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Hello. This is Arianna Portelatin with the Becker's
Dental and DSM Review podcast.
I'm thrilled to be joined today by doctor
Jeffrey Carter, the founder and chief medical officer
of the US Dental Surgery Network. Doctor Carter,
thank you so much for being here today.
Thank you. It's my pleasure to be here.
Mhmm. To start us off, can you introduce
yourself and tell us a little bit about
your background?
Sure.
I I'm currently a practicing oral and maxillofacial
surgeon.
I was one of those early,
MD, DMD type trainees that that developed in
19 seventies. I spent pretty much my entire
career in the gap of medicine and dentistry.
That that is important because it's been able
enabled me to be able to learn lessons
in medicine and see how they transferred it
to dentistry.
Early in my career, I was an academic
chairman. I ran an oral maxillofacial surgical residency
program at the Carls Clinic in Illinois.
And then after
a period of time in academics, I transitioned
back to Nashville
and built a 5 location oral surgery practice.
That was in the early days of electronic
health records where we're building them before the
mouse was invented. So we've been at this
for quite a while and have seen quite
a bit of innovation.
After that, I was I built and designed
the first,
dental ambulatory surgery center that was Medicare certified.
That was built at Nashville.
And, I served as a medical director of
that facility for about 27 years.
In my more recent,
iteration, I I've sold those enterprises, and and
now I'm building a mobile oral surgery platform
to provide oral and maxillofacial surgery and general
anesthesia to to the large DSOs
that want to incorporate in house oral surgery.
So, so far the process of this over
the last 6 years, we're in about 70
different locations in 6 states.
Great to hear about your extensive experience. Thank
you so much for that.
First question here, what are some of the
biggest issues that you're following right now in
the dental industry?
Sure. Well, one of the the trends that
I've I've noticed is I started to leave
one state go to multiple states is is
how the demographics of what's going on in
the dental industry has changed. And I'm excited
to finally see that they're we're getting some
national
dental licensing and reciprocity
rules that are being built. There's these large
cooperatives
where if you're in one state, you have
reciprocity in another. And when when I first
started this enterprise, I think I, of course,
had to accumulate
9 different dental dental licenses in 9 different
states. And if you know one state, you
know one state. So they're they're all very
different. But when you start to do things
like,
have office inspections for general anesthesia,
the the individuality between the states even becomes
more and more granular. That's a hard thing
to do. But, hopefully, at least with the
with the National Dental Licensing and Rest of
Process, it's gonna be easier for providers to
to move from location to location.
Dental licensing has, for a long period of
time, been a huge barrier to to opportunities,
and, certainly, it's a barrier when you're trying
to build a a multistate
organization.
I think the second thing is is the
issue, and everybody talks about this, but it's
it's real. It's real, and that is the
recruiting challenge.
I'm in a specialty
in a dental specialty recruiting,
silo where we're we're trying to recruit,
young surgeons. As you know, there's only about
250 oral surgeons trained each year, and there's
no immediate plans to increase that. I think
there may have been one residency added, by
CODA in the last
the last 3 years. So it's not a
large population of people coming out. And by
last count, I think there were 17,
oral surgery DSOs that are at the different
stages of evolution
all chasing the same talent
pool. So if you're if you're a solo
practitioner looking for a partner, if you're a
group looking for a 5th man, or if
you're a DSO,
there's a lot of a lot of competition
for the same talent. So that that's a
significant,
challenge for all of us.
And are there any specific strategies that your
company has put in place to really help
with these, recruiting challenges?
Well, we use, professional recruiters. We've tried that.
And then, you know, the other the other
interesting thing is that when you lose use
professional recruiters,
you're basically going, pretty much head to head
with everybody else's offers. So what I've what
I've seen over the years of going to,
like, the annual oral surgery meetings, it used
to be that, you know, you would you
would interview somebody in that location. Now that
that's been totally hyped up and amped up.
But you have you have recruiters
basically camping out in residency locations,
signing contracts for people before they get out
of residency,
giving them the sign on bonuses,
with with or without payback, you know,
clauses to try and entice them to to
sign up for a company 3 years from
the time that or, you know, 3 years
from the time they get about to finish.
So there's a lot of heavy recruiting,
heavy heavy recruiting that goes on and there's
some people making decisions even before they're fully
trained search. That's all new. You know? So
it's it's tough to try to
try to compete with that. You just have
to try to find the people that have
the best fit for what you're doing.
One of the things that our organization,
allows is the ability for people to be
independent contractors.
Now a lot of the younger surgeons don't
really understand the the full tax implications of
being an independent contractor versus an employee, but
but they're numerous. And so the people that
kind of understand that are attractive to come
to work with a platform like ours because
all of our our our doctors are independent
contractors, which gives them the same flexibility that
they, they potentially would have had if they
were a solo practitioner.
