If we follow the dotted line into the future, as the economics of dentistry changes to control costs and increase access, the capitated model will increasingly become the model of choice for reimbursement.   –Dr. Marc Cooper

As we review our intentions for the future, please look at the quote above. I have placed the entire article below.

The Director of Dentistry model is not a pie in the sky concept. It is real. It is the reality that those of us older folks were trained by. It is the reality that many of my students expected when they left their residencies.  Many of them were disappointed to find that it was not the case. Is it a reality for you?

Are you assigned periodontal diagnoses and full treatment plans by someone else or are you developing the treatment plan in conjunction with that referral source? Is the prescription surgery that you are given something that you feel needs to be done or do you do it to make the referral source happy?  How do you feel when you do so?  How do you feel if you refuse to do a procedure that you in your heart of hearts know doesn’t need to be done?  How do you feel in your heart of hearts when the referral source says that he or she will take care of the perio, you just do the graft or the implant?

If you believe that this is your reality, and if you are a young periodontist, there’s more to come if Dr. Marc Cooper is correct.  And with ICD-10 codes becoming the reality for dental diagnostic reporting, is that not an indicator that Marc is correct?

And if you are in mid-career or even in the latter stages of your career, you see that the paradigm has shifted too.  Will you be able to hang on to the current practice model as long as you would like?

So yes, there will be a two-tiered system. The question is whether you are prepared to choose one tier or the other.  And I venture to say that if you don’t make a choice, if you don’t start to acquire the tools to be the Director of Dentistry, the choice will be made for you.  It may not happen now.  But it will happen.

Look.  The future of dentistry is upon us.  Clear Choice, Heartland, Aspen, and others in your area are only the beginning. It won’t stop there. The business model dictates that each of these corporate entities will survive and flourish utilizing the model of least resistance.  There is nothing wrong with adopting that model as long as you maintain your integrity within that model.

But there still is that patient, that patient who doesn’t fit that model, that patient who doesn’t want to fit that model, that patient for whom that model doesn’t work. It is that patient who needs a Director of Dentistry.  It is that patient who needs someone with the highest ethical standards, with the highest level of diagnostic and treatment planning ability to help him or her to that high plateau of dental health.  Not every patient needs that, but there are many in your community who do.

We are concentrating so much on what we do.  Let’s concentrate for a moment on who we are. We are periodontists. We are the thinkers of dentistry.  We assess biologically.  We recommend treatments that correlate to prognosis and to predictability. We communicate. We get results.

This is business. It is your desire to run your business, your practice, in the way that you know it ought to be run that is at stake here.  And your decision to take charge of that business, to learn the current tools of running today’s periodontal practice, will make a big difference not only to your bottom line, not only to the way you feel when you finish the day.  It will make a big difference to the patients who are looking for a doctor to trust.  And when that trust results in dental stability, how then will you feel?

It is scary. It is frightening to abandon what we thought was going to be the stable model that was going to carry us for the rest of our careers. But let me say this. You have some time to learn the new model.  You can do it gradually. You don’t have to sacrifice the referral sources that you work with.  But the longer you wait, the fewer those referral sources will become, the more sudden and drastic the change that you will have to endure, or not endure if the gradient at that time is too steep.

If your desire is to control your patients’ outcomes, if you feel that complex dental patients are better off seeing you for complete diagnosis, if you feel that your practice model needs to take a step in the direction of “primary care periodontist,” if you feel that the integrity of your patients and even you are being compromised by catering to the whims of others and you want to change that, then this is the time to begin to make that change.

Will the change be easy?  It will be easier now, while there is still time.  And frankly, and I can tell you this from personal experience, it will be a lot of fun.

Lee Sheldon



(reprinted from a broadly emailed essay from Dr. Marc Cooper)

If we follow the dotted line into the future, as the economics of dentistry changes to control costs and increase access, the capitated model will increasingly become the model of choice for reimbursement.

Dentists, solo or group, respond to economic incentives. In a fee-for-service practice (FFS, pay-for-procedure), dentists tend to diagnose and treatment plan more high-end restorative care and cosmetic procedures than they would in a capitated program. In a capitated program, patients receive fewer high-end restorative procedures and less cosmetic dentistry. The intention of capitated programs is to blunt the overuse of incentives for fee-for-service.

In a capitated program, there is stronger emphasis and responsibility for dentists to manage the patients’ risks – risks associated with lifestyle, predisposition to caries and periodontal disease and other diagnosed conditions. In a capitated program, dentists will also have the responsibility to prudently use defined reimbursements from 3rd party, government and very limited out-of-pocket, assuming greater financial risk. So capitation shifts more risk, oral disease risk and financial risk to the dentist, while reducing cost and increasing access.

The heritage of dentists is based on payment for services around the individual encounter (i.e., FFS). In contrast, capitation dissociates physician reimbursement from the patient encounter. An organization, a group of practitioners, or a single dentist contracts to deliver care for the individual patient for a defined interval of time. Payment is made prospectively on a “per-member-per-month” (PMPM) basis for a contracted number of months.

As the payment system moves toward capitation, dentists who have established and sustained their practices based on fee-for-service will have a difficult time transitioning into a capitated model. Solo practice and small partnered practices will have the greatest difficulty.

I realize that capitation was tried before in dentistry and failed. But that was then, and this is now. Given the issues of access and cost, given the leverage of third parties and government, the chances of success of capitated programs are much greater than before.