Sound off: The dental community talks 'corporate dentistry'

Wherever you call "home"—Canada, England, India, Pakistan, Turkey, the United States, or somewhere else entirely—you're seeing the industry's consolidation. So we thought we'd ask:

What do you think of DSOs or "corporate dentistry"?

And oh, did you answer!* 292 of you shared personal experiences, triumphs and woes, outlooks for the future, and musings about what it means to work in dentistry. Representing a broad range of occupations, ages (from 20 to 70-plus), and geographic areas (all of the aforementioned countries and then some), the perspectives you shared are as diverse as you are.

Here's a look at what you told us . . .

*As a matter of fact, you shared in so much detail that we would have needed to turn this issue into a 500-page book to fully do your thoughts justice. Since we were unable to do that (hey, we're only three editors and one art director!), we invite you to keep an eye on our website for more perspectives.

Editor's note: This article is a part of the Apex360 feature, "Corporate Dentistry 2.0." To see the additional articles in the feature in online format, click here. Download the full PDF version of this feature as it appeared in the digital magazine here.

WE SAID:

"Tell us about your perspective on dental support organizations or 'corporate dentistry.'"

DENTISTS SAID:

• "In today's world of high-cost education, many young recent graduates are fortunate to have somewhere to practice. Yes, there are 'problems' with corporate dentistry, but the great majority of [DSOs] offer what consumers want, or they would not be in business. Corporate dentistry knows that they have an almost an endless supply of dentists, especially recent graduates, and older dentists who do not want the responsibility of private practice but still want or need to practice."

• "They are in a position to provide care to underserved and low-reimbursement policyholders, but at the same time, they provide quality of care [that is lower than the standard]. They help drive down the cost of supplies, but I believe they hurt the image and quality of dentistry more than helping."

• "Both provide an 'outlet' option for recent dental graduates, many of whom come out of school [with] debt loads. These options are tempting and often the last resort for those graduates who need immediate income. However, the structure of some of the contracts they enter into are an additional weight they must tug along. Many of them are not business-savvy and sign onto contracts they later come to regret. Most current dental school curriculums fail at imbuing their students with [the] necessary business acumen to make informed, intelligent decisions in this expanding new market. The age-old axiom of 'let the buyer beware' is, many times, learned too late."

• "I worked at [a DSO-affiliated office] for six months and left after growing very uncomfortable with the practice model. The best way for me to include all of my perspectives is in a list format: (1) It seems that the business model in a corporate setting is to exploit/marginalize a patient's insurance and collect as much cash as possible for treatment, often without the proper informed consent. (2) Patients came to the office not understanding their insurance and a good majority of them would leave after a new-patient encounter wrought with confusion about their treatment plan—why it costs so much, what portion their insurance covers, what the alternatives and options are, etc. (3) Providers are asked to upsell everything at every opportunity and not to offer some lower-cost alternatives. (4) The quality of lab work is exceptionally poor; I was encouraged to use any lab of my choosing, although I would have to pay my own lab fees [to] use any lab other than the one owned by [the DSO]. Such lab fees would effectively negate my entire personal profit for a procedure. (5) Filling appointments are booked [in a way that] providers are expected to finish every filling on a patient's plan in a single visit due to the low production. Exams and emergency visits are usually done without pay, and providers are asked to set a personal goal of starting two same-day high-end crowns on new patients each day, regardless of any other variables. (6) Proper scheduling and time management is not apparent, especially for patients who see dental specialists [who] travel between offices. Some patients wait several hours routinely to see a particular specialist despite their scheduled appointment times. In the end, I left because I was being asked to 'play the game' of upselling treatment and taking the human components out of the dental equation. I refused to compromise my ethics or patient-centered treatment model, so I was effectively encouraged to leave the company if I did not 'improve' my practices."

"I left because I was being asked to 'play the game' of upselling treatment and taking the human components out of the dental equation."

