S3 E06: Dental Industry Predictions for 2024

Wright: [00:00:00] There are so many big questions facing our profession right now, from the current state of the dental workforce and overall economic outlook to new clinical breakthroughs. It can really be hard to keep up. Hello, everybody. I'm Dr. ArNelle Wright.

Ioannidou: [00:00:14] And I'm Dr. Effie Ioannidou. So what's in the store for dentistry in 2024? We are about to find out.

Wright: [00:00:24] Yes, we are. But before we do, and before we jump into today's episode, we want to invite everybody in our community to find us on all platforms, wherever you get your podcasts. So if you like to listen to this on YouTube, make sure you search for the American Dental Association and click the podcast tab and you will be able to see all of the things that we are doing here at Dental Sound Bites

Announcer: [00:00:50] 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's daily wins and sticky situations.

Ioannidou: [00:01:06] This episode’s topic and guests are always fascinating. So we are excited to have Dr. Marko Vujicic back. Marko is the Chief Economist and Vice President of the Health Policy Institute of the American Dental Association. I know Marko quite well, and I know he's going to be amazing. So welcome to our show, Marko.

Vujicic: [00:01:26] Thank you. Great to be here.

Wright: [00:01:27] Yay. We're so glad to have you. Yeah. So Marko, for some of our newer listeners, can you tell us a little bit about yourself and what you do and all about HPI? Tell us a little bit about that.

Vujicic: [00:01:39] Sure. So I have the pleasure of leading the Health Policy Institute at the American Dental Association.

I'm trained as an economist. I've worked in healthcare my whole career. For the past 12 years, I've had the pleasure of leading this group. And look, to put it bluntly, we are data wonks. We are statisticians, economists, health service researchers, survey experts, et cetera, and we're best thought of as a think tank housed within the ADA that focuses on dentistry. So we try to use data and research to look at emerging trends in dentistry. We think a lot about the future where the sector is going. Nothing clinical. We're not clinicians, but we look at the market for dentistry and have a whole bunch of insights. I want to share with you. 

Wright: [00:02:23] I'm so excited to get into it.

Ioannidou: [00:02:25] It's amazing. I'm like dying for this because it really helps us make decisions about career paths and all this. And this is so useful for young dentists. So yeah, let's just dive into this. And tell us, Marko, what should we expect for dentistry this year? 

Vujicic: [00:02:40] Great. So again, we're, we're really rooted in data. So I'm happy to share this is the first time we're sharing this data. We polled thousands of dentists each month. And in our last month, we asked them two things I want to share with you. One is a little bit like what's keeping you up at night. So we asked them looking ahead to 2024, what are the main challenges you see facing your practice?

Then the second thing we asked them, what do you intend to do next year to kind of adjust to some of these trends? So let's get right into it. In terms of the top three challenges that dentists are saying they're facing looking ahead to next year. Number one, this is a big one. Staffing shortages, recruitment, retention issues. Sixty percent of our dentists out there said this was issue number one.

Number two on the list was dealing with low insurance reimbursement, denials, administrative issues related to third party payers. That was a big issue at number two. And the third one is what's keeping them up at night, rising overhead costs.

Now, when we look to what didn't make the top list, I'm going to go to the bottom of the list in terms of so called what's not keeping dentists up at night. And it's anything related to patient ability to pay, that was interesting, that did not, that came to the bottom of the list, so it wasn't a huge headache, so to speak.

Competition among other dentists and DSOs, that didn't come up as a huge issue, that's at the bottom of the list. And finally, remaining out of network being a concern in terms of carriers, that didn't come up big. So I think these are telling us a story. Now, the interesting thing is concretely when we ask dentists, okay, look, of the various things you can do next year to adjust in your practice, what do you plan on doing?

I'll just share top level highlights here. About half are very likely, or somewhat likely, to add staff. So that kind of goes hand in hand with shortages being a big issue. Majority of practices want to add staff next year. So the demand for hygienists, assistants, front office staff is going to continue. If anything it will grow.

A big share, 42% said they are going to seriously consider dropping out of some dental insurance networks. That is a big thing that came out from our research. And then there's a big drop off. There's about one out of five that are in practices that intend to invest in some type of software or equipment.

So those are some of the big things in terms of what the data say practices intend to do next year.

