Where purpose and practicality meet: The role of DSOs in improving the oral health of children in America’s underserved communities
Dr. Polly Boehnlein examines how DSOs can help underserved communities.
No matter where you are on your career path - a student, recent graduate, or established dentist - it’s never too late to choose a practice setting that fulfills your sense of purpose.
As managing dental director for a national provider that brings dental care to children in some of the most underserved communities in America, I am fortunate to have a career in dentistry that is both professionally challenging and personally rewarding.
I knew from a very young age that I wanted to work in medicine and help children. As a young girl, I remember asking my father, “What’s that name for a doctor who works with kids?” I was certain I wanted to be a pediatrician. Science and math were also in my bones: I found myself drawn to the simple yet beautiful idea that there can be a solution to even the most complex problem. I loved the challenge of figuring out the problem and the joy of finding the answer.
As I grew older, I learned that life is not always so objective and clear cut. When I was in junior high school, my best friend’s mother, Susan, was diagnosed with breast cancer. A single mom, she was proud to work hard and be self-sufficient. Her determination to provide for those she cared about went beyond the four walls of her home. She worked tirelessly in the community with at-risk teens and running our community food pantry, all the while raising a teenage daughter by herself.
She fought and won her first battle and became cancer-free. Sadly, her cancer reoccurred when her daughter and I were juniors in high school. When her health insurance denied coverage for an expensive and potentially life-saving treatment, qualifying for Medicaid became her only option. While she was in the hospital undergoing a bone marrow transplant, her daughter was unable to bear the looks she received when using food stamps in the checkout line, so she began traveling to a nearby small town to do her grocery shopping. When I looked back on this time in my life and the lives of my friends, I was able to identify the roots of my own drive to pursue a life that impacted others. Even in the midst of what had to be continual fear and uncertainty, our group of friends still gathered at Susan’s house after school and on the weekends. She made us feel welcome. She had an energy and life force that gave comfort to everyone around her. She was someone to emulate.
Incredibly, during her illness, she was still volunteering and finding other ways to give back to her community. Susan made it through her bone marrow transplant and lived long enough to see her only child go to college, the first in their family to do so.
Susan’s passing had a profound impact on me. It influenced the trajectory of my life in such a significant way that I see her as an inspiration for my work today. She taught me that compassionate care requires empathy - because you never know what a person is going through, or where they have been. Through her examples, along with my parents’ examples, the joy of helping others was instilled in me.
Flash forward to another defining moment on my path toward a meaningful career: a conversation I had in college with - of all people - my dentist! During a regular checkup, I was mulling big decisions about my future. I decided to major in Economics and while I enjoyed science and math, medical school was still a big question mark for me at that point (I had been accepted into an early entrance program for med school, but with Susan’s passing, I wasn’t so sure medicine was for me). We chatted about all of this over the course of my checkup, which led me to ask my dentist why he chose his profession. He said that what he loved most was the artistry - how it was hands-on and at its core about working with people. That struck a chord with me. With economics, we take the math problems and apply them to real life, to the tangible. In dentistry, we take the science and innovation and apply it to one of the most fundamental parts of the body – the mouth. And out of the mouths of babes, we learn some of our greatest lessons. What a mission! I could help ensure the well-being of children by giving them a healthy smile. I realized then that I could combine a sense of purpose and my love of problem-solving through a career in pediatric dentistry.
Pediatric Dentistry and the ‘Dental Divide’
Upon graduating dental school, I set my sights on opening a practice that would focus on giving back to children in need. I was particularly troubled by what policy experts have termed the “dental divide” - the widening gap between those who can access affordable, quality dental care, and those who cannot.
As the rate of early childhood caries (ECC) continues to climb, children from low-income families are especially vulnerable. According to a 2014 study by the American Academy of Pediatric Dentistry, 60 percent of children will have ECC by age five, including the 40 percent of children who have them upon entering kindergarten. The same study cites a direct correlation between childhood dental disease and poverty: as family incomes decline, the prevalence of childhood caries increases. For example, the rate of tooth decay is five times more common among children below the poverty line than children in families 300 percent above the poverty line.
As providers and professionals, we are all familiar with the consequences of early childhood dental disease. Tooth decay remains one of the most serious but treatable (and preventable) chronic conditions of childhood. It results in over 50 million hours of lost school time each year, and studies show these children use costly emergency room services more often and encounter worsened job prospects as adults, compared with their peers who have access to dental care.
Still, going to the dentist isn’t a luxury every American family can afford. In fact, the Centers for Medicare and Medicaid Services (CMS) reports that 60 percent of the 33 million children on Medicaid did not go to the dentist in 2010.
