Q: How can Dental Service Organizations position themselves to better serve the expanding aging population?
James Bramson, DDS; Doug Brown, BS, MBA; Mary Lee Conicella, DMD; Lisa A Stepanian; and Stephen Thorne IV, BA, MHA
Dr. Bramson
Since the “Great Recession” of 2008-2009 the volume of dental services has been significantly impacted. Dental incomes, while dropping during the recession, have been steady now for several years, and the industry is predicted to have modest growth in the foreseeable future.1
One area of dental care delivery that has good growth potential is within the senior population and their expanding dental needs. Demographically, as baby boomers age, there simply are more elderly in America. By 2050, the population aged 65 and over is projected to almost double that of 2012. Baby boomers are largely responsible for this increase, as they began turning 65 in 2011.2
People are living longer, too; one could argue perhaps that 70 is the new 50. Edentulism continues to decrease3 and many seniors are taking fuller dentitions into their later years. Dental service organizations (DSOs) can be a significant resource for serving this growing population for a number of reasons.
Size and pricing—DSOs, including the largest dental firms (ie, 500 or more employees), are growing rapidly in terms of the number of dental establishments owned and/or managed.4 Personal industry sources estimate that about 12% to 15% of the entire dental market is now delivered by large DSOs. DSOs are typically quite strategic in their growth, market positioning, and operational systems beyond what is typically seen in traditional solo or small group dental practices. The sheer distribution and size of some large DSOs could easily lend them to target certain communities or areas that have large elderly populations and uniquely niche their offices in those areas. Also, because of their purchasing power, DSOs often have a greater economy of scale when negotiating for supplies, equipment, and other business overhead expenses. This affords them to be more aggressive with treatment pricing and financing, which for a senior population on a fixed income may be attractive.
Efficiency of operations—Recent American Dental Association studies showed that the percentage of dentists with a perceived workload of “not busy enough” was at about 27% for all dentists.5 A targeted elderly population could help increase the demand for care and conceivably fill some of that empty chair time. Special staffing, equipment, or transportation services for seniors could be more efficiently used and patient flow directed to certain facilities where that special staffing or equipment is located. Seniors could conceivably provide the mid-day scheduling volume that many practices struggle to fill. Also, DSOs, which are usually adept at marketing and optimizing chair time through the full use of ancillary staff, could focus on outreach programs to nursing homes and other senior facilities.
Training—Most DSOs have significant internal continuing education and professional growth training opportunities for their staff and could easily partner with dental schools that have an expanded geriatric dental curriculum. Training the staff to treat a growing elderly clientele would enable employees to gain a more thorough understanding of the overall dental needs of these patients, which in turn would allow the DSO to provide a more targeted service to them. Furthermore, with the growing emphasis on medical–dental integration, chronic disease management, and understanding multiple drug interactions, DSOs could concentrate their treatment expertise within their overall expertise, business strategy, and office operations.
Convenience—Consumer concerns about receiving care from large healthcare retail settings, such as a Walgreens or CVS, appear to be waning. Patients, including seniors, seem to like the transparency and convenience of these retail operations,6 and a DSO large group model fits within this overall changing philosophy.
In conclusion, the delivery of dental healthcare continues to evolve and DSOs appear to be positioned to capture much of the growth that is expected to occur. Aging baby boomers and the senior population will have significant ongoing dental needs and are likely to be a strategic business target for large DSOs.
Mr. Brown
Edentulism rates in the United States are eye-opening, with estimates suggesting that about 178 million Americans are missing at least one tooth, and 35 million of those are completely edentulous in one or both arches.7,8 Understandably, Americans in their 50s, 60s, and beyond represent a disproportionate slice of this group. This patient demographic is accelerating in growth as baby boomers age, exit the workplace, and make appropriate lifestyle changes. Moreover, it presents unique clinical and nonclinical challenges that many dentists feel underequipped to address.
The expansion of affiliates of provider networks of denture and implant services, such as Affordable Dentures & Implants®, into new markets across the United States reflects an opportunity for the dental profession to more fully embrace this expanding population. By delivering a narrow range of tooth replacement services at a national scale, affiliates of large provider networks concentrating on denture and implant services are able to provide high levels of experience and convenience while passing along critical cost savings.
The author’s provider network sought to develop a practice model that addresses this unmet need. Crucial to the success of this model are strategies like a one-to-one practice ownership structure, where a clinician owns and operates 100% of his or her practice. As a result, turnover is low, and experience in extraction, implant surgery, and removable prosthodontics deepens over time. Additionally, every network practice location in this model features an on-site laboratory, where dedicated lab technicians work in tandem with “front of house” clinicians and staff to enable same-day service. This allows older patients, including those with job demands or who are living on a limited income, to benefit from only having to take one or maybe two days off from work. Because denture patients often have to travel significant distances to reach a tooth replacement practice that is not cost-prohibitive, this same-day service can be invaluable.
By limiting their service offerings to extractions, dentures, and sometimes implants, affiliates within the network do not have to staff or absorb costs related to services like hygiene or restorative care. This helps keeps overhead low and also allows fees to be kept low. Older patients often present unique financial and insurance situations that too often prevent them from accepting treatment. Network affiliates, however, typically are able to set fees at or below insurance co-pays and can offer special financing to their patients that facilitates in-demand solutions like implant-supported mandibular overdentures.
