DSOs & the Future of Dentistry

This ADSO podcast is about dental careers in a DSO, where we discuss the advantages of a DSO environment and why you may be interested in pursuing a career as a supported dentist in a DSO.


Hello and thank you for joining us. Welcome to our ADSO podcast about dental careers in a DSO where we discuss the advantages of a DSO environment and why you may be interested in pursuing a career as a supported dentist in a DSO.

Hi, my name is Dr. AJ Acierno and I am very excited to talk with you today in regards to dental support organizations in the future of dentistry. Of course I’m a CEO of DecisionOne Dental Partners. We went ahead and we started our organization back in 2011, it’s my brother and I. My brother is older and he is a dentist also. we are both in Chicago, Illinois. We have 23 offices in the Chicago land area and we are planning to continue to grow our organization as we see fit. My brother and I both went to Creighton University. I graduated Creighton Undergrad in 1998 and then I graduated Dental School from Creighton also in 2001. I worked for Heartland Dental from 2001 to 2004. And then from group practice of Heartland, I went into private practice. Private practice at Acierno Dental, I took over traditionally I bought another dentist and he retired and I went ahead and took over.

During that timeframe between 2004 in 2011, 2012 I was in private practice and what we did was we consolidated some offices that were in the same building as us. So I had three other dentists that were in the building that I was in and all three of those dentist retired and came into my practice. And I enjoy doing that. I enjoyed the acquisition process and I enjoyed the consolidation. I also enjoyed seeing more patients in my practice and that’s where my passion started to grow.

In 2012, we founded DecisionOne Dental Partners. And that was my brother and I after a lot of consulting in trying to figure that out. And as you could see, this is why we created it. We wanted to bring together a group of dentists who refused to see our profession suffer the same fate as medicine. So during that process of consolidation, and us bringing other dentists’ into my group or into my single practice what I started to realize was dentistry was changing around me, things were becoming different. They were starting to look a little bit like some of my friends in medicine were starting to deal with. And I really enjoy my profession. I love my profession of what it does. I enjoy having the relationships that I build with my patients. And I wanted to see that throughout my entire career. At that time, I was in early 30s, and I wanted to make sure, hey there, I’m going to be in this for a long time and I want to make sure that my profession stays the way what I loved about it when I first got in.

And so as we did this our vision is to change the way dentistry has done to improve lives. And our belief is that we want to stop the train of what dentistry is looking like. We want to go ahead and make sure that we preserve the great relationships that we are building with our patients. We want to make sure that our dentists have autonomy. We want to make sure that our dentist can create those relationships and provide an environment for them. And as you’ll see later on in this presentation of some of the things that are going on with groups and some of the things that are going on in private practice that might challenge that. So the current state of dentistry and what we have. So of course they say that dentistry is the best job in America and I will be honest with you.

When I first saw this, I was like, man, what is going on in America that dentists have the best job? Because if we have the best job, I feel bad for other people in America. But the reality is that we do have a very good job and we do have an opportunity to create a relationship with an individual and make them better. So that does make our job great. And there are a lot of things going right with our job. One of them is that our profession is based on relationships and helping people. We have low unemployment rate. Our work life balance is very well in dentistry. We do get paid very well. And that can be a positive and negative. We’ll see that in a second here. And we have a positive employment outlook.

Dentistry is a very hot field right now especially in the group practice sector. And so that is a very positive employment outlook for us. What is going wrong? Well, as I said that we do get some great take home pay. Although the dentistry salary is declining now, there has been a challenge that there might be a little bit of an upswing coming, but it’s still declining from what it was. There’s rising cost of education. The insurance company issues and the government involvement, all these, I’m going to be getting into a little bit more in depth as we go along. Again, all these negatives are something that we can’t make better, we are making better. And I think that’s where group practice comes into play. I think group practice is a huge positive to making sure that these negatives can swing in the positive direction.

As you could see the dentist salary declining 2006 average salary and the 2011 average salary. I don’t think any of us really want to take a pay cut. I think we work hard. We take on a lot of responsibility. We’re taking on a lot of guts in order to become a dentist and I think that we should be paid fairly for what we’re doing. And I think that any group and any decisions that we make should have the decision of how do our dentists get paid justly of what they deserve. And we’re really working hard on that. And I think all groups are really working hard on that. The rising cost of education. And that’s something that a group can help with. Of course, that just deals with the schools and the education that we’re getting, but the reality is that all education is increasing.

