AME: Student Loans, DSOs and All on X

[00:00:01] This is a production of The Very Dental Podcast Network Alan Mead is a dentist with too much time on his hands and too much recording equipment in his basement

[00:00:16] Armed with an obsession to bring entertaining and informative content to the dental world in a way that's never been done before I give you the Alan Mead experience Well hello and welcome to another episode of the Alan Mead experience. I'm your host Dr. Alan Mead

[00:00:35] I'm a dentist, a podcaster and a father today, I'm sitting here in the under the stairs Harry Potter podcasting studio I've built for myself at home and It is Father's Day. I've spent quality time with my children. I went mountain biking

[00:00:56] I went over and visited my dad brought him gifts. So we're doing pretty good. It's a good Father's Day. I Have a topic or a podcast I've been thinking about for a little while

[00:01:08] And I'm just gonna I'm just gonna brace you I could be wrong about every single thing that I'm talking about I don't know. I'm not I'm wading into an area that I don't necessarily have a ton of direct experience with

[00:01:19] But what I do have a lot of experience with is I've talked to lots of different people in dentistry over the years And I've been a dentist for 27 years. I've been a general dentist doing

[00:01:30] You know plain old mom-and-pop style practice for a long time. And so I have opinions I have opinions in spades and I just wanted to kind of talk about some stuff that's been going through my mind. So interesting

[00:01:44] One of the things that that I think doesn't get talked about very much because it's not very sexy But I think it's really important. Is that one of the differences between like a physician or a dentist? a health care professional and a trades person is the fact that

[00:02:05] Allegedly I the Hippocratic Oath kind of thing We are supposed to be we are supposed to be looking out for the best interests of our patients

[00:02:17] Now the problem with it like like the easiest way to do that if in a perfect world if our job was to just Take care of the best interests of the patient we would all have the exact same exceptionally good training and

[00:02:33] There would be no profit motive whatsoever in other words, we would everyone would be salaried at a level that they're perfectly happy with and So we would have literally none of the the treatment that we were offering or delivering to these patients

[00:02:49] Would be connected to a dollar amount that we're getting paid for it But unfortunately, it's not the way it works in our world. And so on some level it is very difficult to separate

[00:03:02] The patient's needs from say the financial needs of our businesses our practices and let's be honest Most dentists probably more so than than physicians and in the medical people in medical group. Most of us are

[00:03:16] More connected or paying attention to the bottom line of the business that we work for or in most cases or a lot of cases own So like this profit motive thing is is tough. I've I've Battled with this for a long time. It's been it's been

[00:03:33] Something that that I feel like it's important We're supposed to be looking out for the best interest of our patients, but in the same breath we're also supposed to be making our business go and we're supposed to be wildly profitable and making lots of money and and and

[00:03:47] We make lots of money in dentistry by delivering care to patients what we don't we don't make a ton of money by doing exams And telling patients What we're seeing necessarily. I mean exams and treatment plans are are important

[00:04:02] They're probably not the most profitable part. The profitable part is is the work that we get patients to accept And so I don't see that there's any way really to detach the the profit motive from

[00:04:19] The patient well-being part of it like on some level and the other thing is to we're all trained differently So like an ideal treatment plan in my office might not look anything like an ideal treatment plan in your office. And that's that's a

[00:04:33] Has something to do with our personal experiences it has something to do with how we were trained It has something to do with our clinical experiences. It has something to do with our patient population

[00:04:44] There's a lot of factors obviously that fall into this and so what's ideal in one person's office might not be ideal in the other Person's office and that's okay. Now all that is fine I don't really I'm not trying to make that a thing

[00:04:54] But I thought of three things that I wanted to kind of talk about that are big Features of our Dental landscape as a business and as practitioners in reference to putting the patient's best interests first So the first thing I want to talk about is student loans

[00:05:16] Because most of us on some level or another have Had experience with student loans to get our education Dental education has always been pretty expensive But the reality is like I graduated in 1997 I've told this story literally 6,000 times on the podcast

