Corporatization of Dentistry: What Does it Mean to You?
July 29, 2014
Dr. John O’Keefe introduces the concept of corporatization in dentistry in an attempt to begin a conversation about the topic:
- What does corporatization mean to you?
- Have you had any experience working in a corporate entity?
- Were you approached by a corporate entity to buy your practice?
- Do you have any questions about corporatization?
We’d love to hear from you and share your experience. Any approach, correspondence, or conversation will be held in confidence.
- Email us at: jokeefe@cda-adc.ca or oasisdiscussions@cda-adc.ca
- Call us at: 1-855-716-2747
I have little experience with the corporatization of dentistry. It seems to play a minor role in my area. However, I believe in larger cities and especially in the United States it plays a significant role. I would be interested in learning about any statistics or trends regarding the corporatization of dentistry and related possible future scenarios for the corporatization of dentistry.
Mark
The direction that a segment of the business side of our profession, and the marketing companies largely responsible for driving some dentists toward promotional hyperbole, appears to be trending supports a notion that patients are losing value in the personal relationship with a specific healthcare provider and would instead show an unfortunate tendency to make choices not dissimilar to how they shop for tires for their car or take away food. The growth of faceless websites, internet coupons or franchise offices lacking a specific dentist’s name should alarm anybody who is convinced that our profession needs to defend our privilege of self-regulation and guard our reputation from hucksters and scoundrels who have little or no skin in the game at the end of the day.
I have limited direct experience with this format of practice. However, we do have some local members who are embracing the concept of the satellite group practice clinics. However, I have “inherited” some patients who became frustrated by seeing a different dentist every time they visited this type of office and felt they were more of a client than a person.
I did have an interesting conversation with a gentleman who visits a clinic of this format in the US and found it to work very well. In that office, the satellite clinics were owned by a few different dentists, but great care was provided to accommodate patient’s schedules and to ensure that patients saw their “own” dentist. Each dentist tended to work a few hours or days at each of the clinics and hours were often flexible (perhaps starting early to accommodate one patient, but then finishing early in that same day, while another day, the schedule might start later to compensate for the previous early morning). As well, considerable time was taken by the dentist to discuss treatment options and costs, therefore reinforcing the value of good communication. I think this type of offices can be effective if organized and run with a patient-centric approach rather than a pure business/revenue model. From good communication and good patient care will come great business success as patients will become loyal to their care provider.
Strong Point Margo
The PROBLEM is that these corporate entities exist to earn a PROFIT for their Owners/Shareholders. Whenever a dentist opens a second office for himself, or a corporate dentist group buys out an existing practice, the intent and the GOAL is to EARN MONEY. Because of that, the ethical, professional, health-oriented service aspects are much lower on the priority list.
They are staffed by Associates, often new grads who lack experience and judgment. In some corporate offices, the morning huddle compares each provider’s yesterday production against each other, and sometimes against other nearby corporate offices. There is considerable pressure to produce.
In addition, these associates have incurred huge university debts, and this is a great tempting income stream for them. These associates will also be raising a family, needing a home, a car, may buy a practice, etc. They are in great need of money. (There is also the possibility that when they leave the corporate environment, they will continue to utilize that corporate production approach to provide that needed income.)
As a dental consultant for an excellent, comprehensive, very-low-coinsurance Union Dental Benefit Plan, I SEE these dental pre-determinations and claims.
These entities seem to depend on production and making maximum use of dental benefit plans WITH assignment i.e. from what I see, it is: Fill EVERY incipient [has it been there for years, arrested? OR recent?] Fill EVERY cervical [”sensitive”] abrasion, every incisal [”sensitive”] slight wear hollow, etc.
The pre-determinations are often detailed lists, filling by filling, with surfaces given. Too often, these are at maximum possible surfaces, complication/ situation and fee. Ditto re services like extractions. [Sometimes, even an extremely easy [x-ray provided] 71101 is coded as 71201.] The fees are always at full suggested fee guide, with no (as suggested) reduction for quadrant dentistry, and sometimes, like one I saw recently, accompanied by 4 units of nitrous oxide sedation per quadrant–thus producing an (estimated) very beneficial hourly gross of $800 – $1,000.
I do not see anything on the pre-D’s or claims that indicate patient education, oral hygiene, preventive dentistry, etc. I have not seen anything indicating observation of incipients, minimal or moderate cervical abrasion/minimal or moderate incisal wear, etc. I am governed by the specifics of the dental plan and I adjudicate accordingly, although sometimes with great personal angst.
We do NOT adjudicate by computer, nor do we individually itemize routine treatment on pre-determinations. We still utilize paper claims, adjudicated by sharp, knowledgeable, trained assessors who then input into the computer. However, most large carriers utilize computers to determine if it is a covered service, and will itemize the available benefit item by item. The risk then is that when the treatment is completed, it is extremely tempting to simply click the “done” button and the claim is sent as predetermined, quite possibly with little relationship to what was actually done. However, the provider dentist or hygienist is the one responsible for the accuracy of that billing and claim. THEY are the ones at risk.
I am DEEPLY CONCERNED about this still small but growing segment of aggressive opportunistic dental care. Is it ethical? Is it professional? Is it changing our profession toward being seen as a retailer of product?