Gives a lot of autonomy. Gives a lot
of flexibility of their life.
Okay. Yeah. I'm also curious. I know these
workforce issues, were happening before the pandemic, and
then COVID kind of,
exacerbated everything.
What did shortages and really the workforce overall
look like when you first entered the field?
Go back.
Yes. It's very different back back in the
eighties. You know, the 19 eighties, we we
would hire we would hire dental assistants or
surgical assistants. They would be with you for
for 25, 30 years.
And on on the on the surgeon side,
you'd hire us you'd hire a surgeon and
you expect them to be your partner for
30 years. Well, that doesn't exist anymore.
And so if you grew up in that
mentality where you're trying to find the perfect
fit, I mean, the probability of that is
is pretty much 0. You know, when you
look at the medical profession, and I've heard
people tell me in the nursing profession, the
average nurse stays in a job, you know,
over 24 months. Okay? When I first went
to practice, I had a head nurse that
stayed with me in my entire academic career
of 8 years, and I had others that
stayed with me in my private practice days,
you know, for for 15 or 20 years.
And and that that's absolutely unheard of today.
It doesn't seem to make any difference kinda
what what the benefit package is and what
the work environment is. If if somebody moves
or somebody has a child or somebody has
a family, if that that the demographic movement
of the workforce in dentistry and medicine is
so mobile,
that you just can't keep keep people grounded.
You just have to continue to be very
good at,
at onboarding and teaching and getting people up
to speed as soon as possible. I think,
you know, back you know, as as I've
seen that transition over the over the 35
years I've been doing this, you you see
the transition. You saw it first in the
mobile workforce of the dental assistants. You know,
the majority of those are females. They're sometimes
they're they're childbearing age, and so they're gonna
be very, very mobile in terms of their
mobility. And then in dentistry, you know, we've
seen the same thing. With dentistry, we've seen,
know, the significant expansion of of women in
dentistry,
and then you're you're now seeing the same
type of mobility issues with,
with the with male and female providers. You
know? So that's it's a it's a demographic
shift and and the industry just has to
figure out how do you how do you
cope with it. But it's it's hard. I
mean, I I can remember being a surgical
resident of Vanderbilt. We had we had a
female neurology resident, and it was a big
deal when she was pregnant. People couldn't figure
out what to do. You know, that was
that was back in the stone age. But
now, you know, you look at that. You
have maternity leave. You have paternity leave. You
have ways. You have gaps. You know, you're
running a surgical practice. It's really tough to
replace somebody. They disappear for 9 months or
6 months or 3 months. You know? So
those are new challenges. We have to kinda
figure out how to do how to how
to build around that. And we'll we'll figure
it out. Just just it's a question of
basically being innovative and and trying to,
you know, micromanage people's time and access. But
but I see the workforce I don't see
that problem getting any better, to be honest
with you. Okay.
And I'm also curious. What are you most
excited about when it comes to dentistry right
now, and what makes you nervous?
I'd say the thing I'm most excited about
is,
kind of the applications of technology to dentistry.
I guess there's probably 2 examples I would
cite.
One is a project we're working on with
a mobile, portable dental, electronic dental anesthesia record
to replace, the generations old paper anesthesia records.
There's been a lot of innovation in dentistry
and and, you know, billing systems and revenue
cycle stuff, but it's not not much on
the
the the anesthesia side. There's been innovations for
all surgery medical records and so forth, but
you also the anesthesia piece has kind of
been left left to the side.
And one of the things we found early
on is that we if we're gonna go
to multiple locations and deal with multiple DSOs
with multiple EHRs,
we had to have kind of a stand
alone, anesthesia record that could go and follow
us around and take care of all of
the requirements that are that are mandated by
these different states. And we were in the
process we've we've kind of built an enterprise
doing that, to try to figure out how
we could do that digitally. And so we
we've come up with a device that basically
does it with an iPad.
It's very mobile, very nimble, so we can
pretty much go into any office, and we
can have our own, isolated anesthesia record, which
which tracks all of the necessary parameters that
are required by each of the individual states.
As I mentioned before, you have a lot
of different variations.
For instance, the state of Texas has its
own set of rules that are very different,
and your anesthesia record has to have, you
know, 17 or 18 bullet points. If it
doesn't have that, it's not acceptable, and you
don't get a permit. And that's very different
than what you see in Maryland. It's clearly
different than what you see in Kentucky. So
the ability to have a system that can
morph and meet the demands of each state
is really, really, really important to be able
to offer a quality product.
