Insights in this post are based on a Becker’s Healthcare and Clerri survey (February 2026) of 105 dental leaders, the majority of whom oversee multi-location organizations with 20+ practices and $50M+ in annual revenue. Read the full report here.
As DSOs have scaled over the past decade, revenue has not kept pace.
Most organizations now operate across dozens or hundreds of locations, yet patient engagement, workflows, and revenue generation still vary—creating a gap between scale and standardization that is shaping the next phase of performance.
Having spent nearly a decade building the marketing and patient engagement function at a multi-location dental group as it scaled from 10 to 27 locations, I can tell you that the gap between strategy and execution doesn’t announce itself – it compounds quietly until it shows up in the numbers.
Over the past three years, 50% of dental organizations have reported declining insurance reimbursements while overall costs continue to rise, making margin pressure structural and elevating consistency across locations as the primary driver of financial performance at scale.
Variability is the hidden constraint on margins
Predictability and control increasingly shape margin performance.
As DSOs scale, financial outcomes depend on how reliably revenue is generated and managed across locations. Without standardization, performance becomes difficult to forecast, control, and optimize at the enterprise level.
Multi-location complexity introduces variability in how revenue strategies are executed, leading to uneven production, uncoordinated patient engagement, and limited visibility. 81% of organizations operate without a standardized approach to engaging cash-pay patients, creating a clear gap between strategy and execution.
Insurance dependency compounds this instability. Reimbursement rates fluctuate, administrative burden increases, and pricing control remains external. Meanwhile, costs rise internally while revenue depends on inconsistent execution across locations. Workflows, tools, and engagement approaches differ, directly shaping financial outcomes.
As a result, revenue performance becomes uneven across the enterprise, limiting leadership’s ability to predict, control, and scale outcomes with confidence. This misalignment drives structural margin compression, as variability continues to shape how revenue performs across the organization at scale.
Growth is shifting toward controllable revenue
A meaningful portion of the patient base already sits outside traditional insurance structures.
96% of dental leaders report that 10%–30% of their patients are uninsured or underinsured, a segment that continues to grow alongside workforce shifts such as independent and gig-based employment.
At the same time, 35% of organizations report losing these patients, often with attrition rates of 10% or more—linking patient engagement directly to revenue performance.
A 10% attrition rate in a 25-location DSO can represent approximately $10 million in lost lifetime revenue.
In practice, that attrition rarely looks like a single failure point. It looks like inconsistent front-desk conversations, pricing that varies by location, and patients who quietly stop coming back because the experience didn’t feel reliable.
Growth is increasingly tied to how effectively organizations retain and serve the patients they already have.
The execution gap reflects a system gap
Most DSOs recognize the opportunity in fee-for-service patients.
81% of dental leaders report strong revenue potential in cash-pay patients, yet only 19% have standardized their approach to capturing it. A gap that’s driving performance variability across locations.
This is one of the most consistent patterns I’ve seen in dental organizations at scale: the awareness is there, the intent is there, but the execution fragments the moment it reaches the practice level.
Strategies are often defined centrally but executed locally using different tools and workflows, leading to inconsistent performance across the enterprise.
Organizations experience unpredictable enrollment, uneven retention, and limited visibility into what drives results. Nearly half rate their ability to attract cash-pay patients as poor or below average, and only 23% feel confident in understanding impact.
At scale, these inconsistencies compound into material revenue loss, reinforcing the need for a structured approach that maximizes performance across the existing patient base.
Standardization is becoming the growth engine
The organizations getting this right aren’t just adopting better tools – they’re making a deliberate architectural decision about how revenue should work across their enterprise.
Leading DSOs are shifting from localized tactics to standardized approaches built on three principles:
- Revenue models designed centrally
- Execution standardized across locations
- Performance visible at the enterprise level
Reducing variability increases predictability, making consistency the driver of growth.
DSOs like Smile Partners USA have already applied this approach, simplifying membership and improving performance across more than 100 locations.
Membership is becoming a reliable revenue model
Membership is becoming a standardized approach to generating recurring revenue by aligning patient access, payment models, and operational workflows.
At the enterprise level, it strengthens retention, aligns incentives across locations, and reduces reliance on insurance-driven variability.
Every location operates within the same framework. Every patient interaction contributes to a repeatable, measurable revenue model. Revenue becomes structured, not variable.
This shift reflects a broader move toward connected care, where access, engagement, and payment are aligned to drive more predictable outcomes.
Reducing variability unlocks financial performance
The financial impact of standardization is measurable.
Practices that implement structured membership models see 2.7 times higher production from uninsured patients, lower no-show rates, and increased patient lifetime value.
At enterprise scale, these gains compound. Consistency in engagement and retention directly improves organizational revenue performance.
Technology enables system-level execution
Standardization requires infrastructure.
Only 20% of organizations use enterprise-wide technology to manage membership programs, while approximately 50% are evaluating solutions—reflecting a growing shift toward connecting strategy to execution.
Enterprise platforms enable consistent workflows, centralized reporting, reduced administrative burden, and faster decision-making, ensuring predictable performance across locations.
The new definition of scale
Scale in dentistry is being redefined.
Historically, growth meant expanding locations, providers, and patient volume. Today, performance is defined by consistency across locations, predictability of revenue, and visibility into outcomes.
Organizations that align these elements operate with greater control, stronger margins, and more resilient growth models.
The next phase of DSO growth will be shaped by how organizations standardize execution and reduce variability across the enterprise. Leading organizations are designing revenue models that operate consistently, centralizing patient engagement, and investing in infrastructure that improves visibility and control.
As this shift continues, DSOs that reduce dependence on insurance and adopt membership models are building more predictable revenue and stronger long-term financial stability.
The organizations furthest along on this journey share one thing in common: they stopped treating membership as a product and started treating it as infrastructure.
This move from growth tactics to operating models separates those scaling strategically, from those simply getting bigger.
See how DSOs are improving visibility, increasing retention,
and turning haphazard performance into predictable enterprise growth.
Download the full report.
Juan Prado is a healthcare marketing leader with nearly a decade of experience building the patient engagement and growth function at a multi-location dental group — scaling it from 10 to 27 locations across four states. He currently leads Product and Customer Marketing at Clerri, a dental membership plan platform serving DSOs nationwide. https://www.linkedin.com/in/juanprado1/
