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Recognizing Regulatory Risk in Business Arrangements Jovan Dragovic
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An MD's Perspective on Dental Sleep Medicine Edward T Sall MD DDS MBA
Jeff Burton, RN Editor Jeff is the founder & CEO of Lyon Dental. He has over 15 years experience in healthcare in clinical and administrative roles. His current focus is to help dental practices across the country with reimbursement and documentation for medically related procedures.
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Consistently Filling Your Practice Beyond Capacity Maureen E. Uy
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Five DSO Trends to Watch Craig Castelli
The consolidation frenzy engulfing the dental industry shows no signs of abating as we approach the mid-point of 2019. Here are five trends to watch over the coming years. Multi-state expansion - According to data from Henry Schein, there are over 800 “local” DSO’s with 5-19 offices in a single state, and another 80+ regional DSO’s operating in multiple states with under 100 locations. These groups will continue to consolidate, increasing the number of large, multi-state DSO’s as well as creating new national DSO’s. Flight to Quality - Gone are the days when any group with $5+ million of EBITDA or 20+ locations automatically fetched a premium valuation. Private equity investors and strategic buyers are increasingly valuing quality over scale. Specifically, they value groups who have built regional density, demonstrated strong and consistent organic and inorganic growth, strong profit margins, and the highest levels of clinician retention. Expect this trend to last, as many investors fear a recession in the next 12-24 months. Partnership Models - DSO’s are changing the way that they affiliate with practices and employ associates, moving toward partnership models at all levels. Whether it’s through joint ventures, the DSO-as-private-equity-fund approach, or the proliferation of associate-to-partner pathways, the leading DSO’s are finding creative new ways to recruit and retain talent and attract market leading practices to affiliate. Specialty DSO’s - As competition for general dentistry practices continues to intensify, investors are beginning to build specialty DSO’s. Orthodontics and pedo/ortho combinations are the hottest, but both oral surgery and endodontics have experienced their own private equity activity in recent years and all signs point to increased specialty consolidation. Medical Integration - DSO’s will continually have to evolve their service delivery models, and one early stage trend is the integration with health systems and other medical providers. Two recent examples are North American Dental Group’s partnership with the Cleveland Clinic, and Sonrisa Family Dental, a local Chicago DSO, integrating with community health providers in impoverished communities. By strategically partnering with a patient’s medical home, a DSO can leverage the benefit of networks to better share health information with other providers while accessing a more captive population..
Dear Readers, I would like to welcome you to the first edition of DentalMED Quarterly, a unique publication focused on business and administrative aspects of dental treatments that cross over to the medical space. More GPs and Specialists are offering services such as oral appliance therapy for sleep apnea, TMD treatment, and surgical procedures for medical conditions than ever before. Dental professionals have an abundance of continuing education around the clinical disease process or the technical approach to the procedure. However, there are knowledge gaps when it comes to marketing, documentation, billing, and even legal considerations that are associated with providing such treatment. The goal of this publication is to deliver relevant content from experts on these topics to our readers. Significant improvements in the overall health of patients has been made and we should do everything possible to continue this momentum. It would be a mistake to overlook some of the critical business-related aspects that often present barriers to dental practices. New procedures bring new approaches to reimbursement, referrals and other practice management functions beyond the chair. We hope to make DentalMED Quarterly a trusted resource for dentists and practice administrators. I would like to thank our contributors for their professional expertise as well as our sponsors who both have made this possible. Please enjoy this first issue and many more to come! . Sincerely,
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IN THIS ISSUE
Five DSO Trends to Watch
Letter from the editor
Craig Castelli Founder & CEO Caber Hill Advisors
In the last 5-10 years there has been increased awareness in the diagnosis and treatment of Sleep Related Breathing Disorders and the associated co-morbidities associated with these disorders. Despite this increased awareness, 80-85% of the patients remain undiagnosed. In the past, the primary form of diagnosis has been the in- lab PSG followed by a subsequent CPAP titration. When the diagnosis was severe, if time permitted, a split night PSG was obtained to expedite the initiation of therapy. CPAP was considered the “gold standard” and the majority of patients were placed on CPAP, regardless of the severity of the OSA and Oral Appliance Therapy was a secondary recommended treatment. In 2009 CMS approved Portable Monitoring (or Home Sleep testing) for reimbursement and a code was established as well. Over the next 10 years there has been a dramatic increase in the number of patients that have been tested in the home in lieu of the in-lab PSG. Additionally, there are many companies that provide home testing units to the dentist and primary care physicians, by-passing the sleep physician entirely. This trend has coincided with the rise in acceptance of Oral Appliance Therapy as