88: Dentistry Is Where Primary Care Was in the 1980s and Group Dentistry is the Disruptor, Elevating the Quality of Care with Mitchell Goldman, CEO, Mid Atlantic Dental Partners

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When I was working as an associate right out of school, I never imagined I could own these many practices with this amount of support. So thank you.

You have helped build my marketing mind

to a whole new level.

You have this natural talent, this unique ability.

And welcome to another episode of DSO Secrets. I'm your fearless host, Emmett Scott. And today in our DSO CEO series, here we have Mitch Goldman of Mid Atlantic Dental Partners. Mitch, thank you so much for, for being on the show today. I really appreciate it.

Thank you for having me.

Well, there's lots of questions for CEOs out there, and so we're having this series here to ask those questions. But, Mitch, why don't you give us a little bit about your background and how you went into the dental. How you got into this dental space.

Well, the dental space. How I got in the dental space is a long story, so I'll keep it short. I was a healthcare lawyer for 35 years with a practice that I started from scratch during the time of HMOs, and this was in 1980. So I've got a lot of history, a lot of miles on me.

So you have a lot of wisdom around health care, right?

I do. I've seen a lot of change and I've. And it's been a very, very important part of how I came to dentistry because I've seen the changes that have happened in the dental, in the healthcare field generally, and they're all applying now to what I see in dentistry. But I practice healthcare law. I built a practice around three different areas. One was all in payment and reimbursement. I represented providers, mostly medical doctors and hospitals, but a handful of dentists as well. And at the end of my career, I actually represented a DSO that had some payment issues. And we, we were able to help them as well. And that's what kind of got me focused on, wow, this is kind of interesting. This is where I kind of looked at the dental industry and said this is kind of where primary care was in 1980. I have a very strong feeling about the importance of group practice across the healthcare, healthcare spectrum. It really doesn't matter. Where solo practice is very, very difficult when you have high cost technology when you have a market driven program. So let's talk about primary care in 1980 and let's look at dentistry now. It's the same kind of issue. A lot of solo practice, a lot of focus on. How do I describe it? It's small scale. And what's happening in these industries is as soon as. As soon as something. I apologize.

Oh, it's probably one of your docs calling you.

It could be, but this could go on for a while. I hope it doesn't ruin the entire activity here of.

Should I just.

You want to stop it?

No, you're fine. You're fine.

In any event, the long story is, the short story is group practice. Dentistry is something that is very late coming to where healthcare is. Okay? Because if you take a look at every specialty across the medical field, every specialty is in a group practice model. Why? Because number one that no one talks about is group practice. And the studies all show it across every profession. Group practice has better quality. And I think the most important thing about quality in dentistry is we need to focus on it. It's one of the most important pieces of the puzzle. If you don't have enough resources to stay current in the technology, to stay current in the research, to be able to buy properly and to be able to manage the business side, it's hard to deliver high quality.

I mean, you're going to get us right into a controversy here. So I'm going to go there with you. So you've got this amazing background which I actually think is really cool to have here on the show because you've been in healthcare for a while longer than probably most of our listeners, frankly. And part of what you said, and then we'll get to the quality side, is that you said, I've already seen this song and dance before. I think a lot of us in dentistry feel like this is the first time this has ever happened and definitely feel like it's. It's the first time for us, so to speak. So you're saying this has been going on for a while. We've just lived in a more protected bubble from it in general. So are we not the first healthcare industry to have group practice start to come together?

Far from it. Right? I mean, take a. Just let's look at what we know, okay? 1980, if you went to a primary care doctor, you were going to his house and it was a him, not a her, okay? And maybe there were three or four other people in the office, almost all women, okay? That's what Happened over time.

This was your primary care, primary care doctor, and many times your blood work done everything right?

