Changing with the Times

For decades, the Washington State Dental Association has relied on a financial model employed by business and trade associations across the country: members pay dues in exchange for representation in the halls of government, access to continuing professional education, opportunities to network with peers, and a variety of other services.

But, in the famous words of Bob Dylan, “the times, they are a-changin’.”  The model that has served WSDA well in the past may no longer be viable – or, at least, may no longer be the most effective way to fund the organization.

Assistant Executive Director Kainoa Trotter underscored the importance of keeping up with the changing times.

“As an association, we’re at a point where we need to do a complete remodel of what membership looks like,” he said. “We’re not tearing the whole house down to the foundation, but we are ripping the walls back to the studs.

“We certainly don’t want to become the association equivalent of Blockbuster. Netflix came along with a new model, and Blockbuster refused to change. Now they’re gone.”

Ensuring that WSDA never goes the way of the former video retailer has been a priority for the association’s board of directors for the last few years, according to President Dr. Nathan Russell. The effort began as a conversation among the full board, but then transitioned to become a primary focus of the association’s officers.

“We’ve seen a trend in declining membership in all trade groups and membership associations like ours,” said Russell. “We evaluated what is happening nationwide against what is happening with WSDA, and the trends are consistent. The situation here in Washington is less acute than what we’re seeing elsewhere, but the trend lines are heading in the same direction – down.”

Indeed, in 2006, WSDA could count among its membership more than 80 percent of practicing dentists in the state. As of the last tally in 2023, that figure had shrunk to just under 60 percent.

According to WSDA President-elect Dr. Chris Dorow, a look behind the numbers revealed several important conclusions. First, younger dentists – those within five years of graduating from dental school – were the hardest to attract and retain as association members. Second, the primary barriers to membership among this group are financial. And third, when a member is lost, they very seldom return.

These results are hardly surprising. The dental profession has changed dramatically over the years, with most dental school graduates leaving school with a significant student debt burden that makes association dues difficult to balance against other professional and family financial obligations.

Additionally, new dentists today begin their careers in a much wider variety of practice models than the traditional small, dentist-owned practice. According to WSDA board member Dr. Crystal Vo, that too has implications for association membership.

“I work in a FQHC, and each of us are given an annual CE allotment that has to cover not only our continuing education classes, but also scrubs, loupes, organized dental memberships, travel expenses – basically anything beyond malpractice insurance and licensure,” she explained. “For many of us, if we’ve been out of school for more than five years and are paying the full tripartite dues, it used up a good chunk of our CE funds. So for many of my co-workers, if they weren’t going to PNDC, they stopped renewing their WSDA dues. They weren’t seeing the value for the cost.”

“We need to address not only barriers to join, but also how to maintain our members. Beyond removing barriers to membership, it’s also about providing great value,” he said.

The first step will be extending discounted membership for a longer period of time, up to six years.

“When younger dentists are leaving school with mountains of student debt, and working to get themselves established, maybe buying into a practice, it’s a tough time for them financially and a tough time for us to be asking them to make a major commitment to an association,” he explained.

Step two is all about providing value.

“We also still need a commitment to traditional membership that long-time members have come to expect from WSDA,” said Dorow. “That means delivering value. So we will be adding value in the form of services for our members, including those who have been here a long time. As members utilize those services, they’ll be reducing their operating costs – and partially or completely offsetting the cost of their WSDA membership.

“These services are going to meet the needs of our members, provide great value, and will be very popular. People will search us out for that value, and membership will be more closely tied to services. As we increase our membership footprint, we can deliver even more on our other benefits, like advocacy, which can admittedly be harder to quantify. It’s hard to hang a price tag to something you stopped from happening,” he said.

“Another benefit is that it will generate more dollars for us to up our philanthropy game. I’d love to see us become the top philanthropic force in oral health in Washington,” Dorow added.

He also said that WSDA has no intention of discontinuing its service to its members upon their retirement. Many dentists step away from active practice, but want to continue to serve patients, on either a part-time basis or as a local or international volunteer.

WSDA is in the midst of launching a multi-year pilot program for ADA Life member retired dentists. Participants continue to pay regular dues, but have free access to WSDA events like PNDC, which helps offset the cost of continuing education and maintaining licensure.

“It’s a way to keep people involved in dentistry, to maintain their connection to their profession. We think it will be very appealing to give ADA Life retiring members the opportunity to maintain that experience, the camaraderie, the collegiality. They’ve earned it,” he added.

