S1 E4: A new day for dentistry

Transcript

Wright [00:00:00] Hello. Hello, everyone. I'm Dr. Wright.

Hanlon [00:00:02] And I'm Dr. Hanlon.

Wright [00:00:03] And we want to welcome you to Dental Sound Bites, an ADA podcast where dentists address the solutions to challenges in both life and work. Today, our conversation is going to be on the topic of dentistry is changing and why it really is a new day for dentistry.

Announcer [00:00:21] From the American Dental Association. This is Dental Sound Bites created for dentists by dentists. Ready? Let's dive right into real talk on dentistry, daily wins and sticky situations.

Trends impacting dentistry

Hanlon [00:00:37] Today. We're talking to Dr. Marko Vujicic, chief economist and vice president of the Health Policy Institute at the American Dental Association. We love talking to Marko because he has so much great insight into everything that's happening in our industry. So, we're really looking forward to doing this episode. We're going to examine some of the trends and how they'll impact the profession. Everything has been changed quite a bit. We all know that. But how are things changing and what does it all mean for the future of dentistry? A look at the new opportunities and challenges and what every dental professional needs to know now to navigate a new day for dentistry.

Wright [00:01:11] Welcome to the Dental Sound Bites, Marko.

Vujicic [00:01:12] Pleasure to be here. Thanks for having me.

Hanlon [00:01:14] You know, some of us have really known you for a long time, but can you tell the audience a little bit about yourself and what you do?

Vujicic [00:01:20] So, I've always been passionate about bringing evidence and data to practical policy debates, and I've done that in various aspects of health care. I lead an amazing team of analysts, researchers, economists, social science researchers, psychologists, you name it. We have all sorts of skill sets in a group called the Health Policy Institute at the ADA. And we're kind of the numbers people. We're looking at what the data are showing about trends in the dental care sector.

Dental workforce data

Hanlon [00:01:49] So, let's dive into the latest research and data about the dental workforce. What can you tell us about the dental population?

Vujicic [00:01:56] Something we're really proud of here at the ADA and in my team is we have monthly data collection, so I'm bringing you stuff that's basically in real time. The latest numbers show that we're at about 90% of pre-pandemic patient volume, patient flow. That's pretty good. Given where we were a year ago or even six months ago. That has been kind of flat the last few months. And some of the indicators are showing that we're probably in a holding pattern or a new normal in terms of foot traffic in dental offices. But issue number one, loud and clear, is the hiring challenges in the sector. So, we have the latest data show about 40% of practices are in the market to hire either an assistant hygienist, front office staff. Those are huge numbers. And when we ask them how challenging is it, 90% plus say that it's nearly impossible or very, very difficult. Right. So I think, honestly, where we are today is the patient side has recovered quite healthy, I would say, throughout this whole last two years of the pandemic and post-pandemic, if we can call it that. But issue number one that's really affecting practices is this workforce shortage. And it's kind of across the board. We can talk a bit more about that. This is large groups, small groups, you know, rural areas, urban. It's even worse in rural areas, practices. Honestly, there's a major shortage out there.

Hanlon [00:03:23] So, what is at the heart of it, Marko, is it just people in general don't want to go back to dental offices after COVID?

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Dental offices after Covid

Hanlon [00:04:14] So what is at the heart of it, Marko? Is it just people in general don't want to go back to dental offices after COVID?

