Dentists Debate Proposed Rule Change Amid Conference in SA

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2014 American dental Association conference attendees learn new skills during a workshop. Photo courtesy of the American Dental Association Twitter @AmerDentalAssn.

2014 American dental Association conference attendees learn new skills during a workshop. Photo courtesy of the American Dental Association Twitter @AmerDentalAssn.

Thousands of dentists from around the country will gather today in San Antonio for the last day of ADA 2014, the annual meeting of the American Dental Association.

The week of meetings arrived in the middle of an ongoing, state-wide dispute over the operation of Dental Support Organizations (DSO) in the industry and new rules that would restrict them.

DSOs are third-party, for-profit companies that contract with dental clinics to provide non-clinical administrative support to dentists. Such services include administration, accounting, and human resource and legal support.

“We bring a high level of efficiency to the table,” said Keith Newton, the CEO of DentalOne Partners Inc., a Dallas-based DSO. “We take a lot of non-clinical responsibilities off dentists’ shoulders.”

This year, the Texas State Board of Dental Examiners (TSBDE) proposed a new version of Texas Administrative Code (TAC) 108.70 and one new rule: 108.74. These proposed changes restrict the ability of independent clinics to contract with DSOs in the interest of halting “improper influence on (dentists’) professional judgment.”

The first rule (108.70), sets new restrictions on contracting with “unlicensed persons” who set regulations on any aspects of dental practice, including treatment timelines and equipment. The second (108.74) seeks to make dentists who own practices responsible for all operational functions, including those sometimes contracted out to DSOs.

These proposed rules follow an attempt early last year to pass similar restrictions through the Texas legislature. In the summer of 2012, Frontline conducted an investigation of two private-equity owned dentistry chains, Aspen Dental Management (a member of the Association of Dental Support Organizations) and Kool Smiles, which owns several offices in Texas. The investigation reported that dentists of both firms had conducted unnecessary procedures in order to boost profits. After the initial investigation, it was revealed that Kool Smiles had been under investigation by the Attorney General for Medicaid Fraud.

In response to the investigation, Senator Jane Nelson proposed Senate Bill 151, which detailed a process of certification for DSOs and sought to make illegal any contracts that allowed DSOs to have influence on care decisions made by dentists.

After the Texas Coalition of Dental Support Organizations argued that the laws already in place regarding uncertified corporate pressure were enough to prevent it, the bill failed last year in the 83rd Legislative Session of the Texas Senate.

The rules recently proposed by the TSBDE represent a second attempt to restrict the operation of DSOs and the risk the organization believes comes with it. Though the rules have already been passed by the board, and the “comment” period, in which stakeholders may issue statements in hope of changing them, has ended on Oct. 6. The same day, the Federal Trade Commission released a statement urging the board to reject the laws on the grounds that they would deny consumers the benefits of healthy competition within the industry. Bill Hammond, the CEO of the Texas Association of Business, also decried the rules.

Andrea Janik, a San Antonio dentist at Culebra Smiles and Orthodontics, believes the rules would hinder her ability to practice dentistry.

“In a traditional situation (in which a clinic does not use a DSO’s services), dentists have to oversee everything,” she said. “With Culebra’s DSO, I simply have more time to be a clinician.”

For Janik, the increased efficiency that her contract with a DSO provides her leads directly to her ability to serve her community.

“The work they do provides me with increased time and capital,” she said. “This boost lets me reach out to the community with services they need.”

Annually, Culebra participates alongside other clinics in “We Serve Day,” during which dentists provide free services to those unable to get care along traditional routes.

“SACDC operates largely by way of volunteers, and thus does not utilize a DSO’s services,” said Gloria Canseco, executive director of the San Antonio Christian Dental Clinic (SACDC). “However, the (DSO) model is just good business, as long as ethical mandates are observed.”

RDA Program graduate Eddie Acosta and two volunteer dentists on their way to see more patients. Photo by Paola Longoria.

SACDC’s RDA Program graduate Eddie Acosta and two volunteer dentists on their way to see more patients. Photo by Paola Longoria.

Canseco said she believes hyper-regulation is already rampant in the industry.

Ultimately, this debate could prove critical for dental care in San Antonio. The state of dental care in Bexar County rests well below the national average. According to AFTCO, a dental consultancy network, the ratio of dentists to citizens within county borders ranges from 41 to 23 dentists per 100,000 residents. The national average is 61 to 100,000. Those arguing against the TSBDE’s proposed rules state that their full adoption would raise costs for dental care and limit the types of insurance private practices could accept, exacerbating the problem in the Alamo City and elsewhere in Texas.

Janik agrees.

“My DSO’s expertise with navigating the complexity of insurance types allows our clinic and clinics like it to accept more types of insurance, and, thus, serve more people in need. If these rules are accepted, many clinics will have to completely rethink their operations,” she said.

As for fears that DSOs might lead to a lower quality of care, Janik said she has never experienced any undue pressure from her contracted organization. “I make all care decisions independently.”

With dentists from around the country gathered in San Antonio, there is no better time for real discussion of the issue. Janik, who is Texas’ representative member of the ADA New Dentist Committee, has been attending ADA 2014 throughout the week, and confirms the issue’s presence at the conference. “It’s a national convention, but I believe this issue with the board is in the back of everyone’s minds given the location,” she said.

Participants of the 2014 American Dental Association conference banded together on Sunday to provide free dental care to deserving city residents through Mission of Mercy. Photo courtesy of the American Dental Association Twitter @AmerDentalAssn.

Participants of the 2014 American Dental Association conference provided free dental care to deserving city residents through Mission of Mercy. Photo courtesy of the American Dental Association Twitter @AmerDentalAssn.

The conference, held at the Henry B. Gonzalez Convention Center, offered more than three hundred continuing education courses in which dentists could sample new technologies, network with their fellow professionals, and learn about the latest cutting-edge care techniques. Attendees of the conference, which is expected to bring $21 million in tourism-related revenues to San Antonio, even banded together on Sunday to provide free dental care to deserving city residents through Mission of Mercy.

ADA 2014 was joined throughout the week by several other industry gatherings. The American Association of Women Dentists met on Thursday, while the American Association of Dental Boards and the Association of Dental Support Organizations (ADSO) met in the middle of the week.

For now, the DSO debate continues. ADA 2014 closes today, and the TSBDE is set to hold a final vote on the proposed rules on Nov. 21. At that time, the Board may decide to delay the vote or propose further changes to the rules. Any significant changes would open the rules to another “comment” period.

*Featured/top image: 2014 American dental Association conference attendees learn new skills during a workshop. Photo courtesy of  the American Dental Association Twitter @AmerDentalAssn.

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