Russell was quick to point out that any new approach to dues and services can only be implemented with the support of the WSDA membership.

“Our budgets all have House of Delegates oversight. The Board can’t make these changes on its own,” Russell explained. “Reimagining the dues structure was presented to the House and it was overwhelmingly approved. They approved us doing the revised membership dues pilot with the ADA and a handful of other states, and the results will go back to the House for reapproval before we move forward with any permanent changes.”

Building Non-Dues Revenue

Having a dues structure that recognizes the needs of dentists at different stages of their careers is important, but so are the revenue-generating services that can help WSDA members reduce the cost of their practice and their membership. Before looking at some of the more recent initiatives and plans that are in the works, it’s important to note that the significance of generating non-dues revenue isn’t a new concept within WSDA.

Timely and strategic investment decisions by the association’s former leaders have resulted in WSDA owning a valuable commercial office building in a vibrant Seattle neighborhood. Even as the post-pandemic world adjusts to remote and hybrid work models, tenant lease payments generate important revenues for the association.

Similarly, the Pacific Northwest Dental Conference is another important money-maker.

According to Trotter, the more than $1.5 million  in total revenue generated by the conference’s sponsors, trade show participants, and attendees has traditionally provided more than one-third of WSDA’s operating revenues.

“The really important thing about PNDC is that it provides a lot of value for our members. In addition to offering an opportunity for a dental professional to get most, if not all, of their continuing education credits at one time, the pricing structure delivers a huge incentive for someone who wants to attend to become a WSDA member,” he said.

Another important resource is one that’s already familiar to many WSDA members – albeit with a few very important recent changes.

Specialized Expertise

Washington Dentists’ Insurance Agency (WDIA) was founded in 1990 as a fully owned, for-profit subsidiary of WSDA. Every member of WSDA is also a partial owner of WDIA.

WDIA Director of Insurance Matt French has spent more than 20 years working with WSDA and WDIA, and currently leads of team of 10 employees who provide insurance options tailored specifically to the needs of dentists and dental practices.

“When WSDA member dentists come to us, they’re shopping at their ‘home’ agency,” French said.

“The WSDA – WDIA relationship is very valuable to both parties,” he said. “WSDA members are our primary source of clients, so we do a lot of marketing, advertising, and sponsorships with WSDA to reach them. In addition to reaching our target market, that helps reduce our tax liability.”

Maximizing WDIA’s net income is important, because it all flows to WSDA to support advocacy, continuing education, philanthropy, component societies, dental schools, and other association programs.

“We are a very focused and specialized agency that works only with dentists. Many other health care practices are organized differently than dental practices, so the intersection of a dentist’s personal and professional insurance needs can be unique,” said French.

WDIA also serves dentists who aren’t members of WSDA; these clients still receive the benefit of the agency staff’s specialized expertise, but they don’t receive the additional benefit of WDIA net income supporting their professional association and helping keep dues down.

An Important Transition

French and his team are currently in the midst of an important transition that will not only serve current clients, but also set up the agency for even more success in the future.

For years, WSDA and WDIA offered professional liability insurance through NORDIC, a company in which the association owned a 25 percent stake. But about five years ago, the majority owners of NORDIC agreed to be acquired by The Dentists Insurance Company (TDIC). WSDA decided to sell its minority share of NORDIC to TDIC at that time. Unfortunately, that transition eventually impacted a number of WSDA members and WDIA clients.

“TDIC’s underwriting guidelines wouldn’t allow us to continue insuring a number of dentists who had been long-term customers of WDIA,” French said. “These dentists were frustrated. They’d been working with WDIA and wanted to continue the relationship. We wanted to provide them with choices, but we didn’t have the ability to utilize other traditional carriers, because our relationship with TDIC called for exclusivity.”

When the WDIA contract with TDIC was about to expire, WDIA and WSDA leaders asked to continue the relationship on a non-exclusive basis, but TDIC declined, so WDIA went with other options. That decision was aided by the results of a Request for Proposal (RFP) process that had been conducted at the time of the NORDIC to TDIC transition.

“Back then, we were very impressed by what we learned about MedPro Group. We ultimately stayed with TDIC to maintain continuity at the time, but when we decided to terminate our exclusive relationship with TDIC, MedPro became an obvious alternative to consider,” French added. “They are highly rated and a part of Warren Buffet’s Berkshire Hathaway family of companies.”