As a wet-gloved still-practicing dentist, I know that I do not “get paid in $” for educating, promoting excellent oral hygiene and diet, etc. BUT I CHOOSE TO DO IT – because I am a professional first. And then, I find that it is even more appreciated by my patients. That actually makes me more of a professional in their eyes. MY raison d’être as a dentist is to make my well-informed patients dentally HEALTHIER & HAPPIER [less fear, + cosmetics, ortho, etc.] UNfortunately, that coincides with seeing each healthy patient for less [but more health-oriented] dental care. Hopefully, this is compensated for by referral of more patients who want that level of care. It certainly is a nicer work week with happier, more fulfilled staff and dentist. We can also sleep well at night.
I do not know if “regulation” can improve the above situation. It is a PERSONAL & PROFESSIONAL CHOICE.
There is another worrisome RISK aspect deeply involved in this area.
There are perhaps a dozen code series that apply to most working days. There is also the possibility of a handy “crib” sheet. Yet, so many dentists “cannot be bothered” or “its too difficult” to learn the needed procedure codes. I can not understand this when there is the obvious comparison of supermarket checkout clerks who learn hundreds of codes within a month, and who have the handy-dandy crib spinner there as well.
Every practitioner is required to ensure the accuracy of what is put on a bill, a pre-D, a claim, etc. BUT MANY dentists, including the corporate groups, have the front desk “interpret” FOR them, the [clearly-written?] technical notations written on the chart by the dentist or hygienist. The potential for MIS-interpretation is great, and it will likely be toward a larger procedure, more surfaces, higher fee–possibly even to a covered service in place of a non-covered service. This is great for income, but is it worth the risk of a discipline hearing with its accompanying risk to the Associate’s registration?
In my opinion, the fastest, simplest, easiest way for the dentist’s accuracy and security is for the provider to clearly note the tooth code, the procedure code, the tooth surfaces, + any reduced fee in the proper column on the patient’s chart as part of the note write-up. That means there can be no guessing by the front desk staff who will proceed to enter the accurate data. Should there be a later conflict, it will be obvious to the RCDSO that it was the front desk. The dentist will have done a great deal within his/her power to ensure accuracy.
It is NOT SAFE or PRUDENT for the Associate or Hygienist to abdicate and delegate the above to the front desk staff, especially in a corporate office. Yet, In many corporate offices, everything except the dentistry is currently “done for the Associate”. Similarly, what happens if the front desk writes-off the coinsurance? The deductible? Does the Associate have a policy agreement with the corporation saying he will not agree to co-insurance write-offs? Would that be an impediment to his working there?
I strongly believe almost all associates are UN-aware of these serious risks, and take no preventive precautions. I believe that they either trust the office, or resignedly believe they have no other options.
RCDSO regulation could have a definite beneficial effect here by requiring that the treating dentist MUST enter these items on the chart FOR the front desk staff.
I do not have any easy answers for this sort of thing.
I look forward to a great dialog in this area.
I have extensive experience in all practice modalities as a long standing associate and more recently as a partner and owner in a practice. I have practiced in a hospital setting, an HMO in the United States, as an associate in both large and small practices urban, suburban and rural.
This is a topic that requires a great deal of evaluation and would be difficult to respond to in just an e-mail. I would hope to have time to further discuss this issue with the CDA at some point in the near future.
What I can say is that, the best patient care is supplied by the patient seeing the same dentist and even ideally hygienist. The patient should also have the choice of who provides them with their care. The dental team then learns the patient’s particular needs and personalit;y thus, delivering to them the patient-centred care they deserve. Trust can be established over time also facilitating the patient’s treatment needs most effectively. This cannot be provided within the framework of overriding production goals and targets. No matter what the “industry” might say, it does not result in the best care possible.
This doesn’t need to be so much a conversation with respect to giving advice but one of evaluation of regulatory bylaws to ensure that the best care possible approach is being implemented. We have had too many conversations over the last 10 years with the result being a continued erosion of individual patient care. The continued encroachment of Health Management Organizations, Franchises and non dentists owning all or portions of practices is a violation of the spirit of the dentist-owned and operated delivery of care, the purpose of which has been to ensure a patient-centred approach that the dentist would invest in. Profit would be secondary.
Dentists may say that they don’t care about these new models as people will realize the substandard care provided and come to see me anyways. Well, the next step in dental care evolution solves that problem for the HMOs and Franchises and is already here to a limited extent. Preferred-Care-Provider Plans and Capitations.
These plans will be negotiated by the employer and the dental community dictating fees and where a patient is eligible to receive care. The dentist must accept the terms of the plan or be denied being able to submit claims on the patient’s behalf. Often these plans will dictate fees for services that aren’t even covered. The patient is not covered, if seeing a provider not enrolled with the carrier. In an economy with continued shrinkage of disposable income the patients are reliant on whatever benefits are possible hence have their access to care and choice limited. They are financially obligated to see providers enrolled whether they find them competent or not. This includes specialists. HMOs and Frachises exploit this to their advantage willing to accept lesser fees for volume. Consultants and managers are hired to maximize billings per plan parameters. These consultants and managers are hired, promoted and fired depending on how they “perform” with respect to profits not patient satisfaction. The only people who gain in this model are the ones not receiving or delivering care, but still taking a proceed of the profits. I know I have worked with them.
My individual experiences of the negative within these models are too many to mention. Again, organized dentistry and regulatory bodies should feel a legal and moral obligation to look into what is happening within our profession and return it to the ethics and nobility it once had. Patients deserve the best individualized care possible and deserve choice. Everyone wins in this model not just the people sitting in an office cashing the cheques.