My Life in Corporate Dental

Corporate dental mushroomed in the late 1990’s, as equity investors poured hot money into creating today’s major dental chains; among the biggest– Aspen, Coast, Christie, Heartland, and Kool Smiles.
None of these equity investor/owners, have a doctorate in dental medicine or surgery.

Before this phenomenon, the law was very clear– one had to be a licensed dentist to own a dental practice.
This allowed dental licensing boards to discipline against malpractice.
Equity investors never get sued for malpractice, even though they are directly responsible for much of it in these corporate dental offices. [1]  [1a]

How is a corporate dental chain allowed to legally operate without a dentist owner?

Aspen Dental, is actually called Aspen Dental Management, Inc (ADMI).
Whenever pressed legally or in an interview, ADMI claims they simply manage the offices for the dentists, so doctors can concentrate on treating  patients instead of running a practice. [2]  All of corporate dental is based on the ridiculous premise that running an office can be separated from the dentistry.  Of course it’s money, not arguments that rule the day.

Aspen Propaganda

My alter ego worked for nearly a year at Aspen Dental, and became intimately familiar with how they operate.  I was employed through a temporary agency, which kept me from being locked into a contractual obligation with Aspen, allowing flexibility in dealing with their corporate nonsense.  In my time with them, I would regularly have to stop working for them when frustration set in, take a few weeks off (or work somewhere else), then go in again for awhile.  I needed the work, and it turned out to be quite an experience.

In the end, all these corporate dental chains are the same, a hopeless proposition for the dentist, as a large part of what they are doing is designed to crush the doctor’s spirit.

For instance, in most Aspen Dental locations, there is no private office for the doctor.  This is exceptional in the field of dentistry, and by design– to diminish the importance of the doctor in front of patients, staff, and management.

ALL doctors needs a private office to isolate themselves from distractions, in order to think clearly when making patient notes, considering treatment options, prescribing medications, etc… Aspen Dental considers this to be of secondary importance.

The office manager (OM) runs the office, and typically has no dental experience, but instead a strong background in sales.  They get a private office, which is used for the all-important closing-of-the-deal with new patients.  It’s hard-sell tactics at the top-producing offices, with a huge push towards third-party financing, such as CareCredit.

Getting paid upfront by a third-party is a vital part of their profitability.  Whenever possible, the whole treatment plan is charged out immediately after the OM closes on a patient.  Sometimes the work is never done, and reimbursements to the patient have to go through a lengthy corporate review in New York.  Other patients never get their money back, or end up with unpayable/oppressive debt.  All these dental credit cards have exorbitant interest rates, which can be applied retroactively if a payment is missed.  Many patients are very confused, by the time they are through with the office manager at Aspen Dental.

Problems occur in medicine & dentistry (which are the same thing), when doctors have little/no control over the schedule, and are forced to wear roller-skates to meet corporate-imposed production goals.  All these chains target low-income communities, where dentists have to work harder, for lower reimbursement under the insurance plans they accept.  This unquestionably causes malpractice dentistry to occur at a much higher rate. [2]
No doctor welcomes an increased risk of losing their license, but often ADMI compels its dentists into negligence, just to make production goals; under the implied threat of being fired.

My professional experiences with ADMI included one particularly unscrupulous office manager, whom I caught changing a treatment plan of mine– to include more extractions.  The changes had been written in (unbeknownst to me), on my treatment plan with my signature at the bottom.  Any auditor looking at the chart (always paper) would have thought those were my treatment recommendations.  After calling the OM out on this, I was blown off, then fired from the assignment at the end of the next day.  Happens all the time in corporate.

Aspen Dental- Immediate Denture Case

Human Dentition

The radiographs above are a rubber-meets-the-road example of the ethical dilemma dentists are constantly being placed in at Aspen Dental.  This patient (40 Yrs/W/M) has oral hygiene & decay issues, with fairly healthy bone– despite the early periodontal disease.  The first time I saw him (and the x-rays), he was scheduled for full extractions upper & lower, with immediate dentures already made.  That’s a lot of production.

On the maxillary (top) arch, teeth #4 and #6-11 were healthy– some needed small fillings. Tooth # 13 needed a buildup & crown. The patient didn’t want any root canals, so the rest needed to be extracted.  The top teeth were his priority.

All the remaining mandibular (lower) teeth (except decayed root tips– #21 & 29) were easily salvageable with root planing, and good oral hygiene follow-up.  The critical canine tooth #22, needed an easy root canal, then a crown.  Patients change their minds on routine procedures like root canals, when doctors earn their trust.

The patient could then be fitted for partial dentures in both arches, which is always better than full dentures– if they are motivated.  The patient expressed his desire to keep as many teeth as he could, considering his limited financial resources.  A new treatment plan was made up for fillings, extractions & partial dentures, which cost the patient about the same as extractions & immediate dentures.

The patient left the office very discouraged and confused.  This updated treatment plan was much better for the patient, but required much more work by the dentist & staff– for the same or less money.  I wasn’t part of that conversation.  A few weeks later when I returned to the office, I was told by a staff member that this patient had all his teeth removed & immediate dentures.

