray can summarize what those are and we can talk about what we're doing in response to those issues. Hiring challenges. Issue number one. Third party payer pain points. Issue number two.

Mouhab Rizkallah, DDS Mass Prop 2:
Hiring challenges are not issue number one. Dental insurance is issue number one.

Mouhab Rizkallah, DDS Mass Prop 2:
Okay, fine. You can flip them. But the research last month showed their hiring was number one. But whatever, their top, top three always. So and we could talk about what we're doing there and MLR is one of them etcetera. But look, the point though, Bob, is, I don't know, in my view, there is a need to also lead the profession long term. And have a vision for 20 years down the road or a decade down the road. Problems, frankly, you maybe are not even seeing because they're not here today. And I think an important role the ADA plays and, I don't mean to speak for Ray, is to kind of look ahead and anticipate and lead through those turbulent waters. So this issue to me is a great example where we could, again, a strategy could be fight, fight, fight, fight, fight, fight. Hold this off. And eventually, when something comes in, okay, we'll deal with it. Right. Strategy B is to say, accept this is coming at some point downstream, get involved, shape it so that it's very provider friendly and patient friendly. Like would you rather have kind of a dental group influencing some of the rules around this versus an insurer or like a government program? Like that's kind of the thing where, you know, we need to decide now. .

Mouhab Rizkallah, DDS Mass Prop 2:
That's really feeling like this is getting a bit unbalanced, you know?

Bob Dee, DDS, Moderator:
You're going to start now. They're five minutes is over. We're going to have ten minutes of discussion as well. Go ahead, Dr.Rizkallah.

Mouhab Rizkallah, DDS Mass Prop 2:
There are so many things that have been said here that I just reject. Okay. The idea that the ADA is an information clearinghouse is not what I what I believe the ADA is. We are we are looking for advocacy. Okay? And what we don't need in advocacy is someone who says this is your doomed destination. Okay? That's not an advocate. I would never hire an advocate that says to me, you're doomed.

Mouhab Rizkallah, DDS Mass Prop 2:
I would say we need to find a way not to be doomed. So this article where where we're talking about.

Marco Vujicic, PH.D., ADA Chief Economist:
There's a whole table Dr.Rizkallah that says, if you don't want to be doomed...

Bob Dee, DDS, Moderator:
Let him finish, please.

Mouhab Rizkallah, DDS Mass Prop 2:
This article is saying you're doomed and it's saying we're directing you take a step closer. But it does more than this, right? It actually when we look at what that article, what's happening behind the scenes of that article, right, what we have is this. This is the Dental Quality alliance and and this is their April conference. And what are they talking about? Well, Marco did did did a lecture on value based care. Right. This is not just we're talking about it and we're letting you know what might be coming up the pike. No, we're saying this is what we're presenting in our dental quality alliance. But Marco is not alone. Who else is talking about it? Well, Cherag Sarkari. He's talking about value based care. Who is he? Liberty Dental plan. Who else is talking about value based care? Michael Adelberg. Michael Adelberg is the executive director of the National Association of Dental Plans. I could go on and on and break down what's happening at the DQA. But that actually wasn't the question right? The question that you posed, Bob, was should members be leading and guiding the ADA on what membership wants in terms of advocacy? That was your question, right? And the answer to that question is a resounding yes. And the second answer to the question really becomes you said it. How do you do it? How do you get there? How do you get that information? And there are many ways to get there. But what I want to point out is that, you know, there was a wonderful article recently put out in Doctor Bicuspid. Debate, the better dentistry, the future of organized dentistry. And and this was a debate between Richard Huot and Abe Abdul. Dr. Abe Abdul is the president elect of the Massachusetts Dental Society and is a wonderful advocate for patients. And what he basically describes here is how these how, look at what he has here, dental social, social media platforms, SMPs are basically going to help to guide our wonderful flowering tree. We are a wonderful tree. You know, I know my voice sounds frustrated. I'm frustrated at any level of denial that there are branches that are having a problem and don't need pruning. They do. But I'm not frustrated that we don't have a great organization because we do absolutely. Powerful organization. But I would encourage anyone who hasn't read what Dr. Abe Abdul put out, which is really, really illuminating on how we can get information from our members so that we can install that information as a guide in our group so that we are avoiding crazy things like capitation. Marco should not be lecturing on capitation side by side with Liberty Dental Plan and the National Association of Dental Plans. I don't know what's going on here. We don't need advocates who are steering us in a direction that we never asked to go to. Well, we are asking to go to is a completely different place with a federal medical loss ratio.

Bob Dee, DDS, Moderator:
Thank you, Dr. Rizkallah. I want to kind of quickly mention something. When you shared your screen, there were advertising on the screen for another company that I'm actually involved with. That was not intentional for anybody watching.

Raymond Cohlmia, DDS, ADA Executive Director:
Am I allowed to respond to your statement, Bob, earlier?

Bob Dee, DDS, Moderator:
Absolutely.

Raymond Cohlmia, DDS, ADA Executive Director:
You're certainly saying quite a few statements for said what are we advocating? What is the ADA advocating?

Bob Dee, DDS, Moderator:
One second. I'm sorry, for Federal Trade Commission reasons, I have to mention that was not a commercial for anyone that is present here. We have ten minutes to do discussion. Want to go with Dr. Cohlmia and then I'm going to go to Dr. Leader. Since Dr. Rizkallah and Marco have participated. Go ahead, Ray. Thank you.

