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Clinical Vs. Nonclinical Activities in the Dental Practice
As business models evolve, patient care remains firmly in the realm of clinicians
For decades, other health professionals, such as physicians, pharmacists and optometrists, have successfully organized their practices by making their own decisions as to how to (and who should) handle the nonclinical activities within their practices while they concentrate on what they have been trained and licensed to do: address all clinical activities and matters in their practices.
Every state’s dental laws set forth a demarcation between matters and tasks that are “clinical” (which are fully reserved to dentists licensed in that state) and “nonclinical” (which can be performed by any individual, including a dentist). How the dentist-owner of a practice choses to handle his/her practice’s administrative needs is left to the dentist-owner. Some dentist-owners may choose to outsource all or a portion of their administrative needs (to one or more contractors) while other dentist-owners may choose to address these tasks internally, either by themselves or by employees of their practice. Regardless of how a dentist-owner chooses to address the nonclinical administrative needs of his/her practice, the fact remains that the decision has no bearing on how the dentist addresses clinical matters in the practice.
What Defines a Practice?
The American Dental Association’s (ADA’s) “Proposed Classification of Dental Group Practices” confuses the universal truth that all clinical decisions are left to the dentist by attempting to define a dental practice by how it handles its nonclinical needs. The ADA’s attempt to define and distinguish between a “Dentist Owned and Operated Group Practice” (which the ADA defines as a dental practice that is completely owned and operated by dentists) and a “Dental Management Organization Group Practice” (which the ADA defines as a practice having contracted with a dental service organization, or DSO) fails to address the fundamental fact that dental practices that hire DSOs to handle their practice’s administrative needs remain dentist owned and operated. State dental laws and regulations prohibit the ownership of dental practices by non-dental professionals in all but a handful of states, and even in those limited exceptions, the law is clear that clinical decisions are the exclusive purview of the licensed dentist. The ADA does note, however, that “[n]o practical system for classifying group dental practices can be precise, since there are unique variations among group practices even within general categories.”1
The Division of Labor
In every state, there exists a demarcation between clinical activities, which are regulated by a state’s dental board (or equivalent state body), and nonclinical activities, which are not considered professional matters (and over which the dental board has no authority). Licensed professionals are free to choose from a number of vendors, consultants, and professionals with respect to how best to structure their practice for the delivery of clinical services. What is common in all states, however, is that only a licensed individual can perform certain defined functions, while both licensed and unlicensed persons can perform the administrative and operational activities that are considered nonclinical in nature. A general sample of functions identified as clinical versus nonclinical is provided below.
Clinical activities can only be performed by a dentist and include the following:
· Patient evaluation and diagnosis
· Determination of treatment options
· Patient treatment
· Hiring/firing/employment (including compensation) of dental professionals
· Hiring, training, and supervision of dentists and hygienists
· Preparation and ownership of patient treatment records
· Clinical protocols
· Clinical Q&A and peer-review activities
Nonclinical activities that can be performed by anyone, including a dentist, include the following:
· Bookkeeping, accounting and tax preparation
· Payroll administration and processing
· Payor relations, billing, and collections
· Banking and financing
· Creation and placement of dentist-approved advertising, promotion (social media), marketing
· Information technology
· Human resources
· General office management
· Property management
· Risk management: legal and regulatory, compliance, insurance
State dental boards guard and enforce their existing statutes prohibiting non-licensed individuals from performing or even attempting to perform a clinical function reserved for licensed professionals. What is equally clear is that activities on the nonprofessional side of the clinical/nonclinical line do not involve the practice of dentistry and, as such, do not require a license to practice dentistry to perform. The sanctity of the clinical/nonclinical line
also applies in alternative practice arrangements, such as nonprofit and insurer-provider entities as well as government-related entities. In an effort to create a distinction where one does not exist, the ADA and Academy of General Dentistry (AGD) identify elements from the nonprofessional side of the clinical/nonclinical line, such as how a dental practice chooses to address its billing, human resource and other administrative matters, as illustrative of differences on the professional side of the clinical/nonclinical division. The problem with this, of course, is that what happens on the nonclinical side does not change the duties of licensed professionals on the clinical side. Regardless of how a licensed professional chooses to address or outsource the administrative aspects of his/her practice, the professional’s clinical duties and obligations do not change. “[Dentists] supported with DSOs have professional support, but still lead their offices and make decisions regarding their patients and teams. In that regard, there’s really no difference between a DSO-supported office and a non-supported office, except for the extra support and training DSOs offer.”2
Both DSO-supported and traditional dental practices commonly utilize the services of non-dentists for a wide range of important administrative and operational tasks, such as bookkeeping, accounting and tax preparation; payroll administration and processing; payor relations, billing and collections; banking and financing; creation and placement of dentist-approved advertising, promotion (social media), marketing; information technology; human resources; general office management; property management; housekeeping; and risk management, including legal and regulatory, compliance,, and insurance. The fundamental difference between dental practices supported by DSOs and those not supported by DSOs is not the types of administrative services actually 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, consultants, and professionals to perform the myriad tasks and services.
