Edward H. Meckler, DMD
A founder of the Sears large-group dental practice 30 years ago shares how that model—which offered convenient hours, locations, and the ability to use a credit card—changed the face of dentistry.
Interview by James B. Bramson, DDS
Inside Dentistry (ID): What were some of the economic and practice factors at the time you founded the original large group practice model?
EDWARD MECKLER (EM): Things were quite different in 1981 than they are now in 2011. Back then, dentistry was practiced mainly in medical buildings, or sometimes even upstairs above drugstores. The concept of what is now called retail dentistry was very limited. There were not many free-standing strip center-type offices—in fact, there were far fewer strip centers in the early 1980s—and professional services, including dentistry, were never advertised. In those days, there were no health maintenance organizations (HMOs) or preferred provider organizations (PPOs), and although dental insurance existed, it was limited. Credit cards were issued mainly by department stores; they were not used to pay for professional services. What’s more, most of the dentists were solo practitioners and male—there was only one woman in my graduating class from dental school. Dental offices kept bankers’ hours and were generally closed on Wednesdays.
ID: How did your model attempt to overcome some of the limitations of dental services then?
EM: Our model was much more patient-friendly and transparent. We catered to the needs of the public. As we were in Sears stores early on, we were where people shopped and we were open during retail hours—80-plus hours, 7 days a week. Locations were convenient, there was plenty of parking, and the Sears affiliation was an enormous asset. We advertised to create awareness and to deliver our message. Adding to those benefits was that people could use their Sears Credit Card, offering them the means to pay for dental services when no other credit cards filled that need. We also made sure that people knew what they were getting into, unlike when they would go to the doctor and then get the bill. We published a dozen or more of our fees prominently on a sign outside our waiting room.
ID: What in your background or experience led you to see this need for a more corporate environment in 1981, and is this model still relevant today?
EM: It’s partly common sense, but I was also aware of the Sears optical business in Cleveland. I was greatly influenced by that model, where a licensee of Sears managed the business portion and the optometrists were able to work freely in the offices. I recognized that we could similarly provide dental services more efficiently and affordably, with more technical services, by having multiple doctors sharing the costs, including equipment, advertising, and support staff. It allowed for a division of labor in which the dental professionals could focus on patient care, while what we now call the dental services organization (DSO) could focus on the business aspects.
The model is basically the same today—with convenient hours, multiple doctors, and efficient staff—but we have adapted to changing times, using new technology both for managing information and in removing obstacles for affiliated dentists to provide dental services, new ways of attracting patients, and placing a greater emphasis on patient satisfaction. Our affiliated doctors today are more scientific. They do more cosmetic-related procedures and implants now, and the equipment—for example lasers and CAD/CAM—is more technical. Dental insurance has also changed the scenario; the large practices may bring in patients through Medicare or Medicaid, or by subscription to a PPO or HMO program. We generally strive to offer convenient, personalized care and to continue to understand and cater to patients’ changing needs.
ID: Describe the structure and characteristics of DSOs and how do they impact patient care?
EM: The doctors own the practices, although there may be equity sharing with the business that services their practices. Professional staff, typically the doctors and the hygienists, are employees of the professional corporations or of the doctors, depending on how the practice is structured. Service employees, such as the receptionist, may be employees of the DSO.
Management oversight is the key to the efficiency at which the large group models excel. Well-run management is essential to supporting the clinical practices, and this really trickles down to patient care. The DSOs provide operational support, as well as employee training.
Basically, because the DSOs cover the nonclinical needs of a practice, doctors have more time to work in the chair. All of the groups have modern facilities with the latest technology. We typically have centralized practice support with administrative experts and tailored human resource systems and benefit programs. We also have the available capital to invest in supporting the healthcare delivery approach of the practices we service, with funds for research and development, state-of-the art tools, and new products. We try to stay ahead of the trends and the technologies and we provide innovative practice management tools.
One of the greatest advantages of our size is the buying power we have to purchase equipment and services. When you can purchase equipment for several hundred dentists at once, there are price breaks. Our ability to market and attract more patients also allows us to provide dental services at a lower cost.
We also assist dentists in developing programs that ensure consistent patient confidence, quality of care, and team performance. As part of ongoing education and training, DSOs offer training in communication, so—in combination with other patient satisfaction initiatives—we’re better able to understand and service our patients’ needs.
ID: How is patient information—including patient satisfaction—gathered and evaluated in the large practices?
EM: Many of the groups—including ours here and most of the larger practices—outsource to companies that have the expertise in surveying patients. They do it by phone, mail, and e-mail. This allows us to compare one office to another or to private practices or other dental service organization to see how we all fit into the field. Many of the patient satisfaction measures are qualitative. For example, we want to know if doctors are explaining needed treatments clearly and specifying their costs, if the staff is courteous, and if patients are reminded about return appointments.
In addition, the sophistication of information technology systems makes it possible to gather and evaluate information on performance levels—enabling us to determine our own best practices while still maintaining patient privacy. Large groups often offer metrics, such as comprehensive care analysis, in review. Patient surveys, too, are up for review. Large group practices are able to invest heavily in training for patient satisfaction.
ID: What does the large-group segment of the industry look like now?
