Corporate and Group Practice Models: What Dental Can Learn from Medical

Over the past 20 years, dental services organizations (DSOs) and large group practice models have been increasing in dental practice types. Meanwhile, over in medical, large medical groups and medical management services organizations (MSOs) have preceded DSOs in growth by at least a decade or more. We can explore the changing growth rates in dental practice types and what the dental industry can learn from the medical industry regarding the development of these practice models.

How dentists like to practice has changed over the past 2 decades. Just before the Millennium, the majority of dentists were solo practitioners. Per the Health Policy Institute of the American Dental Association, 65% of dentists in 1999 were solo practitioners. Twenty years later, that number has decreased to 50% in 2019, a proportion of 1 in 2. In other words, these days dentists are just as likely to be solo practitioners as they aren't.

Also, the age of the dentist affects their probability of skipping the solo practice type. Amongst dentists under 35, the proportion of solo practitioners drops to 1 in 4.¹

Moreover, these numbers and trends do not include the curveball that COVID-19 threw many dental practices in 2020. Based on what dentists learned about what can happen when you are a solo practitioner without anyone in the chair for several weeks to months, these percentages could have changed even more.

So, how do dentists want to practice today? Many of them are working in groups; others are joining DSOs. In the DSO model, dental practices join the DSO, which then supports the dental practice for their non-clinical operations. Per the Association of Dental Support Organizations (ADSO), DSOs allow dentists to focus on delivering patient care with the support DSOs provide in professional office management.²

Dentists like it too. In 2019, 10.4% of dentists in the U.S. were affiliated with DSOs, up from 7.4% in 2017. Also, the ages of these DSO dentists are skewing younger; 34% were under 49. Female dentists like them too; 13.3% of dentists in DSOs were women.³

DSOs are offering an attractive option for dental professionals, although they are not where most dentists practice. The idea of "corporate dentistry" still has a long way to go in the dental community to become like the medical community where large groups and managed care organizations are nothing new to medical doctors. MSOs have been a part of medical practices for years, growing in popularity with the adoption of a managed care approach to medical care that prevailed in the 1980s and 90s.⁴ Unlike dental, medical has already navigated many problems and pitfalls of this change in practice type—and dental practices should take note.

Learning Vicariously from Medical Software Development

There are a few things that large medical groups can teach the burgeoning DSO organizations in dental. One of the most significant is implementing the software functionality medical uses in dental software programs.

Mike Uretz, Executive Director of Dental Group Partners and founder and editorial director of DentalSoftwareAdvisor.com, works with many group practices in the DSO space. He also worked in medical software for 12 years before moving into dental, where he saw the potential for improvement. He thinks DSOs can learn a few things from large medical groups regarding the technology they use:

1. Use the cloud: Medical groups have embraced cloud-based software systems. Uretz says that dental software and practice management systems have been moving toward cloud-based systems, but there is some resistance to them from practices still tied to their physical servers.
2. Choose integrated solutions: Uretz says DSO and multi-location groups need to put everything they need in a single integrated database, from financial to patient care to operational information. While he says that many dental software vendors have integrated databases, it is not to the extent that Uretz would like to see.
3. Focus on Clinical and EHR software: Although operations and claims management are key to a DSO’s success, it is also critical to focus on having good clinical and electronic health record (EHR) software. Software evolved in the medical industry and moved from concentrating on practice management functionality to including more powerful clinical care management and EHR tools in their software. Uretz would like to see dental do the same. He says that one of the criticisms of large DSOs and groups is that they can't deliver a good level of personal patient care, but by showing that you can with state-of-the art clinical and EHR software you can defend against that bias.
4. Take advantage of analytics and business intelligence tools: Medical groups and MSOs have used analytics and business intelligence (BI) to manage their practices' key performance indicators (KPIs) for years, Uretz says. He would like to see DSOs use these tools more consistently.
5. Support Interoperability: Medical has many different software systems that can talk to each other, which has been essential with the EHR following patients through their medical path. Uretz thinks dental practices must communicate with their medical counterparts and other dental systems, but dentistry has a long way to go in this area.

