The Influence of Corporate Dentistry


In the last 30 years, and especially in the last 10-15, we have seen a dramatic increase in dentistry as a corporation. First let me say that I am neither against corporations or their involvement in dentistry. Dentistry is a business and as such, we are here to earn an honest and fair living. Dentistry is also part of the healthcare field, and as doctors we are subject to the Hippocratic oath. This applies to the smallest private practice as well as the largest dental corporation.

I am in a little bit of a unique position to talk about corporate dentistry. I have worked for four entities that I would call corporate dental practices, meaning they have multiple dental offices owned by a single entity. They prefer themselves to be called Dental Service Organizations, or DSOs. I also worked for a private practice owned by two dentists. There are many hard working and ethical dentists working in DSOs, and just because a dentist is part of a larger corporation does not necessarily mean that you'll be getting inferior care.

However, there are some troubling aspects that I have seen in corporate dentistry, and it really depends on the ethics of the organization. I have worked for what I would consider very ethical and well-meaning organizations as well as those that I would consider highly unethical (I didn't last long there).

Dentistry is a business and must make a profit to survive. This creates an inherent conflict of interest, present in any healthcare profession. That is why the ethics of the organization are so crucial. I found that the pressure to make money existed in even the most ethical company I worked for. In a corporation or DSO, incentives are designed so that the employee dentist can earn as much as possible as well as making the organization profitable. This certainly colors the way that an office approaches dentistry. While this isn't any different than a private owner practice, this tends to get amplified in a larger organization.

At one organization I worked for, I was constantly pressured by the office manager to do dentistry in a way that I was not comfortable doing, in order to make more money. I tried to make it clear to her that my first priority was doing what is right for the patient.

One particular office I worked for took every insurance plan on earth. It turns out that some insurance plans have perverse incentives, especially what we call capitation plans (HMOs). These pay the dental practice a certain amount each month for every patient they have enrolled at the practice. In exchange, the patient gets a huge discount on dental treatment that in some cases doesn't even cover the overhead of the practice. Working for one company, I was expected to do procedures in which I actually lost money due to these HMOs. The way this organization had their pay for dentists set up, I literally had to pay out of my own pocket in order to do certain procedures (which I did). I also have seen these plans manipulated in order to maximize profit in ways that wouldn't be done with the average patient. I've seen practices add unnecessary procedures and codes, or upgrade procedures whether or not it was actually done, in order to "make up for" the discount. This is unethical.

Additionally with the capitation plan (HMO), the incentive is for the patient to never come into the dental office, because that way the practice gets money from the insurance plan, without the patient ever walking in the door. The first priority should be prevention and patient health, which means that the dental office should be encouraging patients to keep their hygiene appointments in order to ensure that they are preventing problems before they happen, not hoping that the patient never comes in so they can collect their monthly check.

Another troubling aspect to corporate dentistry is how they teach dentists to use certain phrases in order to influence the patient towards treatment. Every time we speak of dental treatment, we should always be talking to the patient about: the Risks, Benefits and Alternatives, or RBAs. I have found that often corporations, in the quest for higher profits will attempt to get the employee dentists to only speak about the benefits, and minimize or ignore the risks. This terrible for both the patient and the employee dentist, and is also unethical.

Corporations often have a high turnover rate, not just with assistants and hygienists, but with the dentists themselves. Some of them have a revolving door of dentists and you will be seeing a different dentist at every appointment. While it is important that dentists communicate with their colleagues, it is also important that a patient receive continuity of care. This is virtually impossible if the patient is seeing a different dentist at each appointment.

One thing to be aware of, while some corporations brand all of their practices similarly, like Aspen Dental, others do not. Heartland Dental is one of the largest dental corporations in the country, that most people have never heard of. This is because each of their offices are named individually, and so the public would never realize they are actually going to a corporation. If you are uncertain, just ask them if they are part of a DSO or corporation! For disclosure, I am not specifically speaking to either Aspen or Heartland as unethical organizations. I have worked for Heartland and have not worked for Aspen.

One positive aspect of corporations is that the dentists can communicate with each other, which helps make sure that they are getting a variety of perspectives and opinions. However, private offices can do this as well. Because it is important to be well within the standard of care, I am part of several organizations, including the American Dental Association, Academy of General Dentistry, and the Crown Council, amongst others. These organizations are committed to the highest standard of dental care and allow me to gain the perspective and utilize the experience of other fine dentists in the field. It is important that dentists do this.

One myth about corporations is that they are cheaper than private offices. I have found that, actually, corporations often are more expensive that private offices. The offices that take the lowliest of insurance plans and truly are less expensive, often will encourage overtreament or manipulation of insurance plans. They also often cause their dentists to burn out, thus the high turnover rate.

The worst organization I worked for tried to lower the prices as much as possible to attract patients. This might seem nice to a patient, but it didn't allow us to practice dentistry appropriately. It also wouldn't allow me to spend enough on the dental supplies to get the highest care to our patients. I was using burs that extended well beyond their use. They had a overhead light tied together with dental floss, a panoramic radiograph that was totally useless (but charged the patient anyway), as well as encouraged to do procedures that only specialists ought to have been doing. Not only was this particular corporation unethical, it was downright dangerous to the patient. (If you ask me privately, I'll tell you which company it is, as I wouldn't send my worst enemy there.)

Due to the explosion of costs in dental education in the last 20 years, students are coming out of dental school with more student debt than ever before. This puts extraordinary pressure on new dentists to earn a high level of income coming right out of dental school. I have seen dentists being put into high pressure corporate offices, being encouraged to do procedures that they are truly not fully trained and ready for. The patient is the one who suffers, the young dentist unwittingly puts their license on the line, and corporation collects their profit. Additionally, this puts pressure on private offices to adopt the procedures that corporations adhere to, in order to be competitive.

This perspective is why I am proud to be a locally owned and private office. While I may hire associates in the future as my practice grows, I will always employ local values and ethics of prevention and honesty. This is my commitment to our patients.

Written by: Harold Henderson, DDS September 26, 2019