The 2016 average debt of a dental school graduate is 260, 000 it’s times more than any debt of 1990 dental graduates. So this is the first time that I figured out that I was getting a little older when I started looking and saying Penn, my debt was nowhere near what some of these new docs are coming out with. And I really do feel bad for them. I mean monthly payments of $4,000, that is a tough check to write every month in regards to that. And it makes it very much more difficult to purchase a practice. So again, traditionally when I came away from Heartland, I was able to go and get a take on the and absorb the debt that it required me to get a private practice. Today’s day and age, it is very difficult for these young docs to do that.

And that is we’re a group practice can come into play and help out tremendously. Insurance companies, patients are becoming more increasingly more reliant on using insurance and they should, I mean insurance is a great product for them. It helps them out tremendously. Insurance companies are great. The problem is insurance maximums have been the same for decades. The reality is that the reimbursement rates that we are getting are continuing to stay the same or getting lower. So they keep on increasing how much insurance costs for our patients. So their premiums are increasing but the reimbursements are decreasing and the maximums are staying the same. So it is a great deal for insurance companies and you could see that as they have a record number of profitability. The problem is that that creates a bad situation within the dental office.

It creates a bad situation with the patient relationships. It is creating an environment kind of like medicine where it is you have to see more people. Dentist have to be able to see instead of 10 people a day, they got to see 40 people a day. And what they’re doing is by seeing people they get the same take home pay. There was a lot of insurance companies that we have sat down with him and spoken with and their suggestions are, while you need to decrease expenses and you need to see more people that sounds all well and good and there’s probably some efficiencies that I can do in group practices are able to teach you those efficiencies very well. But again, we want to make sure that we’re in business to give top quality dentistry.

So some of these things that they are recommending for us to do are creating a negative environment to creating great dentistry for our patients. And that’s what we’re in business for. And so what we want to make sure is that we can go ahead and create these efficiencies and create these systems within an office that can go ahead, even if the insurance companies go and decrease reimbursement or keep reimbursement the way it is and all our expenses around us are increasing that we are still able to give our patients top quality dentistry like we’ve always promised. As you could see government involvement. Unfortunately this is probably going to be more and more as the years go on. We’ve already seen a little bit as group practices are constantly discussing how government is approaching into our world with rules and regulations. They are going to make it more difficult for us as providers and we do not have to look far, but we can look far to our colleagues in medicine and see how difficult government has made their jobs.

I don’t think it’s any secret that as government has encroached into medicine, medicine has declined worldwide in the United States of the service that we provide our patients. And I don’t think that anybody, any patient should be should have less healthcare in the United States. I just believe that, I firmly believe that. I believe that we should do everything possible to be the best in the world, in our field. And if government continues to get involved in dentistry, my assumption is that we are going to decline in the type of care that we provide. And I believe that as a group we can defend that. And I think as a group that we can make sure that that does not happen.

Solo verse group practice. And this is really where it gets to. I think first and foremost, I think solo practices is awesome. I think group practice is awesome. I think there is a world of dentistry that involves both solo and group and everybody works together. I think there’s positives and negatives of both. What we did at DecisionOne is we sure tried to blend both of those. We tried to blend both the great aspects of a solo practice and the great aspects of group practice. So as you could see solo practice, the pros and the cons, the pros, the autonomy. I mean you don’t answer to anybody but yourself when you’re in a solo practice. The pride of running and growing a practice, I mean this is your baby, you’ve taken the all the weight on your shoulders and you’re moving forward on there. Community based businesses.

Usually these we are small business owners in solo practice, so we are getting involved in the community. We are doing things in the community and you’re providing jobs for the community. It’s a great service as a solo practitioner. Some of the kinds in a solo practice, I mean, supply and lab costs are getting out of hand, especially as a group practice. As you see the benefits that you get as a group and lab and supplies, it really is, they’re extremely high supply and lab costs. Rigorous business demands. We constantly hear this from Solo practitioners that there is a demand on them to create a great business and the hours that they have to put in and be involved in that. Insurance headaches, constantly going after insurance companies and denials are increasing tremendously for all of us throughout a dentistry.

And then you get marketing. Marketing is a whole different animal. In marketing there are so many technical advances in marketing. you have to have a marketing major in order to be able to run a business in marketing, legal, HR and accounting responsibilities. All these things take a ton of time. Most importantly, we’re not taught that, we are running a practice we’re great dentists. We’re great at our field of what we can do to provide great dental health. We are not great at dental business and we are not taught dental business. Most of the times we are just learning this on the run. The problem with learning on the run in today’s day and age when you have high supply costs and overhead is increase and reimbursement has decreased, is that the margins have become slimmer. And when the margins become slimmer, you do not have the luxury of making mistakes in business.

