September 5, 2013
My Mama’s small Oklahoma town does not have a Starbucks but it has a “corporate” dental practice. Corporate practices are on the rise. The ADA chose corporate dentistry as a hot issue for last year’s ADA Mega Topic forum for our House of Delegates. Frontline and the news are all over it. Rumors of poor quality, overtreatment and lack of consequences for the corporation’s role in adverse patient outcomes cause grave concerns for dentists and the public.
What is a corporate dental practice? The most salacious definition is they are dental mills hell bent on making a profit at the paying public’s expense. Others say they fill a niche market and provide good value for patients and worry-free practices for dentists. Neither definition truly defines an exact business plan, policies for ethical treatment of patients or corporate consequences for adverse outcomes. Therein lies the problem.
So far, I have found several types of corporate practices. Sometimes the dentist is the owner and the corporation manages human resources, supplies and other practice details. Other times, a dentist or private equity group owns several clinics, and dentists are either associates or employees. What exactly is the difference between an employee and an associate? What is the number of dentists one must have before the practice is not just a simple associateship but is a corporate practice?
Does the dentist’s autonomy matter in the definition of corporate practices? Does the corporation set policies or guidelines that effect treatment of patients? Are those policies ethical and do they fall within that state’s dental practice act? Is there punishment for not following policies? I want to know! So does the United State’s Senate. They just finished a two-year study on several corporate practices that have allegedly overtreated children and committed Medicaid fraud.
According to Washington state law, all dental practices must be entirely owned by a state licensed dentist. This law supports the “corporate practice of dentistry doctrine” which essentially states that only a human being can be screened for integrity and educated to receive a professional license. Residency does not matter. The owner can live in Timbuktu and the practice is still legal. There are a few practices that may not be in compliance. Not every law on the books is enforced. The WSDA is submitting examples to the Washington State Attorney General to get a read on that office’s view on the enforceability of the law and their willingness to enforce it.
Our state’s poverty clinics are not all owned by dentists. Federally Qualified Health Centers were put into place by federal law and are exempt from state law. Free clinics and non-FQHC’s are technically illegal. But these are good people doing wonderful things. I would be surprised if any legislator or enforcement agency would interfere with their good work. It proves the case that we have quite a bit of work to do in nailing down laws, rules and regulations. It also proves that well-regulated corporations can run an ethical dental clinic. But then, they are not seeking profit.
The ADA Health Policy Resources Center reports a 25 percent rise in corporate practices in two years. So why are corporate practices growing? Both venture capitalists and dentists are seeing the value and profitability of large group practice. New dentists cannot afford to start or build practices due to their enormous debt. Some of them see themselves as practice owners instead of drilling dentists. Access to care is a huge problem. Bulk buying supplies and pooled resources make for smart business. A guaranteed salary and benefits like paid continuing education, vacation, and a myriad of paid insurances makes corporate dentistry quite attractive. Corporate dentistry now fits the marketplace.
Having so many dentists wanting to work in corporate practices is an indicator for us not to turn up our noses. These dentists are our friends, our peers, and our fellow ADA members. How we address this issue will affect their livelihood, and their perception of organized dentistry.
Technically, I am a corporate dental director. I have worked for non-profit dental agencies for 22 years. One reason I chose this type of practice was because I thought I would not have to run a practice or discuss fees with my patients. I could barely balance my checkbook. Now I can run budgets, union and non-union employees, grants and supplies, while, almost simultaneously treating disease and helping my patients manage their lack of money. Corporate dentistry has developed me. Corporate dentistry and I have done a lot of good for the world and I am proud of us.
But it is not all good. I generally love the dental directors I have worked for. Much like the dentist owners that live in Timbuktu or a corporate board of directors they are rarely on site. In their absence, who sets the daily moral compass for that practice? Often, a non-dentist clinic manager attempts to play that important role above me, the real doctor. Many of them have very limited education and crude management skills. Most of the time my production is linked to their success. I think that is one place where things go crosswise. I can literally see why the doctrine supporting character screening and education is so very important.
I believe the dentist’s autonomy does matter and plays a big part in job turn- over in corporate practices. How did the practices that the Senate is investigating lose their ethical way? Did they even start with ethics? I believe that anyone who dictates treatment to any dentist is courting disaster. The treatment has to work in the treating dentist’s head, hands and heart. So far only the treating dentist is liable for adverse outcomes. That needs to change. If a corporation makes a policy that adversely affects a patient outcome or creates fraud then they should be held accountable. The dentist should not be left to hang alone.
It looks like corporate dentistry is here to stay. ADA CEO Kathleen O’Loughlin discussed it at the dental editor’s meeting last fall. She described some corporate practices that are designed and managed by dentists that are run on a high ethical plane and are working very well. There are several ADA Councils that are actively studying corporate dentistry. In the mean- time, the corporate clinics grow without proper oversight. We must work quickly on these issues to make these practices safe and sound for our patients and our fellow dentists.
My professors told me that if I take good care of my patients, my practice would grow, thrive, and take care of me. I listened, I acted, and it all came true. If corporations do not accept the responsibility for taking proper care of the human beings they serve, then we must regulate them. And that is the bottom line.