Bigger Thing Ahead

In March of this year, WDIA announced MedPro Group as its new, preferred partner for professional liability coverage. Since then, French; Kerri Seims, WDIA Associate Director of Insurance; and Emily Wilkinson, who was recently promoted to WDIA Assistant Director of Insurance, have been busy responding to existing clients who reached out to review their options.

So far, the transition is off to a very positive start, according to Seims.

“We’ve had a lot of our existing customers requesting quotes from MedPro. There’s a strong team at MedPro and the results in terms of both rates and service have been very encouraging,” she said. “Additionally, we’re now able to offer WSDA members 10% off MedPro professional liability policies, which is exciting.”

The MedPro transition also could set the stage for another initiative that has been in the planning stages: the creation of a WSDA-owned captive insurance company to provide professional liability insurance for its members. The captive would allow WSDA and its members to benefit from not only insurance agency profits, but also from the profits of the insurer as well.

MedPro is aware of the idea and willing to help in forming the captive insurer in the future. In that scenario, MedPro would provide risk management support and the “paper” – or policies – that the captive would offer.

“With more risk comes greater rewards. It’s a huge opportunity for growth. Plus, a captive insurance company would allow us more control over how things are managed in terms of underwriting, rates, and policy structure,” French said.

Reducing Employer Costs

John Meier, president of ERNwest, knows something about balancing risk and reward. ERNwest, which was founded 20 years ago, specializes in navigating Washington state’s workers’ compensation system and is WSDA’s partner in the association’s WSDA Retro program.

“Washington is fairly unique; there’s only one other state that allows trade associations to pool their members into a Retro program,” he explained.

Under the program, participating members are still insured by the state’s Department of Labor and Industries (L&I), but their premiums are pooled into one account associated with the program’s sponsoring association. L&I then analyzes the members’ collective claims over the course of a year and compares that total to the premiums paid into the system. If the premiums paid in exceed the claims paid out, the difference is refunded to the association and can be used to help offset members’ annual dues.

In two of the three years that WSDA has sponsored its Retro program, that’s precisely what’s happened, with rebates of approximately 40 percent one year and 20 percent another. To put those figures in context, a 20 percent refund translates into something north of $500,000.

Of course, if the opposite occurs and the claims paid out exceed the premiums paid in, participants have to make up the difference. Some unusual claims experience caused that to happen in the program’s second year, but the WSDA Retro program is designed to cover  the shortfall so there is no risk to the program participants.

While spreading risk across a broader group of dental practices helps mitigate financial exposure for any given member, another important step in protecting participants’ bottom line is to do everything possible to reduce the number, severity, and cost of L&I claims. Fortunately, ERNwest has a staff of experts that can help analyze potential claims and manage back-to-work programs that can help reduce claims expense – with half of the cost reimbursed by L&I and the other half by the WSDA Retro program.

This expertise is what led WSDA and ERNwest to team up on another important program to save members money.

Enter ComplyBetter

The L&I Division of Safety & Health oversees worker safety programs at state employers. All employers are required to have an accident prevention program, update it regularly, and ensure that employees know what’s included and are trained on the key elements of the program.

The old-school approach to complying with this requirement involved reams of paper, typically filed in a three-ring binder and sitting on a shelf. More recently, learning management companies have offered digital programs, most of which charge fees each month based on the number of employees in an office.

Both of these approaches have disadvantages. It’s difficult for a small employer to create a valid accident prevention program, remember to keep it up to date, and ensure that all employees are getting the required training on the program. If a commercial learning management system is used, it can quickly become expensive for the employer.

WSDA’s Trotter said the idea behind ComplyBetter was “to create the TurboTax version of compliance software.” The idea was to allow a practice owner or office administrator to answer a modest number of questions on an online form, and the system would create a valid accident prevention program and trigger regular updates and program presentations. It would also need to provide the same type of support to ensure dental practices are complying with the infection control requirements implemented by the state a few years back. Finally, it would produce onboarding and training materials customized to each employee position – a receptionist, for instance, doesn’t need to take infection control training, but clinical staff do. And all of this material would be specifically tailored to a dental office environment and available at a reasonable price.

WSDA decided to partner with ERNwest on this venture as well, because of the synergies between having strong accident prevention programs and reducing the number of workers’ compensation claims.