• "The original, purported task of the dental support organization was to help dentists run the non-dental, administrative tasks of the dental office. However, in reality, the structure of the typical DSO is a phony shell used by a large corporation to own and operate dental practices in violation of state laws, which mandate that a dental practice can only be owned by a properly educated, degreed, licensed dentist. The rationale behind the requirement that only licensed dentists can own dental practices is clear: In order to obtain a license, the dentist must first have a fully accredited dental education, must show an understanding of professional ethics, and must pass an examination that focuses upon the dentist's skills and ability to practice in an ethical manner that puts the health and welfare of the patient first. A corporation has no dental education, no license, no ethics, and no reason to defer to the patient's best health if a profit can be obtained by ignoring it. Legislators were wise to limit dental-office ownership to licensed dentists. Corporations answer to their shareholders, who only want profits and have no knowledge of what is best for the health of patients. The owners of corporate dentistry don't know the patients treated by their corporation. They don't care about the patients' families, the growth of the patients' children, and the triumphs and trials of all the family members as time goes by. The corporate owners do not interact with the patients and don't care about anything but rapidly increasing corporate profits. If a cheaper treatment is actually better for the patient's health, the [corporation] will still try to sell the patient a more expensive (profitable) alternative. Corporate dental offices are in a position to evade responsibility for their actions. An individual licensed dentist, on the other hand, is completely responsible for all of [his or her] actions. A real dentist is a member—for life—of the community and is actively interested in the welfare of many diverse patients. A corporate dental office is not a real, flesh-and-blood member of the community. It is only a storefront that exists to obtain the greatest profit possible from the people who actually form the local community. It is unfortunate that most patients do not understand these important differences. They tend to look upon all doctors as impartial experts who strive for patients' best health. They don't understand that a corporate dental office exists only to provide monetary profits for a faraway corporate headquarters that is interested in immediate monetary profit, not in the ultimate long-term health of the patient."

"The advertising is impressive and almost convincing until you see some of the treatment plans!"

• "[. . .] I have a drawer full of treatment plans [for] major treatment on conditions that don't exist. Sad. Some of them don't even have the doctor's name on them—just the corporate logo! The doctors are all just interchangeable parts without faces. The corporation is the only thing that matters. The advertising is impressive and almost convincing until you see some of the treatment plans! Sadly, this is the future because new dentists are too lazy to make a private practice work. You have to get involved in the community, not just advertising, to get your name and image out there. That's too much effort for a lot of them. Eventually oral health practitioners will take over these clinics just like [physician assistants] and [nurse practitioners] have in medicine. A [general practitioner (GP)] in medicine is overpaid and worthless; GPs in dentistry will be the same. Pay a midlevel practitioner half, and they will do all of a GP's treatment in corporate dentistry. We are about 15 years behind medicine in this. It's coming fast."

• "[. . .] Dentistry is a very low-overhead profession. If you want a bare bones office, all you need is a building, a dentist, and an assistant. And you can have the assistant answer phones when you don't need them, like during extractions. So what does this mean? Patients reap the benefits of this type of practice. You can do things much more inexpensively then in a [. . .] megalithic office with four assistants, two front-desk [employees], two hygienists, a dentist, and every high-tech gadget available. (Let's not even get started on the electric bill.) Let's take this a step further. How about four [. . .] megalithic offices with four assistants . . . blah, blah, blah—all owned by the same dentist (a dentist that has been chosen by peers in his [or] her profession for a caring attitude, strong willpower, and curious mind). But even this isn't too bad for the profession. Actually this is good—if a patient moves across town, they can still stay in the office, they won't have to fill out paperwork, and they may even see familiar faces. Now, here's where things get more complicated: Imagine 20 [. . .] megalithic offices owned by a non-dentist who only cares about the bottom line and paying for the staff and dentist and investors. Who pays for these [. . .] megalithic offices? Investors—investors who want a return on their investments. I don't blame them; I would, too. But with that, you add a huge profit motive. The investors are putting pressure on the investment firm, the investment firm is putting pressure on the managers, and the managers are putting pressure on the staff. Goals and incentives for pay are put into place to make [employees work] harder and treatment plan more aggressively. And this hurts the patients, but it still isn't even what keeps me up at night."

• "All [of] that is the short game for corporate dentistry, once they finish buying up all the smaller group practices after the owners fail to find a young dentist to secure financing for $3 to $10 million. Once they finish securing enough territory, they have the upper hand on the insurance companies. [Until] now, insurance companies have been able to to bargain with individual dentists, making us more efficient and slightly less wealthy then our predecessors. This isn't all bad. The free market says that, as long as there [is] someone willing to do a job for a certain price, that is the market value. At some point, dentists will decide that the risk of HIV or hepatitis B infection via high-speed drill transference, the angry [and] combative patients, the high volume of patients, the stress of perfectionism, the stress of malpractice, and everything else isn't worth the price. But 'til then, I think that all insurance companies have done [is bring] balance to the profession. But at some point, 'corporate dentistry' will have taken a lot of territory and will have the upper hand on the insurance companies. They will demand that they will only take certain insurances that pay certain amounts—amounts that will pay for their investors and their doctors who demand certain wages for the risk they take every day. Then who will suffer? The patients. They will have to pay higher premiums to pay the insurance company, the management company, the investors, the staff, and the dentist. What I have described is exactly what happened in the medical field. I beg you to look at the overhead of hospitals versus the salaries [of hospital staff]. Wasn't health care cheaper and overall better when there was just a doctor and a nurse? Now patients have to pay the insurance company, the management of the hospital, the investors for the hospital, the staff, and the doctor. Sounds familiar, doesn't it? Who will suffer the most for this? Patients and their pocketbooks."