Opportunities continue to exist for dental professionals to improve access to unmet needs for senior citizens. One such opportunity is through training and thereby creating more prospects for dental students and emerging professionals to develop clinical skills in implant treatments. Dental support organizations also present a broader opportunity to allow the next generation of dentists to enjoy practice ownership without taking on large amounts of debt. Affiliated practices do not have to front significant business costs themselves, but instead can rely upon service agreements with the dental support organization for nonclinical management services like real estate, marketing, information technology, and staffing.
Dr. Conicella and Ms. Stepanian
Currently, an estimated 50 million Americans are aged 65 or older. This age group is expected to increase to more than 98 million by 2060.9 In 1960 when nearly half of older Americans were edentulous, those affected rarely sought dental care unless they had oral pain or a concerning oral lesion. Now that their rate of edentulism has declined to about 17%,10 it is more common for an older adult to seek regular dental care. Despite declining edentulism, one-third of this group has untreated dental caries,10 and about two-thirds have periodontal disease.11
Treating an older adult may be challenging due to the presence of chronic diseases such as diabetes, musculoskeletal problems, and cardiovascular diseases as well as the side effects of the medications used to treat these conditions. To provide appropriate care for these individuals dental professionals must understand their unique needs. Further complicating the situation: most dental expenses incurred are paid out-of-pocket because about 70% of this age group are not covered by dental insurance.12
DSOs have many attributes that make them a good choice for seniors seeking dental care. To provide better oral health outcomes for the over-65 patient, the dentist must assess the patient’s overall medical and dental history and consult with his or her healthcare team (ie, physicians, nurses, therapists, and caregivers) to develop an appropriate treatment plan. Ongoing analysis of data from Aetna from 2006 to the present shows that members (including those over age 65) have lower medical costs, fewer inpatient admissions, and better lab results for metabolic and inflammatory markers when they have regular dental care.13 Most DSOs have established wellness protocols that can specifically address the needs of their aging patients. These include: performing screening tests for HbA1c, cholesterol, and C-reactive protein; counseling patients on tobacco cessation; or an interprofessional approach that offers primary care and oral health services in the same location with the goal of improved health outcomes and a more holistic patient experience.14
Accessing care also may be a challenge for the aging population. DSOs can address this issue as they grow through the acquisition of solo and group practices, thereby increasing the number of locations where care can be accessed. Many DSOs open new dental centers frequently, further increasing access and making accessibility to care more convenient. With a growing number of aging Americans relying on their adult children for assistance, many DSOs have responded by offering evening and weekend hours to be more accommodating. Some DSOs also offer transportation to assist aging patients in getting to their appointments.
Care for special needs is also enhanced in the DSO environment. Many such organizations offer free training for dentists who treat patients who are medically compromised or who require oral sedation due to conditions such as Parkinson’s disease. DSO advantages are not limited to the operatory, as these groups can leverage centralized administrative support to comply with government regulations, including the Americans with Disabilities Act. This allows DSO offices to consistently offer handicapped parking spaces and entryways, which is another illustration of how DSOs are especially suitable for the senior population.
Mr. Thorne
DSOs are uniquely positioned to serve the population of seniors aged 65 years and older. The most common barriers to these individuals seeking dental care are: (1) cost, (2) poor customer service or experience, and (3) accessibility and availability of services.15 Though unsupported solo private practice has in some markets adequately met the needs of senior Americans, there are still significant gaps to fill. DSO platforms may be leveraged to address many of the barriers these populations face.
Cost of treatment—With many senior adults living on fixed or limited incomes, they often do not seek dental treatment due to the cost of care. The DSO business systems and economies of scale create efficiencies that result in better access to care at lower costs. Because many seniors are retired, they have limited access to dental insurance subsidies. Many DSO-supported practices offer in-house payment plans that allow seniors to finance dental treatment over time, which is important because access to dental insurance in the United States is still heavily tied to employment.
Customer service—DSOs partner with clinicians to provide business support services. These services free up time for clinicians to spend building relationships and championing exceptional experiences for patients. This time is critical for uninsured seniors, as many of them only come to the dental office for emergency visits.16 This extra available time can help create an opportunity to connect with the patient, which is often the catalyst that converts an episodic patient to a lifetime one.
Accessibility and availability—Many DSOs typically invest in high-traffic and convenient real estate. DSO-supported practices often have more than one provider at each facility, which enhances the likelihood of expanded hours in early mornings, evenings, and weekends. The location accessibility coupled with greater availability through expanded hours facilitates improved accommodation of patients of all ages. For senior patients who reside in nursing homes and assisted-living facilities and are dependent on restricted transportation schedules, expanded hours may make the difference between being seen by a provider and not being seen.
Dental business support organizations, such as Pacific Dental Services®, are positioned to help seniors in a variety of ways. A DSO-supported practice is likely to offer modern technology to help make dentistry more accessible. PDS-supported practices, for example, offer same-day CAD/CAM dentistry that eliminates unnecessary trips to the dentist, a crucial benefit for seniors. These practices also offer “under one roof” general dentistry with integrated specialty services. This enables patients to avoid traveling to other facilities to get their specialty work completed.
