by Greg Psaltis, DDS
You are 52, healthy, fit, and at the peak of your career. Your practice is well-established and you enjoy the security of a good income, a group of committed employees, and financial security for yourself, your spouse, and your children. With most aspects of your life under control, you can afford the luxury of putting some focus on your personal health — the one thing that your practice cannot provide for you.
You belong to a fitness club, work with a personal trainer, do your regular aerobic workout each day, and generally feel as good as you have felt at any time of your life. Nothing seems lacking and your life is abundant. On an unexpectedly sunny spring day, you decide to take advantage of the warmth and go for a bicycle ride, rather than staying indoors and doing your typical Stairmaster workout. Water bottle filled, helmet securely fastened, you take off on one of your favorite routes that will not only provide you with an hour of cardio-vascular exercise, but will also swing you past the salt water inlet and through one of the loveliest local parks. Life couldn't be better!
About halfway through your ride, as you are contemplating your next vacation, a driver — unbeknownst to you — reaches for something that has fallen onto the passenger side floor of his car. In doing so, his eyes are diverted from the road and in the few seconds that it takes him to reach the item, he swerves into the oncoming lane of traffic. When he looks up, he sees a car bearing down on him and he instinctively pulls the wheel hard to his right to avoid the collision. The driver loses control of his vehicle, which plows straight ahead toward the curb, passes through the clearly marked bicycle lane and, in the process, runs over you and your bike. The good news is that the final thoughts of your life were positive and you "went out on top." The bad news is that your life is suddenly over, leaving behind a widow and children, all of whom may be well taken care of by your insurance policies ... assuming you took the time to secure them!
Also left behind are your practice, your employees, and your hundreds of patients whose fate is far less clear than your family's. What insurance policy will handle this major part of your life? Which insurance policy will maintain your loyal employees' workplace? Did you take out a policy that will guarantee that the patients who trusted you will have continuity of care? For many dentists, these are considerations that may never fully reach the level of conscious thought that they deserve.
Few of us expect to be the victim of a bicycle accident at the peak of our professional lives, yet the story above is a slightly fictionalized version of an event that happened to a dentist in my community. This is not an isolated incident, either. I can relate similar stories of others doctors I have known, such as the dentist whose car slid off a curve in the road, plunging him to his premature death. I can also recall stories of friends who have endured bypass surgery, cancer, or heart problems that fortunately did not end their lives, but that did put them out of their workplaces for extended periods of time. These are all situations that have happened to real people. In two of the cases, their worries about the fate of their practices were minimal, because they had secured the cheapest insurance possible — membership in a mutual aid group. This is the best insurance and peace of mind that you can buy, because such a group can maintain a practice in the absence of its owner, so that when the afflicted doctor is ready to return, his patients have been maintained and his practice has not lost significant productivity.
Why a mutual aid group?
My definition of a mutual aid group is: several like-minded professionals who band together and are committed to each other to maintain the viability and economic health of an office whose owner is disabled or dies. Although I have never read or heard any hard data on the topic, I would guess that an absence from an office for two or more months might have a significant impact on its viability. Absences of greater duration have the potential for ending the practice's very existence. Without a program for continuity of care for the patients, how long can they reasonably be expected to wait for their needed dental care? Overhead insurance may partially (or even fully) fund the office overhead, but realistically, can employees be expected to sit idly collecting paychecks with nothing to do all day? My team members become anxious on days that we are not fully booked. I can't imagine how they would fare with an empty appointment book facing them for several months! In spite of their loyalty to my practice and me, I can't help thinking that there is a limit.
Mutual aid groups can take many forms, and each one should be customized to the needs and preferences of the participants. For illustrative purposes, I will discuss the elements of the mutual aid group to which I belong. These are not necessarily intended as "the" guidelines, but rather as more tangible examples of how at least one group has put such a program together.
We have implemented our assistance program two times in my 22 years of membership, and not only did both practices survive and continue forward, but the experience itself was, for the most part, very stimulating and educational for everyone. The disabled doctors we aided were tremendously grateful for the support and the adequate time to heal from their infirmities, so they didn't have to return to their practices prematurely. For the doctors who helped out with their practices, it was an opportunity to experience another way of doing things, utilize new materials and techniques, and pick up (first-hand) new tricks. For the employees (and, ultimately, the doctors) of the practices, it was the clear realization of their value, since they ran the office as usual, but now found that the owner was an interchangeable part. This, by the way, can be a very freeing realization for the doctor, too! Lastly, patients were duly impressed that other doctors held the owner in such high esteem that they would take time out of their own practices to come to the aid of a colleague. In short, nobody felt this was anything other than a remarkable and positive experience!
Duration of coverage
It is vitally important to establish the exact period of time for which the mutual aid group is legally and morally responsible for covering the practice of the disabled or deceased member. Sympathy, compassion, or a desire to help frequently will compel a group to continue filling in beyond a point that is advisable. On the other hand, inconvenience, economics, and personal feelings might influence the group in the opposite direction. By setting the guidelines early, it frees the group of any need to make decisions — or, more importantly, exceptions — to the coverage of a practice. The amount of time involved is already established in writing, so that everyone goes into the process knowing just how long the agreement will be in place.