But when you have something like that, all
of a sudden, you now can begin to
improve the workflow
because I don't in dentistry in general dentistry,
we have hygienist and assistants
and while the large DSOs have figured out
ways to use technology to improve workflow.
For example, I remember working with Heartland, they
used to use headphones, and they use, you
know, headphones to be able to tell when
the hygienist is ready and so forth. They
really improved the efficiency.
Well, we we've done the same thing with
the digital anesthesia record. What one example
is if you bring your daughter to have
her wisdom teeth taken out and she's done,
we have to go ahead and contact you,
the driver, to come pick her up. Right?
Well, the one thing we learned about in
COVID
is that,
people like to wait in their cars, and
they're still waiting in their cars and working
in their cars. You know? So we were
able to put in the text system and
the electronic system that says, when the patient's
ready, you know, please drive around and pick
up pick up the patient. That little event
probably saves our our our staff sometimes 5,000
steps a day. That's not tracing people down.
The other part about that is is the
we have the ability now to keep up
with the DEA compliance rules and regulations because
as a mobile surgeon, we're required to have
a DEA number each one of these locations
where we dispense or we actually administer medications.
If you've got 70 offices, that's a big
task. And to try to do that manually
with an Excel spreadsheet, that that's pretty tough.
So we've we've built technology that allows us
to to support
our DA compliance as we go from, you
know, state to state and location to location.
And probably probably the biggest benefit of of
benefit of of something like that, it allows
us to be able to report,
prospectively,
the current
patient safety aspects of outpatient general anesthesia by
by our group. Because,
having run a surgery center for a number
of years, we always used to have to
report things like the number of patients transferred
to the ER, unexpected admissions, those types of
things. Well, none of that's really reported in
dentistry in any systematic way. Some of the
dental boards will require, if you have an
anesthetic misadventure, that means transport the hospital, you
have to report that to the dental board.
But like I say, it's it's state by
state. It's all over the place.
But one of the challenges that we've had
as an association in the oral surgery world
is how do we how do we how
do we actually,
publish our results of the safety of of
our anesthesia programs. And it's always been handicapped
because we've got a paper record. Now you
have the ability to have this in a
digital format, and you can go as you
go back at the end of the year
and say, okay. We saw 10,000 patients and
10,000 patients. One patient was transferred and no
patients were transferred. Then you can actually compare
that to how well the ambulatory surgery center
business does. And actually, when you look at
the data, the transfer rates out of of
large groups that have this type of record
are 8 times lower than what they are
out of the ambulatory surgery center.
The the second technology piece is kind of
the,
the aspect of
of what's,
how the large DSOs are using electronic health
records
to, to kind of build their platforms.
You know, having been in medicine for a
long time, if you go from one hospital
to another to another, you have to jump
you have to take, you know, 60 hours
of education to learn how to use a
different computer system. I was kinda getting that
way in dentistry except it's not 60 hours.
So if you go from one company to
another, you have to learn the system. So
as these systems have built built up, they're
now building institutional silos associated with that brand
name.
And that that is interesting because what that
has done is it's it's be begun to,
you know, pull together a lot of stragglers.
I mean, the dental industry has always been
very fragmented, but now all of a sudden
you pull it together and you put it
on a Dentrix platform, you put it on
the Epic platform. Now all of a sudden
people can talk. You can relate. It makes
referrals from generalist to specialist a lot easier.
It makes the quality of the patient record
a lot better, but also has a lot
more demands that are put on the provider
and the provider team to be able to
keep up with that.
Yeah. Definitely. Some very great insight there.
Last question here. What will the most effective
health care leaders need to be successful in
the next 2 to 3 years?
Patients.
Yeah. I I think,
the thing that the the younger the next
generation of leaderships got to learn, they have
to digest all these some of these workforce
dynamics that we were talking about. You know,
how how you deal with the workforce that's
very mobile. You know, can you get them
licensed? Can you transfer them? You know, can
you can you do this?
I look at some of the multistate DSOs.
I mean, it's not uncommon. The ones we
work with, we're I'm working in Tennessee. You
know, I go in every morning. I see
somebody.
Hi. My name is Sally, and I just
moved here from Texas. I work for the
same company in Texas. I'm able to move
here. So when you have common informatics into
the training of that that the company had
to do for that particular person, for that
particular location is transferable to another location. Just
kind of think of it like it's almost
like being in the army. You know, you
basically you've you had the knowledge of the
particular,
platform that you're working on. You easily can
transfer. You step in, you're ready to go.
You don't have to be retrained. That's a
big deal. I think also the only thing
that that does, that also when you look
at the growth of these companies, whether they're
doing de novos or whether they're doing acquisitions,
if if I'm if I'm basically acquiring practices
and they're on the same electronic platform design,
it's going to make that merger, that marriage
a lot simpler and a lot easier.