Raymond Cohlmia, DDS, ADA Executive Director:
You've all asked and somewhat incriminated the ADA that we're not advocating. We do that each and every day. That is probably the most formidable thing that we do. And we are listening specifically to our members. We hear feedback all the time. What's important to them? We survey our members, we ask questions. We have our counsels that provide input. When you're looking at the mature population, their number one thing is transition of practice, insurance reimbursements and Medicare. We're addressing those things advocacy each and every day with our 25 to 30 lobbyists. You know, under Mark Graham, we are working, we really have made some major changes there. That we kept us in a situation where we weren't going to be drafted into the Medicare process. We are advocating for each and every day. For the new dentist, you know what's their top things? Wellness. Okay. Surprising, wellness. Financial stability, you know, revenue support here. And then, of course, you know, portability. So we listen each and every day and we advocate. We've creating multiple term, multiple items, multiple different things at the legislative, both state and national level to support that. We do that each and every day behind the scenes. We are advocating for what you want. It's also our responsibility, though, to bring some information that you may not want to hear, but help us to define where you want to go in order for us. Because we will continue to advocate specifically for the member. That's what we do each and every day. We actually talk to faculty. I've been taking all the school trips. What's their number one thing? Tax credit, loan reimbursement, state and federal support to support them. You know, it's amazing how much has been discounted to the education industry. You know, they're supporting, they're struggling because they're losing federal and state support all the time. We're advocating for that each and every day. So if you don't think that we're doing things behind the scenes all the time that support you as a member, you're wrong.

Mouhab Rizkallah, DDS Mass Prop 2:
No one said that. No, one said that.

Raymond Cohlmia, DDS, ADA Executive Director:
My turn. My turn. Each one of you all are bringing out a few small negative here. I agree with you and I'm listening very clearly. Dr. Rizkallah, you brought up a couple of things earlier. I'm certainly going to investigate that. I'm going to look at that to make sure we're on the right path of defining where it needs to be to advocate for our members.

Mouhab Rizkallah, DDS Mass Prop 2:
Thank you.

Raymond Cohlmia, DDS, ADA Executive Director:
I love it when you bring things like this. But to say that we're not advocating.

Mouhab Rizkallah, DDS Mass Prop 2:
I never said I never said that.

Raymond Cohlmia, DDS, ADA Executive Director:
Because I am a member. I'm a professional and I'm a doctor. And the American Dental Association represents me as well. So understand that we are doing a lot of things to advocate each and every day for what you all say. We are listening, we are hearing, but we also have to provide information to you what's happening on the outside world. For us to act like it and put blinders on that is asinine and that we will not be able to survive the future. And something's going to happen 30 years from now. And we said we talked about this 20 years ago. We decided not to do anything about it and here's where we are. So I hope that, you know, this is a very passionate subject for everybody, but know that the American Dental Association, I'm proud of what the ADA is doing. And I'm proud of what we will continue to do. Yes, we may ruffle a few feathers here and there. We sure will along the way. But we must make sure that the profession is engaged. If there's one thing that I learned today is that the profession still is engaged. We have people that care and care deeply about the future. And that's what I really was excited about to hear. Despite what our discussions are, that's what I said. Wow. We got people that really support what we're trying to do in the future. That's what I was excited about. Thank you.

Bob Dee, DDS, Moderator:
Thank you. Ray, I want to clarify that neither Dr. Rizkallah nor myself said that ADA is not doing anything. But as we discussed before, there are two important things, in my opinion, of what ADA does. Perception, results. I, you guys, obviously everybody knows you have a communication issue with members and non-members and then the results we need to see. And I've opened my group and my platform to you. You want to come on every week to talk to me, I'm open. It's always there for you guys.

Mouhab Rizkallah, DDS Mass Prop 2:
Let me interject for just one more second. Okay.

Bob Dee, DDS, Moderator:
Go ahead.

Mouhab Rizkallah, DDS Mass Prop 2:
Ray. clearly, this is a flowering tree and a beautiful flowering tree. But when you said there are some small negatives, this capitation conversation is so far from small. It's the biggest potential to destroy our profession. You can't call it small. That limb needs to be cut off. David, I'm sorry.

Marco Vujicic, PH.D., ADA Chief Economist:
What do you mean by cut it off? Like, don't talk about this. Fight it?

Bob Dee, DDS, Moderator:
We'll come back to you. Marco, You'll be next.

David Leader, DDS, Tufts University:
I just want to mention something about the Dental Quality Alliance. The Dental Quality Alliance was established, I believe, by request from CMS, the Center for Medicare and Medicaid Services. A request to the American Dental Association to set up an organization that would look at the quality of care delivery. And it was supposed to include representatives from insurance, from dentistry and from the public. So we've been talking with Krishna and, I hope I get her name right,Aravamudhan who is a vice president of the American Dental Association. She's senior vice president the Practice Institute of the ADA Practice Institute. She is the person who, she is the point person who contacted us back from the Dental Quality Alliance. And she assured us that the Dental Quality Alliance and the American Dental Association are completely separate in spite of the fact that that every time she sent us an email from the Dental Quality Alliance, it had her ID as Senior Vice President. Practice Institute. ADA Practice Institute. Also, we asked her questions about, you know, how do we become members? We were told that we could show up at a meeting at great expense and and we could see what was going on there. We're in the process of becoming members. But I asked her who represents the public, because that's supposed to, according to CMS, that's supposed to be part of the DQA. And her choice for who is representing the public and, I don't want to say their name, but it was a drug manufacturer. And so we have an organization that's housed apparently at the American Dental Association that is run primarily by the insurance industry, that's trying to set quality standards for our industry. And the quality standards are not looking at the quality of dental insurance plans which I think is key to public health.