This is a typical schedule at Aspen Dental:

Aspen Days

This was my first day at this location, which is why the names of the staff are handwritten at the bottom.  Each white-out represents a patient.   There are three columns, the left is “Production”, the middle is “New Patient (NP) Exams”, and the right is “Overflow.”

“Production” means fillings, extractions, and crown & bridge; which make the money.  Aspen Dental advertises free exams & x-rays for all new patients, so the NP column is always full.  The free new patient exam is the hook that brings in new production. Aspen will charge the patient’s insurance for the NP exam & x-rays, if allowed.

“Overflow” is anything to do with dentures, partials, post-op exams, adjustments, impressions, relines, bite registrations, or any other general complaint.  Since Aspen specializes in dentures (60% of their income), this column overflows fast and hits hard.  Dentists are expected to see 30-40 patients/day, as a minimum, which is probably what I saw on that day.

To their credit, this was one of the better Aspen Dental offices I worked in, largely due to the above-average staff.  The problem comes with employee turnover, which is constant. I worked in this office for the better part of two months, and two of their employees were already gone by the time I left.  They both took better jobs in private practice.  Aspen Dental has Tuesday hours of 11 AM – 8 PM (shown above), which is universally reviled among its workers.

Here is an example of their metrics report card, which everyone (from receptionist to dentist to regional/territorial manager) looks at daily:

Aspen Report Card

The most important line to corporate is the top one: Avg of Monthly Revenue & Deposit.  This office (Gainesville) is at >110% of the target goal, so they get an “A+” in this column, which counts 30% of the total grade. No other metric counts more than 10%.

Notice how some metrics are so far off the scale as to be meaningless. For instance, look at the 90-Day Online Review Ratings.  A “B” rating for Aspen is an average ranging from 4.50-4.59, with anything lower than that being a “C”.   Their average online rating is 2.0.  Incidentally, this office was on pace to receive a $100 bonus/employee at the end of the month, with a composite “B” grade.

Here’s what their report card looked like, after I was in St. Augustine for a few weeks:

Aspen St. Augustine-- Report Card

The staff each earned a $200 bonus that month.

Incidentally, this Aspen location used a rotation of temporary dentists for over six months, up until the time I left the company.  Aspen Dental simply can’t sign up enough of their own dentists to permanently fill their vacancies– because of their reputation.

Temp doctors are not paid bonuses, and are always employed though a middleman agency, which keeps a healthy percentage for itself.   It’s all kept very secretive.  Today, the fill-in dentist pay-rate for Aspen Dental is $600/day, plus hotel and long-distance mileage expenses.

Aspen Dental--Words to live by

Aspen’s regional & territorial managers will visit every office biweekly, or so.  Their function is to hammer home Aspen Dental propaganda, while deflecting any serious employee complaints or issues.  Their favorite slogan seems to be:  “There’s no ‘I’ in Aspen.”

My favorite Aspen Dental slogan? —  “As dental professionals, the last thing we want to do is sugarcoat anything.”

As stated earlier, management is strictly sales, there is virtually no dental experience at the upper levels.  Upon their arrival (which seems to always be preceded with great fanfare), regional managers take over an office of their choice, close the doors; and what’s next is anyone’s guess?  It certainly has little to do with communication, or helping the doctor and the staff.

Necessary equipment & supplies are often of poor quality, and in shortage.  Basic tools such as an electrosurgery unit or laser, are not available.   Of course, this should be expected in an company that employs so little dental knowledge & experience.

Bob Fontana-- ADMI CEO

Corporate dentistry has circumvented long-established legal requirements, with a few shell ‘dentist owners’ wherever needed, along with an effective propaganda campaign which has largely confused dentists & the consumer public.
Most working dentists don’t really understand how corporate dental operates.

The American Dental Association (ADA), misrepresents over 200,000 US dentists (and their $100 million in annual dues), by throwing poison into its constituents eyes; publishing puff-piece features & interviews which promote a model that clearly fails to meet the professional standard-of care– in ethics, practice, and legality.
Its monthly organ, the ADA News regularly runs corporate dental advertising, promising great careers with great pay; when they well-know precisely the opposite is true.
The ADA headquarters in Chicago, is a bastion of graft and backroom dealing; with insurance giants, equipment suppliers, management companies, etc…all in on the action.

ADA & Aspen Dental

The dirty secret is: the ADA is partnered with these equity investors and corporate giants, at the expense of their dues-paying members– wet-gloved dentists.
Colleagues who are ADA diehards, constantly claim that dentists need to join & pay up for their “advocacy.”
Whenever someone asks, “What is the exact position the ADA is advocating?”, their response becomes vague assertions and dull platitudes.

What has happened in dentistry is a microcosm of the modern capitalist economy in its death throes, largely characterized by its brazen lawlessness & parasitic nature.  A relatively handful of people, who have nothing to do with creating quality dentistry, are siphoning money from dentists, staff members, and patients.  The workers work harder for less, and the patients pay more– all to enrich the few who do nothing helpful.  Meaningful change only happens when the people on the short end realize they deserve better.