From Marginal to Mainstream: Dental Support Organizations

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic takes a second look at a disruptive force in the dental marketplace and asks what it means for dental schools and programs as they prepare students for practice.

Are we doing enough to prepare students for the shifts occurring in the business of dentistry? Should we be doing more to help our students evaluate their opportunities both as employees and as entrepreneurs?
A lot has happened since I asked those questions in 2014 as part of a column titled “From Bungalow to Big Box? How DSOs Could Change the Face of Dentistry”. At the time, there was even some lingering disagreement about what term to use to describe dental support organizations (DSOs)—businesses that offer a range of nonclinical support services to affiliated dental practices.

DSOs vary, but affiliates are typically group dental practices that have outsourced their marketing, billing and IT functions to the DSO and adopted its corporate branding. From a consumer perspective, these practices appear to be part of a chain, and they are sometimes called “corporate practices” to distinguish them from the solo and small group practices that have long dominated dentistry.

Today, the term DSO is well established, and these once marginal players have gained a strong foothold in the marketplace for dental services. In an age of increasing consolidation among health care delivery entities, this shouldn’t be surprising. Nevertheless, the rise of DSOs represents a remarkable cultural shift.

Why is the appeal of these entities growing? Simply put, they fill a need by addressing a number of the stressors faced by today’s dental practices. Whether a practice struggles to market its services online and through social media; decipher ever-changing insurance contracts; maintain an electronic health record; or finance the acquisition, installation and maintenance of sophisticated digital equipment, DSOs offer a range of services that free up affiliated dentists to focus almost exclusively on the clinical aspects of their profession.

This proposition has proven especially attractive to millennials. By 2015, nearly 12% of dental school graduates entering private practice were choosing to work for corporate practices affiliated with DSOs. This year’s ADEA Survey of Dental School Seniors showed that 16% were making this career choice. Some older dentists have also jumped on board, eager to avail themselves of the ready-made solutions that DSOs offer to the increasingly complex challenges of running a mature practice.

“The days of just sending out a postcard or putting a sign out on the street are over,” says Michael Bileca, President of the Association of Dental Support Organizations. “Patients are ultimately in charge of their choices, and there’s a plethora of information in front of them to make that choice.”

According to Michael, DSOs have evolved to help practices adapt to the new health care landscape by developing different competencies for different affiliates. Some DSOs have strong marketing and branding capabilities and primarily build practices from scratch. Other DSOs focus on technology or on a dental specialty, such as prosthodontics. In recent years, he estimates, DSOs have experienced double-digit growth—in the number of practices supported, the number of dentists supported, and the number of patients seen in DSO-affiliated practices. “Year in, year out, I’ve seen continued growth in the ability and competency of the DSOs to create more value for their supported practices and dentists,” Michael said.

There’s no question that DSOs have a lot to offer, but for those of us educated in an era when independent, solo practice was the norm, practicing dentistry in a corporate environment requires a cultural shift not all of us are ready to embrace. That’s partially due to the unfortunate checkered history of a few corporate practices, a history that has fueled skepticism about the quality of care provided by all such practices.

“From what we hear, in a DSO there is pressure to produce from the start and not necessarily the mentorship where the doctor/owner has a vested interest in seeing that treatment is done properly,” says Gary Badger, D.D.S., M.S., who recently retired as Professor, Chair and Program Director of the Department of Pediatric Dentistry at the University of Texas School of Dentistry at Houston. He is especially concerned that new dentists who work in corporate practices will be less inclined to take the time they need to seek advice when they are unsure about a procedure. “They get the message that if they don’t produce, they are not needed,” he says.

Gary fears these expectations can create an ethical quandary for inexperienced dentists, especially those who graduate with high amounts of debt. In Gary’s view, “It boils down to ethics, critical thinking and how students will perform under pressure.”