a primary form of treatment for the patient with OSA as well as for patients who fail or refuse CPAP. It is clear that there are millions of Americans with OSA that go undiagnosed due to a reluctance to be tested in a sleep lab and the fear that they will be put on CPAP as the primary form of therapy. In October of 2017, the American Dental Association (ADA) adopted a policy on the role of dentistry in treating sleep-related breathing disorder, including the diagnosis and treatment of obstructive sleep apnea. This policy emphasizes the obligation and importance of dentists in screening their patients for OSA and outlines the importance of continuing education in this field as well as the need to collaborate with physicians. This collaboration is designed to optimize the skill sets of the two professions and reinforce that both dentists and physicians are practicing within the scope of their practice. Dentists are in a unique position to impact the number of undiagnosed patients with SRBD (snoring, OSA, sleep-related bruxism) by screening all their patients as part of a comprehensive medical and dental history and as healthcare professionals they have the best expertise to evaluate the oral cavity and associated structures. Once adequately and appropriately screened, the patients should be referred to the sleep physician (via a face-to-face evaluation or a telemedicine consultation with a board-certified sleep physician) for a proper diagnosis. Thus, dentists play a critical and integral role in evaluating their patients with potential sleep-related breathing disorders but require the diagnosis to be made by the physician. The advent of home sleep testing (HST) or Portable Monitoring (PM) has created some confusion and ambiguity as to who should order, perform and or interpret both the diagnostic and the efficacy studies. While many dentists may choose to utilize HST’s to assess the objective interim results of Oral Appliance Therapy (OAT), the ultimate efficacy studies should be ordered, conducted, and interpreted by the sleep physician. It is critical that the sleep physician collaborate with the dentist the timing of the follow-up efficacy study (PSG or HST) and provide efficient and timely reports and communicate them with the dentist. The complexity and comprehensive evaluation and treatment of SRBD’s is best achieved when there is open and frequent communication between the treating dentist (with the proper training and expertise) and the board-certified sleep physician. It is clear that while CPAP is highly efficacious in the ideal world that is effectiveness is compromised by poor compliance. Due to higher compliance and acceptance of OAT by patients, with respect to treatment with CPAP, Oral Appliance Therapy may be a more effective treatment for many patients with OSA. This comparison and recommendation can only be made when dentists and physicians collaborate to provide the best care for their patients. Understanding the concept of mean disease alleviation, Effective AHI, the Sleep Adjusted Residual AHI (SARAH Index) are critical when comparing the relative effectiveness of these two forms of treatment. The more dentists and physicians engage each other in this process the better the treatment will become in this age of precision medicine.
Edward T Sall MD DDS MBA Board Certified Sleep Physician and Otolaryngologist
An MD’s Perspective on Dental Sleep Medicine
Consistently Filling Your Practice Beyond Capacity Maureen E. Uy Managing Partner, Uy Healthcare & Dental Marketing | MA + PhD Healthcare Marketing Communications Candidate at Marquette University
There are so many aspects that go into running a successful dental practice, but let’s focus on one: consistently generating more patients. Most dentists don’t associate marketing with generating patients especially after they’ve been in practice for some time. However, when you add new equipment and treatments to your practice, how do prospective patients learn you have these new skills or treatments (e.g. TMJ, Sleep Services, Aesthetic Dental Services etc.)? Dental Marketing is an investment designed to counteract churn - something every dentist will experience at some point in their career. Regardless of your specialty, patients aren’t thinking about you, or what you do, until they have a problem. Then, the question becomes, How do they find you? As I lecture nationally, dentists tell me frequently they don’t know or understand the effect Artificial Intelligence (AI) is having on their practice. From smart phones with AI programming like Siri, Cortana and Google to home devices like Alexa, Amazon Echo, Google Home, Facebook Portal, Apple Home Pod, etc., voice search is becoming more powerful in mobile search as your best means for reaching patients. For those of you that haven’t updated your web site in the past three years or longer, you’ve got more to be concerned about than it just being responsive. Voice search aggregates billions of searches every day using AI software to determine what is relevant and meaningful for their users. Patients talk to these devices like they’re an omniscient, super human being. If your web site and social media channels aren’t programmed and kept current with new content, you won’t rank or appear on search results pages when someone is looking for what you do. Good examples are: Who can help me sleep better? How can I get a better or whiter smile before my (special event)? How can I stop the pain in my jaw? Is there an alternative to dentures for missing teeth? Finally, if you’re in a very competitive market, it can’t hurt having a licensed healthcare marketing agency like ours analyze your key services with Google Data to see if investing in digital advertising (e.g. Google Ads) can further your efforts to drive more patients to your practice. To contact the author: Maureen.uy@marquette.edu
RECOGNIZING REGULATORY RISK IN BUSINESS ARRANGEMENTS
Jovan Dragovic Attorney Kotz Sangster Wysocki, P.C.