• "I may not love them, but I can live with them as neighbors. I've been in my current practice for 13 years now, and several corporate entities have opened within my demographic base. Although they have encroached on my potential new patient base, I seem to get a lot of 'second opinions' or just transfer patients who seem to be dissatisfied with the lack of customer service and heavy-handed consultations and case presentations for [. . .] what ends up being [unnecessary] or elective treatment. Although they promote patient-centric practices, they are not. Well-managed fee-for-service practices may be under attack by DSOs, but practices that are well managed and have systems and team members who have been trained and offer real 'patient-centric' experiences will survive. There will be enough patients [who] will gladly pay the extra fees for a more personal, if not better, experience. I can live with them. Let them keep doing a lot of expensive marketing, and trust me-they will [anger] enough patients to support my practice, and I will be just fine with them as 'ugly neighbors!'"

• "Having worked in 'corporate dentistry' and as a private practice owner, I found that both models worked well for me. Private practice offers more control, business-ownership tax benefits, and ego fulfillment, along with long hours (essentially working one and a half jobs), lots of stress, and tons of liability. In corporate dentistry, on the other hand, you are essentially an employee (in most cases), who can be let go at any time. In other words, you're just like an employee in any other industry. However, all the stress of running the business is someone else's problem, you can work much less time [with] all of it focused on patient care, and the pay is just as good. When I was a younger, more energetic, more ego-driven man, private practice ownership was great. But now that I'm older (and wiser?) and place more value on work-life balance, corporate dentistry is a godsend."

"There will be enough patients [who] will gladly pay the extra fees for a more personal, if not better, experience."

• "I work for [a DSO]. I am in their practice ownership program. I am very well compensated. I see a lot of denture patients, and I have a lot of patients with very unhealthy mouths that need extensive restorative work. It is a very similar patient base to what I saw at the dental school. I enjoy it. It is not for everyone. The denture patients can be difficult, and dealing with the extensive treatment plans can get overwhelming for new dentists [. . .]. But I find it very rewarding, and I am very well compensated for it. I am not sure what the average general dentist makes, but I definitely believe I am in the top 1%."

• "I started off my dental career in a corporate dental office after completing my [general practice residency]. In the beginning, it was a great experience, but over the course of five years, the quality of 'support' vastly deteriorated as the push to produce increased exponentially. In the end, it was the drafting and distribution of a comprehensive list of all the dentists and how much they produced for the company, divided by region, that was the last straw for me. We all knew that the level of compensation for each doc was based on the amount of collections based off of the production, so seeing my name in the bottom third of the list didn't encourage me to seek out the advice of the high-producing dentists in my region. It actually had the opposite effect and further humiliated me to the point where I had simply had enough. Now I am three years post-corporate, and I own two practices of my own. [I am] looking to purchase a third soon. [I] also have requests from another country asking me to set up an 'American-style' dental practice. All I can say now is that the publication of that list was the best thing that ever happened to me."

• "Our office is supported by [a DSO]. Working with a DSO has many advantages over being a solo dentist. We are leaders of our practice, involved in many managerial decisions while our primary focus is on delivery of dental services and patient care—no worries about payroll, taxes, government compliance, [or] the many cash-flow struggles individual practices endure. Dental supplies and labs are paid on time, allowing us to receive better pricing [for] lab and dental supplies. [. . .] Because of our aggregate buying power, we receive further price reduction and value-added considerations. These increased efficiencies add to our profitability, which we share with our DSO, in addition to our [salaries] and monthly [bonuses]. We also have the option to purchase stock, which has performed [with] above-market returns [in] the past 15 years. Purchasing stock also gives us additional monetary monthly benefits, as well as capital gains as the value appreciates. We have access to many [continuing education] opportunities which are paid for by [the DSO] and our offices, including travel expenses. We have many sought-after dental speakers, workshops, and leadership training. This past year, for example, we had an Aesthetic Continuum where docs received hands-on training, one-on-one with a mentor on a 10-unit veneer case. In 2016, [the DSO] is developing a growth program to further encourage doctors to be actively engaged in [continuing education] and [to improve their] clinical, communication, and leadership skills."