Serving the underserved also needs to be part of the culture when treating the senior population. This culture when combined with large-scale capabilities allows a DSO-supported practice to better serve special-needs populations. PDS, for example, has used mobile dental outreach programs to provide donated dentistry to underserved populations, including seniors. The DSO platform builds clinics dedicated to serving special-needs populations and offers training to help teach and develop dentists how to better treat their patients at little to no cost.
In addition to business support services, DSOs like PDS are also committed to innovation. Most solo practitioners are tied to their own day-to-day operations and often find it difficult to see past the current month or quarter. DSOs are able to gaze ahead and look for ways to improve the practice of dentistry and challenge the status quo. Some areas in which a DSO can offer innovative assistance are the oral-systemic link, integrated interprofessional practice, management software, dental insurance, patient financing, and dentist education. These organizations can also innovate alongside dental foundations and medical associations to support Medicare coverage for medically necessary dental therapies.
In a healthcare system that covers treatment of all medical infections except for those in the teeth and periodontium, the pendulum is overdue to swing back toward consistency and patient-centric models. All of these areas have major implications for how senior patients will access, receive, pay for, and value their dental care in the future.
When done right, DSOs provide a platform that serves clinicians. These clinicians are, in turn, empowered to make dentistry more affordable, accessible, and comfortable for patients of all ages, including seniors. This results in healthier, happier patients. When we reduce barriers for senior adults, better health outcomes should follow.
About The Authors
James Bramson, DDS
Chief Dental Officer
United Concordia Companies, Inc.
Doug Brown, BS, MBA
President and Chief Executive Officer
Affordable Care
Mary Lee Conicella, DMD
Chief Dental Officer
Aetna, Inc.
Lisa A. Stepanian
Executive Director
Dental Network Management
Aetna, Inc.
Stephen Thorne IV, BA, MHA
Founder, President, and Chief Executive Officer
Pacific Dental Services
References
1. ADA Health Policy Resources Center. A Profession in Transition: Key Forces Reshaping the Dental Landscape. American Dental Association. 2013. http://www.ada.org/~/media/ADA/Member%20Center/FIles/Escan2013_ADA_Full.ashx. 2013. Accessed August 25, 2017.
2. Ortman JM, Velkoff VA, Hogan, H. An Aging Nation: The Older Population in the United States. US Census Bureau. P25-1140. 2014:1-28. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed August 25, 2017.
3. Slade GD, Akinkugbe AA, Sanders AE. Projections of U.S. edentulism prevalence following 5 decades of decline. J Dent Res. 2014;93(10):959-965.
4. Wall T, Guay A. Very Large Dental Practices Seeing Significant Growth in Market Share. Health Policy Institute Research Brief. American Dental Association. August 2015. http://www.ada.org/sections/professionalResources/pdfs/HPIBrief_0815_2.pdf. Accessed August 25, 2017.
5. Munson B, Vujicic M. Dentist Earnings Were Stable in 2015. Health Policy Institute Research Brief. American Dental Association. December 2016. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1216_1.pdf?la=en. Accessed August 25, 2017.
6. Sarasohn-Kahn J. Retail health landscape expanding through clinic growth, Accenture forecasts. Health Populi website. 2015. http://www.healthpopuli.com/2015/11/18/retail-health-landscape-expanding-through-clinic-growth-accenture-forecasts/. Accessed August 25, 2017.
7. American College of Prosthodontists. Talking Points – Missing Teeth. 2015. https://www.prosthodontics.org/assets/1/7/ACP_Talking_points_for_Missing_Teeth_1-12-15.pdf. Accessed August 25, 2017.
8. American Academy of Family Physicians. Oral Health – Dentures and Dental Implants. AAFP website. 2015.http://www.aafp.org/test/fpcomp/FP-E_428/pt4.html. Accessed August 25, 2017.
9. Mather M, Jacobson LA, Pollard KM. Aging in the United States. Population Bulletin. 2015;70(2):1-19.
10. National Center for Health Statistics. New Series of Reports to Monitor Health of Older Americans. Centers for Disease Control and Prevention website. Page updated 2010. https://www.cdc.gov/nchs/pressroom/01facts/olderame.htm. Accessed August 25, 2017.
11. Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
12. Raphael C. Oral health and aging. Am J Public Health. 2017;107(S1):S44-S45.
13. Ongoing nonpublished statistically valid analysis of Aetna members. Aetna Informatics, 2006–2017.
14. Guyton B, LeBeau J, Sorci R, Doneen A. Commentary on an innovative interprofessional dental practice for 2026. J Evid Based Dent Pract. 2016;16(suppl):11-19.
15. Borreani E, Wright D, Scambler S, Gallagher E. Minimising barriers to dental care in older people. BMC Oral Health. 2008;8:7.
16. Razak PA, Richard KM, Thankachan RP, et al. Geriatric oral health: a review article. J Int Oral Health. 2014;6(6):110-116.
