Can corporate financial goals be aligned with healthcare goals when a corporation owns a dental practice? A corporation, be it dental or otherwise, exists to make money—as much as possible—whether for shareholders or individuals. A dental practice, however, exists to provide the best evidence-based healthcare services to patients, and making money is a tangential benefit—albeit an important one. Making as much money as possible should never become the primary goal of a dental practice, or a dental student, as it is for a corporation. As one of my mentors once said, “Give the best care you can to each and every patient, and the money will take care of itself.”
How, then, does a dental corporation function? Can corporations be entrusted to hire dentists and manage dental practices?
A recently released “Joint Staff Report on the Corporate Practice of Dentistry in the Medicaid Program,” prepared jointly by the Senate Committees on Finance and on the Judiciary, raises significant questions about whether one can trust a corporation to run a dental practice.¹ The report describes investigative work done regarding the corporate practice of dentistry as it relates to the Medicaid program. Specifically, one company, Small Smiles, was investigated as a result of whistle-blower complaints. The 1,513-page report should be required reading for every student and practitioner of dentistry.
There are numerous video clips online on YouTube documenting the investigation of Small Smiles by Investigative Reporter Roberta Baskin of WJLA TV in Washington, DC, over the past 5 years. The videos make shocking viewing, exposing the inherent conflict of interest when a corporation makes healthcare decisions. How is a corporation, with the goal of maximum profit, able to ethically assess and make healthcare decisions and then convince dentists (trained otherwise, one would hope) to carry out assembly-line, and unnecessary, dentistry? The Senate Report notes that Small Smiles, and some other clinics, answered that question by encouraging maximum billing to Medicaid by setting up productivity competitions, abusing children through unnecessary and hurried treatment, in some cases causing serious trauma to young patients—essentially placing corporate profits ahead of patient care.
While two out of three (some surveys say as many as three out of four) dentists in private practice refuse to treat patients on Medicaid due to “inadequate reimbursement,” “broken appointments,” or “unappreciative patients,”² Small Smiles targeted this population group in their business plan. How is it that a corporation could choose such a population, Medicaid patients, as a good business model if the reimbursement was inadequate and the patients are as described by some dentists who refuse to treat them? The answer, of course, is volume—get as many patients in for as much treatment in as short a time as possible, and ergo, the money, taxpayer money targeted to help the less fortunate, rolls in.
How any dentist can work in such an environment is beyond my comprehension. But when you add to the business-required, assembly-line dentistry, the unethical, savage (the best word to describe some of the treatments seen on YouTube), unnecessary treatment—such as papoose boarding children for up to 1 hour 45 minutes—then we have a complete and total breakdown of the ethical and moral values of all concerned.
While corporations are responsible for business practices, it is the dentists hired by the corporations, often called “owner dentists,” who carry them out. Of course, in today’s world of dental graduates leaving school with vast debt loads—over $400,000 is not uncommon, with some in excess of $500,000—there are many young dentists for whom making as much money as possible is their necessary and primary goal. The future ethical standards of our profession are not helped by dental schools (at least one of which I am aware) that encourage competition among clinic units with a bonus system and rewards of higher grades and time off for the highest dollar productivity. This system of rewards for productivity is a chilling encouragement to students for unethical practice in dental corporations in years to come.
The Senate Report concluded with some excellent recommendations:
Small Smiles clinics, and any other corporate entity that employs a fundamentally deceptive business model resulting in a sustained pattern of substandard care” should be excluded from participation in the Medicaid program.
States should enforce existing laws against the corporate practice of dentistry and, where appropriate, take enforcement action against those that violate the law.
Let us hope that the recommendations are followed and that any corporation or colleague putting profits before patient care takes heed. And I would hope that no dental school would ever encourage high productivity of patient care over the quality of that care, and the time required for preventive and minimally invasive care.
1. Joint Staff Report on the Corporate Practice of Dentistry in the Medicaid Program. Washington, DC: US Government Printing Office, 2013.
2. The Wealthy Dentist. https://thewealthydentist. com/surveyresults/084-dental-medicaidpatients.htm [Accessed August 30, 2013].