Correct. When I went to my dentist in 1980, my dentist was in a house. Same thing. But what happened in 1980 was that HMOs came in and what did the doc. Medical doctors do? Listen to what I'm saying carefully. I don't want to be part of corporate medicine. I don't want anything to do with the business side. I don't want. I'm not interested in money. I've heard all of those. Okay, what happened as the scale of the cost of practice increased and as people started to do marketing, selling to the patient, focusing on the consumer, all of those activities made it difficult for the individual doc. Okay, so HMOs come in and now they're saying they want to look at groups and they're going to own the dollars. They're going to have the dollars. And I had lots of trouble convincing many of the doctors I represented that if we formed a group, we had real power. What we did is the ones that worked with me and came in early, they all were able to provide more care, not less, which is what everybody would. Oh, the HMOs are going to tell me how to practice. They didn't tell them how to practice. Why did we do better? We had better rates and better care because we could measure quality. I could go in and say, every time somebody comes into a practice, this is how they're treated. This is the test they get. Nobody was telling anybody to cut. Everybody was saying, to make sure you provided it all. Same thing with ob, obstetrics, all the different testing for a woman on first visit. Once we were able to show that we could do better, we did better financially. They were inextricably tied.

It's interesting where you're going with quality because I think this is a good place to make sure for our listeners they understand because I know that there's a dentist right now totally ticked off at you by the way, saying. You're saying I'm not doing good quality because I'm an individual dentist. So let's clarify. This is are you saying that a dentist is not able to provide good care to their patient if they're by themselves?

No, absolutely not. What I am saying is they don't measure it. They don't measure it. And I had the conversation the very first time I encountered a DSO was I don't want to mention the names of the people, but I was tied to a very significant set of dentists. Who were in education, training dentists. And I had been involved with someone who was part of a dso, and I asked both of them, how do you measure quality? Which they were surprised at because they thought I was going to ask them all about the business. And I said the first, because I know when I walk into a medical practice, because there's a link now, and this is not what's happening in dentistry, but there's a link between payments and providing quality care. So we're now seeing all of those relationships where health insurers are saying, this is what quality looks like, and we're going to pay you for quality. We're paying you for performance. That's the key, okay? You may not like it, but that's where the payment is. Right now, dental insurers don't have any of that. They don't focus on payment for quality. They're paying for a procedure code. And there's nothing wrong with that. But nobody's regularly.

Mitch, somewhat to untangle what you're saying, then for every dentist that's saying, listen, Mitch, you don't realize. I am. I might not be measuring it, but I am providing a high level of care to my patient. Statistically speaking, that means there's another doctor who is not doing that. Right. And I think everyone can agree that there has to be some other dentist who, without measurements, Right. And frankly, maybe out of ignorance, even, is not providing a high level of care. In other words, there has to be people who are above average and below average, because that's how you get an average, without question.

And I think you're articulating it absolutely better than I am. The fundamentals are we're not saying solo practice is bad. We're just saying across the board. As you're saying it, the nature of elevating the quality across the board is it's not measured these days. No one believes it's done. You can't show it. You can say, I provide better quality, but can you show it? As things change? And these are things that I've seen, okay? As things change, the technology changes. So we talk about cone beams, and we talk about the standards that are associated with new technology. How many dentists have them in their offices? And where do they. Where does that come into play? Well, I learned to practice dentistry 20 years ago. Have I kept up with the technology? Have I done some dentists? Absolutely. Okay.

We know that there's that above average in that, right?

There's always going to be the top performers. Always. So it's not like this is nothing. No one size fits all. But when you take it across the whole spectrum, if you want to elevate the profession, I believe competition elevates the performance overall. But more importantly, I think the sharing of ideas in a group where dentists get to work together and can talk to each other, it's clearly been demonstrated in medical care across the whole platform. I don't have to defend this. I can show you one study after another that demonstrates medical doctors who work in groups do better.

