Astroturfing by the Dental Support Organization Industry

Dr. Michael W. Davis maintains a general dental practice in Santa Fe, NM. He serves as chairperson for Santa Fe District Dental Society Peer-Review. Dr. Davis also provides a fair amount of dental expert legal work for attorneys. He may be contacted via email: MWDavisDDS@comcast.net

“Astroturfing is the practice of masking the sponsors of a message or organization (e.g., political, advertising, religious or public relations) to make it appear as though it originates from and is supported by grassroots participant(s).”^1. -Wikipedia 
Introduction
It is imperative the so-called “dental support organization industry” (DSO industry) employ astroturfing techniques, as their entire business model is formulated on gross misrepresentations.^2-12 In order to obfuscate the rule of law relating to the unlicensed and unlawful practice of dentistry, these corporate entities must misrepresent themselves as only providing limited nonclinical support services for their chains of dental practices. This is patently false, and has been challenged by numbers of legal rulings and studies. In reality, DSOs either represent the true beneficial owners and clinical management for vast numbers of dental clinics, or they provide management for the private equity beneficial ownership. Doctors only serve in a limited role as facade nominee owners. The word “support” is intentionally designed to deceive. The lies go on.

Forms of DSO Astroturfing
There are four basic designs of astroturfing utilized by the DSO industry. At the most basic level is DSOs placing bogus positive patient reviews with online rating services or their website. The next astroturfing technique involves individual dentists who openly advocate for the DSO industry. The third method employs hired public relations and public advocacy specialists. The final level, and often most challenging to prove, is hired lobbyists who direct public policy through directly influencing government agencies and government elected officials. 

Bogus online Patient Reviews
Although this form of deceptive advertising is unlawful, violators are rarely discovered or sanctioned.¹³ The DSO utilizes existing employees or a retained service to generate positive patient reviews for dental services with online review sites, and/or their own website. Often the specific language utilized in the review is a tip-off, that the bogus reviewer is truly not a clinical dental patient, but working in the dental field. Certain DSOs have such a disturbingly high degree of employee turnover and negative staff retention rates, they now resort to posting bogus positive reviews of current or former employees on employment websites such as Glassdoor.com and Indeed.com. One will generally see multiple low rated “one-star” reviews, intermixed with over-the-top glowing “five-star” reviews. Obviously, corporate astroturfing is in play. 

Individual Dentists Espousing the DSO Agenda
On occasion, state legislatures will take up the cause of regulating and restricting the DSO industry to benefit the public interest. Bills will be presented to establish enhanced transparency in true beneficial clinic ownership. Clarification will be added to protect the doctor/patient relationship (contract), and patient rights such as the informed consent process, and always holding the patient’s interests paramount in clinical decisions. Truth in advertising and lending will be advocated. Mechanisms for bait-and-switch schemes will be discouraged.

Another one of those “studies” paid for by Kool Smiles parent company suggests more Medicaid money is needed for dental benefits to serve children in Texas!

I know it’s hard but try to stop laughing and read this ridiculous press release.
(Benevis was formerly NCDR (Kool Smiles), owned by private equity firm FLL Partners.)

Study Finds Only 26.5% Of Texas Children Eligible For Medicaid Dental Coverage Frequently Visit Dentist.

PRNewswire (7/30) carries a release announcing that a new survey by the Benevis Foundation, conducted by Kennesaw State and Emory University researchers, finds that “only 26.5% of Texas parents with children eligible for Medicaid dental coverage consistently bring their children to the dentist as frequently as they should,” with parents citing financial hardships as the primary barrier to more frequent dental visits. Geoffrey Freeman, spokesperson for the Benevis Foundation, said, “This suggests that parents may not be aware of the complete coverage of their benefit, or that there may be secondary costs – such as transportation or unpaid time off work – that keeps these families from visiting the dentist as often as they would like.”

Here’s a challenge -

Here is the Laffer Associates Study that says DSO’s (Kool Smiles, Small Smiles, etc)  perform less procedures per patient than private dentists. It also says they steal less than money per patient than private dentists. Ok, it doesn’t use the word steal…  but still…. 

You can find a link to the raw data at the bottom of page 5 of Laffer’s study. Or at their dropbox here.  Or this dropbox here.