Bob Dee, DDS, Moderator:
Thank you, Marco, go ahead.

Marco Vujicic, PH.D., ADA Chief Economist:
No, on just the thing of reacting to what Dr. Rizkallah said again. So, I mean, my question was just what do you mean by pruning the tree? Like there's, you seem to have this perception that we're pushing for a capitation world. We've clarified that seven times to sundown we're not. Like this is meant to say this is the framework, the trends seem to be going this way and here's some things to make this successful. That's it. You're saying we should do something else we should focus much more on MLR as the solution, right? So these types of debates, they're all this is excellent. What you did was monumental. And I feel think one of the greatest things is, is having a trickle on effect. You ask like, what are some of the impacts? Bob, There are 39 states this year that introduced some type of MLR bill. There are four states now following, including Mass, obviously, where you led the charge, Dr. Rizkallah, that have passed some type of legislation. So and you rattled off all those points about non-covered services and credit cards. So, I mean, there's a lot of emphasis and work and money and advocacy being spent in this area. Nobody is out there pushing for some type of capitation model. I mean, let's clarify that right now. The point is we should decide what is right.

Mouhab Rizkallah, DDS Mass Prop 2:
But you are. You did.

Marco Vujicic, PH.D., ADA Chief Economist:
I'm clarifying that right here. I don't know what else to say. I mean, if you read it.

Mouhab Rizkallah, DDS Mass Prop 2:
We read it.

Marco Vujicic, PH.D., ADA Chief Economist:
You read it that way. But, I mean, you're putting words in my mouth. I'm like, and but...

Mouhab Rizkallah, DDS Mass Prop 2:
I could read your words.

Bob Dee, DDS, Moderator:
Gentlemen, gentlemen, we need to also move on. But I also want to bring this up that although Marco, you're saying that, but telling me how I can thrive in a capitation state is not what I'm looking for.

Mouhab Rizkallah, DDS Mass Prop 2:
He didn't say he didn't say thrive. He said just he said, you're going to hate it. He said you're going to be angry. He said, but you're going to go there. That's what he said.

Marco Vujicic, PH.D., ADA Chief Economist:
Let's go on. How so? I mean, again, what what would you like the ADA to do in this? Forget about the article.

Mouhab Rizkallah, DDS Mass Prop 2:
That's a great question.

Bob Dee, DDS, Moderator:
And it's going to come. Question three involves that. Okay.

Marco Vujicic, PH.D., ADA Chief Economist:
All right.

Bob Dee, DDS, Moderator:
Basically, based on the last question, what are the two most important goals? I want everybody to, I want Dr. Cohimia, to talk about it. I want Dr. Leader, Dr. Rizkallah. What are the two most important goals do you think that we should have for the ADA to accomplish in the next, let's say, five years? Who wants to take this one first? We lost the order.

Mouhab Rizkallah, DDS Mass Prop 2:
I'd love to take it.

Bob Dee, DDS, Moderator:
Take it, Dr. Rizkallah. .

Mouhab Rizkallah, DDS Mass Prop 2:
I've been, I've been saying it. I've been saying it now for a while. The two most important goals for the ADA to take on if they want it, if they want to solve a lot of the symptoms that they're talking about, like Ray talked about, you know, young professionals are interested in wellness. You know why they're interested in wellness? Because they are symptomatically unwell. It's a symptom, not a disease. You see. That's a problem, right? I am I am disease oriented and I'm trying to solve problems really at their source, not at their impact. Okay. And so what's the source of a lot of our problems? Well, it's actually two things. It's private insurance and Medicaid. Those two things. Let me tell you, if you if you solve those two source problems. So many symptoms get solved.

Mouhab Rizkallah, DDS Mass Prop 2:
So medical loss ratio. We need a federal medical loss ratio. That should be agenda number one for the ADA. If you do that, you're going to solve so many symptoms. Let me tell you the symptoms. Okay? Assignment of benefits. Like we work hard on trying to plug holes and fix problems on assignment of benefits. Why does assignment of benefit? Why is it a problem? Well, I'll tell you why. Because insurance companies make less when they assign benefits. They have to pay providers, more that are out of network. Right. But if you do a medical loss ratio. Right. We told you that there's a new paradigm shift, Right. Instead of, they make more by spending less, now they make more by spending more on patient care. Assignment of benefits solved. Did you have to fix assignment of benefits? No, it just it is a symptom of medical loss ratio not being there. Okay. There are so many, capitation, you're describing, Marco. I don't really want to propose capitation. I'm just telling you what's coming. Well, you know what medical loss ratio is not just a sword. It's not just we'll improve dentistry through medical loss ratio. No medical loss ratio is a shield. It protects dentistry from getting worse, getting worse. Dentists who are listening to this, could it get worse? A lot worse? If you read what Marco is saying, we're going to go. I won't say he wants us to take us because he denies this, but I'll just say, where are we going to go? Okay. He's saying it's going to get a lot worse. Medical loss ratio would not let that happen. Okay. So medical loss ratio is the number one thing we need to fix so many symptoms that we're dealing with, including wellness.

