Media covering the dental profession are replete with articles from dentists working for dental service organizations (DSOs). These stories often are chock full of accolades for this industry as they describe these doctors’ favorable employment experiences. They often read more like paid promotional pieces than credible accounts. Can they be believed?
As the dental education-industrial complex continues to expand, with increasing numbers of dental schools and ever larger class sizes, graduating doctors are severely pressed to find reasonable employment. Adding to this glut of dentists on the labor market are more senior doctors who delayed retirement due to the Great Recession of 2007-08. Often, the only viable employment option may be working for a DSO. But is it a truly valid and ethical option?
The DSO industry is not monolithic. Each company targets different consumer demographics. The industry utilizes a vast array of business models. The actual services and the quality of those services provided to consumers may vary drastically from one DSO to another. Even within the same DSO, there may exist substantial differences from one clinic to another.
To be sure, there are horror stories of doctors burned out by working for a DSO. It may happen in DSOs that are new to the industry or have been around for decades. It can occur in smaller DSOs as well as in some of the largest nationally. Of course, dentists who don’t work for DSOs can get burned out, too.
The North Carolina State Board of Dental Examiners conducts contract reviews, but no other state dental board does. That means doctors are almost always on their own when negotiating an employment agreement or service management agreement with a DSO.
Importantly, doctors must never assume that because a DSO has a large national footprint or has been in operation for a long time that its business dealings are ethical or honorable. The DSO industry has been largely unregulated since its inception. Not all DSOs play fair or within the rule of law with their employees or patents. There exists little regulatory enforcement, so many firms operate with a “wild west” philosophy.
One Doctor’s Experience
We spoke with one doctor who had negative experiences with two larger DSOs that employed him.
“How do they operate? By connecting with dentists across the country and selling them titles such as ‘partner’ or ‘office manager’ with no concern for their areas of expertise, all under one firm or name,” he said.
“The dentists are entrapped by promises and incentives, as, for example, the ‘signing bonus,’ percentages of pay for production or for ‘collection,’ basic daily salaries, training for 90 days, paid vacations, a medical plan, continuing education, and a retirement plan, among other ‘perks’ that they can obtain if they join with these organizations and which at first sight appear extremely attractive. The only thing that one must do is that which he or she knows how to do, and for which one has studied all of one’s life, resulting in easing the decision,” he said.
“Up to this point, all sounds good—a marvelous opportunity to grow economically and without major risks. But what happens in reality? The answer to this question is seen in the day-to-day operations of these dental offices. During the period of training, they indoctrinate you by seeking to make you a leader, that you become a productive person and that you induce the people in your charge to produce. This is the word that carries you to success,” he said.
“Nevertheless, not everyone succeeds in this enterprise, and in each of these offices, we see that the manipulation of the agenda, the patients, and the materials and equipment are part of the day-to-day operation, and they condition your state of mind and production,” he said.
“If you are alone in this office, you have no competition with other doctors, which is marvelous. But the manager controls the patients, the time allowed for one of the procedures, and the purchase of materials. The control of expenses does not depend on the principal doctor. It depends on what the company may believe to be convenient. They decide which patient they give to each doctor, depending on his pleasure or affinity, and with no other set of criteria and with total impunity,” he said.
“Here we may see some assistants guiding the patient toward a plan of treatment that best suits the company economically and, on some occasions, changing it and giving other options that the dentist did not include as an option, which is a breach of ethics; changing the plan of treatment and care of the patient; hiring some assistants who are permitted to question the decisions and raise their voices to the dentist in the presence of the patients; and denying him during the procedures the materials and equipment to achieve the optimum result,” he said.
“But try to correct these situations by calling attention to them and speaking to the company, and the end result of all this is the loss of leadership on the part of the dentist and the need to have to win for himself the respect of the personnel in charge,” he said.
“The dentist may have to produce carries and, with it, the need to reduce the amount of time for examining and learning about the patient. Costly plans for treatment are decided upon, keeping in mind only a monthly goal that gives him the option of sustaining himself in this office, which values him only for what he does, and sustaining his family,” he said.
“That which has driven each set decision may be exaggerated. For example, the patient may ‘need’ a root canal when the nerve is not found to be affected and a simple restoration would solve the problem. Or, the patient may ‘need’ three implants with bone regeneration when a single implant would suffice. Or, badly done preparations on teeth may result in the loss of those teeth because at some moment he may be able to convince the patient to buy a crown,” he said.