Ioannidou: [00:05:18] This is first of all, very interesting data, somehow a little bit surprising, but I wonder when you stratify dentists based on years in practice, do you see differences in the issues that keep them up at night?

Vujicic: [00:05:32] Great question. On this instance, no. So we do look at the data stratified by various ways. So in terms of these top three issues, staffing shortages, reimbursement rates, denials, administrative issues with third party payers and overhead costs, that's pretty persistent and common across the board.

Like this is something that's really industry wide. That's gripping the profession. But related to your question, we also look at differences by practice type. So for example, solo practices versus very large practices, DSO affiliated practices versus unaffiliated. And there were some, some slight differences, but I think they're worth noting.

Like for example, solo practitioners were less likely to do anything than dentists who are in group practice, right? Some of those things I said, adding staff, purchasing equipment, investing in software, we saw larger groups were much more likely to be saying, yes, we want to do that compared to the opposite end solo dentists. 

DSOs as well, had some different responses. They were much more likely to say, we're going to invest in software. This is important, I think, ‘cause we want to talk a little bit about AI. And they were also, DSOs were less likely to say we're going to drop out of some insurance network compared to the smaller practices or solo. 

So I think that's interesting too. You have, kind of, these different practice models, shall we say, reacting a little bit differently to the trends that are coming and to the issues?

Ioannidou: [00:07:03] Which makes sense, right? Because I assume that the different practice dynamics can explain the magnitude of the risks that the practice can absorb in terms of, you know, new technologies, training for professionals to adapt to AI or any other thing.

And ArNelle probably has to make a comment on this because she's someone that is DSO affiliated. So I'm sure she, you, identify with some of this, I guess.

Wright: [00:07:29] Yeah, actually. So with it being across the board from staffing shortages, that's definitely something that we're experiencing over here. As far as like AI goes, it's definitely a conversation that's on the table too, to see how we can remain cutting edge and just kind of not miss that wave, if you will.

But I think it's one of those things because I'm in a DSO, there are other people who are at the decision making table. And so, oftentimes we are not understanding or even seeing how those decisions are being made or what's being decided upon until it's already happened. And then it's kind of like you go with the flow and say, oh, okay, well, I'll adapt to this or that.

As far as, like, purchasing certain equipment right now, my office is fully stocked with the CBCT. So that's something that we don't have to purchase because we're already using that. But I'm definitely looking forward to whatever changes are going to be made and just try to be ready for it when it comes.

Vujicic: [00:08:23] And an economist would agree with both of you, right. In terms of, you know, scale and size helps you spread risk. And it also gives you access to capital for these investments. Like this is not all cheap, right. In terms of equipment and practice management software and AI, you know, the larger you are, the more you can spread that across and gain those, what we call economies of scale in economics. So exactly. Your personal experiences are right in line with the economic theory, which doesn't always happen. So when it does happen, it's good. We'll, we'll take it. 

Wright: [00:08:55] So we're excited, right? We'll take it.

Ioannidou: [00:08:58] But you know what, I'm surprised though, Marko. I would, and the reason that I, obviously, I'm sure you, you got this, but the reason I ask about the, years in practice stratification of the data, I would expect that the more junior practice practitioners are the more, they kind of wake up and face the amount of loans that they have to repay. I would think that this, the loan repayment thing, would be one of the major things that keeps them up at night. But perhaps, you know, it's, they have a more realistic approach and the day to day needs in the practice are the priority.

Vujicic: [00:09:32] That's great. I know we wanted to talk about student debt a little bit, but let's talk about it now because I don't know, I have a little bit of a different take and I don't want to get in trouble here with the dentist listening, right? Because we respect all anecdotes and personal stories, but the student debt issue is one of those where, like, the research, to me, is somewhat inconsistent from what you hear from dentists out there. And I'm not saying one is more valid than the other, but you know, we've done a lot of research. We just published a really nice analysis looking at dentists in different types of practice models, like small practice, large practices, unaffiliated, affiliated in FQHCs, private practice, et cetera.

And we generally found – and these were only early career dentists we studied, so it's not like it was seasoned dentists, it was people less than 10 years out of dental school – the debt levels were honestly very similar in all these settings, which goes against everything we hear, right? In terms of, oh, I can't do this because of debt. And I'm, you know, I can't work in a public facility because of debt, or I can't take Medicaid because of my debt. And the research we've done in previous years kind of shows that. The effect of debt, once you control for things like age, race, gender of the dentist, whether you come from a family of dentists, once you adjust for that, the effect of debt is really small. And for many career decisions, it's zero. 