• "As reimbursement for dental services demands more efficiency, DSOs will partner with dentists to improve access to quality patient care and experiences. This also gives dentists the opportunity to practice in a state-of-the-art facility without any personal capital investment and the opportunity to earn income equivalent to private practice with overall improved benefits. With stock purchases, it is possible to see returns that cannot be attained in a private practice setting, as many of our long-term doctors have accomplished. DSOs will continue to [manage more] practices over the next 10 years. Having a solo practice [with a] building, equipment, and staffing [that is] opened only 35 hours a week is not an efficient or highly profitable business model for many doctors. This leaves the doctor [with] little saved for retirement and having to shoulder all the problems of owning a practice. In my opinion, most dentists partnering with a DSO—and especially [the DSO I affiliate with]—will enjoy a more satisfying career. More time for family, less stress, and greater financial compensation. Also [. . .] the personal and leadership training skills transcend into an improved quality of life and better life choices. I am so grateful and blessed to be part of our wonderful profession. I am very satisfied with my decision to join [the DSO I affiliate with]."

"With stock purchases, it is possible to see returns that cannot be attained in a private practice setting, as many of our long-term doctors have accomplished."

• "Corporate dentistry is slowly eroding the public opinion of dentistry. Providers in this structure are pushed to do more procedures in less time. Patients feel this. One of my patients [who] went to a local DSO said that she felt like she was 'in the Walmart of dentistry.' As DSOs accept more and more fee schedules that are ridiculous, dentists are making less and less money with more and more liability. One of my colleagues complains that he is asked to run two to three chairs at a time and is almost always running more than an hour late by the end of the day. This type of practice doesn't give the dentist the opportunity to manage the minutiae of dentistry-not only the minutiae of the actual dentistry but the [nuances of helping people]. [Dentistry] used to be one of the most respected health-care professions. Not any more. I believe that DSOs are at the heart of this. While I believe that group practice can allow for dentistry to be more affordable and accessible than it has been in the cottage industry that dentistry has historically been, DSOs are not the answer."

DENTAL HYGIENISTS SAID:

• "From my experiences working for a corporate dental office for six years, there are many positives and negatives. Positives [include] benefits [as well as] support and mentoring from others in the company. There are many people up the ladder who can help or give advice. The negatives [include] always finding ways to cut corners and make more money, and those working in management [are] always so busy with having multiple offices that things don't get watched or done in a timely manner as they should. Our offices are basically left to do as they want for long periods of time, and then management swoops in later on and comes down on us for not doing what they want."

• "Appointment times are short, and equipment is not the best, but I believe corporate dentistry fills a need for a large population of people. They are the chain restaurants of dentistry. Yes, mom-and-pop eateries can be nice with better-quality food, but sometimes people want the reassurance of [a] recognizable brand with a menu and pricing structure that they feel more comfortable [with]."

• "I would compare them to assembly lines in factories. I worked in factories prior to becoming a dental hygienist, so I truly see the similarities. I have been a dental hygienist since 1993, so I am not new to the profession. I also manage my husband's pediatric dental practice. He is a solo practitioner and started the practice from zero patients. It is a very long road to establish your reputation in a community. After 12 years he is known in the area for his ability to treat difficult children and his fun personality. However, in recent years with insurance companies paying at such low rates, it is not possible to remain in-network while still maintaining competitive pay for our employees, preparing for our own retirement needs, and meeting our overhead expenses. Due to this, we have been changing to out-of-network status with many insurance companies so we are paid our full fees. We cannot compete with a high-volume corporate dental facility. My husband is not going to change how he operates his office to see more patients in a day and provide care in a rushed and impersonal manner, which is necessary in a corporate-run practice. (He joined such a practice early on and left after only one year.) It is sad that some patients do not see the value in personalized care. Fortunately, some patients do stay with our office [after] they go elsewhere to 'save money' and are not happy. Others never leave, knowing from past experiences how large practices operate. We can only hope that our community continues to value the personal care their children receive. We are proud that our staff members have been with us for long periods of time, as they are also happy with how we run the practice. Many people value the fact that their children can see the same hygienist year after year. Two of our best hygienists temped at corporate dental practices prior to coming on board with us, and they are so happy to work in my husband's practice now. There's something to be said for actually having the time to get to know what your patients are doing in their lives—not just their dentitions. I think that if our health system continues on the path it is on now, private [practitioners] in all specialties will find it more and more challenging, especially [when] starting a solo practice. I suppose that was a really long answer to state that I do not like corporate dentistry for many personal reasons!"