And I think that's that way, it's a
lot easier to
to expand and to kind of prepare yourself
for an acquisition if that's that's what you're
the business are doing.
I think, you know, the the the other
thing you're asking about, what I was excited
about, what I was nervous about. The other
thing I I guess I'm kind of nervous
about is kind of the future of the
solo practitioner of the dentist.
You know, when I went to dental school,
that was kind of the gold standard. That's
what everybody aspired to be because that was
how dentistry is practiced. And I think, you
know, the effective labor cost and the cost
of cost especially the cost of health care
insurance and so forth, it's pretty much made
it nearly impossible for a solo practitioner
to kind of know everything there is to
know
about about the business, about,
about running the organization because it's gotten a
lot more complicated over the over the years
I've been in it.
I think the last thing is kind of
the,
the the leaders are gonna have to understand
how to
build their organizations
to be able to capture,
this this nomadic mobile dental workforce, whether it's
the assistant hygienist or the dentist or the
specialist because everybody seems to be moving around
a lot more.
I just read an article where it it
said that the,
you know, a great number of physicians coming
out are now basically going into,
into locus positions to start out because they're
not sure what they wanna do. Their decision
making I think this is kind of true
of the COVID population too. A lot of
the people that trained in the COVID area,
a little bit indecisive. They may not feel
is is ready for prime time when they
get out as other people, and so they're
looking for mentorship or they're looking for a
way to be able to hook up with
somebody for a short period of time to
prove their skills, increase their confidence before they
go out into the workforce.
Yeah. Definitely. Wanted to go back to a
point that you made earlier about solo,
practice. I know you said that you're nervous
about the future of solo practitioners.
Do you see, in your opinion,
a good amount of dentists still striving for
solo for solo practice, or do you think
that number has kinda gone down?
Yeah. I I think it's I think it's
going down.
I I think it's I've always I've often
said that the the total cash dental practice
is an urban legend. We I think a
lot of people come out of dental school,
and that's what they think they're getting into.
And then they get out into the real
world, and they find that that's really not
how this industry is going.
This industry is so so driven and shaped
by by dental insurance, from the standpoint of
the, you know, the PPOs. And certainly now,
in my career, I've seen a lot more
coverage on the on the government side, you
know, through through Medicare and and Medicaid, of
course. You know? So there's this huge population
of people that that need treatment that are
in those in those,
in those,
payer sectors, and and and somebody has to
be the provider of choice for those particular
people. And if you're a a solo practitioner,
you know,
needing to collect it, you know, a huge
a huge fee for a service,
and that's that fee has to be 3
times what the average is or 4 times
what the meds fee value is, it's it's
it's very difficult to stay alive in that
situation. So, I mean, I think a lot
of people aspire to do it because they
don't like the hassles of dealing with insurance.
But I would say this, it it did
say over the years I mean, when I
when I left academics and I went into
private practice, we we spent a lot of
time kind of sword fighting with insurance companies.
You know? Is it covered? Is it not
covered? Is it medically necessary? Is it not
medically necessary? And all that stuff has kind
of evolved, but it's it's sure taking a
lot longer than I ever thought,
because now if you come in and you
say, I need to have a crown. Okay.
Are you eligible? Well, you can figure that
out electronically before you've been there. You can
figure out in a matter of seconds. Next
question is the code coverage. Yes or no?
Asterisk. Well, it's based on medical necessity.
Well, if you're if you're in business and
you're trying to say, can I deliver this
service? Am I gonna be paid? Well, I
don't know. You know? So that that's a
very, very difficult problem for a sole practitioner.
Now when you scale it up and you
have large databases and you're running across multiple
states and you know how you've profiled all
of these insurances and you understand how they're
gonna behave, all of a sudden that that
task can be greatly aided by AI. But
you can say, well, how about a guardian
person working at Sikorsky Aircraft in Connecticut with
in this plan? What's it gonna be covered?
All that information is now being shared because
the the payers have learned that it takes
too much money to answer the phone, answer
the questions. And even even with bots, it
doesn't seem to make a difference. But if
you go ahead and make it accessible, it
lowers the cost of both ends, and that
I think is gonna be the driving force
going forward. I think by myself, it will
be much more transparent.
But, you know, it it just it takes
a lot longer to get there.
Okay. Yeah. Definitely a great conversation here. So
thank you so much for joining us today,
doctor Carter. It was,
a great pleasure speaking with you, and I
look forward to connecting with you again in
the future.
Okay. Thanks for the opportunity. Have a good
day.