So I, as a researcher, take that as I think we sometimes overestimate how much student debt impacts career choices based on the research. I don't want to discount any personal experiences at all. So, that's not to say we shouldn't do everything we can to reduce student debt. You all know the American Dental Association is committed to that. We lobby like crazy to try to get student debt relief. It's a good thing, right? But I don't think it's the key driver of a lot of these practice trends we're seeing.

Wright: [00:11:31] While you're there, can you tell us, when you looked at the research for the early career dentists and you said, you mentioned about decision making, so debt not being something that's related to decision making. And just correct me if I'm understanding this incorrectly, but what is it that you're looking at as far as the decisions go?

Vujicic: [00:11:48] So this last study we released this year was simply the practice modality you are in. So it's something we called affiliated practice would be one category, where it's a DSO or some large group where you have, you know, other non dentists helping with the management side. Or unaffiliated, which is kind of like your classic, let's say practice model, including solo practice in small groups where like the dentist is running everything.

And then we had FQHC dentists as well, FQHCs as a setting. And then we had like other. But previous research, when I talked about career decisions, right, where things like, do you own a practice? That would be one career decision. Do you accept Medicaid? So I'm mixing a whole bunch of research, but the newest stuff was really cool because it's based on a huge sample of early career dentists, less than 10 years out.

And we got some really good insights there.

Ioannidou: [00:12:40] I like this because just to spell it out. So the hypothesis on this would be that the magnitude of the student loans do affect your career choices, right? And your work shows that it doesn't really affect the career choices.

Vujicic: [00:12:55] I would characterize it, it affects it slightly. And much less than other characteristics. Like simply race of the dentist has a huge predictor on what type of practice model you're in. Whether you take Medicaid, whether you're in a rural area, etc. Same thing with gender or sex, female versus male dentist. Huge thing.

Wright: [00:13:13] Can you dive into a little bit of that while we're here?

Vujicic: [00:13:16] Yeah, well, the gender aspect or the sex aspect is, there's clear data. Like, female dentists are much less likely to own a practice. And that's controlling for, like, age and specialty and things like that. They're much more likely to be in larger groups and in affiliated models such as DSOs and other types of affiliated models.

Those are a couple of things. They're more likely to accept and treat Medicaid patients as well than male counterparts. That's pretty clear from the data. So given that 56% of the incoming dental student body is women, like, this is not even 50/50 anymore, right? Like this in the data are clear.

This is a, this is a majority female, well, soon will be a majority female profession. I think we're going to see, because of this and other reasons, an acceleration of these trends in the practice model. Shifts that I've been talking about, and my team's been publishing. I think we're at the early stages of this movement of practice consolidation, where dentists are working in larger groups, whatever shape or form that group is, right?

Dentist owned, private equity owned, there's all sorts of flavors of this, but bottom line, dentists are more and more likely to be in larger groups, to be affiliated with other locations, to be affiliated with companies that help them with the non clinical side, and are less likely to be working alone.

That's just very clear in the data. And I think it's going to actually accelerate in the next five years.

Ioannidou: [00:14:43] So great information. You know, you make me think as you present this data, which is brand new, and I'm so glad that we're having the conversation. You make me think that with this specifically with the gender data that you brought up and the demographic change in dentistry, and you know, you said within the next perhaps decades that we will have a majority, the feminization, as they used to say, of dentistry.

Vujicic: [00:15:04] Vujicic: We need a, we need a better word. I mean, I should probably know what the right word is.

Ioannidou: [00:15:08] Yeah, I know. I hate this.

Vujicic: [00:15:09] It doesn't sound right.

Ioannidou: [00:15:13] Something negative. Yeah. When they were talking about the feminization of dentistry and the papers that were written, they incorporated some negativity as to what dentistry will become, you know, with limits. And then they follow the female work ethic, which is compromised compared to the more male work ethic. Right. And people ignore the social demands of this model. Right. Given the fact that the expectation socially is that, you know, you have to take care of kids. You have to take parental leave, you have to, there are so many needs for this model to be successful because the expectations of how people perceive a work ethic based on this, but mostly on the need for appropriate workforce policies.