• "I have worked for two different DSOs. I was very fortunate for the offices that I had worked in. At the first, I was an office manager. I was in the dental field for many years prior to working for a DSO. The dentist in this office sold his practice to the DSO and was working for them. We managed this office like private practice, not overselling dentistry or products. It was a very successful office, and our production was up in the top, compared to other offices in the corporation. At the second office that I was in, I was a dental hygienist. It was a new office to the corporation and had several issues that needed to be addressed. The front office staff had little (if any) training, which meant the office did not run smoothly. The patients were frustrated before they even got in the dental chair. When we did start working as a team, the patients became comfortable with the practice. Then the corporation started pushing numbers. It was no longer what the patients needed for their dental health; it was how much money we needed to produce each month. I didn't feel I could ethically work there anymore. I was told I needed to do four quadrants of periodontal scaling on patients who had one to three four-millimeter pockets [. . .] who had not had their teeth cleaned six months prior, just to meet a quota. Then I was told I had to place so many Arestins per month. To meet that quota, I was told to place 23 Arestins on a patient who had implants that had no bone and were so exposed and loose in his mouth. I quit. The concept of the DSO and providing good dentistry is great, but when they push numbers without thinking of the patients' dental health and financial situations, there is a problem. So I have seen both situations with DSOs."

• "[. . .] Hygienists are given bonuses for the amount of money they make in a month-thus the temptation to overdiagnose and overtreat our patients. We, as hygienists, were yelled at in business meetings that we weren't 'diagnosing enough perio.' Our offices were given new guidelines to make more money in the hygiene department. We were expected to do [scaling and root planing] on four-millimeter bleeding pockets with no bone loss. My dentist and I refused [due to] ethical issues. Because my dentist and I stood our ground, we did not have to follow this directive, but our corporation was not happy. I resigned a few months later and anonymously sent the president of our corporation an article from RDH magazine [about] dentists and hygienists being put on probation and being fined for overtreating patients. The new guidelines were thrown out in the next year, and the dentist in each individual office decides the perio directives for the office."

• "Love it! Great support and education. Great benefits as well! Always busy!"

• "I worked as a hygienist in 'corporate dentistry' for almost two years. There are benefits and negatives that I will share. I will begin on the negative, so I can end on a positive note! Negative: All is geared on production and is visible on a central computer for all to see-production numbers and goals. To have high production, assisted hygiene is necessary. On paper, this is great. However, everyone has to work as a team for this to flow. Many things get overlooked due to the fast-paced schedule. There is a bonus system, which is awesome, but that brings competition among the employees that I have seen divide the team [. . .]. [There is an] increase in the workday hours and weekdays open for operation, which is great for the patients but difficult for the employees. All these result in a turnover in employees that affects the 'team' and the flow of the office. Positive: Cutting-edge equipment and training. Nice offices. Bonus system and benefits. I am not against 'corporate dentistry,' and on paper, it is a wonderful system for employees and patients. Implementing this is altogether different, and I felt as if the patient care was not optimal like you find in a general practice!"

• "There are pros and cons to corporate dentistry. Keep in mind when you use the word 'corporate' that it equates to a profit-driven company. Here are some of the pros: (1) They will give you everything you need to be successful in the way of making profit. This includes all equipment, [personal protective equipment], and training. Everyone can stay on the same page if everyone is given the same training, and office protocol is standard from one office to another. (2) They've 'got your back.' Because of the litigious society we live in today and the fact that they are successful, they make all amends to keeping patients in the right-to-know [about] consequences if they don't follow recommended treatment [or if they refuse] to allow full diagnosis with regards to using radiographs and other diagnostic tools [. . .]. They [keep] patients informed and follow through with written and verbal consents. Everything is documented! (3) Job security: While the previous dentist decided to take a few weeks off during the year, without regard [for] keeping the staff fully employed during those breaks, the office now remains open with set time off for the dentist and/or refusal to allow the current dentist ('employee' now) to take extra time off since it reduces the profit for the office. Also the office is driven to secure new patients on a regular basis to keep the practice growing continuously [. . .]. (4) Employee benefits: If you received minimal benefits or diminished benefits due to the economy 'tanking' in the last decade, the corporation gives a full benefit package to those who meet full-time requirements. [. . .]

