The delivery of oral health care in America: the economic impact of chain-store dentistry on private practice

April 1, 2007
While the delivery of health care is a focus of many national debates, reports, and pundit columns, the delivery of oral health care to Americans has been marginalized...

by Edward F. Rossomando, DDS, PhD; Mathew Moura, BA

While the delivery of health care is a focus of many national debates, reports, and pundit columns, the delivery of oral health care to Americans has been marginalized and overlooked by the media and policy makers to such an extent that, for many Americans, oral health has now reached the crisis stage. The recent tragic death of 12-year-old Deamonte Driver of Maryland, who died from complications of an acute dental infection, highlight the current inability of oral health care to reach those in need. In 2000, the magnitude and scope of the crisis was spelled out in a report from the Surgeon General of the United States titled “Oral Health in America.” In his report, the Surgeon General detailed the crisis in terms of a lack of accessibility. Although the report paints a rather bleak picture for those without access, it fails to consider the changes taking place in the delivery of oral health care ­- changes that today require the problems associated with access to be reconsidered, and may provide access for those who may not have had it before.

Until recently, oral health care was provided by dentists usually in a private practice setting. While some oral health care was delivered in public health or hospital settings, for most of us oral health care was provided by our family dentists, who were compensated for their services on a fee-for-service basis. However, the delivery of oral health care in America has changed: insurance rates have been decreasing, more and more companies are cutting back on employee insurance plans (especially dental), and managed care payments are not universally accepted by dentists.

The chain store model for delivery of oral health care

In a recent Time magazine article, Bernard Stamler wrote of the convenience, predictability, and relatively inexpensive nature of chain store and franchise dentist practices (citing the European company, Vital Dent, as the prime example). What this delivery method means for those who cannot afford out-of-pocket expenses and who are surrounded by dental practices that do not accept insurance reimbursements, is access to oral health care.

It is important to understand that such franchises like Vital Dent are not necessarily providing lower-quality oral health care; they are designed to fill a particular market niche. This market “niche” in America includes 108 million people without access to oral health care.

Another aspect of the appeal of franchises such as Vital Dent is the convenience offered to consumers. Americans often feel that convenience can make up for slightly less quality, especially if it comes at a significantly cheaper price. One can see what has occurred in the pharmaceutical industry. The past 15 years has seen a decline in privately owned drug stores of more than 20 percent while chain stores and mail order have acquired half the market of pharmaceutical drug retailers, leaving the “mom and pop” stores a mere 14 percent. It is not that mom and pop stores were necessarily inefficient: it was that stores such as CVS offer greater convenience and are often less expensive.

The delivery of oral health care through traditional private dental practices has remained unchanged for most of the 20th century: there is either a single or several dentists who own the practice, a few hygienists, several assistants, and various support staff, such as a secretary, office assistant, office manager, etc., depending on the size of the practice. This delivery system can limit access for patients, mainly due to geography and income levels. Because franchises often do not gain revenue solely through one service or item, and can afford to lose money at one location and continue investing there until it becomes profitable, they are more adaptable to geographic and economic forces.

How can the chain store dentistry model be profitable?

While examining the phenomenon of chain-store dentistry, it is tempting to ask what makes this type of delivery system economically feasible. One factor is that the availability of new technologies and products allow for the delivery of oral care services faster and at less cost to the practice. These cost savings can be passed along to the consumer.

Vital Dent and the chain-store delivery model work because technology has allowed dental procedures to become more efficient by providing a decrease in chair time without a decrease in quality. While traditional private dental practices also can use technology to increase the number of patients and the quality of care they receive, they have not done so to a significant degree. As an example, one can look at the slow adoption of digital X-rays in private dental practices. Although digital X-rays vastly improve efficiency by allowing images to be provided faster, e-mailed, enhanced, and compared, most dental practices continue to use traditional X-ray machines.

Increasing dental practice efficiency and productivity requires changes in the dental school curricula

In 2002 the National Institute of Dental and Craniofacial Research (NIDCR), a component of the National Institutes of Health, funded an initiative to encourage research and training. Its purpose was to identify educational programs that promote the transfer of new bio-based discoveries from the research laboratory to the dental practice. One of the programs funded was the Biodontics Educational Program (BEP) at the University of Connecticut (UCONN) School of Dental Medicine (SDM).

The program informs students of the profession’s history, current challenges, and future trends. From visiting dental material manufacturing companies to guest lectures on malpractice cases, students are shown all aspects of the dental profession. From the program’s emphasis on innovation and entrepreneurship, students learn to respond more sensitively and critically to various opportunities within the profession. Also, the program emphasizes the use of new technologies and management practices that allow dental practices to become more efficient and capable of responding to changes in the delivery of oral health care.

The BEP offers lectures and presentations that consider the dentist as CEO of a company. Kaizen training, once limited to business schools and retreats, teaches dental students how to operate their dental practices with greater efficiency, regardless of size.

Greater efficiency and new technologies can allow dental practices to see more patients and offer a higher quality of care than a chain store; thus, the private dental practice can remain profitable and relevant in the changing market. Also, it will allow for greater access to oral health care for those who are uninsured or underinsured, because the dentist can see more patients and provide better, less expensive care by transferring cost savings gained by greater efficiency.

The economic impact of chain store dentistry on the private practice

The emergence of chain-store dentistry, a new and different model of oral health care delivery, suggests the need to teach dental students new technologies if private practice is to remain economically viable. BEP is one attempt to educate a new kind of dentist, one with a skill set that incorporates the latest technologies and more efficient management techniques. The ADEA has instituted a Commission on Change and Innovation (CCI), headed by Dr. Kenneth Kalkwarf. Such commissions and the experimental educational programs funded by the NIDCR all have similar goals in seeking to adapt the dental school curriculum. The coexistence of chain-store dentistry and private dental practice is necessary to improve oral health care and increase accessibility to quality care for the public. By understanding what oral health care looks like in America and the technologies in which dental students and dentists need to be trained, the entire dental profession can better understand its obligation to provide superior oral health care to the American public.

Dr. Rossomando is a professor in the Department of Orthodontics and Director of the Center for Research and Education in Technology Evaluation (CRETE) in Farmington, Conn. He earned a DDS from the University of Pennsylvania, a PhD from the Rockefeller University, and a MS in Management from Rensselaer. He is the founder of Biodontics, an educational program focused on incorporating the latest in bio-and nano-based technologies and products into dental practice, and received the Penn Dental Alumni Society Award of Merit.

Mathew Moura is the Director of Educational and Special Programs Center for Research and Education in Technology Evaluations (CRETE) at the University of Connecticut School of Dental Medicine. Moura earned a BA in History and English Literature from the University of Connecticut at Storrs. He has published several articles, served as fiction editor of the Long River Review, and has taught in the Connecticut public school system. He joined CRETE in 2006.

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