Vujicic [00:04:22] People are reevaluating the place of work in their life. Great resignation or a great reset or great rethink or great upgrade. I've heard so many of these terms. And we're still we're still going through that. That's economy wide. Right. And that is biting. In dentistry, for example, we've lost about 5% of the hygiene workforce compared to pre-pandemic, been kind of early exits, early retirements or not wanting to work as a hygienist anymore or not wanting to work, period, etc.. On the training side, the latest data show that in hygiene programs, we've we've recovered to pre-COVID levels after being down for a couple of years, but we're not seeing any upward trend. And you look at existing programs, there's been a long term downward trend. Right. So part of it is just the workforce behavior changing in terms of choices. And that's not dentistry specific that's going on all across health care and other jobs. You see it everywhere, right in the economy. But there is kind of slow, I would say stagnation or downturn in training programs. When we look at this as as economists, I mean, you don't need a Ph.D. in economics, which I have. This is not a situation that's resolved overnight. I think this is this is going to take multiple years, in my view, to kind of work through this shortages. And I mean, you are both dentists, there there are a lot of you know, people are trying to find what are technology solutions that maybe can can replace some labor. What are ways to more effectively use the workforce for efficiency gains? A lot of companies or I see popping up with, you know, basically temporary staffing in innovative ways. So, there's a lot of innovation there. But practices are really hurting for staff and that's one of the reasons keeping that patient volume down. I want to highlight that too. Like when we asked practices, why aren't you seeing more patients in your practice this week? There tend to be two camps right there. There are those that say, well, it's patient cancelations or not enough patients making appointments, but there's a significant share, up to one third of practices saying it's because I can hire more staff if I can hire more staff. Dr. Wright, you're in the field and with you, Dr. Hanlon, too, if that resonates. But that's what the data show.

Hanlon [00:06:36] We're even seeing practices that we've turned the hygienist into a two chair producer because they're motivated, entrepreneurial and and want to be treated like the dentists. And in our view, we actually prefer to see a proactive hygienist and team together. And we've had really good success with that because that the team is making more money and we are also showing increased benefits in our small group of practices that where we're running in, and that's making a difference too. So I wonder if these few things that we could do. I mean, dentistry has never thought about paying benefits or never thought about, you know, providing extra, you know, whether it's learning services for their team, anything like that for the staff. And I think it's time that we start looking at our team as as a true team and we are running small businesses, so let's treat them like that.

Driving retention among dentists and the dental staff

Vujicic [00:07:31] I'm so happy you raised that because we we recently released in September a pretty in-depth report looking at what drives retention among dentists, dental assistants and dental hygienist. And I really want to underscore, Dr. Hanlon, what you say, because the research is crystal clear in support of what you just said: culture, benefits, growth opportunities. Those are the three factors we found are very strong in driving retention and recruitment. And I got to tell you, there was something that really surprised me on something that I just took for granted. Paid sick leave. We found that if you look at a national sample of dental practices across the country, only 45% provide paid sick leave for hygienist and 55% for assistants. So I just took that for granted. I'm like, of course you have paid sick leave.

Hanlon [00:08:23] We don't.

Vujicic [00:08:24] But there's something there, right, that I think honestly in the future environment that's going to get more and more competitive. So, you know, to the dentists, the hiring, people listening in, I mean, you're going to have to take a hard look at your benefits package. 401ks, retirement packages. We're seeing more practices start to offer those very interesting innovation. One of the larger DSOs, Peak Dental, they're offering ownership equity tracks for hygienists. That's the first I've heard. It's an example. I thought of something out of the box. Right. So talk about trying to keep somebody long term. Right. So, I'm really happy you both raised this because this issue of kind of, again, workplace culture, the benefits landscape and growth and development opportunities, you're absolutely right. This cannot be viewed anymore as like temporary, short term labor that doesn't have a long career track, no more. Yeah, we have to view this as an integral part of the team and have long term retention strategies.

Wright [00:09:22] I love that.

Hanlon [00:09:22] Couldn't agree more.

Hanlon [00:09:23] I was actually going to ask for newer dentists in my age group, even those that are not owners yet. Like with the data that you're going to present and the conversation that we're having today, where should we focus in and how what should we extract from this conversation? I know we're going to talk a little bit about, you know, where new dentists fall.