It's interesting because I think one of the things you're hitting on that's a challenge for health care is this term standard of care. And the reason that it's a challenge is because it's not standard. Right. And so the clinician early on will say, well, I did things according to standard of care. However their colleagues are saying, well, how you're doing, it's wrong, etc. I think part of what you're interpreting quality as is to make standard of care actually standard. Maybe if an industry could organize themselves enough to truly create that and have that right discussion, then maybe some of these other pieces wouldn't happen. But in a lot of ways, then what happens in group practices is allows the clinicians to come together and make standard of care standard, at least amongst them. Right. And that's where you get a Kaiser and a Mayo Clinic and some of these other high performing groups that are really revolutionizing healthcare in their studies and in their works with these cross discipline type things. And I think that probably skews the curve to make that quality look really high.

Yes. But I also think that what you're starting to describe when you talk about the Kaisers and some of the other and the Mayo's and the Cleveland Clinic is that I think there's a vision that we share at different levels about the importance of dentistry being elevated in the importance of a person's overall health care. I happen to be totally committed to that. I view our mission and as a DSO is to be able to support our dentists in a way that they can provide the highest quality care. Okay. And be able to be seen as a co equal partner with medical doctors in the treatment of a patient's overall healthcare. That's simple, uncompromised. Okay. Because I've now listened to this pandemic and I don't want to be on a soapbox. But you know, I know what the Adso has done, our trade association in terms of aggressively being out there being advocates for dentists. You know, we get criticized for what we're doing right now, that's what I'm doing. I'm spending my time trying to figure out how dentists can do testing in their offices. And I don't mean just COVID testing. They should be able to do testing. Okay, do you think it's better to have a test done in a pharmacy, or is it better to have it done with a professional who knows how to deal with infections, who's dealing with hiv, who's dealing with hepatitis A, B, C and Q? I mean, these guys have done all of this stuff.

Well, Mitch, you hit on something that again, maybe being in a group allows dentists and other healthcare providers to do is they get together and they say, hey, guys, what's the next level we want to go to? I think a lot of times when we think about going into a group environment, the feeling is, is that things get watered down, that P&Ls become the most important part. And instead, what you're trying to describe here, I think, is how do we actually bring value by giving more value to the marketplace? Right. If pharmacies are going to be the place and dentists could be the place, or if they could be integrated into healthcare at a higher level, what's keeping us from taking that on? And a lot of times it's, we're just not organized enough to take that on. I was really like punch in the gut when Chris Badgley of Adso said that they had approached the CDC trying to help Dennis with all of this. N95 requirements around mask fittings, and how do we go find a health care provider that can do that? And the CDC's response was, well, I thought dentists were healthcare providers. It just was that push of, we need to step into the opportunities that have been given to us in this industry to. To elevate it, not to dilute it down.

Right. But I also think the message has to be, maybe we haven't done a good job as an organization to make sure that people understand that good dentistry is good business. That people tend to think, oh, if we're really concerned about the money, we can't possibly be concerned about the dentistry. And I'm actually out here to make that claim every single day. That's nonsense. That the way to make this work is to be able to provide the highest levels of quality. And it's hard think about being a solo practitioner right now. Right now I have to stay current on 18 different dental boards because I'm in 18 different states. But I have a team of people who do it supported a little bit by Adso, but I'm also supported by a team of professionals who can do that. I wonder, even if they only have to deal with one dental board, how an individual practitioner stays current with the stimulus 1, 2, 3, 4 packages, the SBA loans, all the different things that people are getting stuck with now because of the pandemic. How do they do that? And I can see this. What's important to me is to be able to provide the resources to our dentists to do, you know, let's talk about PPE.

Let's talk about PPE, because, you know, here's some things I've heard about DSOs. You guys are providing, you know, level one masks to the docs and, you know, they don't have the right procedures around them, et cetera, et cetera. So, you know, tell us a little bit. First of all, tell us. Tell us a little bit about your chief clinical officer.