Michael agrees that the transition to practice is challenging for new dentists—in any environment—but he disputes the idea that DSOs are responsible for poor clinical decision-making by employed dentists. “Clinical decision-making is the responsibility of the practice owners,” he says, whereas the DSO is responsible for the business support services. “The more we can support the business of dentistry in the areas of marketing, IT, insurance contracting and the like, the more it leaves the supported practices able to focus on clinical care, and that in and of itself is a tremendous value.”

Gary acknowledges that all corporate practices are not alike. He thinks students can—and should—vet all potential employers as they make their post-graduation plans. He wants students to find out about an organization’s reputation before signing on and scrutinize contracts to make sure they leave room for decision-making based on ethical principles rather than financial goals.

Helping students formulate appropriate questions for future employers is one recommendation that Gary and his co-authors put forth in a 2015 paper in the Journal of Dental Education. They urged dental schools to enhance their practice management curricula in four ways:

  1. Explain shifts that occur in the business of dental practice.
  2. Provide a clear understanding of the legal structure of the corporate practice of dentistry and the dentist’s rights and responsibilities in this practice model and others.
  3. Review time allotted in the dental curriculum for inquiry into the corporate dentistry practice model, and assist students in developing the appropriate questions to make an educated decision regarding this and other practice options.
  4. Develop interactive and engaging experiences that give students the opportunity to explore various types of practice models that include interprofessional experiences.

I agree it is incumbent on us to educate students to make informed decisions about their employment options after graduating and to better prepare them for the transition to practice. On the most fundamental level, our graduates need to understand that, as Gary and his co-authors put it, “[T]here are no circumstances…that absolve dentists from responsibility for the treatment of their patients.” That may be harder to appreciate in a corporate environment than in a small private practice setting—or not.

Many DSOs offer mentoring and formal continuing education (CE) programs structured to help recent graduates transition to practice. Heartland Dental, the largest DSO in the United States, invests heavily in professional development, offering 200 hours of supported CE courses to its dentists each year. Patrick Ferrillo, Jr., D.D.S., a past president of ADEA who served as dean of three dental schools and, until recently, sat on the Heartland board of directors, told me that Heartland even incentivizes CE with significant financial bonuses, some of which are large enough to pay off a dentist’s student loans. That financial benefit aside, he says the reason DSOs sponsor professional development programs is to cultivate better dentists. “If you are better educated, better prepared, your practice is only going to flourish,” he says.

Pat joined the Heartland board at the request of a former student at the Southern Illinois University School of Dental Medicine: Heartland founder Rick Workman, D.D.S. At the time, Pat recalls, DSOs were highly controversial. Although he had moved to the University of Nevada, Las Vegas, by then, Pat knew his former colleagues in Illinois didn’t like the idea of a large corporate practice competing with their alumni for patients. Nevertheless, he was curious. “I saw this as a new opportunity for our graduates to consider, and I knew Rick was very conscientious, that he cared about the quality of care, so I decided to be engaged,” Pat told me.

After 12 years serving on Heartland’s board, Pat has concluded that the overall concept of DSOs is positive, and that there’s a reason they are experiencing such rapid growth. “It’s an attractive alternative for graduates coming out of dental schools and for those who are thinking of slowing down, so to speak, and want to sell their practices,” he told me. Part of that attraction is that DSOs allow dentists to practice dentistry and enjoy a better work/life balance than those who own their own practices.

In Pat’s observation, dentists at Heartland were happy, especially the younger practitioners. He characterized their perspective as “‘I want to work, I want to have a good life, I want to have a great income and I’ve got to pay off my student debt.’ They seem to be very content with that.”

So how would he like to see dental education evolve to better prepare students for the changing practice environment? Pat would like faculty who are sending a message to students not to consider DSOs to keep an open mind and let students decide what is right for them.

I agree. One size does not fit all, and now that DSOs are part of the mainstream, we should do more to help students explore all of their career options. As Gary stated, that means helping our graduates to ask the right questions.

Pat recommends these two:

  • Will the DSO I join support me in my personal career development?
  • As a dentist, will I drive the decision-making when it comes to patient care?

If the answers to both questions are yes, then DSOs appear to be a career option well worth considering.

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