Trends among new dentists

Vujicic [00:09:41] Doctor, I don't know if you're Gen Y. Gen Z, I presume you're not Gen X, but there was there was there was a really interesting, just recently, a DEA, the Dental Education Association, did their survey of seniors and they found that 35% of the Gen Z cohort of graduates that's coming into the profession plans to go into a DSL and dental service organization. So again, I use that more loosely. The point here is that we are seeing a big generational turnover among dentists. We have a lot of Gen Y, Gen Z dentists, we have a lot of boomers and we don't have a lot in between. So,, it's almost like there's two big groups of dentists out there. It's not like a smooth bell curve, so to speak. It's like two big factions or two big demographics. And in the next five years, a significant share of that boomer cohort is going to age out and retire. So, then we're left with a really young dentists to workforce. So, the point here is the big trends we're seeing and what the data are showing clearly is that younger dentists are much more likely to be going into group practices of different shapes, forms and sizes and multi-specialty. DSO where I'm an employee DSO where I have an equity track or large group that's dentist owned and dentist manage, where I have an equity ownership track somewhere, I don't have an ownership track. All sorts of flavors of large group practice. That is about to take off and accelerate faster than we've seen before. I'm convinced of that. 57% of the incoming dental student class is women. Only a few years ago it was 50. And so there's a big gender angle there, right? Or sex angle. And we know that women are more likely to be in larger groups than their male counterpart, dentists. We're seeing more diversification by race and ethnicity. We also know that plays into practices. That the white dentist population tends to be more of that private practice. Also legacy, maybe I plug into my dad, mom's uncles, aunts practice, etc. We're not seeing that in kind of the nonwhite dentist population. So, there's a lot of change going on. And I really see we're actually at the early stage of what I think is going to be a big transformation of the practice model.

Transitions from dental practices to DSOs

Hanlon [00:12:02] So Marko, I'd love for you to elaborate on this transition to the DSO market because being a boomer, I know that that many of my friends and all the docs that I started in practice with are heading in that direction. So, what is it going to look like? How are they going to sell their practices? Are they selling most of their practices to DSOs? I know there's a huge part of that generation who refuses to sell to the DSO. So, what what's going to happen there, do you think?

Vujicic [00:12:28] I mean, definitely that the trends are that kind of fewer young dentists out of school are going to be buying up a solo practice and practicing solo. We don't have hard data, Dr. Hanlon, and we're pretty disciplined researchers, on kind of okay of the practice sales last year, who bought them, etc. but I'm comfortable saying that increasingly it's larger groups in DSOs that are buying up the practices versus again. Now again, those are general trends, right? There's space for every type of practice model, a large group, concierge fee for service, all that there's there's space for all this. I'm giving you a big picture. 30,000 foot trends, right. It's undoubtedly going towards larger groups are increasingly the buyers there. To your point about, you know, is it a retiring dentists vision that they sold to a large group or a DSO or a quote unquote, corporate practice versus having their associate kind of take it over, etc.? I've heard lots of stories of people going through associates and they don't want to buy it. They don't want to buy it either. Like, I don't know, maybe Dr. Wright can chime in. It's just a different generation and I've given some reasons why in terms of the demographics of who's going into dental school. But there's a whole business side to right the complexity, right? As an economist, when you look at the complexity of running a successful practice today, I mean, it's exponentially changed from even five years ago, let alone 20 years ago, putting up the proverbial shingle. That was fine in the eighties. Right? You cannot do that now. You need sophisticated H.R.functions. You need somebody dedicated to dealing just with insurers, right? You need data systems. Now, think of the technology needed to run a successful practice? Its just very complex and more competitive. So I think that's a big one, too. And frankly, I don't know. I'd love to hear if Dr. Wright has hobbies and side gigs. You know, the new generation's got a lot of things they want to do after 5:00. Right. And and on the weekends instead of doing payroll. But Dr. Wright, I mean, is this resonating?