• Cons: (1) Because the office is now strictly profit-driven, [. . .] insurance is utilized for maximum profit to the business in the guise of helping the patient achieve optimal dental care. This doesn't mean unnecessary treatment, per se, but getting the most from the patient in regard to treatment options. This may include offering whitening treatments, implants, Invisalign, and other procedures that may not be necessary but would increase overall income to the company for profit-making purposes. The fact that it may not be a covered expense for the patient is secondary to meeting financial goals for the office. (2) Don't expect to receive any compliments about your work or patient rapport. Small talk or social chit-chat is frowned upon [for] slowing production and being meaningless unless it produces results (profits). (3) If you think you had a good, productive day, think again. They are never satisfied and will continually expect you to reach higher levels in regard to the dollar amount. Meanwhile, you will not see any increase in salary. [. . .] They will put the hygienists on production-based pay to drive you toward [producing] more income for the office, [so] your hourly rate will suffer if you do only the basics. You don't derive profit from educating the patient through the whole 'time equals money' appointment crunch. Your patients will be questioned if they learned anything, and you will be questioned if you offered them other 'services.' 'Would you like fries with that?' is what made McDonalds increase their revenue, and this isn't much different. (4) Stress: If you are a competent hygienist, you will want to be thorough. Your allotted appointment time must be completely guided [by] getting the patient in and out exactly on time. This can be a frustration as you await the clinical exam by the dentist.

• These are just a few of the pros and cons off the top of my head. On a daily basis, it has its frustrations, as it seems as if every minute is tracked for production. I often feel like I should be wearing a GoPro [camera] on my head as corporate staff will visit the office to see if we are complying with the company's policies, and of course, [if we] are on goal with production endpoints. And don't let me forget, the whole process of tracking and documenting everything takes time away from your clinical treatment of the patient-either that, or you will not have time to thoroughly document your treatment, and they will be checking on that, too."

• "I currently work for a corporate dental office and find that I have a consistent patient base that offers greater job security than when I worked in private practices. I have also found that I no longer have to worry about providing supervised neglect, as I was made to do prophies on patients with active periodontal disease. I make my own schedule and can see patients for the amount of time I need."

• "Our employer (a DDS) made the decision to sell his practice to a corporate administrative organization. We were told that, aside from seeing a different signature on our paychecks, we would not notice any differences in the way the office was run. In the months since the changeover, we have upgraded our OSHA practices, had long-overdue reviews and raises, hired another DDS and RDA, switched computer programs, had some change in employees, and had actual marketing done to bring in new patients. Overall, the results have been positive so far. The negatives are the way the change was presented to us and the fact that we had to switch 401(k) programs, and there is a one-year wait for the employer match to take effect. I am grateful for my job; my dedication is to my patients, and I understand it [was] my employer's choice to do what he did."

• "I was told this company was 'different' because the dentists owned part of the practices. I was being triple-booked and pushed to doing minimal work on the patients just to get them in and out the door. I was told not to worry about perio charting and oral cancer screenings when I didn't have time. Patients put so much trust in our knowledge and professionalism and deserve more than that. Also, I value my knowledge more than letting it go to waste."

• "I think it's ridiculous that one of the largest corporate dentistry groups consistently breaks Colorado law, and nothing gets done about it. Assistants are doing prophies, and the patients have no idea [about] the substandard care they receive. Everyone in dentistry knows about this!"

• "DSOs seem to make sense from a business perspective, but [I hope] the dental industry will learn from the medical industry and not repeat the same 'mistakes' that occurred there during the similar consolidation. It is important to keep the patient at the center of everything that we do. When a 'corporate' office can offer a patient services and efficiency that [are] not available in an individual practice, consolidation is working. When the corporate office becomes impersonal and just another medical professional looking out for themselves, the system is broken." -A strategy lead

OTHER INDUSTRY PROFESSIONALS SAID:

• "DSOs have gotten a bad rap, largely due to some bad apples. There are bad apples in every industry, including among solo practitioners. I do think many dentists will greatly benefit from the support DSOs provide in managing the business which is becoming ever more complex. There are increasing pressures on revenue from insurance carriers and increasing pressures on costs as practices become more reliant on expensive technologies. Managing the revenue and expenses is becoming much more critical to being successful in this industry, and most dentists do not receive any training in these areas. The larger dental groups also generally look to provide total patient care and often are able to introduce specialty services at the patient's local practice, making it a more comfortable, efficient experience for the patient but also providing direct interaction between the GP and the specialist. In addition, most dental groups have quality assurance programs ensuring quality care is being delivered. If you are operating as a solo practitioner, who judges your quality?" -A consultant

• "DSOs are the future for dentistry, as stated by Wall Street in 2012 . . . and the future is now. How can a new dentist fresh out of school, loaded with six-digit debt, [who has] virtually no business experience expect to service their debt and have enough money left over for a new ground-up dental practice? Or [how can this new dentist] have strong enough credit or the skillsets required to purchase an existing practice? If nothing else, DSOs will provide great pay, an opportunity to build clinical speed and expertise, and the opportunity to increase dental business acumen, which at some point, will allow [new dentists] to have their own practices." —A consultant