Mouhab Rizkallah, DDS Mass Prop 2:
Okay. On the second point, there are five Medicaid laws that I and David and Margaret Scarlett and others in our in the American Alliance on Dental Insurance Quality. I'm the president of the American Alliance of Dental Insurance Quality. What we have been saying is that there are five Medicaid laws that if the ADA took it upon themselves to evaluate every state's Medicaid program against those five laws, it would find every state violates every single one of those five laws. And if they simply did a study and you could hire you could hire an MPH student to do this in a region, northeast, southwest. Okay, whatever. They would do an analysis and they would find all of these states that are violating those laws and guess what would happen? You submit them to CMS. CMS being the center of Medicaid service. Okay. That's the federal policing arm of Medicaid for states. You submit it to them and you say these states are in violation of the Medicaid laws. Guess what? All of that would get solved. And I could show you the laws, but won't take the time unless you ask me to. But we have we have put together a single page of those five laws. If those two things were solved, you would, if these two items, medical loss ratio and enforcing those five laws, if that was actually done by the ADA, it would revolutionize our entire profession and serve patients in a way they've never been served.

Bob Dee, DDS, Moderator:
Thank you. I'm going to go to Dr. Cohlmia. Dr. Cohlmia, you have five minutes.

Raymond Cohlmia, DDS, ADA Executive Director:
Well, you're asking me the two goals for the ADA. I would have to go for a different perspective.

Mouhab Rizkallah, DDS Mass Prop 2:
But the two goals of members.

Raymond Cohlmia, DDS, ADA Executive Director:
The goals of members. Yeah, well, you know, there's two things. First of all is delivering content the way they want, especially, you know, creating a good member relationship is critical to us. I do want to comment real quick. We are taking action on so many things that Dr. Rizkallah said. You know, it's not just the MLR. You better start talking ERISA, you better start talking realistically. And we're taking some aggressive movements on that as well to actually make sure that these companies don't slip from the MLR side and go to the ERISA side, which is what they're planning on doing. But if I were to look at the two specific areas, my job is to provide you all the security of the future of your profession. You provide input, but you provide leadership of where we need to be. If it were up to me, the two specific goals would be incredible advocacy. Some of the things you talked about, Dr. Rizkallah, are absolutely amazing, but advocacy does require members. Members requires people. We got to have dues to do this. This is, not none of this is for free to continue to move this process forward. And then of course, creating a perfect experience or the best experience for each one of our individual members. Because what interests each and every one of you does not necessarily interest the other 200,000. Every individual, you know, we can no longer use the mentality of the ADA, one size fits all. Because, you know, as far as I'm concerned, when one size fits all, it means it doesn't fit anybody.

Raymond Cohlmia, DDS, ADA Executive Director:
So we have a lot of work to do, customizing experiences, creating the needs that they have to do, the information that they need to make the decisions and providing the information and the support that they need to be successful in their practice as they move forward. So my two goals are different than yours. As a professional, I can answer what my two goals would be. As the executive director, my job is to provide the American Dental Association and create an ADA that supports what you need in order to be successful in your practice and to take care of the profession. That's a multifaceted answer and a multi process. There's no two one things that's going to solve or actually create a future that's going to be well defined. It's a lot of things that we have to do at the ADA. I know that was some of a generic answer, but each of you are individual members. I have to be catering to what you want specifically and what the Generation X wants or the new members and the old members and across the board, because everybody wants something different out of their ADA. I have to respond to that as an individual customer group.

Mouhab Rizkallah, DDS Mass Prop 2:
So but, I think my understanding of his question was he's talking about having what are the two most important things to members.

Raymond Cohlmia, DDS, ADA Executive Director:
But sir, that's that's illogical. You stated earlier that a question, the way it was framed is illogical. That can't be a question to me, the executive director. I have to the two things to each individual member that would vary with 25,000 different things.

Mouhab Rizkallah, DDS Mass Prop 2:
No, no, no. That's not. I'm saying if you were polling. If you were polling.

Raymond Cohlmia, DDS, ADA Executive Director:
We are, Dr. Riskallah, and we come up with multiple different things. We poll members each and every day. We poll different groups and the differences between one generation to the other is dramatic. What's characteristic for you is not characteristic for the younger generation, the millennials. We receive so many different things that the ADA should be doing. Literally 20,000 different things. So I cannot identify two different things. When you say all members in general, two different things that does not exist, sir. That question does not exist in my language because I have to address as many things as I possibly can.

Bob Dee, DDS, Moderator:
I have to defend my question when I bring up one of two, and we have ten minutes to discuss this and everybody's welcome to join now to debate this, the two topics that I wanted you guys to bring up was what is most important to dentists as a whole. We are very much alike. I know you're saying the different generations and different settings have different needs. However, that is not my experience. My experience from talking with thousands of dentists is that when you talk about what's your main problem, every single person is going to say dental insurance.

Mouhab Rizkallah, DDS Mass Prop 2:
Exactly.

Bob Dee, DDS, Moderator:
I don't know anybody else that says I'm sorry health. I'm the one. Health is probably the my number one. I drank. I drank six shots of espresso for this interview. But my main concern is that maybe we should have these topics ranked and then and then look at, you know, how we talk about value based dentistry. Let's talk about value based ADA

Bob Dee, DDS, Moderator:
What we're going to get out of our efforts. It is really important for us to see results, results. We can sit here, all five of us, and fantasize, and then the dentist around the corner is struggling to fill his chairs. You know, we need to address those. I joined to help you with that. I'm going to recruit people for the American Dental Association. Dr. Leader, I want you to start with this topic. What do you think are about the stuff that Dr. Cohlmia and Dr. Rizkallah mentioned?