Embrace the Cloud and Prioritize Integration

Before becoming Director of Marketing for Planet DDS, David Means also worked in a healthcare technology company, specifically an ephemeral messaging app company tasked with helping medical professionals communicate more effectively. Like Uretz, Means also thinks a critical priority for DSOs is to use a cloud-based system rather than a server-based. Not only is it more remotely accessible and less vulnerable to theft or destruction, but cloud-based practice management systems are also less prone to in-house maintenance and obsolescence. Plus, your data is more secure in the cloud than it is physically in the practice.

"Unfortunately, dentists are becoming more of a target for ransomware attacks because a lot of practices do not have sophisticated security in place on their systems, but instead have rudimentary passwords or encryption on their servers," Means says. "But if they have a practice management solution in the cloud, then there's physical security, but also additional layers of security behind firewalls that are going to make it much more difficult for somebody to be able to access the patient data inappropriately."

Means also agrees with Uretz that DSOs should prioritize integration. For example, when Planet DDS works with large DSOs, many of them centralize their back-office operations first thing. However, that team still needs access to the data from all the individual locations to assess the opportunities for improvement. Means says having an integrated product like Denticon is an excellent way for growing DSOs to have a common place for everything. Moreover, the technology optimizes the patient experience to ensure patients receive a consistent delivery of care each visit, a metric that investors—and dentists— like to see.

"They are putting in a process that enables the staff to ensure that they're giving great quality service and everything that patients need every time," Means says.

Bridge the Communication Gap Between the Different Practices for Patient’s Benefit

Dental and medical sciences have operated independently from each other for over a hundred years. However, research shows a connection exists between patients' overall health and oral health. In addition, more medical professionals see dental as a specialty for oral health, like a cardiologist is for heart health. As a result, Uretz thinks the future of financial and clinical success of all dental practices—solo, group, or DSO—will be enhanced by electronic communications with patients' medical counterparts.

Unfortunately, most dental software vendors haven't embraced this concept or prioritized it in development. Uretz would like to change that.

"Most people who read the studies can see where this relationship between medical and dental is going, but we don't have enough tools and software to make that relationship work," Uretz says.

Sam Ahani, DDS, CEO of Refera, an online referral platform for G.P.s and specialists, agrees that medical is doing better than dental for investing a lot in technology that supports the more effortless transfer of patient records. Investing in technology that can centralize recordkeeping and facilitate sending the patients' EHRs to other practices, medical or dental, is essential to large dental organizations.

However, dental practice management systems are not as compatible or ubiquitous as the large practice management systems for medical. Moreover, it is difficult for app developers to work with dental systems. For example, in the development of Refera, an app that connects general practitioners and specialists for patient referrals, Dr Ahani says one of the biggest obstacles was communicating with the practice management software. However, software developers are connecting multiple practices and getting the systems to talk to each other.

"But it feels like we're a long way from consolidating the platform," Dr Ahani says.

Finding Ways to Focus on Practicing Dentistry, Not Running a Business

Means says that the solo-practitioner is like a one-man band because they have to manage everything. From staff to payroll to human resources to administrative headaches, the solo-practitioner handles it all while also trying to deliver exceptional patient care.

Post-COVID, Means thinks the growth of DSOs will accelerate. Many dentists experienced first-hand the dangers of going it alone last year during the pandemic when most dental practices, especially smaller, older general practices, were shuttered.

"It was like, 'Well, why should I do this when I can have a partner help me manage this risk moving forward?" Means says.

Dr Ahani says that DSOs got off to a rough start. DSOs learned that focusing on delivering exemplary care was the recipe for success, a lesson he thinks medical had already learned. Large medical practices allow doctors to be "in the zone."

From the doctors' perspective, Dr Ahani thinks that DSOs and selling to a corporate dentistry organization appeal to dentists. Many dentists feel like artists and want to practice dentistry, not run a small business and all the details that entails. Dr Ahani thinks medical group practices are heading in the right direction.