We have a rock star. Okay. We have a total rock star. All right. When I came into this, I'm a data guy, okay. I looked at what we have, and I said, okay, we have a little over 2,000 employees. That's in all the different practices. It's across the board, but, you know, they're not all hours, okay. Because they're supported, but they're in the dental practices. 84% of the workforce is women. Okay. Average age 34. It's a women's run organization. I have to go find people in the right spots who understand millennials. I'm not a millennial, in case you didn't notice. Okay.

Missed it by that much.

Yeah, yeah. Close, but not there yet. Okay. I had to understand the workforce and what was needed in the workforce. And we made a judgment that we were going to start to. We wanted to be a place that was going to be top end for women to work. And so I needed to find women in serious places. I'm struggling right now to find one on our board because we've been turned down because a number of the women dentists that we've sought are not thrilled about the DSO model. Okay. But Vicki Yu is our chief clinical officer. She was a dentist at Heartland. Okay. She then built her own practice from scratch, two practices in Maryland. Ran them very successfully, but wanted a bigger challenge. Nobody works harder. And she is one of those people who just wants the challenge to be able to demonstrate that she can build a better mousetrap. She is the biggest advocate for this company that we have. And everybody's in it. We believe, you know, Philosophically, I've always believed that my management team had to be owners. So we've made. All of our key management people are either owners because they invested money or they became owners by virtue of our. Of our. What we call units grants program, which for some people.

Can you kind of walk us through what process she used to. To kind of determine? Of course, you're in multiple states, so there's lots of complexity there. But how did you all determine for the safety of the patients and the staff, what to do?

Well, let me be first. Let me say this. As a healthcare Lawyer, please remember 35 years of health care law. I'm very good at reading regulations. I do understand the difference between guidance, statute, which I think is really where the confusion is. I have never seen anything this confusing ever.

Good. You just validated, like all our listeners who've been trying to navigate this. So we do appreciate that comment.

I want to be really clear because I've been dealing now. I feel like I've been running a political campaign for the last probably 10 weeks. I've dealt with more governors and more governor staffs and more United States Senate staffs. And all these people clarify for me what urgent means, emergency means. They all think everything is so simple until it has to be executed. Okay, I drafted this stuff, so we understand it. But let's go through the question that you asked. What was the process we used? Number one, Vicki is a prodigious reader. So this was just in the order of business. She never even lifted her eyebrows and said, oh, this is complicated. We would meet, we had a conversation. She would then talk to the other dentists, part of group conversation, so people would weigh in. And then we went to our procurement people and we went through the standards and criteria that we had to use to meet in all these different states. Now, that's not been simple. I don't even want to make this. I can't even think about how complicated this has been. Okay? Because everybody thinks we need. And I now know all this stuff, even though I'm not a dentist, what an N95 mask is. Okay. If you want, I can go and run over to upstairs in my house and bring down one to show you if you want. Okay? And then the discussion about, is that required? And then all of a sudden we get a KN95 mask, and I'm told, oh, no, no, no, no, can't use a KN95 mask. Wait a minute. I just looked at the CDC requirements, and it's approved KN95. And they were looking at Me like you don't know what you're talking about. You're not a dentist. It's only N95. I said, no, I'm a lawyer. And. And we have to go through this process. Okay? So we had a deliberative process about what was required. And just to make it more confusing, and I know you probably know this, but there was certain mask. Certain mask producers who were on the CDC list as approved and were taken off the list later. Well, how did that happen? Well, the mask companies had to self disclose and then they were told they were taken off. So some people say, oh, you can't use them. No, that's not true. They have 45 days to demonstrate to CDC that they meet the requirements. Okay. None of our offices have level one masks. Now, there's also not. Also issues that are not true have to do with. We were told in Pennsylvania. This is where I really go nuts.

Okay, we can feel your attorney coming out in you. So let's settle one thing before you go into this. Ultimately, who made the decision on what ppe happened between you and your clinical coordinator?