You have to come out and you have to be smart and business in order to succeed and in order to stay afloat. So there’s a lot of the cons of some of the rigorous demands that we have in business. It could be very, very damaging to us. In the last year you see as no comradery with colleagues. It used to be the great thing about solo practices, hey, I don’t have to answer to anybody. I’m autonomous and I don’t need to deal with anybody, but what do you do is you get stuck in your four walls and all you know is what you know in those four walls. And has efficiency and has system, then all these things come into play and help to fight the negative influences that are coming on in our field.

We can’t stay in our four walls. We got to get outside our four walls and figure out what are people doing great and what can I learn and what can I do with my colleagues to help me continue to learn. And so the days of just staying in our four walls are no more a pro, that’s more of a con. As we look at group practice, the pros, economies of scale learning again from the labs and from the supplies. CE opportunities, learning. I mean just learning like I was just saying the efficiencies and what we provide and how to be better clinicians and how to manage our patients better. Mentorship from other doctors. I mean, I graduated in 2001 and every day with our doctors in our group, I am learning something different and I think that is one of the greatest things that I could ever have done. I can’t imagine myself in private practice, not learning from these individuals that are just tremendous dentists.

And then of course the business support. And that’s really what a DSO is, right? A DSO supports the business aspect of a practice and that is the biggest headaches. We are not business people. We are great healthcare providers. And in order to become great at business, we’ve got to surround ourselves with great business people. And that’s a great pro from a group practice standpoint. Some of the cons, of limited autonomy. And I put a question mark there. I’m not quite sure if we have limited autonomy and I don’t believe that it’s true.

Production goals. Again, I don’t think there is production goals. I think there are goals of how to grow a practice and that is the same as private practice. There are very few private practice people, private practice dentists that I meet that say, hey, so do you want to just stay the status quo? Or do you want to decrease in what you were doing last year? No, everybody wants to increase. And if you don’t set a goal for yourself and then that’s not a reality, that’s just a dream. So you have to have goals. Is it production goals? Well, that’s one way to measure it. You could also have goals of new patients. You can also have goals of how many patients you want to see per day. You also can have how many operatories do want to grow too.

These are all goals that you can have as a group practice. Some people want to put those in as cons and I don’t know necessarily if I would put that in as a con. No sense of practice ownership. Well as more models are coming out in group dentistry and in group practice, believe me, there are a lot of opportunities to own. Whether you own on the DSO level, whether you own on the individual office level, there are ample opportunities to own. So again, one of the group practice I would say is a con is if you have a burning desire to be an entrepreneur, you have a burning desire to want to deal with the business. You have a burning desire to build something greater. Yes, that is something that you should do on your own. That is something that you can be successful at.

That as something that probably joining a group practice wouldn’t be your desire. As we move forward, why our model works? I think like us and in a lot of group practices I would probably say a majority of practices have this type of model where our model of bringing the best aspects of a solo practitioner and the best aspects of group practice and blend them together to create to give ownership, to be able to give autonomy, to create lower overhead, to be able to mentor doctors, to be able to take all these things, IT, HR, marketing, insurance issues, accounting and take all these business aspects that were not great at and get support of those things. To take CE to another level, to be able to take what we would have to as a solo practitioner to go out and take time off of work and spend a lot of money and maybe take back 10% of what we’re learning.

To be able to take that to another level and to be able to engross ourselves in a continuing education program or a continuing education track that creates us better clinicians. And these are things that are just great. It’d be the ability to give back to the community, the ability to be able to become a community dental practice. We said that was a positive in solo practice. Listen, I think that as groups grow, we are creating individual great community organizations within, there is no question that groups can do that. There’s no questions that groups are giving back to the community. They are creating great job increases within the community. These are things that groups are doing. And that can still be a huge positive. And again, when we were talking about ownership a lot of docs want ownership. There are ample opportunities for ownership within group.

The clinical autonomy. So this is probably one of the biggest topics that come up within group practice. And my group is telling me what to do clinically and I’ve heard that that’s what groups do. Here is the reality. The reality is that DSO are there to support the business. The other reality is that we’re able to help clinically dentist become greater clinicians. This is the reality. And when somebody says to me, well, I don’t know if that’s good. What do you mean by help? And how much do you insert yourself? I think when I look at clinical autonomy, the role of a DSO is to encourage and support excellent clinical care, not to tell doctors how to treat. So that’s a key sentence right there. We do not tell doctors what they should and should not do to treat an individual, but we are going to support them in excellent clinical care and standard of care.