"They're doing what they are supposed to do by building a lot of infrastructure and technology to improve the patient experience," Dr Ahani says of the medical group practices. "I also like the technology coming out, like the My Health online app, which is all about keeping patients in the loop and in control of their healthcare."

DSO's rough start was in part because of pushing productivity and profit improvements. From a business standpoint, boosting production is suitable for a dental practice. However, as a solo practitioner, Dr Ahani says it is difficult to put into place the marketing tools and staff you need to boost production while managing the patient schedule. So the DSO takes on those business marketing tasks, enabling dentists to focus on patient care, which will increase output inherently.

"You're producing more because you are doing what the patient needs," Dr Ahani says. "I don't see anything wrong with that."

"Becoming a part of a group practice or DSO helps free up some of those administrative, overhead management tasks, and allows practitioners to focus on patient care," Means agrees.

Use Technology to Give Patients the Experience They Want

Means also thinks that something dental can learn from medicine is how to use technology to practice better dentistry. Implementing technology helps dental professionals efficiently manage the practice and allows them to pinpoint what they could be doing to ensure they deliver the best care. For example, functionality like secure patient messaging built into the patient communication technology ensures that patients follow the treatment plan and return for prescribed periodic screenings and recommended checkups.

Also, technology gives patients more of what they experience in the other parts of their lives, like secure payments on their phones. However, technology applications can take you even further than that regarding patient experience, per Means.

"In our post-COVID world, people want to spend less time in a waiting room. They want to get through the process as quickly as possible, so having touchless options that you can provide to patients is going to help with patient experience," Means explains. "They want that touchless experience in other areas of their life, and they are expecting that same type of experience when they go to the dentist."

Providing these types of technology integrations in the patient experience is an area where the larger practices on the dental side are excelling. Solo guys, he says, aren’t necessarily there yet. However, if dentists want to remain competitive, Means says, solo practitioners will need to start.

"They need to have practice management solutions to enable that," Means says.

What Dental Does Better Than Medical

However, dentists do have some legs up on the medical side when it comes to imaging integrated directly in the practice management software. Uretz says that dental software also does a much better job using technology to manage imaging models within the software itself. Naturally dental practice management and clinical software needs to have imaging “baked in”

"Therefore, what I found, is that the idea of integrating images in very creative and user-friendly ways is doing well in dentistry," Uretz says. "There is a lot of exciting work being done with imaging and software in dentistry."

Uretz says that dental software programs have made it possible to pull images from the cloud. So, if an extensive practice has 20 locations or even 100 locations, any office has access to images, even 3D images, in the cloud.

Managing digital imaging isn't the only thing dental does better than medical. Means thinks that dentists' relationship with their patients is more emotionally engaging than the ones patients have with their medical doctors.

"The quality of their chairside manner is better when I go to the dentist versus when I go to see my medical doctor," Means says.

DSOs have been improving over the past 10 to 15 years, too, Dr Ahani says. DSOs’ original approach was to consolidate individual practices to deliver a consistent experience, like a McDonald's or a Starbucks. Now, DSOs support the unique culture of the dental practice and focus on optimizing it. In addition, these "invisible" DSOs produce excellent results by buying a majority interest in the practice but keeping the dentist as part-owner and managing the dental practice behind the scenes.

"They give then economies of scale for supply purchases to get better pricing. They help them with their human resources, which is a huge problem for dentists right now," Dr Ahani says. "This version lets dentists do the things that they want but helps them a bit in the background."

References

1. How Many Dentists Are in Solo Practice. Ada.org. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIGraphic_0121_1.pdf?la=en. Published 2021. Accessed July 1, 2021.

2. About DSOs. Association of Dental Support Organizations || TheADSO.org. https://www.theadso.org/about-dsos/. Accessed July 15, 2021.

3. How Big are Dental Service Organizations. Ada.org. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIGraphic_0720_1.pdf?la=en. Published 2020. Accessed July 1, 2021.

4. Mullner R. Managed care | health insurance and system. Encyclopedia Britannica. https://www.britannica.com/topic/managed-care. Accessed July 15, 2021.