Vicki made all those. No, no, let me be really clear. There was no way. We are not in the business of telling dentists how to practice. And I told everybody the same thing. Safety was our number one issue because I don't trust the governors in these states to make decisions for our staff. And I've been very, very worried. And I know you're in Texas. I watch every single day. I watch four projections. Not one four. And I have friends in two of them. And I'm calling them, and they told me three weeks ago, be careful about opening in Texas. It's going to spike. That was three weeks ago, not now, when it's spiking. And I worry about the fact that, yes, we're open, but should we be open if the pandemic is still growing, if the exposure is still growing? So it's not my job to tell

people what don't ultimately make the decision. But it sounds like you're very conservative and very cautious about what you're watching.

Yes and no. Okay, cautious. Because we've told every dentist in every practice, and I do video with it. So I'm constantly saying the same message. You're in charge of safety of the people in that office. That goes to the patients, that goes to the office staff, that goes to the hygienist, the assistants. That's your job. You decide it's not safe, close the doors. And they've all heard me say it. Why I'm not there and I don't practice dentistry. It's real simple. This is not complicated. What's really important here is that we wanted to figure out how does the business match with safety? Because that's a tricky issue. If we wanted to go buy certain masks and they were price gouging us, which they all tried to do, okay, so the $1.95 mask was now $6, and that's a different issue. But what we're really trying to figure out, and I watch every day because I hear different things and I don't understand them. Sometimes Vicki's real good at explaining it, but there are times when we all sit in a room and my chief operating officer should not be in any way ignored. He's worked with a number of different DSOs. He really knows dentistry really, really well. But again, he works with Vicki. He's not telling dentists how to practice. And our director of procurement, who's the superstar in the space, gets told by Vicki, I need this, I need that, I need this. And then he goes out and goes,

yeah, finds the best solution.

Yes. And that's the stuff that a solo practitioner really can't do. Well. So for us, we have had, had to go buy face shields. We had to put, we put in every practice where the front desk is, there's a, a Plexiglas shield to protect the front desk people. We're now struggling with something because we know that the issue around aerosols is complicated. So from a hygiene perspective, you know, there's a lot of stuff out there that I don't necessarily leave is factual. But we just decided we're going to do hand scaling. Okay. And minimize that stuff. And now we're trying to figure out. We haven't done it yet. We just started to look at it because some people are talking about air handling systems being used differently and perhaps they can reduce aerosols that way. But this is not my area of expertise. I'm way out over my skis right now.

How do you think of dso? Because you were telling me something before the show that you had kind of a way that you broke down absolutely responsibility for me.

If you look at behind you, there's DSO secrets, and if you take the D and make it small and make the O small and make the S big. That's what our job is support. My job every day is to worry about how I keep the company in business. How do I get the teams, the dental teams back for the practices and what resources do we need to support These practices and I believe because of the pandemic, and I'm not happy about this, this is not where I'm oh, this is a great opportunity. We're not vultures here. We're really looking at this as this may be one of the reasons that we prove out the model. Because having the necessary resources and expertise to navigate this is tricky. I've been very concerned because I don't think it's useful for the industry to be in panic. One of the things that we've seen is I've been getting calls on a pretty regular basis from dentists who are struggling to come back and wanting to know if we want to buy their practice. That's not where we are right now. I need to get my team back, I need to make sure we're safe and once we deal with that, we can deal with the business issues. But right now, all of the DSO executives that I've talked to, who are my peers, are all focused on safety and they're not worried about their own practices. They're worried about dentistry in general. And I think the message, if I'm going to leave one with this group, is to think of dentists, DSOs as advocates for high level dentistry because that's what we're providing at every level. I know there are people out there who've been schooled in an area in a headset that I've never fully understood, which was if you're providing health care, you can't be a business person. I can tell you the last 25 years of healthcare in this country has proven that philosophy to be wrong.

It's tough to provide health care if you're bankrupt. That's, I mean, that's the bottom line.