Adding to the access problem is the fact that of the roughly 179,000 practicing dentists in the United States, more than 80% do not accept Medicaid patients. Keep in mind, these dentists are also small business owners who have crushing student loan debt on top of office leases, staff salaries, equipment, and other overhead costs associated with owning a private practice. The unfortunate reality is that most Medicaid reimbursement rates are so low that it is not financially feasible for many dentists to treat this patient population, despite their increasing care needs.
Yet the long-term cost to taxpayers and the healthcare system can be extremely high if early, preventative dental intervention for the underserved is not available. Research has shown that adults with poor dental health have worsened job prospects, and emergency room dental treatments cost about 10 times as much as the same treatment at a dentist’s office.
Leveraging the DSO Model To Expand Access to Quality Care
One day as I was paging through the AAPD journal, I saw an ad for a national dental provider called Kool Smiles. I was attracted to its mission - the belief that every child deserves quality dental care - and to its business model, which is successful at eliminating burdensome administrative workflow for dentists and increasing the amount of time available to treat patients - particularly underserved patient populations, such as those utilizing Medicaid benefits.
I’ve been with Kool Smiles for over five years now and have seen firsthand how the model works for both patients and clinicians. One of the best aspects of working with a provider like Kool Smiles is its Dental Service Organization (DSO) support model. Essentially, the DSO provides additional business management and professional support to dentists so that they can focus their time on quality patient care. It fosters an environment of professional support through peer-to-peer collaboration and helps dentists achieve better work-life balance by allowing us to come in, practice what we love, and leave at the end of the day without having to worry about endless paperwork or financial forms.
Having a DSO support system in place also makes it possible for the dental team to offer patients greater appointment flexibility. At Kool Smiles, we offer same-day and weekend appointments to accommodate patients who might require urgent dental care, or who cannot come to the office during the work week. This kind of flexibility is important for our unique patient population.
Kool Smiles dentists spend as much time with each patient as the average pediatric dentist, according to the AAPD. However, we can see more patients, at a lower reimbursement rate, because we are able to focus 100% of our time on patients, many of whom have complex care needs and benefit immensely from the extra attention and relationship-building we are able to provide.
Our clinical structure and IT integration helps to ensure quality care across the board. In my position as managing dental director, I spearhead the oversight, training and auditing of our dental team to ensure quality adherence and compliance.
Most importantly, Kool Smiles is able to leverage the business expertise of a DSO, and their negotiating power, to lower our operating costs, making it possible for our dental teams to care for patients who utilize Medicaid benefits.
As a private practice dentist, I would have none of this administrative and business support. On top of that, I would be faced with the very difficult decision of turning certain patients away due to lack of profitability. Working with Kool Smiles, it’s a choice I will never have to make.
DSOs and Dental Homes
This is not to say that private practices are not finding ways to give back and make an impact. Indeed they do, and many are spearheading commendable initiatives in their communities such as health fairs and charity care days. But charity alone will not solve the dental health crisis. Real change is systemic and starts with early and regular dental health education and disease prevention. To stop the vicious cycle of early childhood dental disease, young patients across America need a dental home.
The philosophy behind the dental home is consistent with AAPD guidelines and best practices for the optimal dental health care for children. The concept is simple: A child’s chances for good oral health are optimized when dental care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way. This starts with a baby’s age one (or first tooth) dental visit and continuing with regular checkups throughout early childhood.
Many patients come to Kool Smiles having never seen a dentist, and lacking even the most fundamental dental hygiene. In some cases, patients do not have basic items like a toothbrush and toothpaste at home. Because of our unique patient population, we often encounter children with a significant amount of decay, multiple cavities, and no familiarity with dental treatments. Establishing a dental home for these patients provides an opportunity for ongoing, comprehensive, and preventive dental health care and education.
Recognizing that restorative care is one of the last, least effective options to solving the oral health crisis in America, we also invest a significant amount of time and resources to community programs that provide dental health education and teach preventative healthcare.
By creating a dental home for patients in traditionally underserved communities, we have seen significant gains. Over a four-year period, the average Kool Smiles patient’s need for restorative dental services declined by 28 percent – a clear indication of improved oral health in the communities we serve. Government-published Medicaid data show Kool Smiles patients receive approximately 40% fewer operative procedures per patient than the average dental practice. On all restorative codes, our patients show clear indications of getting healthier over time at a lower cost to taxpayers. The bottom line is that dental homes create healthier patients.
At Kool Smiles, we are providing a dental home to thousands of children across America who would otherwise go without care. We’re proving that you can provide quality care to families utilizing Medicaid benefits and run a business successfully. And, we’re improving the oral health of communities we serve - one smile at a time. It’s a model I’m proud and honored to help lead. #
More information about working with Kool Smiles can be found at www.mykoolsmiles.com.