Keeping the Options Open
The use of terms such as “corporate dentistry” only confuses this issue. As the ADA states, “there is no definitive, accepted framework for classifying the alternative practice models that would fall under the umbrella of ‘group practice,’ ‘corporate practice’ or ‘retail dentistry.’”1 Similarly the AGD also notes “universality in the terminology in this field has not yet been achieved.”3 If the provision of nonclinical services to dental practice owners by non-dentist employees and contractors implicates the corporate practice of dentistry, then many non-DSO-supported dentists, in both solo and group practice settings, are aiding and abetting the corporate practice of dentistry. Within this context, it is debatable how many dental practices can justly claim to be utilizing a traditional solo practice model.4
In 2011, when legislation was proposed in the North Carolina House of Representatives that would serve to “significantly undermine the DSO model” after more than 30 years of successful operation in the state, the United States Federal Trade Commission (FTC) noted the value of the model in a letter to a North Carolina State Representative.5 In addition to emphasizing the benefit to consumers from competition among health care professionals, the FTC countered the position that restricting the DSO business model is necessary to ensure quality of service,5 citing an FTC report which noted that “’the majority of studies find quality to be unaffected by licensing or business practices’ and in ‘some cases quality actually decreases’ in response to the restrictions.”5,6
Within the larger health care context, it should also be noted that the Affordable Care Act enacted in 2010 contained provisions for the establishment of Accountable Care Organizations (ACOs) in the Medicare program “by encouraging doctors, hospitals and other health care providers to form networks which coordinate patient care and become eligible for bonuses when they deliver that care more efficiently.”7 In an era when increased efficiency, value, and quality are mandated by government and private payors and demanded by consumers, can the dental profession limit its own options through restrictions placed on the DSO business model?
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 April 27, 2015.
2. Barr MI, Workman R, Thorne SE, et al. End of the solo era? Dentaltown. April 2014:64-73.
3. 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 April 27, 2015.
4. Climo T. The solo practitioner and the 2 business models of dentistry. DrBicuspid.com website. www.drbicuspid.com/index.aspx?sec=wom&pag=dis&ItemID=315454. April 2, 2014 Accessed April 27, 2015.
5. United States Federal Trade Commission Letter to The Honorable Stephen LaRoque. Federal Trade Commission website. www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-letter-nc-representative-stephen-laroque-concerning-nc-house-bill-698-and-regulation/1205ncdental.pdf. May 25, 2012. Accessed April 27, 2015.
6. Cox C, Foster S. The costs and benefits of occupational regulation. October 1990. Federal Trade Commission website. www.ftc.gov/system/files/documents/reports/costs-benefits-occupational-regulation/cox_foster_-_occupational_licensing.pdf. Accessed April 27, 2015.
7. Gold J. FAQ on ACOs: Accountable Care Organizations, explained. Kaiser Health News website. http://kaiserhealthnews.org/news/aco-accountable-care-organization-faq. April 16, 2014. Accessed April 27, 2015.