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The Role of Dental Support Organizations in an Evolving Profession
The executive summary of a recent ADSO report on changes in dentistry
Several recent publications have discussed the current state of oral health and the dental profession in the United States, the challenges ahead, and the role of dental support organizations (DSOs) therein.1,2 According to the American Dental Association (ADA), more than 181 million Americans will not visit a dentist in 2014.3 Like physicians aligned with management services organizations (MSOs),4 dentists supported by DSOs are able to focus on treating their patients and providing affordable care—particularly for underserved populations such as working-age adults, the young, and the poor.5 MSOs and DSOs allow physicians and dentists, respectively, to be more attentive to patient care and allow knowledgeable business professionals to assist with the “nonclinical” administration of the practice. By spending their time more efficiently, dentists who hire DSOs are able to deliver dental services at lower prices, thereby increasing the accessibility of dental care to wider segments of the communities in which they practice.
Dentists Hold Responsibility for Patient Care
The thousands of dentists who choose to practice in a DSO model maintain the same requirements and professional standards as dentists who perform administrative and business tasks themselves or with the assistance of multiple service vendors and consultants. As the Academy of General Dentistry (AGD) noted, “Regardless of who holds the responsibility for business decisions, dentists hold the responsibility for their clinical and ethical decisions, whether before a state dental board, a court of law, or the court of public opinion,”6 and “regardless of practice modality, the ultimate responsibility for compliance with state laws and regulations falls upon the practicing [licensed] dentist.”6
The Association of Dental Support Organizations (ADSO) Code of Ethics specifically outlines six principles of member company conduct that are consistent with a dentist’s responsibility. These include:7
1. act with integrity.
2. focus on meeting the needs of dentists.
3. never interfere with dentists’ clinical decision-making and treatment services (including never set quotas).
4. employ qualified staff and use proven methods to deliver effective support.
5. provide a variety of business support services to meet the needs of dentists.
6. support dentists as they meet needs at home and abroad through charitable activities.
When referencing DSOs, certain commentators cloud the discussion through the use of inflammatory phrases such as “corporate dentistry” or “private equity.”7 These critics infer that a dental practice hiring a DSO violates its legal, moral, and ethical duties by transferring responsibility for all patient care decisions to the DSO. To the contrary, at all times, dental practices in a DSO—like many sole practitioner arrangements—are owned entirely by licensed dentists who are expressly responsible for patient care.
Mandates in the Affordable Care Act, state laws, and the innovative nature of dentistry are moving the profession to invest in electronic health records, CAD/CAM technologies, digital diagnostics, and more—all of which benefit patients. Unless a dentist is independently wealthy or has the means to afford bank loans to fund these investments, the dentist and his/her patients may have to do without such technologies. DSOs are able to invest in innovative technologies and in new practices on terms that dentists of even moderate means can now afford. These financial resources help promote greater efficiency and expand access to care for the benefit of patients and dentists alike and without requiring tax dollars to accomplish these objectives. Private equity represents a free-market solution within the dental profession—as it has with hospital companies, ambulatory surgery centers, and others—at a time when government reimbursement for dental care is significantly lower than for general healthcare services.
Clinical vs. Nonclinical
Every state’s dental laws set forth a demarcation between matters that are “clinical” (matters of patient care that are fully reserved to dentists licensed in that state and regulated by its dental board) and “nonclinical” (operational tasks that can be performed by any individual). How the dentist-owner of a practice chooses to handle administrative needs is left to the individual. Some choose to outsource all or a portion of their administrative needs, whereas others address these tasks internally, either by themselves or by practice employees. Regardless of how a dentist chooses to address the administrative needs of his/her practice, the fact remains that the decision has no bearing on how the dentist addresses matters of patient care in the practice.
Both DSO-supported and traditional dental practices commonly utilize the services of non-dentists for a wide range of operational tasks, such as accounting and tax preparation; payroll administration and processing; payer relations, billing, and collections; human resources; etc. The fundamental difference between dental practices supported by DSOs and those not supported by DSOs is not the type of administrative services performed by the licensed dentist; the difference is that the former outsource administrative and other nonclinical services through a single source, while the latter use either internal resources and/or a number of outside vendors and consultants to perform such tasks and services.
The “Silent Epidemic” and Increasing Access to Care
Former Surgeon General David Satcher noted the “silent epidemic of oral diseases is affecting our most vulnerable citizens—poor children, the elderly, and many members of racial and ethnic minority groups.”8 In the national fight against oral disease, DSO-supported dentists already play a pivotal role. A 2012 policy brief estimated that DSO-supported dentists provided more than one fifth of dental care services to children in Medicaid in 2009.9 According to the author, the DSO business model is “able to reduce operating costs” and provide flexible scheduling that recognizes the “impediments that many low-income families face with transportation and work arrangements.”9
In providing dental care to children in Medicaid, DSO-supported dentists not only increase access to care but also provide value to taxpayers. In a review of Texas Medicaid data from fiscal year 2011, the cost per patient per year at DSO-supported clinics was $483.89, compared to $711.54 at non-DSO-supported practices—an annual per-patient savings of nearly one third.10 Lower overhead costs enable DSO-supported dentists to accept insurance from a broader range of payers, both public and private, and has helped open states to managed care plans.11 Cost savings provided by DSO-supported dentists and practices have also been identified beyond the Medicaid setting. A 2012 study found that DSO-supported practices charged, on average, 11% less than traditional practitioners.12 Additionally, DSO-supported dental practices are frequently located in underserved areas, providing lower income populations with treatment options close to home. At the same time, patients of DSO-supported practices have consistently given their experience high marks on patient satisfaction surveys. For example, patients of practices supported by the country’s largest DSO, Heartland Dental, consistently rank their experience in the top quartile of all dental patients nationwide based on the nationally recognized Press Ganey Patient Satisfaction Survey.13
Impact on the Dental Profession
The challenges of governmental regulations, along with rising supply and technology costs and reductions in employer-sponsored dental insurance coverage, are producing dissatisfaction among dentists with the business side of their profession. These caregivers are increasingly tasked to manage student loan debt, requirements for asepsis, malpractice liability, and practice compliance rather than prioritize the needs of their patients. The central demand in the profession seems singular: practice management relief. In fact, many of the factors identified by the results of the ADA’s 2012 Group Practice Survey—work–life balance, flexible schedule, guaranteed salary, and less interaction with insurance companies—also appear to be perceived benefits of relief from some of the time and effort spent on managing a traditional solo practice or partnership.