A Global Effort

Bringing that vision to reality has been a long and winding road from Seattle through Cambridge, Massachusetts to Ukraine and back. ComplyBetter has been built upon an open source learning management system (Open edX) created by computer scientists at MIT. The WSDA team found a group of software developers known as The Raccoon Gang, which operates out of Ukraine, to take that Open edX platform and customize it to manage dental office compliance with accident prevention and infection control regulations.

Working with a team located 10 time zones away is not without its challenges, and things get even more complicated when your vendors are located in the middle of war zone, but it’s worked well so far, according to Trotter.

“We meet somewhere between three and five hours per week,” he said. “Early in our relationship, sometimes there were missile warnings during our meetings. It puts things in perspective. We think we’re having a bad day if we forget to put the garbage out, and they’re getting missile warnings! But it hasn’t disrupted their services so far.”

“The war was something we had to consider in selecting the Raccoon Gang. But the price advantage is approaching 40 percent compared to what we would have paid to have this program designed here. And they’re very good, very process-oriented. They have robust, tight processes that help us avoid falling into rabbit holes.”

ComplyBetter is currently in beta testing with a group of offices that volunteered to test drive the system. After the beta testing is completed at the end of June, feedback will be incorporated into the initial commercial roll-out, which is hoped to take place as early as October of this year.

“Software development is a fickle thing,” said Meier. “The work has gone very well, but the amount of time and detail that it takes to do it well is something we recognized at the outset. The current beta testing will be important to identify how to make it as easy as possible to use for small businesses. As a small business owner, you don’t have a lot of time, so the key is making the platform very easy to use.”

While regulatory advocacy has always been a priority for WSDA, the association recently reconfigured its staff roles to support the development of ComplyBetter and hired Trish Flaig as its new manager of Regulatory & Compliance Services. Trish will be the lead advocate on regulatory issues and provide subject matter expertise and content development for ComplyBetter.

“Having Trish on the team has been amazing”, said Trotter. “Her nearly two decades of dental experience in various roles allows her to have great insight into the regulatory and compliance issues facing dental offices.”

Long-Term Growth Potential

ComplyBetter’s potential goes far beyond initial offerings to WSDA membership. More than 10 other state dental associations have already expressed interest in adapting the system for their members. Additional required training, such as on HIPAA, can be added, making ComplyBetter a “one-stop shopping” destination for regulatory compliance. And based on his work with employers in other industries – from other health care providers to hospitality to construction, all of which have their own unique regulatory compliance burdens – Meier believes the program will generate lots of employer interest in the future.

“One of the reasons it has taken as long as it has to build this program is that we did it with the full intention of making it flexible enough to easily adapt to the requirements of other industries,” said Trotter. “It’s a little more time on the front end, but will ultimately save time, work and expense in the long run.”

The long run – it’s a perspective that everyone involved in remaking the WSDA dues structure is taking.

“For years, the debate in association management was whether to grow non-dues revenue or to increase dues when membership is shrinking,” Trotter said. “We’re turning that thinking on its head. We are looking to build non-dues revenues and bring our dues down at the same time, so we can make membership more accessible for all dentists.”

Trotter sees the need to take dues down to a dollar amount that most people can afford, and to demonstrate the return on investment of whatever the dues are.

“We need to continue communicating the value of a membership. We need to show dentists what we are doing for them, the value of the services we’re providing,” he said.

For Dorow, revamping the WSDA dues structure is all about continuing to bring dental professionals together.

“If we lose people, we aren’t as strong and we can’t do as good a job of advocating for our profession or our patients. But we also will have fewer people to be there for one another,” he said.

“No one knows what we go through as dentists except for other dentists. Early on, when I was a young dentist, the ability to be collegial was a key attraction of WSDA membership, coming together, sharing problems, getting advice. I knew I could count on the knowledge of older dentists who had practiced for 20 or 30 years.”

“Now we’ve gone from a society of colleagues to a society of competitors. That’s not good, because we’re not as good when we’re all on our own little islands. We need to get past the differences in practice models today and recognize how much we have in common,” Dorow said.

“Today, people expect to see more tangible value from their membership. They’ll keep showing up when they recognize the value. Removing barriers will get someone in the door, but it’s the people and experience that keeps them.”

This article originally appeared in Issue 2, 2024 of the WSDA News.