WARNING – if you have a copy saved as an .xls file instead of a .xlxs your speadsheet does NOT contain all the data! 

Here is the challenge – Debunk it!

According to the study they found 35 Texas Providers Identifiers for Kool Smiles in Texas. Considering Small Smiles used at a minimum 25 provider numbers for 4 of their dental centers in 2010, I betting there were a whole lot more than 35  numbers used for Kool Smiles and their many clinics in 2011.  Hell, there are at least 55 “providers” in the Indiana Kool Smiles centers.  It might have been 35 that could be identified, for Texas in 2011, but that’s the point, isn’t it?

Laffer says this about the data:

Data and Methodology
We were provided Medicaid claims paid data for the fiscal year 2011 by Kool Smiles, who had received these data from the Texas Medicaid Program via a Freedom of Information Act request. We did nothing to verify the authenticity or accuracy of these data.
Before going into the results of our analysis, let me provide a few definitions. In Texas, Medicaid covers children in families from no income up to 185% of the federal poverty level for children up to 1 year old, up to 133% of the federal poverty level for children from 1 year old to 5 years old, and up to 100% of the federal poverty level from children 6 years old to 19 years old.

Thus, the data contain all Medicaid claims arising from children aged zero through 19 years, 11 months in families with income up to the applicable multiple of the federal poverty level (the federal poverty level is an annual income of
$18,530 or less for a family of three as of 1/1/12), regardless of what type of dental provider treated the child.

We counted as a procedure every separate dental activity that was charged to Medicaid with a Medicaid billing code.
Unfortunately, the data did not contain a separate total count of patients accessing dental services. Instead, unique patient counts were provided for each Medicaid billing code. To derive an estimate of the total number of patients, we added the number of patients treated via each code for a prophylaxis cleaning and used that count as our number of unique patients.

We used this procedure for all DSOs and all non-DSOs as well.
Prophylaxis cleanings, or “prophies”, are the standard dental cleanings that every patient receives as part of a routine dental visit.24 These dental cleanings, which are typically billed under the same code each visit, provide a more reliable method for this patient count than other routine services, such as exams, which might be billed under different codes and lead to double counting. There are three codes for prophylaxis cleaning, each based on age: D1110 for patients 13 to 20 years old, D1120 for patients 6 months to 12 years old, and D0145, 25 a code specific to the Texas Health Steps program, for children under 3 years old.

The Medicaid data we received contained a count of clients who received the procedure associated with each Medicaid billing code, broken out by location of dental service (see below). Summing the number of clients receiving each prophylaxis procedure thus provides a proxy for the total number of unique patients treated under Medicaid in Texas in 2011.

Accordingly, we use “prophies,” a routine procedure administered with regularity, as the count for unique patients, or “patients,” as we’ll refer to them in this analysis.

Additionally, the data quite naturally did not explicitly identify which dentists were associated with DSOs. The amount of reimbursement doesn’t differ for DSO dentists and non-DSO dentists. In order to receive reimbursements for treatment
performed on Medicaid patients, however, a dentist must apply for and be assigned a Medicaid Texas Provider Identifier (TPI) number. We made a list of all of the DSOs we could identify that do business in Texas, and any TPI that filed a claim using an identified DSO address was counted as being a DSO dentist (see Appendix A for a full listing of all DSOs included in our calculations). All other TPIs were counted as non-DSO dentists. In the process, we dropped the claims data for any TPI that filed with Texas Medicaid but was associated with an address that was not within or immediately bordering Texas.

An important caveat is that the total population of DSOs within the data represents office locations, and not individual dentists. In going through the data, we were unable to find multiple dentists working at the same DSO office billing
separately. With few exceptions for non-DSOs, it seems a rule that most group practitioners bill under a single base (7-digit) TPI instead of their unique and individual 9-digit TPI.

Basically, I read this to say “GIGO” – Garbage In – Garbage Out. So someone spent a hell of a lot of money for a report that means nothing and I mean nothing. Goes to show you though, tell a company what you need it to say, and they can get the data to make it so.

As well, these DSO’s work very hard to hide the fact they are operating as a DSO, since it’s illegal, so the number of non-DSO dentists numbers have to be distorted, right?  Like I said, GIGO!