David Leader, DDS, Tufts University:
I'm a little lost. I mean, Dr. Cohlmia, I think, rightly says, that the two most important goals over the next five years are going to be different based on who you are. I think that by trying to be something to everyone, it's difficult for the ADA to perpetuate the high cost of membership for every member. Because there's no possible way that the ADA can provide the services to me that I need as a full time professor at a dental school, as when I was a practice owner, as when I was recently out of dental school deeply in debt. I know that there are benefits at each level, and I've been a member for a long time and I appreciate membership and I will continue to be a member. But it's and I can market membership to my recent graduates, to my students, but one thing that I think will will help all of us, the practice owners, the people who are recently out of practice, the people who are close to retirement and want to sell their practices is if we can get this federal MLR through. The federal MLR needs to be job number one right now for the largest, most effective dental organization in this country.

Marco Vujicic, PH.D., ADA Chief Economist:
Okay. On that can I just to add to what Ray said. So we're all having the same vision here. By the way, like you just both said, you know, MLR number one, Medicaid reform, number two. Make no mistake, this is massive efforts in this area within the ADA. And you talk about results. I just mentioned them earlier. There are nine other states that passed legislation that have something in play this year in their legislatures that are for including Massachusetts. So this is spreading. And this is not random. The ADA is investing massively in this. So, Doctor Rizkallah, we are supporting that effort. You're saying tactically, I heard from you, we should go for the federal route. I know our advocacy folks. You know, you've talked with them. They think at least now it's better to go state by state. Look, that's not my area. You guys can provide them input. That's tactics. But we're all about the same thing. We're trying to really expand this, ensure accountability. Right. That's what this is at the end of the day. And with Medicaid, we've had a record year the well, the past two years, let's say, in terms of things like adult benefits being added to Medicaid programs. You mentioned more about the the nitty gritty about, you know, the rack audits and different types of administrative and low reimbursement in Medicaid programs. Major, major problem. Trust me, that is a massive investment in our states and there's been successes. So I think it's a little unfair to say you're not working on these two issues. We are. And they are priority number one. Honestly. Like we're all agreeing we need more accountability on third party payers. We need transparency. We need to have a different model of insurance even that actually pays for the care that you all as clinicians say is important versus having these caps, etcetera. We can talk about the tactics and all that, but everybody is on the same page here. This is issue number one, Bob. So and there is that.

David Leader, DDS, Tufts University:
I'm sorry, Marco, but why isn't that addressed at the Dental Quality Alliance?

Marco Vujicic, PH.D., ADA Chief Economist:
I don't know. It's addressed in different areas. I mean, we can talk about maybe we need to come on more programs like this with the folks that are leading those programs. Right. To talk about this. David This is good feedback.

Mouhab Rizkallah, DDS Mass Prop 2:
And the Dental Quality Alliance is a subject that we should, we should get into a bit here. Okay. Because part of, you know, so well.

Marco Vujicic, PH.D., ADA Chief Economist:
Maybe, I don't know, there's other people that are more expert than Ray and I don't know. Bob You can have a whole.

Raymond Cohlmia, DDS, ADA Executive Director:
Other dental quality people in. I keep monitoring the communications. I'm not aware of this, of what you're saying is happening. I've not seen that happen. But you know what, Bob? Let's set up another time and we'll bring people on if that's what you want. You know, this is this is a great discussion, gang, But, you know, just remember, if you start going to a federal MLR, there'll be some other things that you have to address, too. Is dentistry going to be part of primary health care? Yes or no? What's the answer to that? No. These are things you have so and you say, well, no, we want to keep.

Mouhab Rizkallah, DDS Mass Prop 2:
Federal MLR does not require us to get...

Raymond Cohlmia, DDS, ADA Executive Director:
So there's a lot of other factors we have to look at. But again, these are hot topics, no question. And with all due respect, I'm sorry to say, when you all said dental insurance is the number one. No, it's not. It's not. When we listen, we we survey everybody. And you'd be surprised the diversification of answers that we receive. So I have to respect that fact that, yes, you know, those are the groups that you're talking to that seem to be the hot topic. But there's other groups out there that have other things. I'm simply trying to provide so much to do for to be become more of a diversified ADA that supports individual members, to provide them information, the stuff that they need. There is no two one things. There's no two things that each individual. It varies so dramatically across the board. It's actually amazing. But we are doing so much on MLR. Dr. Rizkallah you created a movement that I am so excited about. I mean, I want 22 states and I want 24 states and I want to continue to push this forward hard and we are indeed doing that. We've got to get MLR as one of the greatest things that we can do for the future of our profession, no question. But we have to keep an eye on all these other things at the same time.

Mouhab Rizkallah, DDS Mass Prop 2:
Thank you for that. Let me say that I'm thrilled to hear that, you know, that I would I would say. When you said insurance is not the biggest issue, it actually it is. And frankly...

Raymond Cohlmia, DDS, ADA Executive Director:
It's not the...

Mouhab Rizkallah, DDS Mass Prop 2:
Let me just finish my thought. .