[00:05:34] So you've heard it before I apologize, but I came out with $85,000 worth of debt for four years at the University of Minnesota and I felt like I mean, I felt like it was a lot. It was a lot of debt I was able to I

[00:05:52] Refinanced it like I mean like weeks after I got out of school for as I remembered it might not might have been longer than That but it seems like I refinance it almost as soon as I got home from school in my my loan

[00:06:05] Interest rate was tiny. It's like I don't know It was less than 2% or something like that My accountant told me that if I ever paid that off any faster than I had to It'd be the dumbest thing I could do because it was the best rate

[00:06:15] I was ever gonna get on anything and so I so I remember I had my $85,000 worth of debt. I remember my payment was four hundred and forty six dollars and seventy one cents a Month for a good while, you know, I've been doing this for 27 years

[00:06:29] So I paid it I think I paid it off in 10 or 15 years So it's been a long time since I've had a student loan payment But the other thing is that student loan payment was more the size of like a car payment than like a house payment

[00:06:44] So fast forward a few years and we're looking at poor dental students coming out now with with multiples of hundreds of thousands of dollars in debt in a lot of cases not all cases, but a lot of cases and that's a

[00:07:00] That's not just inflation like that's not just inflation from my measly $85,000 in debt that's that's significantly more So what you're talking about is these schools are able to charge more than even inflation would necessarily indicate I mean a

[00:07:17] Dental education right now is really expensive in and literally continues to get it's not unheard of for people to be at four and five hundred thousand dollars For dental school loans and and I suspect that it's the same kind of thing when you're in dental school

[00:07:31] You've committed to do dental school. So the bottom line is like you're just I mean You're here to get the job done. Let's do it and you sign on the dotted line

[00:07:39] Whenever they call you down into the the financial aid office and that's that so you've signed up for these loans but like I don't know how often if ever they they

[00:07:49] Bring you in and give you an idea how much that monthly payment is gonna be but that is a significantly different like I said, mine was kind of like a Car payment and I think if you're looking at four and five hundred thousand dollars

[00:08:02] That's more like a big-ass house payment is what that is That's you know in my neck of the woods four or five hundred thousand dollars to get you quite a bit of house Maybe not in Seattle. Maybe not and you know, San Diego

[00:08:14] But Central Michigan four or five hundred thousand dollars gets you a pretty dang nice house Let's just say that so and that's a that's a pretty big. That's that's a pretty big mortgage payment around here So the concern I have is What what does a new dentist do?

[00:08:32] With with that How does that affect a New dentist being able to look at the patient's best interests in other words is a new dentist Going to be able to look at I had a conversation

[00:08:54] With someone online who basically was talking about how lately they've gotten a lot of a lot of patients that have left DSO offices we'll talk about DSOs in a second to Had left DSO offices because they felt like DSO offices a lot of times. They're they're getting upsold

[00:09:10] whether it's you know, constantly badgering them to do Invisalign or selling them toothbrushes or different services that are sort of above and beyond and there

[00:09:20] These are people who probably have been going to the dentist for their whole life and they just basically want to show up for a cleaning and talk to the nice lady for an hour and get their teeth cleaned and walk out and

[00:09:29] Basically that is a patient a healthy patient That's doing everything that a dentist can ask them to do flossing their teeth and they don't have a lot of decay and they're not Breaking teeth that is not a valuable patient to a dentist in the office

[00:09:41] Which is a super fucking gross thing to say To say that the patient is not valuable because they don't they are not an income Potential is gross and I think it's if dentists are looking at patients like that

[00:09:56] They really need to check themselves a little bit except for the fact that it's true. It's true. They're not Having patients like that in your office is probably not only are they not profitable

[00:10:07] But you might even be losing money seeing those patients at this point because the one thing, you know For sure if these patients if you're if you take if you take assignment of benefits from an insurance company And these patients have insurance

