As Dentistry Changes, Practitioners Must Adapt

It’s not the old-school way of doing dentistry.

At the Roseville and Lincoln offices he oversees, dentist Tim Herman has seven dentists, with different expertise in dentures, crowns, extractions or root canals. On weekdays, they start seeing patients as early as 7 a.m., and stay open as late as 7 p.m.

In May, the group added Saturday hours, handling emergencies and routine appointments for six hours straight. In addition, they’ve got an orthodontist for braces and a periodontist for gum treatments and tooth implants, both of whom work as independent contractors.

For Herman, who’s been practicing since 1989, it’s all about adapting to what patients want.

“One of our biggest challenges: People truly don’t want to go to the dentist. So we’re in competition for their discretionary dollar,” said Herman, 52, head of A+ Personalized Dental Care. “I have patients come in and say, ‘Oh that (treatment) is so expensive,’ but they’ve just spent $200 on [unnecessary expenditures] in Reno. … It’s a reality we all live with.”

Like Herman, America’s dentists are stuck with a major, nagging toothache: Not enough people are going to the dentist, and those who do don’t spend much.

And it’s been true for the last decade, well before the last recession, says the American Dental Association, which calls the current environment a “watershed moment” for dentistry.

Only 61.6 percent of adults, ages 18 to 64, said they saw a dentist in 2011, according to the most recent data by the National Center for Health Statistics. That’s a drop of nearly 4 percent from 1997.

Likewise, per-patient expenditures on dental care in recent years have largely flat-lined for children and working-age adults. And the outlook is bleak, ranging from 0.22 percent to 1.25 percent annual increases in per-patient spending over the next decade, according to the ADA. That compares with almost 3.9 percent a year between 1996 and 2002.

Further, the ADA noted, two out of five American dentists say “they are not busy enough and can see more patients,” a significant increase over prior years. Overall, the “near-stagnant growth seen in the last few years may be the ‘new normal,’ ” the ADA said in a recent report, “A Profession in Transition.”

A combination of factors are reshaping the dentistry mold. Dental benefits by employers are eroding. Reimbursement rates by insurers are stagnant. Some patients are postponing – or giving up – their routine dental care.

“Dentistry becomes the easy part … the hard part is managing the business,” said JoAnne Tanner, a Northern California dental management consultant based in Granite Bay.

For many, it’s about scrambling to figure out a new future. For some, like Herman, that means staggered scheduling and Saturday office hours in order to accommodate working adults, the folks most likely to have dental insurance. Or bringing in specialists as independent contractors, so that fewer patients have to be referred elsewhere for treatments.

“Dentists who are still only open 8 to 5, Monday through Thursday, are struggling,” said Tanner, a former U.S. Navy hygienist and business school graduate who’s done dental consulting for 20 years. “Patients don’t want to take time off from work to get a routine cleaning. They want to come in before or after work.”

Nor are dentists getting any pain relief from the new Affordable Care Act. Dental care isn’t among the “essential” health care benefits to which all American adults are now entitled.

Although tooth care for children is a mandatory benefit, the low reimbursement rates are not expected to add much to regular dentists’ bottom lines.

Like all health-care providers, dentists are being pressured to bite down on costs, not only by insurers but by government, employers and consumers.

“It’s more and more expensive to operate a dental practice. It’s increasingly difficult for the fees to sustain a practice,” said Dr. Lindsey Robinson, president of the California Dental Association.

The CDA is currently in binding arbitration with Delta Dental, the state’s biggest provider of dental care benefits, over Delta’s plans to reduce its reimbursement rates for next year. According to the CDA, the exact rates have not been disclosed but are expected to be 8 percent to 12 percent lower.

Also, while the state is reintroducing its Denti-Cal coverage for lower-income adults next year, the reimbursement rates for dentists will be 10 percent lower than in 2009, when the program was dropped. For a routine cleaning, reimbursement will be about a quarter to a third less than what a dentist might charge in private practice, said CDA’s Robinson. “Finding dentists willing to take the program will be challenging,” she said.

Some say the industry’s pain is causing dentists to push more aggressive treatments or expensive hardware. As health care shifts more responsibility onto consumers, the ADA believes more dental patients will become more cost-conscious, especially tech-savvy consumers who are accustomed to comparing prices online. It advises dentists to be proactive by posting more information online about dental treatments and prices.

“It’s more difficult to make a (dental) business work. That’s going to shape diagnostic opinions to varying degrees,” said Ken Hajek, who gave up traditional dentistry in 2011 to open a “second opinion” dental office in Carmichael.

At Straight Talk Dental, he sees patients who’ve been recommended $3,000-and-up gum cleanings that he feels weren’t warranted.

One of Hajek’s clients, El Dorado Hills resident George Anthes, said that three years ago, his dentist recommended about $1,900 worth of dental work: fillings for two new cavities, replacement of several old fillings and, most worrisome, a “deep pocket” cleaning treatment to prevent gum disease. Alarmed by the distressing procedures and without dental insurance, the former real estate sales agent said he stopped seeing his dentist.

When he went to Hajek for a second opinion, he heard a very different prognosis: one loose filling, two potential cavities that were “watch points” that didn’t need immediate filling, and no evidence of gum disease. But he was advised to rev up his brushing and flossing and pay better attention to his overall dental care.

“It just felt like the dental office was trying to bring in more revenue,” Anthes said.

No ethical dentist would engage in that type of product-pushing, said dental consultant Tanner. Dentists who over-sell products or procedures won’t be in business for long, since their patients’ word-of-mouth dissatisfaction will spread, she said.

“You give a patient a chance to say ‘Yes’ to the best dentistry possible,” said Tanner. “It’s all about patient satisfaction. If they’re happy, they’ll refer you (to friends) and the money will follow.”

Likewise, CDA president Robinson said the association’s 25,000 members must adhere to a code of ethics that includes offering treatment options that show they are “thinking of the patient’s best interest, not the practice’s bottom line.”

Given the options, “it’s up to the patient to decide the best way to go for that particular tooth,” said Robinson. If patients aren’t satisfied with their dentist’s recommendations, they should seek a second opinion, she said, similar to what’s commonly done in medicine and orthodontics.

Another factor affecting dental practices is the crushing cost of dental school. At top programs like the University of Pacific graduate dentistry school in San Francisco, the annual cost of tuition, books and fees is about $115,000, without room and board. And that’s just the first year, meaning new dentists could easily graduate with more than $345,000 in student debt.

Nationally, those cost pressures – along with competition for patients and a need for cost efficiencies – will likely prod more dentists to join group practices or corporate dentistry, says the ADA.

Robinson said that’s already increasingly common in California, especially among young dentists. Many go to work in corporate practices like Pacific Dental Services, where the overhead, billing, staffing and other administrative functions are handled by the corporation, not the dentist’s own staff.

Other changes include dental reimbursements based on oral health outcomes. For instance, pediatric dentist Robinson said, if a practice achieves a certain percentage of kids who receive anti-cavity sealants on primary molars, it might earn enhanced reimbursement rates.

For general dentists like Herman, who love their work, it’s all about adapting to change. Although declining to state his group’s overall annual revenues, Herman said it spends about 5 percent of its gross on marketing, mostly direct mail, and did so even through the recession. He said it’s partly what kept the practice afloat through the lean years.

“It’s no longer the cottage industry that our fathers and uncles had,” said Herman. “I enjoy being a dentist, but the business of dentistry has challenges. There aren’t any more than before, they’re just different challenges.”