Healthcare legal and regulatory risks are frequently not obvious. Like all “Physicians,” as defined in section 1861(r) of the Social Security Act, doctors of dental surgery or dental medicine must be aware of the prohibitions of applicable health care laws, including, the federal physician self-referral law codified at 42 USC 1395nn, commonly known simply as “Stark” and 42 USC 1320a-7(b) the “Anti-Kickback Statute” in order to mitigate regulatory risks. Although the foregoing laws prohibit specified conduct, it is often the relationships among health care industry participants that lead to the conduct that triggers liability. Entrepreneurial-minded practitioners often look for methods to expand their services and increase revenue. Frequently this involves exploring relationships with other health care industry participants through business ventures. Arming oneself with a general knowledge of the types of arrangements that create risk can be helpful in identifying the existence of a potential issue, which should prompt the individual to obtain professional counsel to verify the existence of, and quantify in a relative way, the risks of a proposed arrangement. For Stark, the fundamental prohibited conduct is maintaining a financial relationship (e.g. ownership or compensation arrangement) with another entity to which the physician refers designated health services (e.g. laboratory tests, advanced diagnostic imaging, physical therapy, etc.). If a proposed arrangement contemplates the physician to have an ownership interest or compensation arrangement in another entity that performs and will submit claims for designated health services, then the physician should stop and get legal advice from a health lawyer before proceeding with the arrangement. For Anti-Kickback Statute liability, any arrangement between two referral sources/recipients can implicate the prohibitions. The distinguishing feature of a kickback is generally a quid pro quo of anything of value for the referral of a patient or business. Obviously, business arrangements are seldom if ever not intended for the mutual benefit of the parties to such arrangements. This effect of the Anti-Kickback Statute’s proscriptions – capturing within its scope arrangements that are lawful – prompted the implementation of the so-called “safe harbors,” which protect participants to specified arrangements from liability under the Anti-Kickback Statute. But, not all suspect or problematic arrangements are so obvious. In recent years proposed arrangements between dentists, medical doctors, and durable medical equipment suppliers, especially in the area of sleep medicine, have increased. Arrangements of this type implicate anti-kickback concerns and justify reminding industry participants of the federal government’s somewhat longstanding view on contractual joint ventures. In 2003, the Office of Inspector General of the United States Department of Health and Human Services (“OIG”) in its Special Advisory Bulletin reiterated and expounded on its assertions set forth in its 1989 Special Fraud Alert addressing contractual joint ventures between health care industry participants. The OIG identified certain “indicia of suspect contractual joint ventures,” including: (1) the health care provider engages in a new line of business; (2) the new business relies predominantly on existing patient base; (3) the incurrence of little or no bona fide economic risk by the expanding provider; (4) one joint venturer is a would-be competitor of the new line of business of the other; (5) the joint venturer who would otherwise be a competitor provides many key services to the new venture; (6) the practical effect of the venture is to provide the health care provider with the ability to bill and collect for business that otherwise would be provided by the other joint-venturer; and (7) the parties to the arrangement may seek exclusivity through restrictive covenants like non-competition provisions. Most significantly, the OIG advised that safe harbor protection may not be available for such suspect contractual arrangements even if the various contracts making up the arrangement individually could satisfy the requirements of the safe harbors. As a result, there is more pronounced risk attendant with contractual joint venture arrangements between health care industry participants. The key concept to take away from this is that careful analysis of any proposed arrangement between health care industry participants, such as doctors of dental medicine and surgery, should be performed with the assistance of experienced health care counsel.