[00:10:21] The the amount of time that they spend in your office, you know These are healthy patients that probably don't need a full hour with a hygienist and frankly the way that we're paying hygienists now

[00:10:31] What their insurance is paying probably isn't covering it anyhow. So the bottom lines those are probably not profitable patients Those patients deserve to be seen in the dental office as much as anyone else I suppose Except they really are not

[00:10:43] I mean as a dentist when you're looking at the bottom line and I'm thinking as a new dentist who has a giant nut to Crack before they can even buy groceries

[00:10:52] Before they could even you know, make a car payment before they can, you know pay for an inexpensive apartment They've got this giant house mortgage student loan payment that they're looming over their shoulder every month How does that how does that affect?

[00:11:08] the way that a dental student looks at Making sure that they're taking the patient's best interests at heart I think it's really difficult and I'd love to tell you that I have answers. I don't have answers

[00:11:22] I don't have answers, but I'm gonna tell you right now if I were a patient in an office that Had a bunch of new dentists Looking over my diagnosis if I knew what I know, I'd be a little nervous

[00:11:37] I'd be a little nervous that I'd be looking for the upsell I'd be a little nervous knowing that there's dentists out there talking about Patients in their office that just aren't very valuable to them because they because they can't charge them anything. It's tough, you know

[00:11:50] Dentistry is a business but also We kind of took an oath to say that we're gonna put the patient's best interests at heart if you've got a healthy patient Their best interest is not more care

[00:12:00] Necessarily and I know people can I know people can have different opinions on that So I'm not even I don't I don't mean to sound like a passing judgment But I do think it's something we need to think about

[00:12:08] I think I think in some ways when we're looking at patients as commodities, you know New patients are gonna be X amount of profitability. They bring to your office. That's pretty gross

[00:12:18] You don't know that you don't you don't you need to get to know the patient you need to know I don't know. I really struggle with that. So The first thing I was talking about those student loans

[00:12:27] How does that affect the incentive when you're looking at making sure that you're putting the patient's best interest art? Secondly DSOs dental service organizations are buying practices a lot of and a lot of dentists probably my age are looking to sell their practice to a DSO or

[00:12:45] They're looking to Be part of the DSO where they're buying more practices Maybe it's someone who's entrepreneurial who has a real bent for that kind of thing

[00:12:53] And so what what you're happening? What you're finding is that DSOs are able to if you can wrap multiple practices under the ownership umbrella of one DSO You there's a ton of efficiencies you get where the whether it's you know

[00:13:06] a purchasing power or you can negotiate with an insurance companies for better reimbursement or you can your marketing coverage can be There's a lot of efficiency that it's one of the reasons DSOs are fantastic

[00:13:18] but I think the other reason the DSOs are able to do some really good stuff is that Individual practitioners have ethical responsibilities as individual practitioners a

[00:13:29] DSO I mean, I could be completely wrong about this and I am perfectly open to hearing the argument but DSOs do not have an ethical The similar ethical responsibility as an individual practitioner we we as practitioners are held by our state boards and our in our

[00:13:45] Contract to be ethical and one of the ethics is to look look for the best interest of the patient And I got to tell you I don't as DSOs They can kind of skirt this a little bit because they're the ownership is not by any individual dentist necessarily

[00:13:59] I guess they can be but the reality is is that the DSO can look for the profitability of their particular business system That's similar like you've got Incentives that are pretty crazy. I was talking to someone who has worked in a DSO as a mid-level manager

[00:14:16] And I was asking them why why is it that that Hygienists are able to be paid so much better by a DSO Why is it that DSOs are able to to? hire so much more easily than individual offices because I and I do believe that they are

[00:14:30] And I said a couple things first up they pay better I'm like how they pay better because they make more money maybe but they also pay better because they have

[00:14:40] They have bigger purchasing power for potentially for benefits than maybe a small office something like that, but the other thing is DSOs teach their hygienists how to sell they they do lots of training So so hygienists are able to sell more profitable things

[00:14:56] So basically if you're a mom-and-pop shop who's basically doing basic hygiene kind of stuff Versus a DSO that's that's selling a lot of other products procedures upsells that sort of thing You're probably gonna be more profitable and a lot of these hygienists are being paid on

[00:15:13] Not only they probably have a base wage and then they probably get paid on production So all the sudden the incentives for production are there where they might not be in in another, you know a more traditional office where it were there Can an incentive for production?