DSOs offer an important additional choice for dentists faced with these practice management challenges. Many will continue to opt for the independence of a traditional solo practice, whereas others are likely to consider DSO models for meeting their personal and professional needs.11 In a free market economy, dentists who choose to focus more time on patient care than on the challenges posed by practice administration should have the ability to consider the arrangement best suited to their objectives.14 Specific examples of dentists who can benefit from practicing in a DSO environment include dentists who desire flexible schedules; recent dental school graduates with significant student loan debt and a need to improve their clinical competency in an accountable and structured practice model; and dentists with limited business acumen who have an appetite to learn from proven business methodologies rather than anecdotal experience of the traditional solo practitioner. For these individuals, the DSO model represents a valuable new pathway into the profession.
The dental profession is faced with significant challenges while the United States contends with a national oral healthcare crisis. Dental support organizations offer vital assistance in the fight against oral disease, providing dentists with a single source for practice administration and development resources, training, financing, and other nonclinical services that would otherwise involve numerous vendors or hours of the practitioners’ valuable—and limited—time. Today’s dentists must navigate mounting debt from student and practice loans as well as increasing liability and compliance requirements. DSOs provide a way for dentists to reduce the time, expense, and stress associated with the administrative aspects of their practices provide care for a wider community base including patients who have been previously underserved. Through collaboration with the ADA, the AGD, and other leading professional organizations, the ADSO is committed to assisting dentists in a common goal—the improvement of oral health in the United States through the accessibility of high-quality dental care. Put another way, the DSO model enables dentists to focus their time on patients—not paperwork.
About the Author
The mission of ADSO is to communicate the benefits and resources that DSOs bring to dentistry, which enable participating dentists to focus on increasing accessibility to high-quality dental care. The ADSO has DSO members in 46 states plus Canada, Australia, New Zealand, and the United Kingdom. These members support 4,000+ dental practice locations with more than 8,000 affiliated/owner dentists and 32,000 employees serving more than 27,000,000 patient visits annually. For more information, visit www.theadso.org.
1. Guay A, Warren M, Starkel R, Vujicic M. A proposed classification of dental group practices. American Dental Association website. www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0214_2.ashx. February 2014. Accessed December 4, 2014.
2. Academy of General Dentistry Practice Models Task Force. Investigative report on the corporate practice of dentistry. Academy of General Dentistry website. www.agd.org/media/171772/corporatedentistrystudy.pdf. 2013. Accessed December 4, 2014.
3. American Dental Association. Action for dental health–year one: 2014, a report to Congress. American Dental Association website. www.ada.org/~/media/ADA/Public%20Programs/Files/Report_to_Congress_ADA-Action-for-Dental-Health-1.ashx. May 2014. Accessed December 4, 2014.
4. Anderson GD, Grey EB. The MSO’s Prognosis after the ACA: A Viable Integration Tool? Presented at: American Health Lawyers Association Physicians and Physician Organizations Law Institute; February 11 and 12, 2013; Phoenix, Arizona. www.healthlawyers.org/Events/Programs/Materials/Documents/PHY13/B_anderson_grey.pdf. Accessed December 4, 2014.
5. American Dental Association. A profession in transition: key forces reshaping the dental landscape. American Dental Association website. www.ada.org/~/media/ADA/Member%20Center/FIles/Escan2013_ADA_Full.ashx. August 2013. Accessed December 22, 2014.
6. Academy of General Dentistry Practice Models Task Force. Investigative report on the corporate practice of dentistry. Academy of General Dentistry website. 2013. Accessed December 22, 2014.
7. ADSO code of ethics. Association of Dental Support Organizations website. http://theadso.org/about/code-of-ethics. Accessed December 22, 2014.
8. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
9. Edelstein BL. Dental visits for Medicaid children: analysis and policy recommendations. Children’s Dental Health Project website. www.cdhp.org/resources/173-dental-visits-for-medicaid-children-analysis-policy-recommendations. June 30, 2012. Accessed December 22, 2014.
10. Laffer AB. Dental service organizations: a comparative review. Pacific Research website. www.pacificresearch.org/fileadmin/templates/pri/images/Studies/PDFs/2013-2015/2012.09.19LafferDSOs.pdf. September 19, 2012. Accessed December 22, 2014.
11. Barr MI, Workman R, Thorne SE, et al. End of the solo era? Dentaltown. April 2014:64-73.
12. Taylor DH. Independent Review and Assessment of North Carolina Dental Health Marketplace Study. May 2012.
13. Press Ganey Patient Satisfaction Survey overall results by quarter, 2012-14. Please provide more information here—link or publication information.
14. Gray B. Dental practice management: causing toothaches or smiles? The John Locke Foundation’s Statewide Issues Blog website.e://lockerroom.johnlocke.org/2012/04/20/dental-practice-management-causing-toothaches-or-smiles. April 20, 2012. Accessed December 23, 2014.
The preceding material was provided by ADSO. The statements and opinions contained therein are solely those of the organization and not of the editors, publisher, or the Editorial Board of Inside Dentistry.