We want to make sure that our patients are getting better dentistry than what they did before. We are here to make dentistry better. And when I say dentistry, I mean clinical dentistry. We are here to make that better. If we are coming in as a group and all we’re doing is saying, we did a great job of making their business better? I don’t know necessarily if we have moved dentistry in the right direction. We can honestly say that medicine is a better business, I’m sure is a better business. There are large groups that are making a lot of money in medicine and I’m sure it’s a better business, but on the other hand, the clinical aspect of medicine has decreased. And I think that is something that we can never see happen in dentistry. So providing that support to create an environment for excellent clinical care is necessary.

And so when I’m looking at this and say, well what does that mean? And what that means is that supporting excellent clinical care is going to be continuing education, study clubs and mentoring technology. Great clinical products. I mean we have an individual doc in our group, our small little group that looks at every single product that any doctor wants us to look at. And what we’re going to do is we’re going to vet those products and we’re going to make sure those products are what they say they are. Lab partnerships, making sure that the quality control in a lab partnership. So we don’t have what happens in private practice when all of a sudden you get a run of six or seven crowns that don’t fit. Why is that happening? What happened? We want to provide that type of support, a clinical metrics, making sure that what we’re doing clinically works.

One of the scariest things that everybody always asks me is that, well what does that mean by supporting clinical care? In private practice we don’t have somebody breathing down their neck. So we don’t have big brother looking at us. Well, if you’re going to look at it as big brother, then yes we have an issue. But if you’re looking at it as somebody trying to help support you to be the best possible, that’s great. The scary aspect that I see and we look at about 20 to 30 dental practices per month to join our group. If I’m looking at those dental practices, the scary part is the type of dentistry that is going on in those practices because nobody is supporting them. Nobody is looking at the standard of care in those offices. So when you look at periodontal disease in the rapid periodontal disease that’s occurring in some of these practices, when you’re looking at the gross negligence of how crowns are fitting and the gross negligence of bonding and with the specific techniques that occur in bonding that just aren’t being done.

We’re talking about supporting those aspects to make sure that patients are getting the best care possible. Again, we are in a different state of health care. It is no more four walls. Even if I owned my own private practice, if I decided to treat my patients just by my four walls and what I just think that is the wrong way of standard of care today in healthcare, we have to make sure that we are going out there and learning the best techniques. We have to make sure that we’re learning the best products that we can provide our patients. These are important aspects on a solo practitioner. In a group practice, we have to run by that same standard of care. We have to make sure that we are continuing to advance in technology. Continuing to get the best products to our patients, continuing to get the best fitting restorations.

These are things that we need to do. And how do you make sure that that happens? You’ve got to measure it. You have to measure those to make sure that you are continuing to move the ball forward or else, again, we’re not bettering the clinical aspect, which is the most important aspect of dentistry. Auditing, so we look at a lot of new docs that are coming into dentistry. We want to make sure that they are improving their skills. They’re going from a dental school environment right into private practice. And we want to make sure that we are taking that transition into practice to make sure that they are doing that well. Meaning that they’re not sitting there actually practicing on patients, that they’re giving patients a great product right away and making sure that we audit that and making sure that we have peers that are helping mentor them is super important when we’re supporting the clinical aspect.

So when we’re looking at DSOs and when we’re looking at the difference between solo in group, solo is great. I love private practice. I loved the private practice when I was in there. What we need to do is we need to think differently. We have to look at the world of dentistry and make sure that we are bettering dentistry after we are done. When I am done serving my patients, I want to make sure that when I retire as a dentist that I’m leaving behind a world of dentistry that is better than when I started. Not the same, not equal, better. And if we do not continue to advance ourselves and think of things differently, if we continue to let negative influences come upon us in dentistry, then yes, we are going to be less of a profession. But if we take those negative influences and as a group we decide how do we beat those negative influences? How do we not let them be negative? How do we just let them be something that’s coming about to us? How do we better the process? How do we better the efficiency?

Those things we can do as a group. And that’s where group practice is really going to make our profession better. So I appreciate you guys listening to me. I appreciate, hopefully you learned a little bit of something. If you have any questions, I am always this my email, please email me. I love to talk with dentists about the future of dentistry and how we’re going to improve our profession. So I appreciate it and thank you very much.

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