[00:15:29] Be in line with the patient's best interests. I Think it depends on the patient Probably depends a little bit on the practitioner But I have to say there's times where those things are probably not necessarily in line with each other

[00:15:42] I'm gonna just say it you may disagree with me and frankly if you do disagree with me Come talk to me about it Let's talk about it on the on the very dental Facebook group because I think this is something that no one ever really talks about

[00:15:53] You know, I I can see a lot of good things that DSOs have brought to dentistry but to be frank I can see some of the some of the coarsening of of dentistry comes from being able to kind of skirt these ethical

[00:16:06] Responsibilities that we have I have a problem with that a little bit, you know if if the increased production Does not go towards an increase in the patient's well-being and the patient's best interests

[00:16:18] I have a problem with that. Like we were supposed to be looking out for the patients and I'm there's times I I'm not necessarily seeing it. I'm not necessarily seeing it me I could be wrong and

[00:16:27] But I do think the bottom line is on a on a one-to-one basis We're supposed to be looking out for the patient's best interest last thing when you're looking out for the patient's best interests and

[00:16:38] We have a procedure that's being sold heavily to dentists and as well as patients but to dentists An all-on-x type thing where you've got a full arch implant Restoration first off. I'm gonna say this right now

[00:16:50] I have plenty of patients in my practice that would benefit hugely from full arch implants These are people who have a bunch of teeth that probably should not be saved and the ones that might be able to be saved

[00:17:04] Are in bad enough shape where if you're just gonna do it do it. We all have that we have patients These are patients that used to just be straight-up denture patients at some point

[00:17:12] They're gonna pull the trigger and they're gonna be a denture patient and an all-on-x is definitely better than a denture It's definitely I mean, it's a great restoration for the right person

[00:17:21] One of the things I have a problem with is the fact that you see so much and I'm gonna just point it out man I'm in visitor on Instagram on Facebook you see all these all-on-x providers doing these amazing surgeries

[00:17:35] But but when I look at the pre-ops, I look and think to myself, you know They'll put pre-op photos. Sometimes they put scans they put x-rays to me These are restorable teeth with some work

[00:17:47] You know and if the patient could commit to taking care of their teeth better You know, they wouldn't need to do an all-on-x. I think I think they've got teeth that could be restored. I

[00:17:58] Think one of the problems with the training option for a lot of these implant cases is that? We're just not gonna save teeth. We're not we're not that's not part of that's not part of what we do anymore now

[00:18:09] Now it's a matter of we're gonna go full arch full arch implants is is Profitable for the dentist the patient gets to leave with beautiful teeth same day in a lot of cases great I'm not gonna I'm not gonna discount the technology. It's amazing. What can be done?

[00:18:22] I'm just saying that for the case selection I think sometimes that option is they get to that option a little quick in my opinion and and again that comes back to the

[00:18:35] What's best for the patient and I don't doubt for one second that people who do a lot of all-on-x like this Think that what they do is definitely best for the patient, but I I it's hard for me to do that when I see a lot of

[00:18:48] You know pre-ops that look like those teeth could be restorable and maybe they're right Maybe it'd be more expensive to restore those teeth with a full mouth three. Yeah, but I'm gonna tell you right now I've never had an all-on-x. I have all my teeth and

[00:19:01] I wouldn't you couldn't sell me on one of those Save my life. They are amazing, but they're not teeth. They're not teeth I'd rather have teeth and You know I have not lived through some of the stuff that some of my patients have lived through with just