So if indeed we extrapolate the data that Marko presented, and we in the future see more people going into consolidated models and DSO type of models, then we would expect those work models to be developing policies that support 56% demographic of women. So I'm glad that you're bringing this up.

It's really a very important conversation.

Vujicic: [00:16:17] There's a whole episode on this we can do, right? But I would also just say the expectations are changing. Even these, you know, this idea of taking time off of your career, long years for childbearing and all that, all that is changing with the next generation of young professionals.

I mean, many, many women dentists are the main breadwinners in their family. That wasn't the case a generation ago. The dynamic of two professionals in a household marrying each other is different than the generation previous, where maybe there was a dentist breadwinner and then somebody who wasn't working or was doing some much lower paying job. All that’s out the window.

I love your point. Like these trends are, I don't think applying, kind of, those differences in sex we've seen in the previous generation to this current generation is valid, because I think all the lines are being blurred and rewritten. Like we see young male dentists also less likely to own a practice today compared to 30 years ago.

Right? So the, like I gave the, there's stark differences between female and male dentists in terms of their probability of owning a practice. But a 30-year-old male dentist today, is far less likely to own a practice than a 30-year-old male dentist 30 years ago. Right. So these are just big trends.

And then, I mean, as we look to the future, right, if we want to talk about a little bit more than 2024. If we talk about the next five years, let's say, or even the five to 10 years, I think we already talked about, there are three big trends I want to highlight, right. That I see are important for dentists and our listeners.

One is this shift in practice modality. We talked a lot about that. Larger groups, different owners of groups, different ways dentists are organizing, lots of entrepreneurial opportunities there, et cetera. That, as I mentioned already, and we don't need to repeat it, I think that's going to accelerate.

We're about to see a big surge in retirements in the next three years. Not 10 years. In the next three years as the Baby Boomer cohort of dentists, which there's a lot of, really kind of  enters those big retirement years, right? So there's a little bit of a retirement bubble we're going to have the next three years.

And that's replaced by a very large number of Millennial cohort dentists, right? We've expanded training in the U.S. in terms of more dental schools and more enrollment in dental schools. That's really, that bubble of millennial dentists is really now starting to flex its muscles. So the next three years is going to be really interesting in terms of that turnover. A generational shift. Yeah? And that's part of what's driving this practice consolidation.

The complexity of running a business in dentistry is also another thing driving this shift. Like it is, you know, you were mentioning ArNelle, right? Like you have a person that does procurement, that does third party payer relations, that does HR, marketing, those are all specialized functions, right? So with the complexity growing, it's harder and harder for, like, a dentist to manage all that in their own practice, right?

The second big trend, let's totally shift gears, is happening on the patient side. Or if we want to call them consumers. But there is a shifting paradigm in terms of patient expectation. Just as we're seeing kind of the turnover in dentists in terms of that shift from Baby Boomer cohort to Millennial. On the patient side, same thing happening, right. Baby Boomer patients being kind of replaced by Millennial and Gen Z, which have a different set of expectations in terms of interacting with.

All healthcare providers, not just dentists, right? And you know what I'm talking about. This is like, I don't want a phone. I don't want to telephone somebody. I don't do that anymore. I want to connect by text or by some app, et cetera. Am I in the habit of booking things out constantly and then adhering to my bookings? Or I just say, hey, it's time to go to the dentist in the next month or the next week or whatever, right?

I'm giving maybe an extreme example, but that consumerism trend, to me, is the next big thing reshaping healthcare, dentistry included, like we're going to see a disruption, this Amazonification, so to speak, of healthcare, and dentistry is a little bit kind of caught up in that as well.

And the third one, which kind of relates, is the technology revolution. I think the, you know, AI certainly is the big thing now in the next year, right, year to three years. But I see some significant shifts coming in, like, workflows in the office, for example. I think AI can help even address the staffing shortage.

It can certainly help on the patient side, right? Like if I want to, you know, I'm like the world is coming where, just like OpenTable, right? Think about how we used to book restaurants or maybe some of us still do, right? By calling and saying, okay, when do you have a table? You know, now it's like, okay, I want a meal tomorrow night. Let me quickly see what's available. And like a few clicks is all I have patients for in terms of a booking.