Raymond Cohlmia, DDS, ADA Executive Director:
You keep saying the number one, it may be behind the scenes, the number one issue, but that's not specifically what members are saying. I mean, you have to respect that each individual has their own opinion of what's important to them. And with all due respect, insurance is not the most important thing for many people out there. I'm just saying. So you're putting the words in a lot of people's mouth that doesn't exist. We survey these people. We know what they specifically say. We even bring up the topics of insurance. And in many categories, it's not rated as the top. I'm just being honest with you.

Mouhab Rizkallah, DDS Mass Prop 2:
So I asked you earlier, what are the two top things? You did not provide an answer, but you're saying...

Raymond Cohlmia, DDS, ADA Executive Director:
I can't give you the two top things.

Mouhab Rizkallah, DDS Mass Prop 2:
Let me finish.

Raymond Cohlmia, DDS, ADA Executive Director:
Yes, sir.

Mouhab Rizkallah, DDS Mass Prop 2:
I asked you, what are the two top things? You said I can't give you an answer. But you said MLR is not at the top. You know, at the at some point you've actually got to provide the information. You have the information. What are the two top things? And if you're not saying it's those and I'm telling you and Bob's telling you and and Dave's telling you, we are members. We are doctors who are practicing, and this is what we're saying.

Raymond Cohlmia, DDS, ADA Executive Director:
Wait a minute. You're not giving me a fair chance. I said, for each generational group and each different area, there are several different top things. We know what they are. Okay. If you want me to start going into all the generations, all the different regions, all the different areas from Midwest to south to north to east, it varies.

Mouhab Rizkallah, DDS Mass Prop 2:
So what I would say is and I think this is an important concept, 90% of getting to the right answer is asking the right question. Right? That's Einstein, right? Einstein said that. So when you're asking the questions, part of asking that question and if you want to get the right answer so that it actually directs the ADA, our mothership, to put their laser where we want it. You have to ask the question in a way that is actually going to get you the answer that they mean to answer, not the answer that they're sort of formulated to answer or or perhaps not directed enough to answer. Here's what I'd like to offer to you. I would like to offer to you the next time that you do a poll, ask me to review it. Okay. I'm pretty good at developing the right format for things to make sure we're getting it to the right answer. Okay. Ask me to look at it. But I want to I want to thank you actually, for, you know, for for pointing out that you're behind the MLR movement. But I want to take a moment also to just perhaps just push this concept of this. These are the five laws that I'm saying strategically. And I think I've I think I have distinguished myself as a pretty good strategist for the health of our profession and patients. If these five laws were were were studied by the ADA on a state by state level to evaluate where is every state's Medicaid program performing? If they were studied and an analysis was provided and we and we sent that to the CMS saying these are the areas that these various states are non-compliant with the with the Medicaid Act. Okay. We would change the our entire country's health care for the most vulnerable patients. Okay. Let me just look at let me show you just the first one. Okay. I call it the geographic area requirement.

Bob Dee, DDS, Moderator:
Wrap up,please. 30 seconds.

Mouhab Rizkallah, DDS Mass Prop 2:
It says payment sufficient to enlist enough providers so that care and services are available under the plan, at least to the extent that such care and services are are available to the general population in the geographic area. What did our legislators in Washington say? Payments sufficient? Because the reason the providers are not willing to serve these vulnerable patients is because they can't get reasonable cost coverage and reasonable profit. They're not able to serve the patients. That's my 30 seconds. If you just work on that five list, we will revolutionize it. Let me help you do that.

Bob Dee, DDS, Moderator:
One second. I'm sorry. We need to move on quickly because we're running out of time. I know Dr. Cohlmia needs to leave. Dr. Rizkallah, I want to ask you one question regarding this Medicaid issue you bring up. In my opinion, the two top problems for dentists are the high cost of education and insurance, that's the MLR. But I wanted to ask you and I think you've told this to me before and I've heard you talk about it, that by reforming the Medicaid laws, this you don't have to be a medicaid provider to benefit from that. That that's because a lot of these programs are administered and handled by private insurance companies.

Mouhab Rizkallah, DDS Mass Prop 2:
So the Medicaid programs, for example, Dentaquest is,it is basically the sister company or was just very until very recently, the sister company of Delta Dental of Massachusetts. Okay. It runs over 30 state Medicaid programs. And what they do is they virtue signal and say we care about kids. But if I showed you what they actually do to these kids and what they do not cover, and David is nodding because we know that the virtue signal and what they do is they take the Medicaid program and they collapse it so that the standards that are met, that are covering these vulnerable kids are so low. And because they control the state, even though they're not government, but they're quasi government. Because they control the state program and the state accepts it. Okay, because they're not paying attention. What happens is they can adopt it in private insurance and they lower the standard in private insurance. So Dentaquest gets paid by the state and then they get this bonuses by having these lower quality programs saying, hey, the reasons we don't cover it and we the reason that we don't that that patient doesn't get necessary care is because we've redefined necessary care because the state says that's not necessary. But who is doing that? It's Delta Dental's counter personality Dentaquest. This is a conflict of interest that even if you're not in the Medicaid programs, you're affected by it and your and your private patients are affected by it.