• "Regardless of how we 'feel' about it, the dental industry is following in the footsteps of the medical industry, and DSOs will soon be the norm. Overhead costs, battling with insurance companies, and even increasing regulations are driving solo practitioners and graduates into group practices with the hopes of less stress, [less] responsibility, [and] maintaining a decent income. We have a generation coming in [that cares] more about immediate access than 'that personal touch,' and a group practice can accommodate that more easily with extended hours, including specialists in the group, and accepting most insurances. Additionally, the practice management decisions are made by either investors or a core team of doctors who understand they are running a business, while providing the best health care according to their standard of care. This means they can set fee schedules that are more balanced, which could potentially streamline the reimbursements (although I'm less sure about this than anything).

• "There are, of course, downsides to DSOs, including but not limited to the ability for the doctor to set their own schedule and make practice management decisions-and in fact, all the entrepreneurial benefits that come with owning your own business. As I stated earlier, as a patient, going to a corporate practice can seem more like going to Trader Joe's than your market down the street; the experience can be less personal. When the practice is run by investors rather than doctors, there is a thin line between 'what's best for the patient' and 'what's best for the business.' This could cause ethical doctors to question their standard of care, doubt in the patient's eyes when it comes to necessary treatment, and dissent [among the staff] if goals are not achieved. I think it's important these 'corporate' dental offices take the route of most corporations today by making sure they're being socially responsible and giving back to their communities. By educating the public on subjects like the oral-systemic health link, they can ensure compliance within a patient base that is becoming more cognizant. There is a sensitivity that comes with adding business to health care, and these offices must ensure that they are ultimately seen as [being] here to do good. Regardless of how we view these businesses, they are here and will continue to expand. We must commit to their success to ensure the future of dentistry progresses in a way beneficial to the patient first and the doctor second. After all, isn't that what it's all about?" -A sales representative

• "For many reasons, corporate dentistry has a place in today's market. Due to the high cost of education, [new] dentists find it difficult to start a business. Corporate dentistry provides an environment that allows [new dentists] to meet their financial needs while learning to run a business. Dental schools have little interest in teaching students the process of starting a business or teaching sound business practices. Dentists looking to slow down but not retire are perfect for the corporate dental environment. Many see corporate dentistry as a threat. It can be a threat unless the private practice dentists realize that developing lasting loyal relationships with patients, the community, and professional referral sources is an absolute necessity." -A consultant

• "In my opinion, dental support organizations are actually a great way to start a career if one just finished dental school. Corporate [offices] provide more training for the new graduate, which is a very essential factor for the first year or two after graduation. On the other hand, the infrastructure of a DSO is made with the mentality to make money and grow. Regardless of patient focus and care, DSOs are there to sell, sell, sell, which could make it very difficult for a dental professional. Fifty minutes to assess, take radiographs, present the dental hygiene care plan, debride, polish, apply Arestin, and/or fluoride treatment [. . .] is just not enough time for a dental hygienist. And this is not even mentioning the dentist's interaction with the patient yet! Fifty minutes [is] simply not enough to time to be able to do it accurately and with patient care in mind. Fifty minutes with each patient is absolutely a disservice. We, as dental professionals, need to get together as a strong group and change this approach. It is not healthy [and] not ethical to rush through the whole appointment just to satisfy 'sales production.' DSOs are not designed by dental professionals. The infrastructure was put together by a whole bunch of investors, [whose] only focus is to increase the money invested by decreasing patient care. DSOs need to be reshaped with patient care in mind." -A dental hygiene student

WE ASKED:

What informed your decision to affiliate with/work for a DSO?

DENTISTS SAID:

"I need work, have small children, and [want] to get more experience before/if I own my own practice."

"At the time, I was forced to find a job to pay off large student loans and gain clinical and management experience."

"The economy killed my practice in 2008."

"I was encouraged to apply for the position by an associate at a corporate-run office."

"Tempting offer based on advertised average salary, flexibility without hassles of private practice ownership, etc."

"My private practice could not compete with the corporate resources."

"It gave me experience when I was first out of school but didn't pay my educational loans. I could not live like that."

"Disenchanted with private practice due to high stress"

"Cashing out"

"I needed a job with a ready-made patient base when I moved to the area."

"I saw the competition of corporate dentistry and saw that over time, the corporate dental companies would be squeezing out the individual dentists. Also, a corporation allows me to touch more patients then I ever could as a solo practitioner."