[00:19:16] miserable with teeth and they're just tired of having to deal with this stuff and I Get it. I do think there's a place for it. But I also have to say I think I think sometimes as a

[00:19:27] profession we're starting to lean into this a little bit more in this maybe This may be more of what I see in social media than anything else It might be my viewpoint that I see it pushed harder than it really is in real life

[00:19:39] I still have to tell you I've only referred I've only gotten a couple patients To go try this procedure out in my area Central, Michigan really doesn't have much in the way of providers for this So I'm having to send them down into the metro area

[00:19:53] So it's not like I have a bunch of people that are looking to do this Frankly, I have more people that would qualify and would probably really benefit from it then don't it's more that when I see as a profession We're we're looking at this as being

[00:20:08] This is being what dentists should be doing where in reality is I just don't see Dentistry as a whole moving into that this still strikes me as a pretty specialized procedure And I think that there's we need a lot of dentists that can take care of regular patients

[00:20:23] And I just feel like that isn't maybe profitable enough for for where we are right now Whether it's the student loans You know the kids coming out with student loans and needing to make a bunch of money just to cover their nut

[00:20:36] Or dentists that have decided that whatever they were doing. It's just not enough. They need to do better I gotta say I feel like being a dentist has been a really It's been a great living for me

[00:20:46] And I have just a regular mom-and-pop probably smaller than average practice and that's pretty good deal But I came in at a point where I was able to buy a practice for a song and you know

[00:20:55] I'm not carrying the same kind of debt, so I'm coming from a very specific place But I do worry about the fact that on some level We as dentists are not we're looking out for ourselves. We're looking out for our businesses

[00:21:08] We're looking out for our profitability maybe more than the well-being of our patients, and we really do owe it to them That's that's the reason that it's a reason that we're allowed to do with what we do

[00:21:16] It's a reason that they license us. It's the reason that the dentists have a run on the market for what we do and I just Feel like sometimes we're missing it a little bit and maybe I'm maybe I'm just an old man shaking my fist at the clouds

[00:21:31] But I do think I think there's something to it and in God love you It's not that I'm against implants, and it's not it's not that I'm necessarily against DSOs

[00:21:39] God only knows you got to go to dental school to become a dentist and it costs a certain amount of money But I just feel like I feel like we lose Sight a little bit of what our our obligations to the to the public are a little bit

[00:21:50] With some of the marketing and frankly social media allows you to fall into a rabbit hole And see very specific stuff. So maybe I'm missing that but I Don't know just something that's been bugging me lately

[00:22:02] I'm curious if you guys have any thoughts about this if you think I'm wrong or if you think I'm right or Whatever. I want to hear about it go to the very dental Facebook group if you haven't joined yet I'm gonna give you one of five passwords

[00:22:13] You can do all five if you want whatever whatever floats your boat But I don't let you in unless you give me one of the passwords because I'm trying to keep it the very dental Facebook group

[00:22:22] Kind of small and tight to podcast listeners. So the the passwords are Timmerman Hornbrook McQuaffey Papa Randy and Lipscomb those are the five one of those five or any or all five if you like if you want to impress me all five

[00:22:37] I hope you appreciate the podcast. I've been doing this for 10 years now. It's amazing to me and I hope you I hope you're enjoying it And I hope I hope you've got thoughts

[00:22:47] That we can talk about in the very dental Facebook group behind is for me to things for me to talk about I really appreciate your support through all these years and

[00:22:55] We've still got so we got great stuff coming up. We got some really cool stuff. I got the I got the incoming president ADA Dr. Brett Kessler coming on. I got a chance to talk to my favorite. Dr. Day. Dr

[00:23:07] Jason Smithson probably in my opinion one of the best dentists in the whole wide world. He's great guy I talked to we all kinds of good stuff coming up

[00:23:13] So if you have any thoughts on what we should be talking about or anything like that, you just let me know You can DM me on Facebook And thank you so much for your support and we will catch you next episode