So we're seeing a lot more innovation in dentistry, like companies that are helping dentists with that online instant booking, right? AI is helping, you know, we had the first big innovation I'd say in automated radiograph reading, automated dentist notes and physician notes is one of the next ones. But I could quickly see, like, you know, front office tasks being automated as well.

So just to summarize those big three, before we kind of open it up, that shifting practice models, number one. Shifting patient expectations, number two. And the technology revolution, number three. I see those as the next kind of on a five year horizon, some big trends.

Ioannidou: [00:22:17] As you are talking about the AI in the front office, I wonder if you know, we will reach a level at some point that large dental offices will become like airlines, that you will never be able to speak to a human person. Like you call to rebook a flight and before you say 25,000 times “representative,” you are just a director called correctly, are you calling about this or that? Are you calling about the flight? Filling or periodontal disease. And you will be saying period, uh, feeling, and they will be like, I don't understand exactly what you're saying. Do you mean filling? So do you see this Marko happening? Like ever at some point, like, how do you predict the future?

Wright: [00:22:59] Are you going in circles?

Vujicic: [00:23:00] ArNelle, are you going to chime in on this? Maybe you've seen this already. I don't know. 

Ioannidou: [00:23:06] Really, you did that now? Oh my God.

Wright: [00:23:07] Yeah. Well, I was going to say, this is a disclaimer and this doesn't not to make any, anyone in any specific practice modality feel a certain way. But, I've know some DSOs, like whenever I try to do a doctor to doctor, for other practices that are nearby, like I have to really, really dig for a number or, and really listen to all of the prompts. And I'm on the phone for, I don't know, five, seven minutes before I can get a human on the phone and that has just driven me crazy. 

So now, in some of my meetings, whenever there's, like, other doctors there that I know that I, like, do patient sharing with, or if they refer and I refer back to them or whatever, I get their phone numbers so that I can send them a quick text.

And like, I know that we've always had that ability doctor to doctor, just to text each other. But sometimes I'm like, I just want to be respectful. Let me call the office. This is something maybe the doctor doesn't have to deal with. But now I'm just like, no, I need to text you because I can't get anybody on the phone. So I feel like there's an increase in this. What are your thoughts, Marko?

Vujicic: [00:24:08] I agree. And look, I mean, I'm the guy that is, like, at the checkout with the human in the grocery store, right? So I avoid self checkout. I am not into automation or I'm not a technology kind of file, so to speak. Right. But I, I mean, I recognize, I love your point though about like, okay, I can't talk to a human anymore, right. I think the key question is, look, did you get what you need? Right. The technology is evolving so fast that frankly, I don't even know half the time if I'm talking to a real person. Right. When I phone airlines or some other.

Ioannidou: [00:24:42]Many times you think you are talking to a real person and at some point you are like, no sucker, no it’s not a real person.

Vujicic: [00:24:48] Or you think you are, right. And you don't know. But look, I'm not an expert in this area and there's lots of innovators that are going to solve these problems.

But I will say very clearly that the pressures to reduce costs and to get more efficient are going to intensify, because the three to five year window is kind of, let's say a stagnating revenue patient volume side, so to speak, with this increased cost pressure, right? Because of staffing and equipment and all these other things that drive up overhead, like this came through loud and clear in our survey, right?

Is there rising overheads a major issue? And our data show, right, the dentist's earnings are there. They took a hit last year, but you know, last decade, they're roughly flat, let's say flat to slightly down. And that's because the cost side is rising faster than the revenue side, right? So there's no huge, like expansion of the patient pool coming unless something big happens, right?

The reimbursement trends, all the providers are, or most providers, complain about like are real. Like the data we look at it, it shows that after adjusting for inflation, on average, reimbursement from insurers is declining. Right. So that's very real. Now, again, I deliver news as I see it. Sometimes people like it, sometimes don't, but that's not, that doesn't matter to us as analysts, right?

My point is, like, I see those key trends, at least in the next couple of years, really staying, right, in terms of, kind of, pressure on the revenue side and this continuing escalation of cost. So the practices are gonna be looking at all sorts of ways to kind of automate or, you know, what could a machine do that, you know, what does a human need to do?