"No other opportunities were present at the time. I hope to leave as soon as possible to start my own practice. Student debt doesn't allow me to open my own practice at this time."

"Loan debt"

"Opportunities to focus on patient care, earn a great income, benefits, [continuing education], and stock ownership"

DENTAL HYGIENISTS SAID:

"I wanted to keep my job with people who provided great quality care for everyone. The practice was sold, but the primary DDS stayed-influencing the decision of most of us to stay in the practice."

"Because my private dentist took full advantage of me [and] my work skills and kept me underpaid without benefits for eight years"

"I was offered a full-time job with benefits."

"It was the job available at the time. But over time I have grown to love working here. The patients are in need of my services and for the most part [are] very grateful. Plus, I get to see a wide variety of patients."

"Commission-based salaries which pay higher than general dentists"

"Not much choice. Boss is retiring and sold practice. In our rural area, employment is very limited."

"I was laid off for a year during the recession, and despite negative feedback from what people felt about corporate dentistry, I needed a job."

"There aren't many jobs available. I applied for the job, but all the while, I was looking for another."

"It was an involuntary decision based on my employer."

"I had no other opportunity."

"It was my first job out of school. I needed experience."

WE ASKED:

If you don't work for/with a DSO, would you ever consider it? Why or why not?

DENTISTS WHO WOULD SAID:

"If I am desperate for a job"

"If [a] DSO had zero influence on [my] practice of dentistry"

"I would only consider it if I could truly decide on treatment plans in consultation with the patients, [unaffected] by the corporate headquarters' drive for bigger profits."

"If I were [able] to treat patients as I do now, I would consider the possibility."

"If the market was headed that way, I would consider selling to a DSO and work to my retirement."

"If it allowed for some improved quality of life (e.g., more money, more free time)"

"I would want some control."

"Maybe just to see if it's as bad as I thought it would be"

DENTISTS WHO WOULDN'T SAID:

"I am a fee-for-service dentist, and the patient's health is between the patient and [me]. My job is to help my patients afford the best dentistry for them. I will not extract teeth that I can save. Ways can be found over time to keep patients' teeth in maximum health, [comfortable], and [functional], [without having] them sign financing to shuck teeth and give them a plastic removable partial or stick them in full dentures and turn them into a dental cripple. So, how do I really feel about this?"

"I would rather quit dentistry than become a dental [sell-out] for these organizations."

"I'd retire first!"

"Why would I want to give up all the freedoms I enjoy to work for someone else? Why would I want to give up 10-14% of my profit to a corporate group? Uncle Sam (20%) and practice brokers (10%) will take a good share of what remains if I sell to a corporate group. When I retire, I will hire an associate, give them much better pay than corporate dentistry, practice one day a week doing Fastbraces and implants, and be able to make more money than if I sold my practice."

"I [became a dentist] to be my own boss and not work for the man."

"I don't feel that most DSOs are representative of what the practice of dentistry stands for: integrity [and] patient-centered care."

"I value my autonomy too much to ever consider working for a DSO. Furthermore, I will not contribute to the takeover of the dental landscape by large corporations. It is a bad trend."

Why would I want to give up 10-14% of my profit to a corporate group?

DENTAL HYGIENISTS WHO WOULD SAID:

"They are the only ones offering jobs now."

"If it were a location that was well reviewed and appreciated by its patients and care-driven as a means to a profitable end, rather than solely profit-driven"

"I would love to get health insurance as a benefit."

"DSOs usually offer benefits, [paid time off], 401(k), and bonuses that most private practices don't, so unless you have insurance from another source, it is a huge perk. Sometimes you pick benefits over happiness and doing what is taught in school."

DENTAL HYGIENISTS WHO WOULDN'T SAID:

"I do not think that the level of care is what it should be. I feel like the need to meet quotas and make so much money can lead to not considering the patients and their needs as a top priority. I also do not feel that employees are valued or treated as well as I have been in the private practices I work for. The doctors I work for know me [and] my work ethic and take an interest in my life. I know that I'm a valued employee. I feel that, in corporate dentistry, we are viewed as easily replaceable because there is not as much of a personal connection."

"I believe all health care (including oral care) is personal and should be administered by a trusted professional provider. I prefer to work and provide personal caring service, not mandatory services mandated to enhance corporate profits."

"I actually was considering a 'corporate' dental position at one time. I wanted to keep an open mind, but the more I learned, the faster I ran in the opposite direction-mostly due to the level of dentistry and professionalism that I believe every patient deserves. I was not willing to be a part of anything less."

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