EM: I’ve heard that the DSO practice management companies represent about 5% to 7% of the $100 billion dental industry this year, and this is the fastest-growing sector of the dental industry. The Dental Group Practice Association (DGPA), of which I’m executive director, grew by about 11% in a tough economy last year. Among the 120,000 dentists practicing in this country, about 10% are now affiliated with large groups.
We have learned a lot over the years about what it takes to succeed. The organizations that have survived and prospered were those with proper organizational support, financial backing, and infrastructure such as that provided by DSOs. Practices that failed early on were generally those that expanded too quickly, thinking they would succeed just because they were dental offices.
ID: What are the greatest challenges facing dentistry in general and the large groups in particular?
EM: First of all, access to care is a concern for all dentists, but it is very much at the heart of the DSO model, which focuses on making dental services available to large numbers of people. While solo practitioners can practice wherever they choose, large group practices are necessarily set up in areas where the need is greatest. It can be a challenge for the large groups to recruit good dentists to go to these areas—mainly smaller communities.
Another challenge is dispelling myths—often generated by those who feel threatened—about the quality of the care given through DSOs. We make every effort to counter the perception that patient care is less personalized in a large group practice, and to convey the fact that the opposite is true. The larger practices actually offer more personalized care than traditional practices because our affiliated doctors don’t have to spend the time on all the non-dental issues, such as accounting, marketing, or employee issues. The model allows for more time with patients than the traditional practice.
We all continue to deal with patients’ fear of the dentist, skepticism about the importance of good oral health, and concerns about fluoride. To compound that, many patients are confused about dental insurance; with so many degrees of coverage, it’s a very complex area. But for the most part, our marketing efforts have had a positive impact on these issues, as well as making patients aware of the locations of the dental practices.
ID: It seems that large groups offer some pretty distinct lifestyle and work balance opportunities for dental professionals at all stages of their careers, including new graduates, mid-career professionals, and retirees who want to scale down their practices. What are those advantages and how does your industry look at using those advantages to attract people?
EM: The nature of our business is that we’re open more hours than a traditional practice, and we need staff to cover those hours. However, rather than expect a dentist to work 75 hours, we can break up the hours and make them more variable. This affords dentists and other employees the flexibility to enjoy lifestyle advantages, such as attending children’s events and sharing childcare, as well as teaching or otherwise pursuing other professional interests. Also, because we have locations all over the country, relocation of a spouse to an area can be accommodated many times within the groups.
These advantages tend to be especially attractive to female dentists, who now compose nearly 50% of dental school graduates. Rather than putting their careers on hold to raise their families, they can practice their profession and earn a nice income. This is, of course, also an attractive option for their male counterparts.
Joining a DSO may also be an option for retiring dentists who don’t want to just sell and walk away from their practices. By associating with us, they can continue to practice without the need to deal with insurance companies, labs, and supply companies. They can focus on their patients.
I have personally benefited from being in a DSO-managed practice. I practiced for many years full time and I currently enjoy other related activities, including being executive director of DGPA, associate professor at the Case Western Reserve Dental School, and chairman of DentalOne Partners, where we provide services to over 320 dentists. My career has led me to path of dentistry where I’m doing many things I like to do, and I hope I can continue to do so for many more years.
ID: As executive director of DGPA, what would you say is its purpose?
EM: The DGPA is a nonprofit organization composed of the largest DSO groups in the country. It was formed about 4 years ago when, after a traditional dental group meeting, some of us recognized that the larger groups had different needs than the smaller groups did. We felt that the large groups’ ability to leverage their size and access—especially during the economic downturn—could fill a special void in dentistry. The DGPA’s mission is to facilitate an environment that allows our members to make their affiliated dentists’ lives easier, so they can focus on the delivery of quality, affordable care. DGPA members do this by making available continuous, forward-thinking dental education and supporting the use of cost-efficient, time-saving, quality technology. We also work with insurance companies—using electronic data processing software—to maximize reimbursement on dental plans. In addition, we work with regulatory and government leaders, as well as professionals and dental students, whom we provide with accurate information about the dental industry and various career paths they might find with a DSO. The members of DGPA provide services to dentists that represent about $4 to $4.5 billion worth of dentistry.
ID: What special opportunities are available to newly graduated dentists?
EM: For a young dentist with $250,000 or more of debt, the cost of setting up a practice can be overwhelming. Putting in the relatively modern equipment needed for a new practice would cost upwards of $300,000, $400,000, even $500,000. Unlike 20 or 30 years ago, in the current economic environment, banks are no longer eager to loan the funds necessary to build a practice to a dentist who, with student loans or other debt, often will have $700,000 or more in loans to service. The DSO model enables a young graduate or associate dentist to come into a practice that is fully equipped, with a stream of patients, providing not just the ability to make a good income, but to start and/or continue to build his or her professional life with a whole benefits package from health insurance to malpractice to disability to 401K. It’s not for everyone, but it can be an attractive alternative for those who fit well into this model, and it has worked well for the growth of my personal company as well as those of my colleagues in the DGPA.
About Dr. Meckler
Edward H. Meckler, DMD, who founded the first Sears Family Dental Center in 1981, is Executive Director of the Dental Group Practice Association, an associate professor at the Case Western Reserve University School of Dentistry, and chairman of DentalOne Partners. During his career, he has also been a Fellow in the International College of Dentists, a delegate to the Ohio Dental Association, a member and past delegate of the American Dental Association, and a member of the Academy of General Dentistry and the FDI World Dental Federation.