Bob Dee, DDS, Moderator:
Thank you. We have one question I want to get to. Unfortunately, we don't have as much time to to to do this. I want to give everybody two minutes to talk about this and then we'll see. We'll see where we go from there. My question is, basically, I want to, as I said, for me to join my mission is to bring more members to the ADA. I'm going to make that clear. We need, we need the power of people to lead the ADA. But in return we talked about accountability and results. I'm going to coin that value based ADA later on, but there is this misconception or perception that the ADA is run by staff. Not just the ADA. I'm talking about the local and the state. What kind of accountability does the ADA have for its employees? Meaning that, I don't know how, how, how long? You know, the president of the ADA to me changes every year. They're not, they can't accomplish anything in one year. So I understand we need to have staff around. Now, what are you doing to make sure the staff is accountable with the needs of the members? I'm going to start with Dr. Cohlmia. You have two minutes. No, this is the time. But go ahead.

Raymond Cohlmia, DDS, ADA Executive Director:
Thank you. Actually, that's a great question. And we are actually moving to mission based accountability. And mission based accountability actually defines and looks at all of our programs, projects, services, everything, and ties outcome metrics to every single one of them to show the effectiveness. You're right. You know, when people say it's staff driven, it's actually not. I will tell you, I've done a lot of business studies in my life and this is the most member driven association and member driven business that I have ever seen. Now, that doesn't mean that we couldn't improve because many times our decisions are made through a motion or made through what we feel that's the best thing to do. We want to provide the information to the members and the leaders of our association about mission based accountability that provides output metrics that defines what we're doing. Then that follows back to our new customer process with the agile form of governance, Bob. That's one of our biggest things we talked about last time, meaning that we're focusing on what our goals are, not on what we had in place. When any time a change occurs at the ADA, an individual say, retires or whatever, I'll say, hold on, do we really need that position? What are they providing? Is it answering the goals that we need to do? Everything is goal driven now and because it's goal driven through the agile form of process, we have to use mission based accountability that verifies that everything that we're doing actually achieves what you're trying to do.

Raymond Cohlmia, DDS, ADA Executive Director:
Remember, everything we talked about today is a value based process. It's a value within the value of the member itself, but it does take revenue to do that. So any time that we have the scale, you know, when you put a value thing here, you got to have revenue somewhere to offset that. I need members. I ask for your membership, please. These are contentious things, no question. But we are driving a future for you to support you in what you're trying to do. So mission based accountability is going to be one of the greatest things that happens to the American Dental Association. Where you see all the programs, the projects, everything laid out run in front of your eyes, including the cost of your governance structure itself that measures the outcomes and looks at that. That's how we have accountability in play. That's what we're moving towards at your ADA. So you're going to see some incredible things. You keep telling me perception versus results. What we're doing a lot of results right now. Perception that all plays that. But if you want to start to look in to see what we're doing each and this is what the responsibility is in our new digital delivery mode is to provide and show the value to each individual member specifically of what they need and how they want it. Delivering the information, how they want it, when they want it, why they want it in the form they want it. So that's what we're doing right now. So when you talk about staff, I'm very excited about this. You're going to see information and transparency like you have never seen before, and you will be able to make evaluations if you want to carry these programs forward and these projects forward. This is an extremely member driven operation. And many of the projects and programs that we are doing, sir, are based upon emotion. And this is what we feel is the best. And we talked to a couple people we want to provide you the information you need to determine whether those are actual programs you want to continue forward with or not. That's what brings the staff accountability. That's what brings the accountability for the entire organization and drives the future of the ADA to be very successful. Thank you, Bob.

Bob Dee, DDS, Moderator:
Thank you, Dr. Cohlmia. Dr. Rizkallah, one of you guys, one of you can respond or comment on what I asked.

Mouhab Rizkallah, DDS Mass Prop 2:
Go ahead, Dave.

David Leader, DDS, Tufts University:
Okay. Well. I'm. I'm not really. I feel like this question is a bit simplistic, but I think that's something that's very important as a member. I would like to know that the American Dental Association is looking out for our interests by making sure that the employees of our organization do not have close relationships with the insurance industry, are not being paid by the insurance industry, are not being given gifts from the insurance industry. Sort of like sunshine laws with the pharmaceutical companies. I think that this is extremely important to being sure that our organization that our personnel have less bias and are definitely on the side of the dentists and the providers.

Bob Dee, DDS, Moderator:
You're bringing up this point, but I don't know. I don't know anything about this. Is this happening? There are staff...

David Leader, DDS, Tufts University:
I'm not. I don't know.

Marco Vujicic, PH.D., ADA Chief Economist:
Where's that coming from, Dave?

David Leader, DDS, Tufts University:
I don't know if it's happening. I don't know..

Mouhab Rizkallah, DDS Mass Prop 2:
I don't really love seeing, you know, Marco in his article, you know, referencing Delta Dental of Massachusetts. Eric Matlock. Okay. Or in LinkedIn or in you know, these are these are you know, basically he's saying that these guys are doing a great job and he's saying that...

Marco Vujicic, PH.D., ADA Chief Economist:
You got to stop with that. Please.

Mouhab Rizkallah, DDS Mass Prop 2:
No, no, I don't have to stop saying.

Marco Vujicic, PH.D., ADA Chief Economist:
I'm not saying they're doing a great job. I'm saying this is examples of things that are happening and it's not insurers. I pick Denti-Cal. I picked a tech company.

Mouhab Rizkallah, DDS Mass Prop 2:
Denti-Cal is Delta Dental, right?

Marco Vujicic, PH.D., ADA Chief Economist:
They have a program in place. I'm not saying this is the best thing in the world. I'm not saying it's trash. I'm saying it exists. Right. Like, I don't know. I don't know what.