I feel that's kind of the question coming in healthcare. It's not just dentistry, right? You know, it's kind of the last field. I'd say healthcare and education. Are the last two fields that really haven't been disrupted so much by the, the technology side, so to speak. Like retail has and, okay, restaurant bookings, like we just said, you know. Think about how we shop today.

Ioannidou: [00:27:04] Going back to the restaurant bookings, because I'm a foodie and I just want to acknowledge my passion. I felt like I was one of the first users of OpenTable, like, at the time that OpenTable was nothing. And I can tell you that now that is that you're right, the trend is there, but also there are a lot of high quality restaurants that really believe in walk-ins.

So they really allow tables to stay unbooked on OpenTable. So they give the neighborhood people, the walk-in people, the people that want to experience, spontaneous, you know,have a spontaneous experience to be able to have a fair competition with, technology. And, but you know. That's entertainment, right?

Do we really want to apply the same model to healthcare? One would say that perhaps it's better to be able to, you know, speak to an automated service and describe your chief complaint to an automated service and maybe this technology will allow for the unbiased transcript and delivery of your message as a patient. The human ear carries also a little bit of a bias.

So maybe we will be able to address gender biases, racial biases, socioeconomic biases that, you know, we like it. We don't like it. Our physicians are not trained to address well, yet. Maybe they calibrated an automated non-human AI Models, if they are calibrated well, maybe they are, will, be able to really transcribe a more unbiased view of complaints, of reports, of whatever.

So I see the positive side on it.

Vujicic: [00:28:43] And look, we have a whole, I mean, I'm not an expert in this, right? Like we have a whole team in the ADA right now that is deeply looking into like, how do we make sure AI is, number one, regulated in a way that's beneficial to patients and avoid some of the potential negative consequences, like bias, right?

So if, if you train an AI based on the existing evidence and that existing evidence is biased, then, you know, guess what, right? You get, so, so there's lots of ways things can go wrong. So it's really important, you know, the ADA, we have a whole group that's, that's trying to influence the regulations on that, right?

Like, that's part of our advocacy. And also, like, how can we bring this to dentists so it's really beneficial? Like an assistant, right? Like a tool to help you. And I don't think this is something that replaces doctors in my view.

Ioannidou: [00:29:35] Which is the fear of the profession.

Vujicic: [00:29:37] I don't know, ArNelle, if you know what, what you think on this. But it's really, I think a way to completely help you as a clinician, but I'm not a clinician.

What do you think ArNelle?

Wright: [00:29:48] Actually after our most recent episode with Dr. Mina, I feel like I have a shift in my mindset. I do still have some apprehensions about the use of AI very heavily in dentistry, but I kind of feel like, even as we've been having this conversation today, it's just like, in my mind, the more you buck against what's happening, it's like you kind of will get overtaken because it's happening so fast.

Just seeing all of the technological advances, just overtaking like my timeline on social media, just seeing all the things that are happening. I can't even keep up myself. And I'm on social media all the time, for example. But I just feel like it's one of those things, like, if you are against it, you may be, I don't know, left behind, unfortunately.

So in my mindset is to try and find the positive and try to find a way that it can be integrated with my day to day, as opposed to looking up and being a late adopter, if you will. 

We'll be back.

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Wright: [00:31:45] Always great to have you on the show, Marko. I want to make a quick shift here. We've talked about some trends. Marko, you have mentioned staff. So from the very, very beginning, one of the things that you said we could expect is something centered around staff. So, I have a couple two part question.

Number one is, can you tell us the trends that you were tracking at the start of 2023 and which did you see carry through? I think the staffing shortages is one of those if I could just jump ahead. And the reason why I was so interested in this is because in season one, when we talked to you, it was 40% of practices that were hiring at that time.

But today, you shared with us that there's like a 60% in shortage. Is that also the same as like 60% of offices are hiring? That same stat from when we had our conversation in season one?

Vujicic: [00:32:33] You're keeping me on my toes, ArNelle. It's not the exact same question. Okay, perfect. But I love that you tied those together. I should have brought you the consistent one.

So, the bottom line looking at various sources of data is we've not seen much change at all since we last talked, ArNelle, in terms of the severity of the staffing shortages. And a lot of that has to do with, we have not seen, let's say a big expansion of hygiene school enrollment, assistant program enrollment continues to trend down.