In my group, we have agreed to a maximum of six months of coverage, no matter what the situation is. It is the collective opinion of our group that this is an appropriate period of time for the practice to be sold in the events of death or permanent disability, or for it to be maintained to allow the temporarily disabled doctor to return. It is less important for this guideline to be based on this article or our group's decision than it is for the new group to discuss thoroughly the goals and needs of the mutual aid program they are creating.
Mechanics of coverage
I feel that the mechanics of coverage must be meticulously spelled out to insure proper aid to the disabled doctor. It is not uncommon for a group to find that inconvenience becomes a factor in stepping forward to work for the person in need of assistance. In our agreement, we have a pre-established rotation that was determined by random draw so that everyone signing the agreement understands exactly when his or her turn will come up. That is, once the disabled doctor's office has contacted the program administrator, it becomes a simple process of assigning days based on the agreed-upon rotation. By doing it this way, nobody can claim that it "wasn't convenient" on a certain day. The order of this rotation does not change. However, each year, it is changed by an increment of doctors that will insure equal opportunity, both at being first in line, as well as being last.
The starting point of coverage is another item that must be carefully defined. In our agreement, we felt that starting coverage three weeks after the first day the member-doctor is away from his practice is appropriate. The group also requires a minimum of two weeks' notice. In a situation where the doctor has been expecting to be back "any time," but misses two weeks before notifying the group, the group would not be required to provide support until the start of the fourth week (since it would be two weeks after the notification). This is an important point to clarify, since the time range may be deemed shorter for some groups. Our feeling is that because each member would be canceling patients at his or her own practice, it would be impractical to start covering another practice less than two weeks after notification. That gives the offices adequate time to reschedule clients. Again, this is merely the guideline we have established, but it need not be embraced by any other group.
Finally, the specific time expectations for the supporting doctors to be in the disabled doctor's office need to be established. When geography creates a challenge for travel, the request may arise for shorter hours at either the outset or the completion of the day to enable the traveling doctor to commute back and forth. In our group, we have established a clear boundary around that potential situation by defining the support as being for the normal working hours of the practice receiving aid.
Any special stipulations
Any group considering a mutual aid agreement should include any special stipulations, such as mutual aid for the circumstances of disability related to alcohol or drug use or high-risk hobbies. In the former, for example, we limit the coverage to a shorter period of time than six months and only agree to provide aid if the individual is in a treatment program. In the latter, it must be decided if coverage will be provided if the disability is related (for example) to skydiving, mountain-climbing, or other hobbies inherently dangerous. You may want to include stipulations about any other situations that could arise out of unusual circumstances.
Because our group has activated our agreement twice, we have learned a lot about the potential pitfalls. As a result, we have continued to create an agreement that will foresee as many of these as possible. No document will be perfect, but the more thought that has been put into the agreement, the higher the likelihood for success.
While I don't put much time or thought into considering my own premature death or disability, I do enjoy enormous peace of mind knowing that under those circumstances, my family, my practice, my clients and my team members would be supported in the best way I can imagine — through the efforts of my trusted colleagues.
I would never suggest that anyone reading this article stop riding a bike. But, I definitely recommend that, at least, some thought be given to eventualities that could radically impact all the people who are important to you. A mutual aid program is not only practical, it is inexpensive. It is the most profound peace-of-mind insurance you can buy!
Many variations exist, but my experience has been a minimum of nine to 10 doctors should be involved in a mutual aid group to be effective. This number enables the group to provide maximum support without crippling the practices of the doctors providing coverage.
A clear contract must be written that outlines the guidelines for the agreement. Included in this contract must be all of the following elements:
• Duration of coverage
• Definitions of disability
• Mechanics of coverage
• Any special stipulations
Perhaps no area of this agreement has more potential for creating misunderstandings or problems than the definitions of disability. You can define disability in a variety of ways, but the easiest way is to look at existing definitions from insurance policies. These may vary, so discussion among your group members will be important. The elements we have included in our agreement are as follows:
1) The doctor must be unable to perform the usual tasks or procedures in his/her professional practice
2) The doctor must be under the supervision and orders of a physician
3) The doctor isn't (or is, as the case may be) expected to return to full-time practice
In addition to these definitions, we have further defined the degree of a temporary disability:
1) If the doctor is unable to perform his or her regular duties for more than four hours per day, the mutual aid group will provide full coverage
2) If the doctor is able to perform his or her regular duties for at least four hours per day, but not for a full week, coverage will be provided only for the days on which he/she cannot be present
3) If the doctor is able to perform his or her duties for at least four hours per day for an entire week, the group is not required to provide coverage
In this way, there are no "gray zones" concerning coverage, and the group has clearly defined limits and obligations on covering for a disabled colleague.