Hanlon [00:14:30] In my mind when I first became a dentist, I only thought about private practice, right? Because that's kind of all that I knew until I was approached by recruiters and things like that from the DSO world. And of course, you know, working for corporate and I say that with air quotes, it's kind of it was frowned upon once upon a time. And once I went into a DSO, I just realized all of the freedom that I had and all of the work that it takes, as you said, to run a successful dental practice. And I will say that my approach is a little bit on the fearful side and not that I want, you know, our listeners to be fearful, but just because of my background, I don't have anybody who I can go to to say, "Hey, how do I run this dental business?" When I say I don't have anybody, I mean in my family, because that's the first place that I would look. If, you know, I were going to be opening a business, I would be trying to turn some to someone who has that experience and who can just literally hold my hand and walk me through it. Now, do I have mentors? You know? Absolutely. But their time is limited and valuable. And they can't just sit with me on a Saturday and walk me through numbers, the PNL. So all of these things, I'm kind of taking a little bit of a slower approach to my path of ownership because I want to make sure that when I do get there, I don't fumbled the ball, if that makes sense, with my business and my career, how I make a living. So, you know, I get a little flack sometimes from people when I talk about it because they're just like, you should totally be a practice owner. And I'm like, in due time, I'm not pressed. I'm not in any rush because I really want to do it right. I want to do it well. And, you know, again, with air quotes, I don't want anybody to think that owning or buying into even a corporate office is wrong, because that's not you know, it's whatever works for you. But for me, I just want to make sure that I understand, you know, my balance sheet, my financial statement, like labor laws and all of these things that we just can't spend enough time learning in dental school because we'd be in dental school forever, in my opinion.

Hanlon [00:16:30] So true. So true. To that point, one of the things that, you know, I've always said, even if you do have an MBA, that doesn't guarantee you're going to understand every aspect of this business. And I think it's important for us to realize that, you know, everybody has their way even you know, if you do have some business background and you do have a little bit of a foundation, it doesn't guarantee you success. I mean, I did have a little bit of a foundation, but I made every mistake in the book so you can learn by the school of hard knocks or you can learn and have somebody consult with you and help you run the practice. But both options are definitely out there for the younger dentist to reach out for.

Vujicic [00:17:11] This is simply a natural evolution of every profession, right? Dentistry has kind of been the last one. And I know there is a group of people are saying, we got to hang on to this. And I'm like pharmacy physicians, eye care, ear hearing care, mental health now, even like every single sector of health care has been through this journey. And to me, like, honestly, I look at the research, I look at the data, I don't see like big negativity around this at all. At all. And I think we just got to honestly, like, get a grip, accept this, move on. There's all sorts of practice models. Dentists are looking for different things. There's lots of diversity in practice models out there. There's room for everyone.

Opportunities for early career dentists

Hanlon [00:18:00] Quick question for you, Curveball about, you know, the boomers are aging out of the field. Do you think that it's going to be the early career dentists who are going to kind of get a grip, take it and run with it? Is that what the data showing essentially?

Vujicic [00:18:13] Absolutely. I see so many opportunities for dentistry to really be elevated.

Hanlon [00:18:20] Yeah, let's talk about opportunities because I think that's what people want to hear about, especially the younger dentists. Absolutely.

Wright [00:18:26] Yeah.