So this is kind of concerning. So to your point, one of the things we said was like, this is not a short term problem that's going to resolve. It's going to be a longer term problem. And you're right. That's exactly what we've seen.

In terms of where we made some mistakes, I totally miscalled this dropping out of insurance plans. So when you look at the aggregate patient volume data, you see the patient mix. Right? You look at all people that go to the dentist in a year in the U. S. If you look at the share of that patient mix, that has private insurance coverage, like, it goes up and up and up every time we analyze this. And the share that are just, like ,cash pay, self pay, full fee patients kind of goes down and down and down.

Based on that, I was like, okay, there's going to be more dentists in insurance plans because that's where the patients are. That's not what the research is telling us, right? That these latest data I showed was, like, dentists are seriously considering dropping out of plans. And in fact, in an earlier version, a few months ago, when we asked, did you, in the last 12 months drop out of any plans, we had way more dentists that said, you know, yes, versus I joined more plans.

So we missed that. So we definitely see a segment of dentists looking to kind of, I don't know, get out of at least some networks.

Wright: [00:34:27] Do you think that that kind of correlates with the other stat that you said about dentists are seeing their patients being able to pay out of pocket?

Vujicic: [00:34:35] Perhaps. Yeah, perhaps. Perhaps something actually we need to dig into further. Thank you. We could, we could more formally study. Yeah.

Ioannidou: [00:34:44] This makes me think if indeed dentists are counting on the fact that their patients can pay out of pocket, who are these patients that can pay out of pocket? Does this mean? Yeah.

Vujicic: [00:34:56] That's a bigger thing. Right. But again. So on this, this is important, right? So that segment of fully out of pocket patients, again, in the data, it's shrinking in terms of the slice of the patient pie, right? So I don't think it's reasonable to say, Hey, new grads, all of you can be in that model, right?

Don't, don't participate in insurance. You could be boutique. That's not true. So I feel like there's always a space for all those segments of dentistry. Right. And again, I don't know individually, ArNell what patient segment you have or FEU and in UCSF, we can maybe guess the patient pool, right? But anyway, that's not the point.

The point is there's diversity. There's all types, all types of practice models in terms of who they target in terms of the patient base. But that slice of that boutique practice self pay is, the data are clear, like there's fewer of them. So competition for that among providers is going to grow. So, yes, providers can go after that, but not, not all providers.

Ioannidou: [00:36:02] And this makes me, exactly what, not all providers. And this makes me think, and I want your thoughts on this. Not all providers, because there are different geographic areas in the country. There are different socioeconomic situations in these geographic areas. So we cannot make assumptions and apply an idea to all, but what are your thoughts? Like, how do you see these trends change between locations? We talk about the demographics. We talk about race, gender, but how does geography affect this?

Vujicic: [00:36:31] Geography is huge. I'm glad both of you are raising this. I see the biggest differences on the practice modality side, but that's partly because that's where we have data.

On the patient mentality or mindset or insurance coverage, there probably are big differences. There just aren't good data that compare that in like, you know, state by state. So, an interesting thing, if we take dentists less than 10 years out of dental school that are practicing, so let's call those Early-ish Career Dentists, and I look at the percent of those dentists that are in large group practice – and by large group, we're defining that as 10 or more locations.

Okay? So this is the percent of early, early career dentists who are in quote unquote large group practice. That's 2%in Montana and it's 37% in Nevada. So these are massive differences, right? Same thing if you look at the percent of dentists of all career stages. Right. That are affiliated with a DSO, right?

That if you look at, you know, Texas, Florida, Nevada, New Mexico, this is in like the, the 30% for early career dentists. And it's next to zero in, you know, Montana, Alaska. North Dakota, those kinds of states. So again, the nice thing is all these data are available on our HPI webpage, which by the way, is it ADA.org/HPI. You can get very easy profiles state by state. We look at dentist earnings, state by state, hygienist wages, state by state. Lots of really cool information, both for practice owners and just dentists trying to get, like, a sense of what the economics is state to state.

Ioannidou: [00:38:19] No, that's very interesting.

And so what's your next step now? What are your goals for 2024 in terms of the HPI tasks and dreams? What's the next thing you're solving for us?

Vujicic: [00:38:33] Sure. Thanks. So one thing I'll be interested to see in 12 months, hopefully if you have me back. So one of the things we're, we pride ourselves on is being really adaptive and flexible.