Mouhab Rizkallah, DDS Mass Prop 2:
You're referring to them and you describe them in positive.

Marco Vujicic, PH.D., ADA Chief Economist:
If mentioning somebody, if you call that an endorsement, then what's the point of scientific research with citations? This is ridiculous.

David Leader, DDS, Tufts University:
Well, I was thinking more of what's going on at the Dental Quality Alliance.

Mouhab Rizkallah, DDS Mass Prop 2:
That's also true.

Marco Vujicic, PH.D., ADA Chief Economist:
Somebody's on an agenda?

David Leader, DDS, Tufts University:
Yeah, it seems like. It seems like the insurance company is trying...

Marco Vujicic, PH.D., ADA Chief Economist:
To bring them back. I think, Ray, you should have the folks back to have a bigger discussion. Insinuating that how insurers are, this is beyond.

Mouhab Rizkallah, DDS Mass Prop 2:
This is actually what I think that's exactly what dentists across the nation are sensing.

Marco Vujicic, PH.D., ADA Chief Economist:
Well, you're sensing it. I don't know if dentists across the nation are and we're clarifying it right here that this is not an endorsement of any of these insurers, any models. You're misreading this.

Bob Dee, DDS, Moderator:
But, you know, Marco, as I said, you know, it's not just the opinions of Dr. Rizkallah or Dr. Leader. I mean, this article was read by thousands of dentists and everybody agrees that this doesn't look like you're in our corner.

Marco Vujicic, PH.D., ADA Chief Economist:
Everybody?

Raymond Cohlmia, DDS, ADA Executive Director:
You said everybody?

Marco Vujicic, PH.D., ADA Chief Economist:
Everybody agrees. Yeah, that's a very, very unique.

Raymond Cohlmia, DDS, ADA Executive Director:
That's a big statement. Hold on. That's a big statement because we had a lot of feedback on the other side, too. Hold on. Wait a minute. Now, So everybody in your group has said that. We've had a lot of other positive comments, too.

Love to see those invite them.

Bob Dee, DDS, Moderator:
The people who have a positive comment about this article..

Mouhab Rizkallah, DDS Mass Prop 2:
I can't believe it is open. I want to see that. I want to see who they work for and why they would think that. Because anybody, you know, capitation is not our future. It's our past. We've been there. We know what it is, okay? Not. Not okay.

Bob Dee, DDS, Moderator:
Gentlemen, I want to take one minute for each of you to tell me what do you think the ADA's five year plan should be? Just one minute. We don't have time. I know. Ray has got to leave. I want to start with Dr. Cohlmia. What? Take one. I know it's...

Raymond Cohlmia, DDS, ADA Executive Director:
Let's get real. You're asking me to summarize a five year plan for an organization our size in in one minute that I spent 5.5 hours speaking and I developed over the last seven months. Really? Okay. Well, if I were to say in one minute, my goal is to provide and help the member of the American Dental Association to be the most successful professional over the next five, ten years, and we do it through multiple aspects. Through public professional advocacy, through direct member benefits. Providing direct revenue and financial support benefits helps right there, supporting the local, national and state. That again refers to the advocacy side. Consistently carrying the message over the next five years to ensure the success and future that nothing interferes with the doctor patient relationship. That we keep the insurance companies or the third party agreements under checks and balances. We have to do that. We know they're not going to go away overnight. We know that. But we have to have reimbursement equitable to our services. That we are important part of the patient's health. That we provide a systematic way that we become a defined that global presence for the American Dental Association says that we are dentists and we are a critical part of the health of the people and we're here to help people further. I mean that's a lot. That's a loaded question.

Bob Dee, DDS, Moderator:
Just did you just you just. Summarized in one minute.

Raymond Cohlmia, DDS, ADA Executive Director:
That's my goal for five years in about a 45 seconds.

Bob Dee, DDS, Moderator:
I appreciate it. For the record, the time limitation is Dr. Cohlmia'schedule. He has to leave, But I want to take, Dr. Rizkallah, do you have anything to add regarding that?

Mouhab Rizkallah, DDS Mass Prop 2:
Dr. Leader and I and Margaret Scarlett and the rest of our board at CDIQ are here to help organize and steer what we know are the members goals, the dentists' goals of this country. And it is, as I described, it is a federal medical loss ratio and compliance with those five Medicaid laws. All things will flow from those two points.

Bob Dee, DDS, Moderator:
Thank you. I've wanted to, you know, we've reached the time, and I know Dr. Cohlmia needs to leave. I wanted to thank you, all of you, to be here. I mean, this was a monumental thing that we sit here and want to make sure, this is going to continue. I want the communication channels to be open. Dr. Cohlmia, my platform is yours no matter how you want to use it. Dr. Rizkallah, you're already in the group. Anybody who wants to come on and discuss the future of our profession. This is the point of this. I created that logo behind us. It's the symbol of dentistry and united we stand and divided we fall. And if we don't continue on this path of uniting people, we will not stand. And we will end up where, unfortunately, other professions, health professions have ended up. With that, I wanted to thank you, everyone, and we can continue this later. Thank you.

Raymond Cohlmia, DDS, ADA Executive Director:
Thank you all very much. Appreciate your input. This has been wonderful. Thank you.

Mouhab Rizkallah, DDS Mass Prop 2:
Thank you very much.

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