Vujicic [00:18:27] Okay. So there are, I think, three big opportunities that I see looking our sector in the face. Right. One is how do you leverage the huge consumerism trends on the patient side? So, we talked a lot about the generational shift in providers, but there's just a significant generational shift happening in society with patients. You're getting boomer patients being replaced by millennial and let's say more Gen Xers and certainly Gen Z coming. Right. That is a different patient mindset. That is a patient mindset that prioritizes convenience, transparency, consumer centric models of care that meet me where I want to be met as a patient. The idea that the office is closed Fridays because the dentist is golfing. That's out the window. Right. That's a very old model. People want to be connected digitally to their health care providers all the time, but not necessarily physically going unless they need to. Right. So there's lots of these trends. I feel that the next generation of dentists is actually going to innovate and harness. And basically you can grow the patient base if you are responsive to kind of these convenience and transparency needs of the consumers. Right. So that's one one big area. The second big area is we know a lot of people don't go to the dentist because of cost issues either. They don't know what it'll cost and they're scared of the uncertainty or they feel that, oh, dentistry is really expensive. Now to the clinicians out there and those that study is, we know dentistry is not expensive. It's better to go now and save money later. That's not how the average person thinks, right? They look at their medical insurance, you know, do I have to pay 50% co-insurance when I go get a heart valve replaced? No. Right. But the minute you need a crown or implant, you run into those issues with the insurance model. So there's a there's a broken insurance paradigm in dentistry that the ADA is starting now to really work hard and try to fix and innovate. But anyway, there's an opportunity there, in my view, for innovations to reduce cost. There are entrepreneurs working out there like How do I make it cheaper? Or for somebody to go to the dentist. So that's the second big one. The third one I think is actually most exciting, and that is in a sense, how can dentistry break down the silos from the rest of health care and the rest of primary care? We know half the population in the U.S. Doesn't go to the dentist and as I mentioned, cost is a big issue. But for the millennial population, convenience is huge. Now think about if you had CVS or Walgreens or primary care physicians or somebody managing a pool of a patient pool of diabetics. What if they really bought into the value of oral health screenings and they wanted to get their patients into dental care? Right now, that's really hard. It's like, go see a dentist. That's very different than "On your way out, we will book an appointment for you in a network of dentists we know accepts your coverage and you can book automatically a convenient appointment time now on our app. Okay, that's a different piece of advice than "Hey, it'd be good to go see a dentist." But my point is the millennial generation of dentists and what follows. I think they're the group that are so entrepreneurial, so open to different innovations and are going to be working in groups. I really think they could bust down some of these barriers between dentistry and the rest of health care. Why are these three innovations important? Again, meeting consumers where they want to be met, reducing cost barriers and making meaningful collaborations with primary care touchpoints that's going to bring millions of more patients into the system. And that's where I feel like if there's one statistic that really grinds my team and kind of upsets us, so to speak, it's that half the population goes to the dentist regularly and half do not. Like, that is not anyone's vision of oral health in America, you know what I mean? So there's so much opportunity to bring dentistry into a new era, and it's going to be to the original question. It's going to be this generation of dentists that's going to do it.

Hanlon [00:22:54] Absolutely. So, Marko, what's coming next in HPI research?

Vujicic [00:22:58] Well, we have monthly data that's refreshed on basically the current economic situation. Some of the statistics I shared, but it look in the coming months for a larger project on how long dentists stay in DSOs and different types of practice models and what the turnover is and do we eventually own practices. So, I think that will have a lot of really interesting stuff for the profession.

Wright [00:23:21] That's going to be good.

Announcer [00:23:24] On the next Dental Sound Bites.

Wright [00:23:26] As we approach Thanksgiving, we want to talk about the mentors we're grateful for, and share tips & resources for networking, mentorship and creating community in dentistry. Plus, our special guest, Dr. Cathy Hung, on the 3 things every dentist should do for their well-being.

Hanlon [00:23:44] Well, Marko, we can't thank you enough for being with us today. I hate to have our conversation end because I think the two of us could talk to you forever. We really, we really appreciate you being here. So thank you.

Vujicic [00:23:55] I appreciate it. And if anybody wants to kind of keep track and receive new research out of my group as it comes, you can simply go to ADA.org/HPI, and there is a button there that says "Sign up for newsletter." But thank you for having me.

Hanlon [00:24:11] Awesome.

Wright [00:24:12] Thank you so much for being here.

Hanlon [00:24:13] Thanks for being here. So, everyone, if you liked what you heard today, please subscribe to the podcast wherever you are listening so you can get our latest episode.

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Announcer [00:24:33] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show's resources and more on the ADA member app and online at ada.org/podcast.