If we take it or you're cutting financial corners. You know, it's difficult and we're not perfect by any means. I mean, we've got a lot of things to fix. But the industry itself needs to embrace a broader view because I believe personally, within next five to ten years, you, you're going to see the integration of medicine and dentistry. And dentists need to stand up and say, well, health care providers, I tell everybody I am aggravated because I see in New York every day everybody's clapping for frontline healthcare providers. And I say, you know what? Our dentists are frontline healthcare providers. We did 100,000 emergencies without N95 masks and without all the protection and we kept people out of hospitals. I don't see anybody in New York clapping for dentists. And dentists are frontline healthcare. Workers to us. That's where I want to be. I want to be in that space where we can prove out a business model that has better patient care and provides a better lifestyle for all the people who work in the company. That's the game plan. And I believe every DSO has that as well.

It's a great vision. No matter who you are, if you want to be an individual dentist, if you want to be part of a group, if you want to work with your buddy, whatever you might want to do, elevate the industry. And I think that's a message anybody can get behind. Now you're pretty involved and I just want to kind of close with some of this. But you're pretty involved in dentistry beyond the DSO and supporting dentists. You're also on. Is it in the education model or the dental board?

I'm on the board of the Penn Dental School. Board of Overseas. The Penn Dental School. Okay, great. Our family has been tied for some long period of time to the University of Pennsylvania and kind of a funny little story, but I used to have a radio show for five years on Sirius xm. And when we were looking at this business, I was trying to figure out what to do. I decided I'll see if I can get the dean of the Penn Dental School to come over and be a guest on the show. Because it's the business of healthcare. I got the, at that time, the head of the Adso. I didn't really even know what the Adso was, but I figured, oh, that'll be great. I'll have a point counterpoint. The two of them are gonna butt heads and this will be a really good opportunity. And of course, the dean comes in and he totally blows it. He said, I love this business model. And I'm trying to get the two of them to kind of have a point counterpoint. And he's saying, this is the model of the future. And I'm going, what's going on here? Are you guys in the same zone? And then the dean says, the future of dentistry is in larger scale. That's how I kind of picked up a lot of this stuff and started to realize that we really need to be able to measure quality in dentistry. And I don't necessarily. Everybody focuses very quick on measuring outcomes. I'm less concerned about measuring outcomes. I'm way more concerned about measuring process. So we know what's happening in the industry on a day to day basis and we can standardize process.

How scientific method of you. Well, Mitch, thank you so much for being on the show for being transparent, for being you, being open, not holding any punches, which is what we love about you. Just open about what you know what's going on and willing to take the feedback. So I really appreciate it. I want to give you a little bit of the ability to give a plug if people want to learn more. I know you said you're not looking for partners and affiliates today, but still, they might want to check you out, what's a good website or if they want to go.

Yeah, we're always looking for partners and affiliates. We're just not looking for them immediately. We will be once we get this business back. But we, you know, everybody's still doing it. Mid Atlantic Dental Partners is the website and we had, we grew very, very quickly. So we still, they can still find us@dental1 and we still have a website that's up as Dental One as well.

Awesome. And you're supporting how many clinicians in general now?

A little over 400 clinicians and 250 practices were in 18 states. And it was a fast grow. We grew by acquisition. We found two distressed assets that we wanted to improve and we raised some real money and made those acquisitions. So it's been a fast paced run for us. Our team is young, it's not me. And you know, everybody's working real hard to get our team back. So we just keep our fingers crossed. This has been a very, very difficult time. So thank you for having me. I totally enjoyed this.

Thank you so much. And I know we'll have lots of comments and feedback and we'll probably have you on again. Maybe I'll find that person to go count, you know, point counterpoint with you. That would be a great show.

Great. Happy to do it.

Well, and to our listeners, thank you for, for listening in. If you want, if you have comments around Mitch or myself in this interview, come over to our Facebook page at DSO Secrets. And until next time, keep smiling.

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