So I'll tell you now. What we're planning, but you never know what comes up in terms of emerging issues. So first of all, we haven't talked a lot about the Medicaid population and overall access to care. So one of the big parts of the Health Policy Institute is really to examine state Medicaid policies.

Like how much are states paying in Medicaid? Like we have that for all 50 States and DC, the percent of Medicaid population going to the dentist in each state. We've got a lot of really rich data, but what we're doing is, the ADA as a whole is doing, intensive support in six states. This is to Medicaid agencies, to the state dental association, trying to improve the Medicaid program in those states.

And there's a component of my team that is trying to really bring the research to the policy maker. So like, what is it that's keeping more dentists in, you know, let's say Pennsylvania from from seeing more Medicaid patients. Like literally, what would you need to change to get more dentists involved in the Medicaid program?

If we pull the patient side, why aren't more Medicaid adults going to the dentist? Is it because they can't find a dentist? Is it because they don't think it's important? Is it because they don't know they have coverage? So not to bore you, but there's a whole exciting research program there that is gonna, not to get wonky. Sorry, not boring. It's not boring, but there's a whole research program we're doing to really try to support improving policies related to access for the most vulnerable. 

The other big thing I'll flag is we are going to be doing a summary and a deep dive into the value of oral health, but from the economic perspective. So I really feel like dental care is undersold. That's not the right word. Is undervalued. Like we all know you can't be healthy without a healthy mouth. And you can't have a productive life and well being if you're in pain or if you're missing teeth, right? We're actually going to quantify that and bring that to policy makers. So, like, what is the toll on the U.S. economy from having poor oral health? And it's really a different way of thinking about what dentists do and the value they bring to society. Like we know that 30% of low income adults have trouble finding a job in the U.S. because of oral health issues. Like that is billions of dollars of economic productivity lost because of how we're addressing oral health. And we're not really making it essential. 

So anyway, we're going to do a different little take on the value of oral health and really bringing the numbers to the economy, right? So I think that's going to engage a whole different audience on why we need to do something big. And get more people going to the dentist.

Ioannidou: [00:41:43] Are you collaborating with the global burden of disease people? The GBTs?

Vujicic: [00:41:47] And a whole other group of people that are the non-usual suspects, let's say, which is important, right? And the private sector. I'm excited.

Wright: [00:41:57] Oh, I'm so excited.

Announcer: [00:41:59] On the next Dental Sound Bites.

Wright: [00:42:01] An episode that's all about giving back. Hear from dentists making an impact locally, nationally, and globally.

Ioannidou: [00:42:08] And discover how service not only sharpens your skill, but also strengthens our entire profession.

Wright: [00:42:17] Well, Marko, it has been so good chatting with you as always. Although you don't come from the dental world, we surely do appreciate all your contributions to our knowledge and just keeping us informed. So we want to say thank you so much to you and your team. And thanks again for being on the show.

Ioannidou: [00:42:33] Marko, it's always a pleasure. I really love the conversation. I really liked the fact that we discussed everything based on data. This is so important, right? Really evidence based. It's always a pleasure talking to you.

Vujicic: [00:42:46] I appreciate it. Thanks for having me. And, we'll hopefully continue this soon.

Wright: [00:42:49] Well, before you go, Marko, can you tell our listeners where they can find all of HPI's great work?

I know you mentioned it earlier, and how they can get in contact with you. Can you leave us with that?

Vujicic: [00:42:59] Sure. ADA.org/HPI. You can sign up to our newsletter. You can get staff contact info there. LinkedIn, Marko Vujicic, just type in my name. That's a good way to stay in touch as well, but all that's on our webpage.

Ioannidou: [00:43:14] So we'll have all the resources and the information mentioned in this episode linked for you in the show notes at. The ADA.org/podcast.

Wright: [00:43:24] And if you liked this episode, please share it with a friend and be sure to subscribe to this podcast, wherever you're listening so that you can continue getting the latest episodes.

Ioannidou: [00:43:34] You can also rate it, write a review and follow us on social media. And don't forget the conversation continues on the ADA Member App. Catch all the exclusive bonus content and everything you didn't hear on this show.

Announcer: [00:43:50] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast.

You can also find this show, resources, and more on the ADA Member App and online at ADA.org/podcast.