“We could name many more forms of treatment that are seen as obligatory for the professional to do in order to survive, because it is in this manner that the invention has begun to devour the small and modest dental offices. When the health professional reaches this level, the care of the patient is lost and the procedures reach a low level, using only the materials that the company can afford to buy without completely losing its profit margin so that the dentist can provide a ‘great’ service,” he said.
A Second Story
These frustrations are not unique. We spoke with another doctor who also offered some of his DSO experiences.
“The DSO I worked in for a couple of years had no provisions for restorations as we know them. If a tooth was broken, or needed repair, the only offer was extraction. I was watched over by the employees who were trained in the philosophy of the DSO,” he said.
“Contrary to state law, there was no comprehensive exam. No charting of pocket depth. I once asked if an assistant would get me a periodontal probe. None was available. Then one miraculously appeared from the back of a little used drawer,” he said.
“My primary job was to sit in the hall outside five treatment rooms. When called by an assistant who had taken a Panorex and done a cursory exam, treatment planned, and arranged financing, I put my signature on the chart with a note that I agreed with the treatment,” he said.
“It was also my job to take alginate impressions in stock metal trays and take a wax bite for the work to go immediately to the lab on the premises to begin fabrication of a plastic partial or dentures. At noon, we invited the patient back into the treatment room, where any teeth to be extracted were performed. Next, at 3 pm, the dentures were delivered to the patient by the dental assistant,” he said.
“After the dental assistant made necessary adjustments and was satisfied that the prosthesis was acceptable to the patient, I was called to the treatment room to affix my signature. Seemingly, that satisfied the legal requirement. When the assistant had difficulties, I made additional adjustments,” he said.
“I remember several times where I delivered all-plastic lower partials to patients who had so much calculus, one could hardly identify the lower anterior teeth from the lingual sides,” he said.
In his concern for the public welfare, this doctor offered to consult with his state dental board.
“I have told the board of dentistry that I am willing to tell them things that they do not know, but it must be off the record. The dental board refused, saying it would only accept testimony as a formal complaint,” he said.
Unfortunately for the public, this doctor is bound to nondisclosure and non-disparagement agreements with his former employer.
“This information I give very reluctantly. I have no idea what kind of contracts I signed with the DSO when I was first employed there several years ago,” he said.
“The governor’s office one year ago appointed one of the DSO’s dentists to the board of dentistry. That individual had only been in practice in the state for less than two years. Very bizarre!” he said.
“My advice? Run from corporate dentistry,” he said. “It is one of the major factors killing our great profession.”
The Bigger Picture
Clearly, lack of regulatory oversight upon the DSO industry is not only deleterious to the dental profession and employee doctors, but also to the public welfare. Moreover, state government regulators in Arizona may have been complicit with one alleged violator at one DSO before that DSO’s chief dental officer resigned from the state’s dental board.
Obviously, not every DSO operates with rampant lawlessness. However, far too many do. Again, very little oversight exists. Chronic lack of regulatory enforcement enables chaos and criminality of elements within corporate dentistry.
Doctors are bound by ethical and legal mandates to place the interests of their patients at the fore. By contrast, DSOs are primarily obligated to maximize a financial return for investors, be they publicly traded shareholders, individual private investors, or a private equity investment company. The contrast in conflicted interests could not be more apparent.
This brings us back to the question of how employee doctors can protect themselves. The employment playing field for dentists is not level. Doctors are at a serious disadvantage in contract negotiations with corporate healthcare firms. Part 2 of this article will offer specific methods to generate negotiations that are somewhat more even.
Too frequently for many doctors, the only current available employment options in a given demographic may be quite negative. Part 2 also will help doctors recognize “bad apple” employers very early into the game. Preplanning an exit strategy is essential. Support of expert legal counsel and organized dentistry is imperative for employment success, especially in the situation of an unscrupulous employer, of which many exist.
Today’s dental employment landscape is a veritable minefield peppered with charlatans, crooks, and entities so enmeshed in avarice that patient interests don’t rise to a secondary concern. State regulators may offer little support, outside of North Carolina, and may be complicit with corporate healthcare violators.
Doctors get emotionally, professionally, and financially destroyed in such a hostile environment. One doesn’t run freely and carelessly through such danger and rationally anticipate remaining whole in mind, spirit, and body. In Part 2, experts will offer solid advice.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at firstname.lastname@example.org or smilesofsantafe.com.